In My Humble Opinion…

bees

So, the world of birth is abuzz this month as ACOG (The American Congress of Obstetricians and Gynecologists) has released their newest Committee Opinion: “Approaches to Limit Interventions During Labor and Birth.”

This opinion might have left some scratching their head and saying, “Duh!” But I want to jump up and down squealing with joy! I think this is a fantastic step in the right direction from the OB/GYN leaders of America. They’re asking their members to consider: “If a pregnant Momma is low-risk, how can we keep her low-risk?”

The answer is: “Don’t intervene unless it’s medically necessary!”

I’m going to break down the recommendations and conclusions section of this Committee Opinion for you here, because there are lots of big, fancy words – and you might appreciate my attempt at a simpler translation. Also, we know that when information comes from people who wear white coats and carry stethoscopes around their necks, it sometimes carries more weight – even if we’ve already heard this same information from different sources. Just saying… In our culture, there’s a hierarchy when it comes to medical advice and opinion – evidence or bias, be damned!

So, this is not a perfect translation (and my editorial comments are included in italics) but in a nutshell here’s what the ACOG has stated in it’s Committee Opinion, Number 687 for February 2017: Approaches to Limit Interventions in Labor and Birth.

  • If a woman is between 39-41 weeks, and is in labor that’s started on its own, and has a baby that’s head down, the use of intermittent fetal monitoring and unmedicated comfort and coping techniques is a good idea. (Full-term according to ACOG. Intermittent – the fancy word that means there are breaks in between periods of monitoring.)
  • If a woman is still in early labor, she doesn’t have to come to the hospital right away as long as she and the baby are doing okay. It’d be great if she was offered frequent contact and support, as well as unmedicated comfort and coping techniques. (See what I wrote here, here and here (It’s a 3-part series!) about how to stay comfortable and pass the time of early labor at home before coming into the hospital.)
  • When women come into the hospital in early labor due to pain or exhaustion, they should be offered education and support, water to drink, encouraged to try various positions that might provide more comfort, and other unmedicated comfort and coping techniques like massage and how using the shower or sitting in warm water can be very helpful. (Hydrotherapy – the fancy word for drinking water, showering and/or sitting in the tub – are great ideas for comfort and can also help labor progress!)
  • OBs and other providers should inform those women whose water has broken at the onset of labor about any risks associated with waiting for labor to start on its own. If there are no other reasons to be concerned for the baby’s health, an informed woman can choose, and should be supported in her choice, to wait for labor to start on it’s own. The exception would be if a woman has tested positive for Group B Strep – antibiotics shouldn’t be delayed, and there may be a preference from both the provider and laboring woman to induce labor immediately, rather than wait for it to start on its own. (Many providers already use “expectant management of labor” – the fancy word for “watching and waiting,” but more providers might now be encouraged to wait before inducing immediately if water breaks at the start of labor.)
  • Evidence suggests that in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor. (YAY DOULAS! And partners, and Grandmas, and BFFs and… DOULAS! You can read my post here about how a doula can be a great addition to your birth team.)
  • For women with a labor that’s progressing and a baby that’s doing well, routine breaking of the bag of waters is not necessary unless needed for internal monitoring. (Amniotomy – the fancy word for breaking the bag of waters before it has broken on its own – is often suggested as a way to “speed things up” but can be associated with more interventions and increased risk for Cesarean Birth if it doesn’t work.)
  • In order to promote intermittent monitoring, hospitals should adopt protocols and train staff on how to use hand-held Doppler monitors for low-risk women who would prefer this type of monitoring. (This one even surprised me! I thought they would suggest using the external monitoring belts less frequently, but hand-held Dopplers would be a fantastic improvement over current practice. So much easier and comfortable for laboring Mommas!)
  • Using a coping scale and the use of medicated and unmedicated coping techniques will help providers tailor interventions to meet the needs of each woman. (Some hospitals have already adopted the use of a coping scale instead of a pain scale, but this little tool can be very helpful in changing the mindset of a laboring woman from focusing on the level of pain she’s feeling to whether or not she’s coping well.)
figure-1-the-pain-intensity-scale-0-to-10-adapted-from-wong-baker-faces-pain-rating

Figure 1. The Pain Intensity Scale: 0 to 10. Adapted from “Wong-Baker Faces Pain Rating Scale”

coping

Figure 2. The Pain Coping Scale: 10 to 0, developed to assess coping during labor and birth. Adapted from “Wong-Baker Faces Pain Rating Scale”

