Could the Rules of Labor Be Changing?

As if pushing a tiny person out of a small part of your body weren’t task enough, mentally preparing for labor alone can also be quite a chore.

Recently, ACOG, short for the American College of Obstetricians and Gyecologists, issued some new guidelines and recommendations for labor, and it had a lot of soon-to-be-moms talking. Addressing issues like spontaneous pushing, inducing labor, eating and drinking during labor and more, it had some wondering if the rules were changing entirely. And although the rules aren’t totally being overhauled, there are some important things you should know if you’re headed into labor soon.

Here’s the link to the full article. But if you don’t feel like getting out your highlighter and Post-It’s, I hopped in and did a little leg work. I skimmed the release and sent some questions to our favorite OB-GYN and contributor, Dr. LaKrystal Warren from Contemporary Women’s Care, who was kind enough to answer some pointed questions about what’s really behind this latest missive.

I tried to keep the questions relevant to some of the biggest things that moms think about when they prepare for labor, which is food. Wait, is that just me? Okay, the question about eating during labor is there, but so are other questions about induction, fetal monitoring and pushing.

Pass the Pitocin and let’s get on it!

Dr. LaKrystal Warren, OB-GYN

1 – Do these recommendations mean fewer doctors will induce labor, either by stripping membranes or inducing with medication?

I don’t think that will change based on this document. In recent years, there has already been a push to avoid elective induction (meaning there is no medical indication and it is done by physician or patient request) and the majority of hospitals in the US are on board with this. We have to fill out a criteria sheet for every induction that we schedule with the hospital and if it doesn’t meet specific criteria, it isn’t scheduled.

Contrary to popular belief, doctors don’t run the show! We don’t schedule anything elective prior to 39 weeks because we know that is associated with higher NICU admission rates for babies. For elective inductions after 39 weeks, we need a reason–and patient discomfort is not a valid one!

Ideally, in the absence of any medical issues with mom or baby, we prefer spontaneous labor. If this has not occurred by 41 weeks, we typically schedule inductions. The latest that a patient can wait is 42 weeks, because waiting longer than this has been associated with poor fetal outcomes including fetal death. This is typically a decision made between provider and patient.

As far as stripping membranes, that is a physician preference and is sometimes performed as by patient request. In our practice, we don’t strip membranes because there is limited data supporting its effectiveness . I don’t think this document will change anyone’s practice.

2 – Do these new recommendations mean women can now eat and drink during labor?

Simply put, no! While the main concern is aspiration during general anesthesia (meaning food or drink is vomited and inhaled in the lungs, which can result in an ICU admission and lead to death), and general anesthesia (“going under”) is very rare on labor and delivery, there are other times where aspiration can occur. Many women vomit during labor and pushing and this still poses a risk for aspiration. The opinion still states that particulate and solid food should be avoided.

Some providers and hospitals may be more lax on liquids, especially in those patients that are not receiving IV fluids, but otherwise, I don’t think anything will change. It all sounds good to eat in labor, but who is really hungry, and who wants to see hot dog chunks in vomit on the floor? That has actually happened to me! [Sonni’s note: REASON A MILLION WHY I LOVE DR. WARREN.]

There is a concern about receiving nutrients and becoming dehydrated in labor, and that is why IV fluids are used. My practice does not require patients to receive IV fluids if they don’t want to be hooked up and they are allowed to have ice chips, sips of water, and popsicles. Our hospital has a policy that the patients must adhere to. The chance of becoming malnourished or dehydrated during labor is low unless there is a prolonged induction lasting days, and in those instances, we let people eat if they are not making progress.

3 – Will certain women now *not* have to be hooked up to fetal heart monitors during labor?

At our hospital and most hospitals, there is an intermittent monitoring policy and women that meet the criteria are able to do this. We have always known that continuous fetal monitoring doesn’t improve outcomes in low risk pregnancies; however, we are not willing to not monitor and risk a bad outcome that could have been prevented.

Some women in spontaneous labor that are low risk are candidates, but other women that have other medical problems (advanced maternal age, diabetes, hypertension) or are receiving medication for induction or augmentation are not candidates. It is important to note that there is not a one size fits all policy to any part of medicine and care for each patient has to be tailored.

4 – What do these new recommendations mean for how doctors will advise women during the “pushing” stage of labor?

These are not new recommendations and have been around for a long time. The physicians in my practice and I have been practicing this since residency. Many—[in fact] most—physicians do as well. We don’t always start pushing as soon as a patient hits 10 cm. We let patients “labor down” and start pushing when the head is lower and they feel the urge. This can take time, especially when a patient has an epidural.

Regarding techniques of pushing and different positions, we have long realized that each patient is different and we have to try different methods to achieve the desired result. For most experienced Obstetricians and Labor & Delivery nurses, the methods that we use work, and we will likely continue to use them, but will tailor to each patient if progress is not being made. Some women need more instruction than others and some women don’t get the idea of pushing. Also, a large number of women have an epidural (by choice) and cannot “feel,” so pushing the way that they are comfortable is not an option.

5 – How long does it typically take for doctors to implement new recommendations like this? Is it immediate?

Again, this is more of a position statement supporting commonly used practices so I don’t know that it will change the practice of many, however, it will likely make providers that already practice this way feel justified and encourage others to consider these methods of waiting and seeing instead of pushing to deliver in the appropriate patient.

A big round of applause for the only OB-GYN who can be so informative and make you laugh about puked-up hot dogs at the same time!

If you’re a woman in the greater Orlando area and in need of great care, I highly recommend checking out Dr. Warren’s practice. You can find more information here.

Any great or horrific birthing stories to tell? Leave ’em Comments below! You know I love a good story. 😉

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