ACOG Guidance: Limit Interventions in Low-Risk Pregnancies
Marcia Frellick; January 26, 2017
According to an American College of Gynecologists (ACOG) committee opinion piece from the February issue of Obstetrics and Gynecology, less interventions may mean better care for women with low-risk pregnancies and who go into spontaneous labor at term.
The new recommendations offer obstetricians an opportunity to re-examine the necessity of certain established practices, such as delaying hospital admission until the patient is 5-6 cm dilated instead of the former 4 cm threshold. The recommendations also underline that emotional support in the early stages of labor, such as pain management through massage, water immersion and relaxation techniques used by one-on-one coaches or trained doulas are beneficial. These practices decrease the need for medical pain management, lead to shorter labor time and fewer operative deliveries according to data from randomized controlled trials.
Lead author of a 2013 Cochrane review -who found out that women who had support were significantly less likely to have caesarian sections- Tekoa L. King emphasized that an epidural, while it relieves pain, may not relieve the concurrent anxiety or suffering. A coping scale, instead of a standard pain scale is thus recommended for assessment of birthing mothers.
Frequent position changes are also encouraged unless they interfere with monitoring. Authors also recommended intermittent monitoring instead of continuous monitoring of fetal heart rate, championing the less-is-more approach for some uncomplicated pregnancies. Although, there are exceptions to the rule.
Although medically safe, IV fluids may be forgone in cases of women progressing naturally through stages of labor and have no complications. Oral hydration is sufficient.
The authors also emphasize that the previously heralded way of pushing, closed-glottis method (Valsalva maneuver), is no longer valid. A review of seven randomized controlled trials found out that open glottis effort in second stage of labor provided no significant difference in length of labor or in number of complications or outcomes. Thus all women should be encouraged to push the way they want to and the method that works for them.
Obstet Gynecol. 2017;129:e20-e28.