  • As long as there are no complications and fetal monitoring is still possible, a woman should be encouraged and supported to change positions often during labor – it will make her feel more comfortable and will help move the baby into the best position for birth. (Being upright and changing positions as often as possible, for as long as possible, allows babies to make all the twists and turns necessary to be born.)
  • Women should be encouraged to use whatever kind of pushing technique she likes and is most effective. (Gone are the days of telling women to assume certain positions and hold their breath for ten seconds! Yeehah!)
  • Unless it’s medically necessary to deliver quickly, women (especially those with an epidural) can be offered a period of rest before pushing – unless she feels a strong urge to push sooner. (“Laboring down” is a really nice way to allow your body to catch up with your labor. Your contractions might have already opened your cervix all the way, but until your baby moves down into a better position for birth, pushing just because “You’re 10 cm dilated – let’s go!” might not be as effective and could lengthen the overall time of pushing, causing undue exhaustion.)

Can you see why I’m so excited about this Committee Opinion?! It aligns so beautifully with what I know to be true for women in labor. Interventions are not “bad” and can be life-saving in certain circumstances.

But if we limit the routine use of these interventions and only use them when medically necessary, we are protecting the normal physiology of birth. And this will result in better outcomes for Mommas and babies.

I am so heartened by this statement from the ACOG and excited to see the impact this will have for laboring women and birth in this country. My sincere hope is that members of ACOG will review their own personal practice based on this Committee Opinion and see where they might step back from intervening too soon or too often. I also hope that pregnant women will read this and know that they should talk with their provider about limiting the use of intervention in their own pregnancy and birth.

Knowledge is power. Be informed.

(You can access the entire ACOG Committee Opinion here in all of its medical terminology, further explanation and extensively cited form. It’s a great read, in my humble opinion…)

Rethinking Early Labor Series: PART III

Re-Think IIIn my last two posts, I discussed how laboring women and their partners are being encouraged to stay at home and away from the hospital for most, if not all, of their early labor. But the definition of early labor has changed. It is now believed that a woman is still in early labor until she reaches about 6 cm dilation. This means most women will be at home working for longer periods of time through the early phase of labor. It’s not enough to encourage women to stay home. We also need to provide some ideas about how to stay home and continue to cope with contractions of early labor without anxiety settling in. This is the final post in my three-part series, “Top 10 Things to Consider in Early Labor.” Here are the last 5 ideas from that list.

6) Clear your day. If either of you had been planning on being at work the morning that labor begins, call in and let one trusted person know that you might be in early labor. Ask them please to not tell the entire office your news as it might prove to be super early labor, or maybe just a good bout of practice labor  – and you don’t want to have to field a ton of phone calls, emails or texts from your excited co-workers.

7) Plan a date. This is the one thing that I get the most heat for encouraging people to consider, but I swear it helps you get your mind in the right place for the start of your labor experience. Most first-time Mommas have loads of time between when labor begins and when they reach active labor. And if you have something to look forward to as labor begins, you’re more likely to enter into early labor with a more positive attitude. This can definitely impact how well you’re able to handle your early labor. This labor day date doesn’t have to be anything special, but there should be some actual direction to it, a potential theme. I’m not sure it’s enough to say, “We’re going to watch a bunch of movies” or “We’re going to play board games.” Which movies do you want to watch? (Make sure they’re pretty emotionally charged – those that are can help boost your oxytocin levels by up to 47%!) Get out the board games and lay down a challenge. Card games that can go on forever are really great because they can be left hanging if your labor should pick up speed. If the weather is nice, plan a picnic lunch. If it’s not, picnic on your living room floor. Go for a walk – just make sure that you pass by your car every 1/4 mile or so in case labor changes dramatically. You don’t want to have to walk 5 miles back to your car with really challenging contractions if labor moves from early into the active phase while you’re out and about. This date should be focused on distraction and enjoyment. This is the last time you’ll be able to go out as a twosome without the baby or without paying for a babysitter. Don’t waste this opportunity. 

