The game-changing new guidelines from ACOG

The birth world has been a buzz about the newly released consensus statement on preventing primary cesareans from ACOG (American College of Obstetricians and Gynecologists) this week. And rightfully so. This statement includes things that the scientific evidence has been supporting for some time now, but that have not been widely practiced by maternity care providers. Some of the new recommended guidelines in the Safe Prevention of Primary Cesarean Delivery statement, and what I believe are the biggest game changers include:

• Slow but progressive labor in the first stage of labor should not be an indication for cesarean.
  For nearly 60 years, maternity care providers have used a graph, known as the Friedman's Curve, published by Dr. Friedman of Columbia University to define a “normal” length and pace of labor. The Friedman's Curve is based on a study about the average amount of time it took laboring women to dilate and has been used to govern how providers manage a woman's labor. It is now recommended that the Constium on Safe Labor should be the new standard of managing labor. In short, this means that evidence is suggesting that laboring women don't always, or even often follow Friedman's Curve and should be given more time before performing a cesarean for “failure to progress.” Rebecca Dekker of Evidence Based Birth has put out a a great article, “Friedman's Curve and Failure to Progress: A Leading Cause of Unplanned C-Sections.”
  
  
• Adverse neonatal outcomes have not been associated with the duration of the second stage of labor.
  The second stage of labor is the pushing stage. It has previously been advised that first-time moms be given up to 3 hours to push their babies out and a multiparous woman (a mom who has already given birth before) be given 2 hours and to add an hour onto both of those numbers if the mom has an epidural in place. The evidence has not shown however, that longer pushing phases are affecting babies negatively. There is also discussion about whether the second stage begins simply at full dilation or once the mother begins to feel the natural urge to bear down. There also needs to be discussion about positioning during pushing.
  
  
• Instrument delivery can reduce the need for cesarean.
  There are concerns that many obstetric residents do not feel competent in doing a forceps delivery. Yes! More training and better training on the use of forceps can and will save many moms from going under the knife.
  
  
• Recurrent variable fetal heart decelerations appear to be a physiologic response to repetitive compressions of the umbilical cord and are not pathologic.
  There is a discussion of fetal heart-rate patterns and solutions other than cesarean. My opinion: maybe we shouldn't be continuously monitoring healthy, low-risk women. Read more about Evidence-Based Fetal Monitoring and Intermittent versus continuous electronic monitoring in labour.
  
  
• Induction of labor increases the risk of cesarean.
• Unnecessary induction of labor increases risk of cesarean section and other complications. Inductions should not be done prior to 41 weeks gestation without medical indication. (The previous recommendation was 39 weeks). There are also new guidelines about when induction should be considered a failure. Some babies need a bit more time on the inside than others and that's OK. Everybody knows that children develop at different rates. Two of my kids walked at 11 months old and one didn't walk until 14 months old. It was no big deal. Babies also develop at different rates in the womb. We need to stop forcing them out before they are ready. 
  
  
• Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.
  Macrosomia is the medical term for a big baby. Those who know me, know that I am a big believer that your body will not grow a baby too big for it to birth. Ultrasounds in late pregnancy are not a good indicator of baby's size. And even if they were, cesareans should not automatically be done just because the baby is big. Your body grew it, your body can birth it.
  
  
• Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate.
  A Chochrane Review published in 2012 by Hodnett and colleagues states that when continuous labor support is provided by a doula, a woman experiences a 28% decrease in the risk of cesarean. Improving Birth's fact sheet titled Doulas and Healthcare Providers: Working Together for Better Maternal and Infant Outcomes lists other benefits of doula support. And Rebecca Dekker of Evidence Based Birth has an article about the the medical evidence of a doula's presence titled What is the Evidence for Doulas?
  
  

These new guidelines offer great hope for lower cesarean rates and safer births for both mother and baby. But, it will be a big challenge to change the culture surrounding birth and obstetrician's attitudes about labor management. History has shown us that once new guidelines have been posted, it takes anywhere from 10-20 years before they are widely practiced. I don't want to wait that long. I'm afraid to wait that long. Our cesarean rate has been increasing steadily. Our maternal mortality rate has doubled in the last 25 years. We are ranked very low among developed nations in infant mortality and morbidity, yet we spend an obscene amount of money on maternity care...the most in the world.

We need these changes to happen soon. How can maternity care consumers facilitate these changes?

• Hire a doula. If I am unavailable or not the right doula for you, the Omaha Doulas Association has many lovely doulas.
• Have a discussion with your provider about things such as their cesarean rate, their induction rate (and reasons for performing both of them), their practices of labor management (do they expect their patients to follow the Friedman's Curve?), their practices during the second (pushing) stage of labor, their competency in the use of forceps, their policy about continuous electronic fetal monitoring, etc. The Coalition for Improving Maternity Services has put out a great list of 10 Questions to Ask your provider. 
  
• Stop giving your business and money to providers that are unwilling to practice evidence based maternity care. There are providers in the area that practice evidence based care. If you change providers because of their practices, write them a letter to let them know why you've left. 
  
• Own your birth. Realize that you are ultimately in charge of your birth. Your doctor/midwife is an educated consultant for your care. Your doctor/midwife and the hospital staff work for you. You are the boss. This is your body, your baby and your birth. With that ownership comes responsibility. Educate yourself. Research. Take a good quality private childbirth education class. Learn your rights as a patient and consumer of maternity care. Advocate for yourself and your baby.