Pregnant in 2017? ACOG Recommends…

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As a doula, getting the latest recommendations on birth updated is almost like Christmas morning. And if you are pregnant in 2017, you probably want to be aware of the latest recommendations by the American Congress of Obstetricians and Gynecologists (ACOG). Whether you are attempting a natural birth in the hospital, or maybe you aren’t sure exactly what you want to do, there are some important points that would be good for you to know. And as we all know, knowledge is power. And what pregnant woman couldn’t use an extra boost of power?

You can read the entire position paper they put out here, or simply read on to get an overview of some of the key points.

These new recommendations consist of a more hands-off approach when it comes to some things (like fetal monitoring and pushing approaches), and they include and reaffirm their past position on things such as eating and drinking during labor (Yes, of course it’s good for you!)

And you know what else is good for you? Continuous support. Although this is not “new” news. This document specifically mentions doulas several times and numerous citations are used to note the mounting evidence that continuous labor support is associated with a myriad of positive outcomes such as:

  • Fewer operative assisted birth such as forceps or vacuum extractions
  • Less need for epidurals and analgesia
  • Fewer cesarean births
  • Shorter labors
  • Higher 5 minutes Apgar scores
  • Fewer reports of dissatisfaction with the experience of labor

So what else might be important for you to know now?

Laboring at home until active labor is encouraged and beneficial

In recent years the definition of active labor has changed to mean until 5- 6 cm of dilation. But that means little to moms who are laboring at home without being checked by a care provider. So the bottom line is, be prepared to labor at home…for quite awhile. It is perfectly normal for a first time mom to be in early labor for 24 hours, or more. Early labor (the latent phase) is a very important part of the labor process that should not be downplayed, in my opinion. A lot is still going on for a laboring woman, both physically and mentally. Research shows that for low-risk, healthy women, interventions are more likely to be avoided if they are admitted once they reach active labor. So it’s important to understand a lot of labor will be happening outside the hospital, and it’s important to have a good plan. I always educate my clients on the process of early labor, what to look for, help them come up with some ideas as to how to spend it, and I help their partners understand they will have a very important role during this time period.

Intermittent monitoring is appropriate for low-risk labors

Woohoo! ACOG finally affirms that for low-risk labors, intermittent monitoring (as opposed to being tethered to a machine by 2 elastic straps the entire time) is appropriate, and sometimes even more beneficial. The opinion clearly states that studies have shown that continuous monitoring has not reduced perinatal death or cerebral palsy for low-risk pregnancies, and has in fact increased cesarean and instrument assisted births. So couple that with the desire to want to move about freely and change positions at will, which naturally will aid in the descent of the baby and the progress of labor, and it becomes quite logical that for low-risk labors, intermittent monitoring is way more beneficial. But you will need to discuss this before “labor day” with your provider, and make sure the hospital you will be attending has this as a true option. Then on labor day, you will need to remind them that this is important for you.

Water breaks before labor starts? You have choices, and equally good options

When a woman experiences PROM (premature rupture of membranes), this means the water breaks and labor doesn’t begin immediately. When this happens, according to the newest findings, “approximately 77–79% of women will go into labor spontaneously within 12 hours, and 95% will start labor spontaneously within 24–28 hours” (ACOG, Feburary 2017). There are 2 types of management in this case. Expectant management is a “hand’s off” approach where conditions are monitored but treatment is withheld until symptoms appear or parameters change. Active management is where induction is started shortly after the rupture of the membranes “to move things along”.

“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”

-Committee Opinion: Approaches to Limit Intervention During Labor and Birth, ACOG, February 2017

Current best practices shows outcomes are the same, whether active or expectant management is used in low-risk pregnancies. So this is another good talk to have ahead of time with your provider. Make sure if you think you might want to wait it out at home, they are comfortable with assessing you, and then letting you do your thing until somethings changes, or you change your mind.

And speaking of water breaking…

Your water will break, at some point before or during, or even after labor (for babies born in the caul). This is a hard fact. ACOG is now recognizing what research has shown for years- that AROM (artificial rupture of membranes) has little benefit to the labor as a whole, and may actually do more harm than good in terms of increasing the risk of infection, causing a malpositioned baby, or in extreme cases it can cause cord prolapse or placental abruption, both which will lead to an emergency cesarean. Expectant mothers should know it’s perfectly normal for waters to release when they are ready, and that there is no need to rush the process.Unless, of course, there is an obvious medical necessity.

Keep Calm and Drink On

The reasoning behind the “no eating or drinking during labor” (at a hospital) rule is primarily to avoid aspiration should an emergency ensue later.  Current findings show current anesthesia techniques (meaning epidurals) are associated with a low incidence of aspiration, and ACOG has stated now that hydrating yourself with fluids is preferable to IV hydration. So bring lots of coconut water, herbal teas, bone broth, juices, whatever appeals to you! They have alluded to the fact that since aspiration risks are so low, eating would in effect help keep a laboring mom’s strength up for the marathon of labor, but they have yet to officially change their stance regarding food and are continuing their “ongoing review” on it. We’ll have to give them more time to catch up on this one.

Push it Real Good

The “purple pushing” or Valsalva (closed glottis) pushing technique is being compared to an instinctual, open glottis pushing which is often accompanied with vocalizations of many varieties (and wow, have I heard it all!) in this recent finding. Studies show that there is minimal difference when it comes to the duration of the second stage, no difference in overall outcomes (meaning cesarean, instrument assisted, APGAR scores, etc.). There is a slight shortening of the pushing phase (depending on the study), between 5 and 10 minutes, when using the Valsalva technique, but there is also increased incidence of “abnormal urodynamics” (hello, pelvic floor, how I miss you so). Also, women are now (finally!) being encouraged to “labor down”, meaning give baby some time to move further down on his own and to following their own instincts as to when to start to push. This is a good thing because you are working WITH your body, when it’s ready. Just because you hit 10 cm. does not necessarily mean baby is down low enough to make pushing warranted or very effective…and no one wants an exhausted mama by the time baby is low enough.

Regardless of what you choose for YOUR birth, having evidence based information can help you make better choices. And it’s important is that these are your choices, what you feel is best for you and your family. Documents such as the one just put out by ACOG make wonderful talking points with your care provider. They tend to like that kind of evidence based stuff, they’re funny like that. And believe it or not some of them who have been practicing for a long time may or may not be up to speed with the latest recommendations. So here’s your chance to share with them.

Share on mamas, share on!

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