New guidelines encourage fewer medical interventions in low-risk pregnancies

Labour is fraught with big decisions: when to go to the hospital, how to deal with pain and how to know if something isn’t quite right. If, by chance, something goes wrong, doctors are trained in interventions to keep you and your baby safe, but when you have a healthy, low-risk pregnancy, chances are that you and your body know best what to do. That’s the underlying message of a new committee opinion paper from the American Congress of Obstetrics and Gynecologists (ACOG).

The paper, which was released earlier this month, suggests that interventions such as induced labour and Caesarean sections should be prevented in low-risk pregnancies and that common obstetric practices that can lead to those interventions should be avoided unless necessary.

In particular, the paper advises against admitting low-risk women to the hospital during early stages of labour, artificially breaking their water or using continual heart rate monitoring for their fetuses—all of which can lead to women undergoing more interventions during labour. It encourages the OB/GYN or other obstetric care provider to carefully select and tailor labour interventions to the requirements and preferences of the woman in labour. For instance, it suggests that women should be able to move around to find labour positions that are most comfortable for them, drink fluids to avoid the need for an IV, push when and how they feel the urge, and choose whatever pain-management techniques suit them, whether that involves drugs or not.

“Many of ACOG’s [existing] guidelines are directed at complications or problems during pregnancy,” says Jeffrey Ecker, an obstetrician in Boston who is part of the ACOG committee behind the opinion paper. “We should recognize that pregnancy is generally a state of health without complications, so it seems appropriate to have a guideline directed at the majority. We recognize that it isn’t always about interventions and technologies.”

Though Ecker says many of the practices suggested in the paper have already been adopted by doctors, this document aims to emphasize that medical interventions aren’t always needed. In fact, some come with risks. For instance, when it comes to continuous fetal monitoring, research into the practice has shown that it isn’t significantly associated with any benefits for the baby in low-risk pregnancies but it is associated with an increased risk of Caesarean deliveries in some studies.

Another good reason to limit continuous fetal monitoring is patient comfort. When a woman is strapped to an electronic monitor that’s listening for the baby’s heartbeat or hooked up to an IV, there isn’t much room to move around. Under these guidelines, a woman with a healthy pregnancy could get up and get a drink of water, take a walk around for a welcome distraction or change positions to help relieve pain. “Using continuous monitoring and/or continuous IV fluids can limit mobility,” says Ecker. “But in the case of a healthy pregnancy, women may safely be out of their beds and out of their labour rooms during the course of their labour.”

George Carson, president of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and a Regina-based obstetrician with 40 years of experience, says that the new U.S. recommendations are quite similar to Canadian guidelines for healthy women that were released last September. “We’re moving from an era when doctors did things for patients to a time when doctors do things with patients,” says Carson. In addition to deferring to the woman’s preference when it comes to pain management and relying on her instincts when it comes to when and how to push, Canadian guidelines also recommend against admitting patients to hospital during early labour and performing routine amniotomy (forcing the water to break).

“Both Canadian and U.S. guidelines have recognized that the rate of progress in labour is perhaps a little slower than what we had thought,” says Carson, explaining why it’s often healthier for doctors to exercise patience during the early phase of labour. “We have a saying when we’re teaching labour management: ‘The most dangerous place for a woman who is not in labour to be is in a labour ward.’ Why? Because somebody’s going to mess with her and say ‘You’re not progressing fast enough.’”

Though the SOGC passes its guidelines on through education and meetings, Carson acknowledges that it can take a while to change the practices of care providers who have been relying on certain interventions for years. Despite the guidelines for healthy women, some care providers may still turn to the technologies to which they’ve become accustomed.

Katrina Kilroy, president of the Canadian Association of Midwives and a practising midwife for 26 years, says she still sees routine amniotomy, continuous fetal heart rate monitoring and instructions on when and how to push in Canadian hospitals. “There have been protocol changes and recommendations, but how that translates into practice is very different,” says Kilroy. She explains that, even though hospitals may make it their protocol to use periodic fetal heart monitoring during healthy labour, which is less restrictive to a woman’s movement, not all doctors follow protocol.

“We should aspire to have people involved in decision-making because, in my experience, it can lead to improved outcomes and improved levels of satisfaction,” she says. To ensure that things go the way you want during labour, she recommends asking your health care provider some key questions about the hospital’s protocol and routine practices surrounding interventions early on. There are a lot of things that can happen in a delivery room, but if you go in knowing that your doctor or midwife respects your opinions and will limit interventions unless needed, it can help make you feel better during a time when you have enough discomfort to worry about.

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