8) Consider hiring a doula. (This actually could have been #1 on my list of things to consider if I were rating them, but I wrote this list more chronologically in terms of what to consider as labor progresses.) Having a doula who is yours and yours alone ready to take your phone calls or texts in early labor or even stop by your house to check in with you can really make a difference in your continued ability to progress in early labor at home and away from the hospital. A doula’s expertise about what labor looks, sounds and feels like for most women will mean that she can normalize what you’re experiencing. She can also suggest comfort measures that can help you continue to cope and remain comfortable in your home for longer. When I’ve asked new parents from my classes what advice they would offer to expectant couples, they usually say, “Tell them to stay at home for as long as possible!” Having a doula to check in with might allow you to do just that. And doulas only get better as labor progresses! If a doula is not possible for any reason, who else can you check in with during this long and sometimes frustrating early phase of labor? What does your provider have to say about contacting them in early labor? If you contact the hospital looking for guidance they will often either refer you back to your individual provider – or tell you to come in to be checked. This defeats the entire purpose of trying to stay home in early labor. An unnecessary trip into the hospital is a real bummer and can start you down a path you might be trying to avoid. Do you have a friend or family member that’s given birth before that you might be able to touch base with for reassurance that you’re moving in the right direction even if it feels long and slow-going? Enlist their help to be that touchstone for either you or your partner during this early part of labor. Remember, reassurance is key during this early phase.

9) Use those comfort and coping techniques that you learned about in an evidence-based childbirth preparation class.  Initially, you might find that focused and intentional breathing are all that you need to get through the peaks of contractions. But don’t forget to think about using different positions, sitting on the birth ball, getting into the shower, vocalizing, looking at a focal point, enjoying lots of massages, using rhythmic movements and getting plenty of encouragement from your birth team members as ways to help you continue to move through your early phase of labor and into the more active phase. Understand that you will need to do some of the hard work of labor before any medication will be a realistic option for you. Pay attention to this section during your classes, even if you are “planning on the epidural.” You’ll need to use some of these techniques at the end of early labor while you’re still at home, for sure while you’re making your way into the hospital and definitely when you first arrive as you move into active labor.

10) Wait until your contraction pattern gets to at least 5-1-1, maybe even 4-1-1, before you head into the hospital. What does this mean? You want to wait until you have a labor pattern where contractions are 5 or 4 minutes apart when measured from the beginning of one contraction to the beginning of the next contraction, each individual contraction is 1 minute long, and this has been happening for at least 1 hour. In addition to this, your contractions should be strong enough that during the peak of each one, you are unable to walk, talk or smile. You are all business and your full concentration is on getting through each contraction. When this is the case, you’ll be working hard and that means that you’re moving through early labor and into active labor. This is the perfect time to come to the hospital or birthing center as any distractions there will have less power to negatively impact your labor progress.

How long will all of this take – this early labor? For most women, it will be the bulk of their labor overall. If you had a 24 hour labor, you could expect  maybe16 hours of it to be in early labor! For the majority of women, they should expect to be laboring at home for about 2/3 of their overall labor. (This is, of course, based on averages of labor and your situation would be contingent on so many different things that makes this just an example. You could be at home shorter or longer than this and all would be in the realm of “normal.”)

I feel very strongly that it’s not enough to encourage women to “stay at home as long as possible” without providing some real tools about how to do just that. We have been fed a cultural construct about birth that makes it seem impossible that we could be in early labor walking around the neighborhood, going out for a bite to eat – passing the time of these short and do-able contractions without it being a huge, dramatic experience. Women need to have more confidence in their bodies and their ability to judge for themselves whether or not they are in labor. Too often they feel they need to have someone else tell them they’re in early labor for it to be “official.”

Coming to the hospital and being told to go home can be devastating for a woman, not just because it’s an unnecessary and uncomfortable car ride, but because it makes her second guess her ability to make the call and determine what “real labor” looks like. Providing women with the “Top 10 Things To Consider In Early Labor” is my contribution to helping women feel like they can cope with early labor and feel prepared to stay home as long as possible to progress in their labor and reduce their risk for unnecessary interventions, medications and Cesarean Birth.

I’ve never had a woman come through my class saying, “I can’t wait for all those interventions – bring ‘em on!” Most are wanting to avoid all of them if possible. Waiting through the early phase of labor before coming to the hospital or birthing center is an great way to start their individual birth story.

How can we, as Childbirth Educators and new parents get the word out about rethinking early labor? What other practical ideas do you think should be added to my “Top 10 Things to Consider in Early Labor?” I’d love to offer as many tips as possible for my expectant families, please feel free to share your own ideas in the comments.

