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| 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
Full text of committee opinion can be found here
[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.
