Obstetric care providers should attempt to limit labor and delivery interventions for "low-risk" term pregnancies, according to the American College of Obstetricians and Gynecologists (ACOG).
Expectant management instead of intervention -- such as immediate admission while in latent labor, and even admission after premature rupture of membranes -- should be considered for those low-risk patients whose labor is progressing normally, stated ACOG's committee on obstetric practice.
Instead, clinicians can use a variety of pharmacological and non-pharmacological techniques, including "frequent contact and support," to help patients cope with labor pain, authors wrote committee member , of Massachusetts General Hospital in Boston, and colleagues in .
"These new recommendations offer providers an opportunity to reexamine the necessity of obstetric practices that may have uncertain benefit among low-risk women," said Ecker in a statement. "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."
The committee opinion was authored by ACOG and endorsed by both the American College of Nurse-Midwives (ACNM) and the Association of Women's Health, Obstetric and Neonatal Nurses. "Low-risk" pregnancies were defined as a clinical scenario for which there is no demonstrable benefit for intervention.
Importantly, the authors noted that suggested the active onset of labor does not occur until 5-6 cm, leading the to support of active and latent labor, where "expectant management is reasonable" for women who are at 4-6 cm where the "maternal and fetal status are reassuring," they wrote.
The authors also cited that found women who were admitted only when they reached active labor were associated with lower rates of epidural use and augmentation of labor and less time in the labor and delivery unit, than women who were admitted immediately. Instead, the authors recommended an "alternative unit" for women in latent labor, where patients can rest and be offered support prior to admission.
Even premature rupture of membranes for a low-risk term pregnancy does not mean the patient should automatically be admitted and induced, the authors argued. They cited a that found expectant management was associated with decreased risk of chorioamnionitis, endometritis, and admission to a neonatal intensive care unit. But they also noted that "the optimal duration of expectant management that maximizes the chance of spontaneous labor while minimizing the risk of infection has not been determined."
Positive outcomes have been associated with one-on-one support to the patient. The authors said that a found one-on-one support linked with shortened labor, decreased need for pain medication, and fewer reports of patient "dissatisfaction" with labor. found that labor support techniques were associated with greater cervical dilation at the time of epidural and higher Apgar scores at 1 and 5 minutes. Employing doulas may even actually
"Providing emotional support and coping mechanisms have proven positive outcomes, therefore, it's recommended that providers consider instituting policies that allow for the integration of support personnel in the labor experience," said co-author , of the ACNM liaison committee in a statement. "This strategy may be beneficial for patients and cost effective for hospitals due to an association with lower cesarean rate."
Examining other interventions, the authors wrote that routine amniotomy for women with "normally progressing labor and no evidence of fetal compromise," and that " with hand-held Doppler devices (as opposed to continuous electronic fetal heart rate monitoring) for low-risk women.
Primary Source
Obstetrics and Gynecology
Committee on Obstetric Practice "Approaches to limit intervention during labor and birth" Obstet Gynecol 2017; Committee Opinion 687.