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Monday Feb 27, 2017

ACOG Confirms What FPs Know: Most Births Need Little Intervention

The American College of Obstetricians and Gynecologists (ACOG) recently confirmed what family physicians have known for years: Most deliveries are low-risk and progress just fine with minimal intervention.

In its February 2017 Committee Opinion (No. 687), "Approaches to Limit Intervention During Labor and Birth(www.acog.org)," ACOG reaffirmed techniques I have used since residency. (For some perspective, I completed my training the same year President Reagan started his second term, Microsoft launched Windows 1.0, and Michael J. Fox went Back to the Future.)

Specifically, ACOG said "many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor."

Providing maternity care adds to my joy of practice (despite frequently calling me out of the house in the middle of the night). Patients come to me for a "natural" experience, and I am happy to oblige them. It's good to know that what I have been doing for decades is backed by evidence. Here are some highlights from ACOG's report, along with my two cents:

  • Admission to labor and delivery can be delayed for women in latent labor when the statuses of both the mother and the fetus are reassuring, including after prelabor rupture of membranes. I have always encouraged walking and being in a comfortable place, including water immersion in a bathtub, during the latent phase. 
  • Nonpharmacologic pain relief methods should be encouraged. I suggest massage, self-hypnosis and having a doula. Acupuncture, aromatherapy and audioanalgesia are also effective.  
  • Evidence does not support immediate induction of labor for women with prelabor rupture of membranes.  
  • Routine amniotomy does little to hasten delivery, and patient satisfaction can be improved by not rupturing membranes.  
  • Continuous electronic fetal heart monitoring isn't necessary, either, and my patients enjoy the freedom intermittent monitoring provides them. 
  • Running IV fluids throughout normal labor is also unnecessary, and it ties down the mom. I usually request IV access, but I don't run fluids.  
  • A recent meta-analysis showed that upright versus supine position shortened the first stage of labor by more than an hour! My patients spend a lot of time standing, walking and in a chair and try to avoid the bed until actual time of delivery.
  • For pushing, it doesn't seem to matter if the mother uses the "open glottis" or Valsalva technique, and she should be encouraged to do what seems most natural for her.   
  • If the patient has an epidural, delayed pushing or "laboring down" should be encouraged before pushing. Use of upright pushing or using a squat bar may hasten the second stage.

ACOG's report offers the latest advice we can follow regarding low-risk deliveries, but there are other recent publications, too. The American Society of Anesthesiologists updated its Practice Guidelines for Obstetric Anesthesia(anesthesiology.pubs.asahq.org) last year. That document supported clear liquid intake, including water and soup broth but not solids, for normal laboring patients when C-section is not anticipated.  

Finally, I would point out that my patients enjoy immediately having their newborns placed on their chest so they can breastfeed and delay clamping the cord. Moms then have time to bond with their babies before measurements are taken or eye drops are administered. I learned this approach in the AAFP's Advanced Life Support in Obstetrics course, and it highlights the fact that patient satisfaction and safety can go hand in hand and add to an enjoyable practice.

Family physicians have practiced evidence-based, natural childbirth for years. Thanks, ACOG, for the vote of support.

Robert Raspa, M.D., is a member of the AAFP Board of Directors.

Posted at 02:30PM Feb 27, 2017 by Robert Raspa, M.D.

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