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New Recommendations Say Labor Should Begin Naturally—When Will Medical Practice Change?

Posted by on Jun. 24, 2013 at 8:14 AM
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1 mom liked this

New Recommendations Say Labor Should Begin Naturally—When Will Medical Practice Change?

A recent blog post on the American Congress of Obstetrics and Gynecology’s (ACOG) website gave me such pause I had to inquire about its validity on Facebook. The language seemed like such a departure from ACOG’s positions and rhetoric that at first I believed it was a hoax—someone posing as ACOG’s president and releasing statements that contradict their ideology. Quickly, though, it was proven that the statement is indeed from ACOG President James T. Breeden. The post, headlined “With Delivery Times, Defer to Mother Nature,” outlines what seems like a radical new philosophy for the organization: We should allow labor to begin on its own, with limited use of inductions and cesarean sections.

It’s important that ACOG, a dominant group in determining obstetric practice, would come out so strongly against these practices. However, it can take decades for these kinds of changes to take effect, even with clear recommendations from groups like ACOG. And that delay could have implications for many pregnant people both in the United States and abroad.

“Let Nature Take its Course”

“Let nature take its course,” writes Breeden in his blog post for ACOG. He continues: “Over the years, I’ve found this saying particularly applies to the process of giving birth. My personal experience as an ob-gyn and reams of scientific research demonstrate that Mother Nature knows best when a child is ready to be born. The start of natural labor is the main sign, but we’re not always patient enough to wait for it.”

Breeden goes on to note that inductions are at an all-time high and that “many of these births occur before the pregnancy is considered ‘term’ at 39 weeks.” This is one of the most extreme examples of the detriment of intervening in the labor process; labor is often induced before full fetal development is complete, increasing risks for all sorts of medical problems for those children. The New York Times reported on this trend in 2008 (emphasis added):

A study of single births from 1996 to 2004 found an increase of one percentage point in premature deliveries, to 10.7 percent from 9.7. Ninety-two percent of those premature deliveries were by Caesarean. Most were “late preterm,” born after 34 to 37 weeks of pregnancy, instead of the normal 38 to 42 weeks.

Essentially, we are producing infants born prematurely through our own practices of c-section and induction. And that prematurity has serious risks and implications for the health of the child, outlined in ACOG’s new guidelines:

Early-term infants have higher rates of respiratory distress, respiratory failure, pneumonia, and admission to neonatal intensive care units compared with infants born at 39 to 40 weeks gestation. Infants born at 37 to 38 weeks also have a higher mortality rate than those born later.

In particular, the new guidelines respond sternly to the practice of inducing labor or scheduling a c-section because of fears of fetal size. From the statement:

There are certain medical indications that require early delivery, including preeclampsia/eclampsia, fetal growth restriction, placental abruption, multiple fetuses, and poorly controlled diabetes. However, suspecting that a baby is macrosomic (large) is not an indication to induce or deliver by cesarean before 39 weeks.

How Long Must Pregnant Individuals Wait?

Unfortunately, it could take years for these changes to go into effect. Just look at the history of episiotomies. In the 1950s and ’60s, episiotomies, a cut in the perineum (the region between the anus and vagina), were recommended as routine practice during labor. At the time it was believed that an episiotomy was preferable to the natural tearing that is very common during vaginal delivery, and that the straight incision of an episiotomy was easier to repair. A 2012 Huffington Post article outlines this history, and how the practice came to dominate by the 1980s, occurring in more than 60 percent of deliveries.

It was only then that clinical trials were conducted to examine the impacts of episiotomy in comparison to natural tearing, and the results were staggering:

Clinical trials conducted in the ’80s and ’90s found that episiotomy cuts can, in fact, turn into even deeper lacerations during delivery, damaging the area around the rectum. Then, in 2005, a sweeping review published in the Journal of the American Medical Association found no benefits to routine episiotomy. A year later, the American Congress of Obstetricians and Gynecologists issued new guidelines, saying that episiotomy during labor should be restricted because doctors had previously underestimated the risk of bad outcomes later on, such as painful sex and possible incontinence.

Decades after those clinical trials, and seven years after the new ACOG recommendations, it’s unclear exactly how the new recommendations regarding episiotomy are being implemented. In 2005, the year before the ACOG recommendations, a study in the Journal of the American Medical Association (referenced in the Huffington Post article) estimated that 25 to 30 percent of vaginal deliveries still involved episiotomy. The 2010 National Hospital Discharge Survey reported that roughly 320,000 episiotomies were performed in the United States that year.

These practices don’t just affect the United States, but also other countries that often follow U.S. medical protocol but that might not adapt to new standards and reversals in practice as quickly. In 2004 I spent a semester studying abroad in Ecuador, where I had an internship at a public maternity ward. Every single vaginal birth that occurred in that hospital involved an episiotomy, even though the medical students and residents studying there told me they knew it was no longer standard practice in the United States. As a nation that often has significant influence on medical practice abroad, the imperative is great to ensure that our recommendations are fact-based and clinically proven.

The point is that it can take a really long time for recommendations from groups like ACOG to actually change the course of obstetric practice in the United States, particularly when those recommendations are trying to address common practices. This is because of how medical education works, how challenging it is to change one’s routine practices after long-established practices take hold, and even the time and attention paid by current practitioners to the most recent research and recommendations.

