New ACOG Recommendations You Should Bring with You to Your Next Prenatal Visit
Despite spending far more on maternity care, the United States has produced some of the worst maternal health outcomes among all other developed countries.
Currently, one in every three women has major abdominal surgery during birth and more than 40% of hospitals have mandatory surgery policies for women with prior cesareans, contrary to current evidence and national guidelines.
In addition, as many as 70% of pregnant folks experience interventions to start or speed up labor, recurrently without medical indication. These interventions are often unnecessary and unwanted, and research has shown no better outcomes for mothers or their newborns.
Outdated practice patterns are the name of the game in most labor and delivery units around the country, driven by liability concerns, financial concerns, and convenience.
So how do you know what kind of care you’ll receive? In the U.S., there is a vast range of maternity care practices—from the highest-quality care to the downright medieval. To make it even more confusing, “luxury care” doesn’t necessarily look that way: Some of the poshest hospitals, with the slickest ad campaigns, have some of the worst birth practices.
Asking your provider the right questions during prenatal visits is crucial and can be the difference between being happy and healthy or potentially traumatized after your birth.
The American College of Obstetricians and Gynecologists (ACOG) recently acknowledged some of these outdated practice patterns and has sought to address them with its latest Committee Opinion: Approaches to Limit Intervention During Labor and Birth.
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Here are six questions based on the new recommendations you should bring with you to your next prenatal visit.
No. 1: When should I come to the hospital during labor?
Your provider should be encouraging you to stay home as long as possible, potentially using the 4-1-1 guideline, which suggests that contractions are 4 minutes or less apart, lasting at least 1 minute consistently, for at least 1 hour. Most hospitals will admit you once you reach 3 centimeters, but ideally you would be in the active labor stage of 6 centimeters or more before being admitted, if you want a low intervention birth.
Research has found, and the new ACOG guidelines note, that if you’re admitted during early labor, you’re more likely to have interventions like Pitocin, intrauterine pressure catheters and a c-section.
For some, exposure to a hospital environment might even stall or stop their labor progression. (Adrenaline can slow labor, and it’s not uncommon to experience an adrenaline rush upon entering a hospital and laboring among strangers.)
Bottom line: The longer you can wait before heading to the hospital, the better. A doula’s support is the best option for staying home longer.
Note: If low intervention is not your goal and you don’t mind things like pain medication or fetal monitoring, do what is best for you. It’s important to understand the short and long term risks to you and your baby.
No. 2: If my water breaks before labor starts, how long can I wait before coming to the hospital?
If your water breaks you probably think it’s go time, right? Unless you have a medical reason to get to the hospital, you can wait it out at home.
ACOG found that 77-79 percent of women whose water breaks before labor go into labor within 12 hours, and for 90-95 percent of women, they start labor within 24 hours. And, even better, they found that there was no difference in outcomes for you or your baby if you waited for labor to start or had it started with pitocin.
Bottom line: If your provider is practicing by current guidelines, they should encourage you to stay home to wait for labor to start. If you go past 24 hours without labor starting, you can re-evaluate with your provider about the risks and benefits of waiting or intervening.
No. 3: What kind of fetal monitoring is expected?
Fetal monitoring has had the single greatest impact on the increase in cesarean rates than any other intervention, without improved outcomes for babies. Continuous fetal monitoring for low risk pregnancies is known to increase your risk of interventions and can lead to unnecessary c-sections with high false positive rates and misinterpreted fetal monitoring strips.
While evidence has long shown that continuous fetal monitoring for low risk pregnancies doesn’t improve outcomes, ACOG has come around and recommended that intermittent monitoring should be offered.
Bottom Line: Your provider and/or hospital should be offering intermittent monitoring. Moving around during labor has several benefits, and being all hooked up to monitors can impede the birth process. You can also choose no monitoring if you prefer.
No. 4: Will you break my water during labor?
Here’s another one where the research has been clear for years: breaking your water during labor has little benefit to you and in fact, increases risk. If someone breaks your water during labor, you have the increased chances of infection, having a malpositioned baby and other risks.
Bottom Line: It’s perfectly normal and best to labor without your water breaking. If your water breaks on its own, it’s important to avoid vaginal exams.
No. 5: What is your stance on eating and drinking during labor?
You know the drill: You check into the hospital in labor and you’re given an IV with fluids, and in some hospitals, still only allowed to eat ice chips. Childbirth is the equivalent to running a marathon, do ice chips seem like sufficient fuel for what is about to be an extremely physical and mentally taxing task?
ACOG has acknowledged the benefits of eating and drinking during labor — finally admitting it can keep a person strong and energized. They even say drinking during labor is preferable to IV hydration.
The Bottom Line: If you have a low-risk labor and aren’t using medication, you don’t need to have IV fluids. If you feel like drinking or eating during labor, do it! Try healthy beverages like coconut water, sports drinks, broth or juice.
No. 6: Will I be instructed on when to push?
“Congratulations! You’ve made it to 10 centimeters. It’s time to push!” Whoa, not so fast. Did you know that you might not feel the urge to push until the baby’s head moves further down into your vagina? Being 10 centimeters is not the only indicator that it’s time to push.
Based on research, ACOG’s new recommendation says people should push when they feel ready. These new recommendations can change the game – if providers are open to them. This article in Today’s Parent has more information on this subject, if you are interested.
Bottom Line: Pushing can be exhausting. Doing it prematurely can deplete energy so that when it’s actually time to push, you are already wiped out.
Before your next appointment, print out a copy of the latest Committee Opinion: Approaches to Limit Intervention During Labor and Birth. This will help you discuss these points with confidence.
If your provider’s answers contradict the recommendations, share the document with your provider and share that you would prefer to follow these new recommendations. Then confirm with your provider that they are willing to support you in that decision. This is assuming no medical indications arise.
Should our provider not be receptive to your preferences, it is a good idea to consider changing providers. This is not always possible for everyone but it’s sometimes easier than people think and we encourage you to seriously explore it. This is one of the most important days of your life and who attends you matters.
Bringing these questions up with your provider before labor can help you be better prepared. Have you discussed any of these new recommendations with your provider? What was their response? Please let us know how it goes.
All good questions – but the real question is, what is the HOSPITAL policy? It’s a rare OB practice indeed where parents see the same provider for their birth that they did for prenatal care. Plenty of individual OBs may profess to offer evidence-based, patient-centered care, but if the delivering parent has a different provider at the birth, or if the nursing staff are not empowered to support the family (especially when it comes to things like eating and drinking or intermittent fetal monitoring) then it hardly matters what the OB says at the first prenatal visit. I desperately wish hospitals were required to publicly share their most basic policies and procedures in addition to their C-section, episiotomy, and VBAC rates. (Pro tip: if the episiotomy rate is over 10%, run!)
What about suing all hospitals that do not comply with the latest scientific standards in their regulations?
Exciting! And a big relief.
Excellent article!! Thank you! Now we just need every CB educator to teach this.