Tuesday, February 21, 2017

ACOG's 11 "New" Recommendations for Birth (that we've kinda been saying all along)



Finally! Have you heard? If you or someone you know will be having a baby soon, I hope you have! The American College of Obstetricians and Gynecologists just recently (finally!) came out with some new recommendations for labor and birth and they're kind of a big deal. It's what many mothers and birth advocates have been begging for for years and ACOG is finally admitting that for most women, some common hospital protocols have not truly been evidence based. In fact, many times the unreasonable requirements of these protocols have frustrated normal labors and caused complications that could have been prevented. 

This is important. This isn't just for "birthy" folk. We need to care about these kinds of things because they directly affect the health of the most vulnerable among us and they affect the dignity with which women and babies are treated. The way women experience their births has a direct effect on families and on how they enter into their motherhood. We need to insist that women and babies are always treated with the utmost of dignity and respect and with solid, evidence-based care that honors the design of God for our bodies and for birth.

You can read the whole official text here. Here's the summarized version of the new recommendations and guidelines (but don't worry, I'm going to break it down a bit for you underneath!):

  • For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.
  • Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.
  • When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.
  • Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term premature rupture of membrane (PROM [also known as prelabor rupture of membranes]) who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.
  • Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.
  • For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.
  • To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.
  • Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions to best meet the needs of each woman.
  • Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.
  • When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing, each woman should be encouraged to use the technique that she prefers and is most effective for her.
  • In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) may be offered a period of rest of 1–2 hours (unless the woman has an urge to bear down sooner) at the onset of the second stage of labor.

Going through point-by-point, here's how I read it:

  • A woman in normal labor should be treated with individualized care, given options, and avoid unnecessary interventions in her labor.

  • If mom and baby are okay, there's no need to be in the hospital during early labor.

  • Women who do go to the hospital in early labor should be helped with hydration (i.e. no one should be keeping you from drinking water, ladies!!) and safe and non-invasive pain management. There is NO real evidence that women should be prevented from drinking during early labor and in fact, not being well hydrated can be make things much harder for mom and even be dangerous. The report even states that the prohibition from eating during labor is also questionable. Moms in early labor should also be given help with non-medical comfort techniques. Newsflash: baths and massage feel good (duh.). Other things like education, relaxation techniques, aromatherapy, acupuncture, sterile water injections, and more can all be helpful in handling labor.

  • If your water breaks before labor begins, you should have the choice to wait for it to begin and not necessarily be on a time clock for birth. The evidence is inconclusive on whether we should push birth to avoid infection or allow her to go into labor on her own to avoid the risks of induction and the cascade of interventions it can create. If a woman is GBS+, however, antibiotics are still advised if her water has broken.


  • DOULAS MAKE A DIFFERENCE. They improve outcomes for mothers and babies!! One on one motional support for birth is better for moms and babies and women should be encouraged to have that.

  • There is no medical reason for a provider to routinely break mothers' water, unless there is clear medical reason that the baby needs to be monitored through his or her scalp. The evidence does not point to breaking the water as a way to shorten labor on its own and doing so may increase risk of other interventions and complications. 

  • Low-risk women in normal labor should be given the option of intermittent monitoring using a handheld doppler rather than the continuous electronic monitors strapped to your belly. Continuous monitoring in low risk women does NOT improve outcomes for mother and baby and oftentimes inhibit movement and comfort for the mom. They also can falsely indicate problems with the baby that prompt unnecessary interventions. 

  • Care providers should be availing themselves of a variety of ways to meet the needs of the laboring woman in front of them and tailoring it to her specific situation, experience, and desires. They should be listening to her and her preferences and offering help and suggestions based off of what she is actually experiencing. This means that they shouldn't be offering anesthesia or narcotic pain relief if she doesn't want it or before she exhibits or says that she might want it.


  • Movement in a low risk mom should not be restricted. Mom should be free to get into and move in whatever position she needs to, provided any truly necessary monitoring of her and her baby can still be done.


  • Women should be free to push in whatever way works best for them!! "Purple pushing" (i.e. counted, breath-holding pushing) is not necessary unless the mom wants that coaching

  • Unless there is a reason that baby needs to be born right away, women should be allowed to follow their body for pushing! This means that she shouldn't be forced to push before she is ready and even allowed a few hours of rest if she is not feeling the urge to push at 10 cm. (This is very normal for some women! Their body gives them a good break to rest before the work of pushing!) 


It's VERY important to know that even though these are ACOG's new recommendations, it will take years, if not decades, for many providers and hospitals to make the necessary changes in protocol. The birth and medical world moves very slowly with this stuff. So, if you're having a baby soon, don't just assume that your hospital or provider will be following these or that they even know about them yet. Open and honest discussions with your provider before the birth are KEY to having a birth experience that is respectful and positive. While making your plans for birth, talk with them about their protocols and if necessary, print the recommendations out to share with them! I think it's important to keep in mind, too, that these changes are tantamount to an "oops!" admission. We make the best decisions we can with the information we have but don't necessarily assume that just because a hospital or doctor tells you something that it is necessarily based on real evidence or is in your true best interest. This change reflects that for decades women were told to do things that weren't necessary or even good for them. (That's not saying that it was mal-intentioned, of course. But being sincerely wrong is still wrong.) Women deserve to have all the information they need to make good choices for themselves and for their babies and always always always be treated with dignity and respect and evidence-based care, especially during the precious and important moments of birth. 


"Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient–caregiver relationship, and the patient’s involvement in decision making. Therefore, obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor." ACOG


4 comments:

  1. I've only had 1 labor (out of 5) where my water was intact through all of labor (broke at the very end) and it was by far the most comfortable, easiest, least painful labor of all of mine. (In 2 of mine, my water was broken prematurely by the dr./midwife and in the other 2, it broke before labor started all on its own. I'm so glad to see that recommendation to leave the membrane intact. It really does make a huge difference in how painful the contractions are.

    I also think walking around while in labor is so helpful, so I'm really glad to see that recommendation to allow women the freedom to move around.

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  2. I was shocked -- SHOCKED -- when my new OB casually mentioned that it's fine with him if I want to eat during labor, even while in the hospital. With my last doc I had to fight to be allowed water! Glad I switched and so glad to see these recommendations changing, even if it takes years for them to trickle down.

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    Replies
    1. Isn't it crazy how much protocol can vary from one hospital or provider to another?! And obviously, when they're directly opposed, one or the other has to be misinformed. I'm glad to hear that your new doctor was good about it!

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    2. Boy, it puts the patient in an awkward situation, too, if the doctor is misinformed, doesn't it?! Obviously the doctor has expertise and training that the patient (usually) does not have, but there are still things that the patient knows that the doctor does not...so much better if the doctor is accurately educated and you don't have to question them in their area of expertise.

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