So I’m glad to see ACOG taking such a bold stance in supporting “mother nature’s” role in the beginning of labor, but I know that it may take a long time for these recommendations to actually affect the use of inductions and pre-term c-sections as parts of standard obstetrical practice. That’s a huge challenge, because these practices very clearly put the health and wellbeing of babies and parents at risk.

http://rhrealitycheck.org/article/2013/04/26/new-recommendations-say-labor-should-begin-naturally-when-will-medical-practice-change/

Feminism is the radical notion that women are people.

by on Jun. 24, 2013 at 8:14 AM
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Replies (1-10):
Aestas
by Gold Member on Jun. 24, 2013 at 8:27 AM

I'm curious how many of you have had your labor induced? And how you feel about it now? Do you believe it was necessary? Did you feel pressured to go along with your OB's recommendations?

What do you think about ACOG's new recommendation that labor should begin naturally?

jllcali
by Jane on Jun. 24, 2013 at 8:37 AM
1 mom liked this
I think that letting nature take it's course is a freaking no brainer, barring special, non elective circumstances.

I was given pitocin because my baby wouldn't stay in station, despite strong contractions. My water broke at 33 weeks. I would never have chosen an elective induction or C-section.
mehamil1
by Platinum Member on Jun. 24, 2013 at 8:39 AM
1 mom liked this

I was induced. I don't think they had my due date right to begin with and my son could have baked a little longer. That inducement caused my sons heart rate to drop and I had to have a c-section. I'm of the opinion that if I had been allowed to go into labor naturally none of that would have happened. I am glad they are making these recommendations and I hope they change quickly. However, C-sections means more money. I feel that is what is fueling the practice. 

Quoting Aestas:

I'm curious how many of you have had your labor induced? And how you feel about it now? Do you believe it was necessary? Did you feel pressured to go along with your OB's recommendations?

What do you think about ACOG's new recommendation that labor should begin naturally?

EireLass
by Ruby Member on Jun. 24, 2013 at 8:41 AM
1 mom liked this

I was not induced. Both mine started in their own time. I had a group of 3 doctors, whose practice had the lowest C-sec rate in the area/hospital. We had no clue as to the 'due date' of my 1st due to irregular periods, and using birth control. The ultrasound measured him to be born on December 7th. He was born on January 21st. No induction...just had stress/non stress tests every week...and let it happen. All was well and healthy.

finnbar
by Bronze Member on Jun. 24, 2013 at 8:48 AM
I would not have consented to an induction. Unfortunately, my son decided to be born at 33 weeks. We had a natural labor and delivery
Aestas
by Gold Member on Jun. 24, 2013 at 8:49 AM
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I agree with you about the C-sections. With my oldest, I was induced at 41 1/2 weeks, though I also suspect the due date was wrong and am skeptical as to whether the induction was necessary. At the time, my OB scared me and made me feel I had to go along with the induction or I'd be putting my baby in danger. For this baby, I chose to go with a midwife and a birthing center. Barring something unexpected (i.e., a medical emergency), I'm hoping for a natural birth this time around: no induction, no pain meds, just my body doing what it was built to do.

Quoting mehamil1:

I was induced. I don't think they had my due date right to begin with and my son could have baked a little longer. That inducement caused my sons heart rate to drop and I had to have a c-section. I'm of the opinion that if I had been allowed to go into labor naturally none of that would have happened. I am glad they are making these recommendations and I hope they change quickly. However, C-sections means more money. I feel that is what is fueling the practice. 


Rhodin
by Member on Jun. 24, 2013 at 8:49 AM
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I was induced at 42 weeks because it had been 42 weeks. I'd have let YDD go another week, but no doctor currently practicing in the US would have been willing to risk the lawsuit had YDD died in there. The lawsuits are why there are so many inductions and c-sections. If there's a live baby at the end, most moms will be too busy to sue.
mommieof38829
by Member on Jun. 24, 2013 at 8:53 AM
My first I was 42 weeks and in labor 29 hours. Finally got my section!! Idiot thought a 22 inch n 11 pound was coming out of me lol. Now it's sections all the way.
momof2cuteboys
by Member on Jun. 24, 2013 at 9:00 AM

My first child I went into labor naturally.  My second child I was induced on his due date because he had kidney issues. My third child I was induced a week early because of how large the baby was measuring.

My inductions went very smoothly.  But I was already dilated to a 4 each time.  They got me to a six and broke my water each time.  My OB knew that when I go into labor it is very intense... no breaks between contractions so when they broke my water they let my body takeover and they turned off the pitocin and I had each of them within an hour of that.  

I'm not against inducing but I also think all the risk should be considered just like with any other procedure.

fiddlerbird555
by on Jun. 24, 2013 at 9:02 AM

I had a c-section for non-labor causes & a VBAC (12 years ago). The doctor was making noises about inducing the VBAC at my 40 week appointment. (Dates were accurate). Fortunately the baby came naturally, quickly, and easily about a day later. They were recommending not inducing VBACs within the next year, but mostly that meant that doctors were refusing VBACs because "we can't induce you and I may not be available"

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