Rethinking Early Labor Series: PART II

 Re-Think III

In my last post, I identified that laboring women and their partners are being encouraged to stay at home and away from the hospital in early labor. But the definition of early labor has changed. It’s now widely believed that a laboring woman needs to get to about 6 cm dilation before active labor has begun. With this change in definition comes a longer amount of time working through contractions at home in early labor. In my opinion, it’s not enough to just encourage women to stay at home for longer periods of time. They need some concrete ideas on how to normalize early labor and pass the time together without added anxiety. To that end, I offer my “Top 10 Things to Consider in Early Labor.” For this post, I’ve listed the first 5 things to consider.

1) If labor contractions wake you from sleep, stay in bed. If these contractions are real-deal, then you won’t really be able to sleep through them, maybe more like rest. But once you realize that you can comfortably have a contraction while lying down, then you should do just that. The bigger question is, do you wake your sleeping partner yet? Some women will say, “Absolutely!” and others will say,”No way!” Check in with your partner to make sure that if they’re wanting to be awakened at the first sign of labor that you honor those wishes. Just make sure that they’re on board with the “stay in bed” regimen first. No need to get up and bust a move until your body requires you to do so.

2) Get busy. Yep, that’s exactly what I’m talking about. A little nipple stimulation, or better yet, great sex can have fantastic results in helping your body continue to move forward in labor. I say great sex, because it’s the combined efforts of prostaglandins found in semen acting to ripen your cervix plus the release of oxytocin when you orgasm that can contribute positively to getting the party started. As long as your water hasn’t broken, there should be no concern in using this technique to help move things along. What a great, connected way to begin labor together! Plus – it might be a while on the other side of baby’s arrival before you’ll be ready to go there again, so you should definitely take advantage while you can!

3) Once you’ve gotten out of bed, drink a big glass of water and go pee. These three things – changing position, drinking a big glass of water and peeing – will give you needed information about whether or not this is the start of early labor or just your irritable uterus talking. Real-deal contractions will continue no matter what position you’re in and if you change the status of your bladder (which, so conveniently sits beneath your uterus) it can help you figure out whether or not this is the start of early labor. If after changing position, drinking a big glass of water and peeing you’re still having contractions that seem fairly regular, you could choose to check in with your provider and let them know you think you might be in the early phase of labor. You could always wait to check in too, but sometimes touching base with your provider helps calm any nerves you might have as labor is just beginning.

4) Eat something. I don’t care what it is and, really, neither should you. At this point in your labor, eat whatever sounds good to you and something that you wouldn’t mind seeing again later in labor (if you get my meaning). Nothing super heavy or spicy or greasy – but other than that, fuel your body. It will be doing a lot of hard work today and you want to make sure it has what it needs to help you get through. Eating in labor should never be denied to you, but it’s important to note that many hospitals have a clear liquids only policy when a woman is laboring in the hospital. One more reason to stay at home when things are just getting started. It’s super challenging to try and give birth to a baby when you’re starving! Eat at home until your body tells you, “No more food, thank you – I’m all done.” This usually won’t happen until you’re farther along in active labor.

5) Take a shower and get ready for the day. Most of us would like to head in to this experience of giving birth looking and feeling as good as possible. So at the very least, a shower is a great way to start. Some women will go into this experience au natural, and others will want to have their hair and makeup done before the harder work of labor begins. I’ve even known some women who’ve had their partners give them a little mani-pedi to help pass the time (often with hilarious results!) There’s no right or wrong to this one. It’s most important that you feel good about yourself as labor is just beginning. Also, any amount of time a you take to get yourself together while contractions are still manageable allows time to pass more quickly – always a plus.

These are only the first 5 on my list of “Top 10 Things to Consider in Early Labor.”

As you can see, they focus on the practical.

I believe much of the rush into the hospital happens as a result of what women are fed about birth from seeing it portrayed on TV and movies from when they were just little girls. It’s hard to get your head wrapped around the idea that birth is normal. That for most women, it starts out slow and stays at a slow and steady pace for a good, long while. It’s hard for a pregnant woman to imagine that she might actually maintain normal activities for most of her early labor. It’s hard for her partner to let go of the idea that they won’t be racing into the hospital at break-neck speed!

But there are real reasons to encourage laboring Mommas to stay at home for as long as possible in early labor: they’ll feel more comfortable in their own homes, wearing their own clothes, eating their own food, stepping in and out of their own shower… If we can normalize and recreate a picture of early labor as something do-able for most women and provide some thoughts on how to help pass the time of early labor at home with as little anxiety as possible, then she can move through early labor feeling confident. Confident in her ability to recognize when she should be heading into the hospital, and confident in knowing that she’s lowered her risk of unnecessary interventions, medications and Cesarean Birth.

