Are we back to the basics again? ACOG issues directive for minimum intervention in labor and delivery in low risk patients!

labor management 

ACOG today issued recommendation for an “hands-off” approach for management of labor and delivery in low risk women for optimal maternal and neonatal outcome.  Basically, it is like allowing nature to take its own time and not intervene to speed up the process in selected group of patients.[1]

The committee opinion was also endorsed by American College of Nurse-Midwives (ACNM) and the Association of Women’s Health, Obstetric and Neonatal Nurses.

Jeffrey L. Ecker, M.D., chief of the Obstetrics & Gynecology department at Massachusetts General Hospital and Committee Opinion author said “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.”

He also said that these recommendations provide the obstetricians an opportunity to reconsider some of the obstetrics practices that may not have documented benefits in low risk women.

Although each patient is different and what constitutes a ‘low risk’ will have to be assessed individually for each patient but, generally speaking a woman with uneventful prenatal period, presenting at term, in spontaneous labor with vertex presentation with no associated medical condition can be considered as low risk. 

The recommendations are:

Latent labor:

Those women in latent phase with reassuring fetal and maternal status should not be admitted to the labor room. Observational studies have shown that admission in latent phase increases chances of arrest in active phase resulting in more C-sections. Previously 4 cm dilatation was threshold for going into active labor, recently data from Consortium for Safe Labor found out that many women do not go into active labor before 5-6 cm dilatation.

These women benefit from education, one on one support, oral hydration and non-pharmacologic technique of pain management.  Involving trained labor coaches as doulas have shown to bring down operative intervention and improve labor outcome.

Be patient in latent phase 

Term Premature Rupture of Membranes:

Women who have term Premature Rupture of Membranes should be assessed by the team and sketch out a plan for expectant management if maternal and fetal status is reassuring. A recent Cochrane review concluded that expectant management vs. active induction of labor does not have very different outcomes in terms of neonatal infection and cesarean section and the women should have all the information to make a choice. These women should be assessed for group B streptococci status and started prophylactic antibiotic and immediate induction as per patient and obstetrician preferences.

Studies have shown that approximately 80% of women will go into labor spontaneously within 12 hours, and 95% will start labor spontaneously within 24–28 hours of term PROM.[2]

However, the optimal window for expectant management that balances the chances of spontaneous vaginal delivery with minimum infection is not yet known.

Amniotomy:

Women who are progressing normally should not undergo routine amniotomy unless it is for fetal monitoring. It has not been shown to accelerate labor according to Cochrane review.

Continuous Fetal Monitoring:

 Use of Electronic fetal heart rate monitoring(EFM) is widespread across countries and mainly used to bring down perinatal mortality and rates of cerebral palsy.  It has however failed to show any benefits in these low risk women, and infact Cochrane meta-analysis of RCTs linked it to increase rates of C-sections. ACOG suggests the use of simple hand held Doppler for fetal monitoring in low risk women.

Coping with labor pain:

Not much data is available on non-pharmacological pain relieving techniques. These agents and technique help women cope with pain instead of actually relieving it. None of them have shown to have any adverse effect on labor outcomes. Water immersion during first stage have helped women to lower pain. Many other options are available and women should be always be offered pharmacological pain relievers if she chooses them.

Oral intake and hydration:

Oral hydration facilitates freedom of movements and can be used instead of intravenous fluids. Clear fluids are preferred over particulate or solid foods.

Maternal position in labor:

No single maternal positon can be advocated to be best in labor. Women frequently change positions during labor and can assume any positon that lends itself to fetal and maternal monitoring. Studies and reviews have shown that upright or lateral position shortens labor and have less incidences of abnormal fetal tracing as compared to supine position. 

Pushing techniques in second stage:

Women when not taught to push down with closed glottis effort (ie, Valsalva maneuver) often push with the open glottis technique. Cochrane reviews and other studies report variable results with this two pushing techniques when it comes to duration of second stage. In view of limited long term data, ACOG recommends to go by women’s preference and what is effective for her.

Nulliparous women with epidural analgesia may be offered a period of rest of 1-2 hours before the active phase of maternal pushing is initiated, unless she has the urge to push down before that. According to a meta-analysis by Brancato RM et al rest for 1-2 hours at 10 cm dilatation allows for spontaneous rotation and descent of the fetus.[3] It is also reported to decrease instrumental vaginal deliveries and decrease pushing time. 

Full text of committee opinion can be found here

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[1] http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth#51

[2] Grant JM, Serle E, Mahmood T, Sarmandal P, Conway DI. Management of prelabour rupture of the membranes in term primigravidae: report of a randomized prospective trial. Br J Obstet Gynaecol 1992;99:557–62.

[3] Brancato RM, Church S, Stone PW. A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor. J Obstet Gynecol Neonatal Nurs 2008;37:4–12.