Latest recommendations and conclusions from the ACOG (American College of Obstetricians and Gynecologists) and ACNM (The American College of Nurse–Midwives) committee from February 2017, regarding approaches to reduce interventions during labor.
Obstetrician-gynecologists, in collaboration with midwives and nurses, can help women achieve their birth goals using techniques that involve minimal interventions and lead to a high degree of women’s satisfaction. Many common obstetric practices are unnecessary for low-risk women. For women in the latent phase of labor who are not admitted to the hospital, shared decision-making is recommended. Sometimes, hospital admission during the latent phase is necessary for various reasons, such as premature rupture of membranes (PROM), pain, and fatigue. Findings indicate that for women with a normal pregnancy course and no evidence of fetal distress, routine amniotomy (rupture of membranes) is not necessary. Furthermore, data show that continuous use of fetal heart monitors – cardiotocography (CTG) – in low-risk pregnant women did not affect birth outcomes. Several non-pharmacological and pharmacological techniques are available for pain relief during labor. When labor progresses spontaneously, routine infusion and IV fluid administration are not needed. For first-time mothers with epidural analgesia and no signs of rapid labor, a rest period of 1-2 hours can be allowed before initiating the pushing phase. Individuals involved in maternity care and childbirth must be familiar with low-intervention approaches and encourage their use in low-risk pregnant women with spontaneous labor.
RECOMMENDATIONS:
– For a woman at term (37-40 weeks) with spontaneous labor and a fetus in cephalic presentation, labor monitoring should be individualized according to the woman’s and fetus’s health status, with intermittent auscultation and non-pharmacological pain management.
– Hospital admission for a woman in the latent phase of labor can be delayed when her and her fetus’s status is stable. The woman should be offered contact and emotional support, as well as non-pharmacological pain management measures (listed below).
– When a woman in the latent phase of labor is admitted due to pain and fatigue, the following techniques can be used: oral rehydration, positioning in a comfortable position, non-pharmacological pain management techniques (such as massage, bath, shower, compresses…), educating the woman, and providing emotional support.
– Obstetrician-gynecologists and other healthcare professionals must inform women about the risks of premature rupture of membranes (PROM – meaning when water breaks but there are no contractions to soften and dilate the cervix and move the baby down the birth canal). For informed women, we can allow time and postpone labor for a while if her and the baby’s condition permits. However, for women who test positive for Group B Streptococcus (GBS), antibiotic prophylaxis should not be delayed. In such cases, many obstetrician-gynecologists opt for immediate induction.
– Evidence suggests that, in addition to regular medical and midwifery care, continuous one-on-one emotional support (one midwife per birthing woman) is associated with improved birth outcomes.
– For women with normally progressing labor and no signs of fetal distress, routine amniotomy is not necessarily performed, unless circumstances require it.
– The use of various pharmacological and non-pharmacological pain management techniques, tailored to the birthing woman, is recommended.
– For intermittent auscultation instead of continuous CTGs during labor, obstetrician-gynecologists and other healthcare providers (midwives) should consider adopting protocols that include the use of Dopplers for low-risk women who desire such monitoring during labor (my addition is that this also requires more staff!)
– Frequent changes in position during labor to increase the comfort of the birthing woman and ensure optimal fetal position are not discouraged, as long as they allow for adequate monitoring of maternal and fetal functions and do not cause health or obstetric complications.
– When women are not instructed on breathing during labor, women in the pushing phase push with an open epiglottis. Given the limited data on differences in outcomes between spontaneous pushing or Valsalva pushing (the Valsalva maneuver is exhaling with a closed epiglottis. The maneuver is performed by taking a breath, pinching the nose or closing the epiglottis, closing the mouth, and attempting to exhale. This opens the Eustachian tube and equalizes pressure on both sides of the eardrum, causing a popping sensation in the ears – this is done when one wants to equalize ear pressure), women are advised to use the technique that is more effective for them.
– When there are no signs of premature labor, birthing women (especially first-time mothers with epidural analgesia) can be offered a rest of 1-2 hours (unless the woman herself wishes to give birth sooner) at the onset of the second stage of labor (pushing).
Many methods and techniques in existing obstetric practice have limited or uncertain benefits for low-risk women. It should also be noted that some women do not want medical interventions during contractions and labor. However, satisfaction with childbirth depends not only on this but also on personal expectations, the support of healthcare and support staff, and the birthing woman’s participation in decision-making. It is recommended that obstetrician-gynecologists and other individuals involved in childbirth know and apply low-intervention approaches, where appropriate and possible, for managing labor in low-risk women with spontaneous labor.
Read more:
- Answers to the research questions of the master’s thesis “Six Areas in the Delivery Room for Better Birth Practice”
- How to promote safe and healthy childbirth?
- How to influence birth culture?
Photo: Canva
