The American College of Obstetricians and Gynecologists (ACOG), is a membership organization for obstetricians and gynecologists, and is dedicated to the improvement of women’s health. ACOG regularly releases statements on trends in birth practices that generally aim toward reducing the rates of unnecessary intervention and cesareans.
Last month, ACOG has released an opinion, Approaches to Limit Intervention During Labor, that might impact your experience for your hospital birth – for the better! Seattle childbirth educator Sharon Muza breaks down what she feels are the top six points relevant to birthing clients and doulas, in this article, Six New Care Recommendations that Every Birth Doula Should Share with Their Clients. Below, I explore her points and explain them in context to our birth climate here in Kitsap County.
1. Hospitals encourage laboring at home until active labor
Both Naval Hospital Bremerton (NHB) and Harrison Memorial Hospital in Silverdale recognize that having pregnant patients wandering the halls at 2cm isn’t good for anyone. The earlier you arrive at the hospital, the higher your risk of increased interventions, which thus, increases your risk of cesarean. Recognizing this, these facilities encourage patients to wait until they are in active labor (measuring this at 6cm), or their water is broken. How will you know if you’re 6cm if no one checks your cervix? You won’t, but your doula can help you interpret your external signs of progress and help you figure out when it might be a good time to head in to the hospital, helping to ensure you don’t go too soon.
2. Active and Expectant Management of PROM are both equally good choices.
Generally, if you are one of the 10% of people whose water breaks before the start of contractions (premature rupture of membranes, (PROM)), providers will begin to be concerned about infection risk, and thus a ‘clock’ is placed on your labor. ACOG’s statement argues that in low risk patients, expectant management (waiting for you to start contractions on your own), or active management (intervening with medications to cause contractions), are both safe and acceptable.
Expectant management is definitely not the norm in Kitsap with our obstetricians – however, it is more so with midwives. The time that a provider is comfortable waiting for your contractions to begin can vary by provider, even within the same practice. Infection risks can be mitigated in several ways, and if you feel strongly about expectant management, it might be worth bringing the ACOG statement to your provider to talk with them about this in more depth.
3. Intermittent Fetal Heart Monitoring is Appropriate for Low Risk Labors
I have seen a resurgence with some of our local obstetricians requiring that all patients have continuous monitoring (belts and monitors around your belly the entirety of the labor), versus intermittent monitoring (20 minutes of monitoring out of every hour, generally.) Intermittent auscultation is offered by midwives at NHB, and by out of hospital midwives. This involves holding a doppler to your belly periodically through your labor to listen to baby’s heart tones, rather than having belts around your belly that need frequent adjustment.
Interestingly, one OB I work with said, “The longer you listen (monitor), the more issues you will find, and that doesn’t mean they’re a problem, but it does force us to intervene more often.”
We know that there is evidence that says that continuous monitoring does not improve outcomes, and does increase cesarean risk by 1.7 times! Talk with your providers about their comfort level with intermittent monitoring so that you know their position, and then do your own research. ACOG’s statement is reassuring that you can argue for intermittent monitoring if you are low-risk.
4. Artificial Rupture of Membranes is not Necessary
Rupturing amniotic sac, or “breaking the water”, is a common intervention that many folks don’t think a lot about. When the amniotic sac is broken, this usually causes the baby to drop deeper into the pelvis, and is usually intended to help speed up a slow moving labor. If baby is not in a good position for birth at the time of the procedure, the fluid cushion that gives them space to move is now gone, and this can become problematic. Having your water broken also puts you on a clock where providers expect a certain speed of progress in a certain amount of time (see point #2 above!)
Talk with your provider about the times they are most likely to rupture membranes, and what kind of informed consent you should expect at that time. Every intervention comes with risks – be sure to ask your provider about those potential risks during your prenatal visits so that you can plan accordingly. Midwives are generally less likely to augment labor by breaking your water than obstetricians, and generally are willing to wait much longer for your labor to pick up speed before suggesting interventions.
5. Eat, Drink and Labor On!
It’s been customary in hospitals to limit food at some point during the labor. Both Harrison and NHB generally limit food after clients have augmentation or pain medication in place, and definitely if a cesarean is anticipated. Depending on the nurse you have when you are in labor, you might be refused access to food once you appear to be in active labor as well. Out of hospital birth midwives encouraging eating through the entirety of your labor, at your comfort level.
Both hospitals require a saline-lock which provides IV access in the event that intravenous medications or fluids are needed at some point during your labor, or there is an emergency. It’s important for families to note that there is a growing awareness that IV fluids during the birth can impact the baby’s weight loss after the birth, thus leading to interventions for feeding issues that might not actually be problematic.
Out of hospital midwives usually recommend eating and drinking throughout the labor in order to keep your strength up, and the climate for food access during labor is changing very slowly in the hospital. Talk with your provider about their expectations with regard to food, and then plan accordingly to bring food for yourself and your birth team so that you can eat at your comfort level.
6. Labor Down and Push Spontaneously with the Urge to Push
In unmedicated, hospital birth it’s very common for providers to check your cervix, find that you have reached 10cm dilation (or are ‘complete’), and ask you to begin pushing. This can be challenging if your baby is still rather high in your pelvis and your uterus hasn’t had the time to bring your baby down a little further, giving you that urge to push. Early pushing can also extend the time you spend bringing your baby down, burning up the time allotted for pushing (which varies by provider, and your situation.)
Talk with your provider about laboring down- letting your uterus do more of the work to help your baby descend, without your active help, before beginning to push. Unmedicated births outside the hospital generally follow the birthing person’s urges to push, and as long as you are comfortable in your efforts and there aren’t signs there is dilation yet still to do, you will lead the way. With good communication in the hospital, the nurses can help you ascertain the best time to start pushing so as to get the most bang for your buck, and not extend that pushing time unnecessarily.
Make sure to give Sharon’s article a read, and click the links I’ve posted here for more information. You don’t have to remember everything and become an encyclopedia of birth, just be informed and have a great doula who can help you strategize in the moment.