My next post will be about the remaining 5 on my list of “Top 10 things to Consider in Early Labor.”

Rethinking Early Labor Series: PART I

Re-Think I

In doing some research for my book, just recently I read an article entitled, “What is women’s experience of being at home in early labour?” This article cites that there were four main reasons women came into the hospital “too soon” despite knowing that there was no need to arrive before active labor was well established: Reassurance, Uncertainty, Pressure from Others, and Permission. This article made me want to write a blog post (which has now ended up being a 3-part series!) about re-thinking early labor. I’m interested in how we, as Childbirth Educators, can do a better job at preparing our couples for the realities of early labor. Later in the series I offer concrete things to consider in helping women and their partners pass the time of early labor and stay at home longer. This is one of the most effective ways to avoid unnecessary interventions, medications and Cesarean Birth. 

First, a definition: Early labor, also known as the “latent phase” is so named because you’re not yet in active labor. This phase is most commonly the longest part of a woman’s labor experience and can easily take up 2/3 of the entire process over all. For over 60 years, we used Friedman’s Curve to describe early labor as moving from 0 cm dilation to 4 cm dilation. In very recent history, this curve has been under increased scrutiny and it’s now more widely believed that active labor does not really begin until a woman has reached 6 cm dilation.

This distinction between onset of active labor changing from 4 cm to 6 cm dilation is important. What this small shift in definition implies for today’s providers is that they should be willing to wait awhile before making the proclamation that a laboring woman who is taking longer to dilate has “failure to progress.” Hopefully this will translate to a more “wait and see” approach rather than moving too quickly to medications, interventions or surgery for the delivery of her baby.

But the implications for today’s laboring Mommas is also significant because this means that she will likely be working longer and harder at home in the early phase of labor before coming into the hospital.

As a Childbirth Educator, I have the specific challenge of encouraging the students in my classes to stay at home for potentially much longer periods of time when they (or their partners) might have great anxiety about doing this. How do we help a woman increase her chances of avoiding unnecessary interventions, medication and Cesarean Birth, but also address the level of anxiety that she (or her partner) might feel about continuing to cope through early labor at home?

First, reassuring every woman that her body is amazing and completely capable of giving birth to her baby should be a top priority. Too many of today’s pregnant women lack that celebration of their bodies and instead of feeling beautiful, strong and capable – they often feel insecure, disconnected and unsure of themselves. First time Mommas especially tend to feel like everything that happens to their bodies while pregnant is so foreign and strange that it’s hard to believe that any of it is normal. Any amount of information we can provide a woman about her body that reinforces how she is exquisitely made for the process of giving birth should be addressed early on in our classes.

The normal progression of labor should be presented in a way that boosts a woman’s confidence. Great care should be taken to explain what early labor really looks, sounds and feels like for the majority of women so they can begin to release the cultural construct that says labor is unbearable from start to finish. Women need help realizing that the depiction of birth they see repeated over and over again in movies and TV shows is done purely for dramatic or comedic effect. In reality, most first time Mommas can expect a slow and steady marathon pace of labor rather than a mad dash to the finish line. This information can help them realize that when early labor begins (after their initial moment of freak-out) they should settle in for what will most likely be a long wait until it’s time to come to the hospital or birth center.

Okay – so, maybe they’ve bought into this idea of waiting until their contractions get to a pattern of 5-1-1, or even 4-1-1, before making the move toward the hospital or birth center. They’ve read the articles that tell them that their chances of having unnecessary interventions and medications go up if they come to the hospital too soon. They don’t want to come in only to be sent home again. They get it.

But how do they manage to stay at home when labor drags on and on? If their water hasn’t broken yet (and for the majority of women this will be the case. Their water won’t break until they’re in active labor or actually pushing their baby out), how will a woman know definitively that she’s in labor and then feel like she has what she needs to pass the time of early labor at home? How can she do this in a way that progresses her labor and doesn’t make her crazy with anxiety? 

That’s where Childbirth Educators come in – we have to convince Mommas, and their partners, that it makes sense for them to stay at home for all, or at least, the majority of their early phase of labor. But – we have to provide them with real and concrete ways to do this.

In my next post, I will share with you the first five ways we can do that from my “Top 10 Things to Consider in Early Labor”.