Fewer interventions may mean better care for women who have a low-risk pregnancy and go into spontaneous labor at term, according to a committee opinion from the American College of Obstetricians and Gynecologists (ACOG) published in the February issue of Obstetrics & Gynecology.
“Practitioners always put the best interests of moms and babies at the forefront of all their medical decision-making, but in many cases those interests will be served with only limited intervention or use of technology,” Committee Opinion author Jeffrey L. Ecker, MD, chief of the Obstetrics & Gynecology department at Massachusetts General Hospital in Boston, said in an ACOG press release.
“These new recommendations offer providers an opportunity to reexamine the necessity of obstetric practices that may have uncertain benefit among low-risk women. When appropriate, providers are encouraged to consider using low-intervention approaches that have been associated with healthy outcomes and may increase a woman’s satisfaction with her birth experience.”
For instance, when a woman is in the early stages of labor and maternal and fetal indicators are normal, delaying hospital admission until the patient is 5 to 6 cm dilated, instead of the previous threshold of 4 cm, may be a good option, the report says.
Women in latent labor with delayed admissions should engage in shared decisions with their provider and agree on a time to reassess, the committee says. It may also help to have an alternate space where the women can rest and get support before being admitted.
Emotional Support Beneficial
The recommendations also say that women benefit from emotional support of one-on-one trained coaches, such as doulas, and from managing pain with massage, water immersion (in the first stage of labor), or relaxation techniques, in addition to any drugs deemed necessary.
The benefits of emotional support include less need for pain medications, shorter labor, fewer operative deliveries, and higher patient satisfaction, according to data from randomized controlled trials.
For example, a 2013 Cochrane review found that a woman who had continuous support was significantly less likely to have a cesarean (relative risk [RR], 0.78; 95% confidence interval [CI], 0.67 – 0.91) or a newborn with a low 5-minute Apgar score (fixed-effect, RR, 0.69; 95% CI, 0.50 – 0.95).
“Techniques such as an epidural can relieve pain but may not ease anxiety or suffering,” lead author Tekoa L. King, CNM, MPH, said in a news release.
King was the American College of Nurse-Midwives’ liaison committee member who, with colleagues, wrote the opinion developed by ACOG’s Committee on Obstetric Practice. It was endorsed by both the American College of Nurse-Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses.
A coping scale for assessing status is also recommended, rather than a pain scale, because some women may not need or want the complete absence of pain, the guidance notes.
Frequent position changes by the mother can make mother and baby more comfortable and promote optimal fetal positioning, and that should be encouraged as long as the positions do not interfere with monitoring or cause complications, the authors say.
The less-is-sometimes-more guidance also covers fetal monitoring, with the authors recommending intermittent instead of continuous fetal heart rate monitoring for some uncomplicated pregnancies.
“[P]roviders 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,” they write.
However, “low-risk” is different for different interventions, and a woman, for instance, who requires oxytocin augmentation would not be a candidate for intermittent fetal heart rate monitoring and would need continuous monitoring, the authors explain.
Thy also conclude that women progressing in labor without complications may not need routine intravenous hydration, and that clear liquids by mouth may be sufficient.
Intravenous liquids are safe, but they constrict movement.
Push the Way You Want
Another aspect of the guidance involves pushing. In the United States, women are often told to push with a long, closed-glottis effort (Valsalva maneuver) with each contraction. But a review of seven randomized controlled trials that compared that method with pushing with an open glottis in the second stage of labor found no significant differences in the length of that stage of labor or in most complications or outcomes.
Given the limited data of benefit for Valsalva pushing, “each woman should be encouraged to use the technique that she prefers and is most effective for her,” the authors write.
The authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2017;129:e20-e28.