BusyMamaMD

I have mixed feelings about the American College of Obstetricians and Gynecologist’s recent Committee Opinion, Approaches to Limit Intervention During Birth.  Now, don’t’ get me wrong; I agree with many of the statements.  Routine amniotomy (water breaking) is not needed.  Women don’t always need continuous fluids running if they are able to drink.  Laboring down (waiting to push for awhile once a woman reaches 10cm) is a good thing.  Yet, I have concerns.

While I agree with a majority of the document, I have concerns that this can (and probably will) be misinterpreted, making the obstetrician’s life more difficult.  We as OBs fight an uphill battle every day.  We are mistrusted and often disrespected.  The “natural” movement that is sweeping the nation includes a rejection of modern medicine.  Patients trust the “naturopath” over their physician.  Women want a lay midwife at home, with no formal training, rather than an experienced obstetrician or nurse midwife in a hospital.  People choose “essential oils” and herbal supplements over regulated and well-studied medications.  I understand that ACOG released this committee opinion to appeal to the “natural” moms.  If these women feel we are on the same page with them, then they are more likely to see deliver safely in a hospital or birthing center.  I get it.  Yet, reading this committee opinion implies that we as physicians and hospitals are doing something wrong.  ACOG uses language like “many common obstetric practices are of limited or uncertain benefit” claiming that much of what we do is unnecessary.  The document states, “routine amniotomy is not necessary” rather than “routine amniotomy may not always be necessary.”  It implies over-treatment. While the goal of the document was to improve the relationship between the medical establishment and the anti-obstetrician moms, I fear it may have widened the gap.   

While ACOG attempts to appeal to the “low-intervention” moms by stating what they do not need, the organization does not address what they DO need.  For example, the document states that continuous intravenous fluids are not required.  While I agree, I have a few problems with how this is stated.  Notice ACOG does not mention what IS required (intravenous line placed).  I am a firm believer that every woman needs an intravenous line (IV) when laboring.  In the case of an emergency, it is much safer for mother and baby if the IV is already there.  It is also accepted that all women should receive oxytocin (via IV) after the baby is born to prevent postpartum hemorrhage.  People who read this document may infer that since IV fluids are not necessary, an IV is not necessary.  It adds fuel to their fire.  I anticipate that when this becomes public, I will see more women refusing IVs and refusing postpartum oxytocin.

The document also addresses areas such as maternal positioning, pushing, and pain control.  Similarly to the intravenous fluids, ACOG only states what OBs should NOT do, either ignoring or skimming over what they SHOULD do.  Overall, it seems derogatory to the obstetrician (look at everything they are doing wrong!)  and does not lend any support to practices that should be done.  I agree that a woman should be positioned how she chooses in a normally progressing labor without problems.  However, labor is unpredictable.  Sometimes, the fetal heart rate drops in a certain position, requiring the mother to turn in a different way.  Sometimes we need to position mothers in a specific way to aid in the head coming down or making a final turn.   In addition, laboring down is a good thing, but is not always possible if concern exists for fetal well being. 

Despite all of the misleading language, I completely disagree with two areas in the document.   The first area I have a problem with is the suggested management for premature rupture of membranes (PROM).  I am a firm believer that once membranes are ruptured, labor needs to start as soon as possible.  In my mind, no benefit exists for expectant management.  Patiently waiting merely increases the mother’s risk for infection.  The committee opinion cites a Cochrane review that compared induction of labor to expectant management in women with PROM.  According to the review, the induction group had a decreased incidence of chorioamnionitis, endometritis, and NICU admission.  Yet, the authors concluded expectant management was acceptable given that Cesarean section and neonatal infection was the same for each group.  I argue that increased infection rates in the mother as well as increased NICU admissions are more than enough reason to recommend induction or augmentation!  Mothers that suffer chorioamnionitis or endometritis need intravenous antibiotics, usually two or three, for at least twenty-four hours.  These infections can lead to worsening infection such as intrabdominal abscesses.  Also, increased NICU admission alone should be enough to recommend augmentation of PROM patients.  Most parents, given the choice, would prefer their child not require support from a NICU. 

Intermittent auscultation is the next area that concerns me. ACOG seems to be encouraging intermittent auscultation in low risk patients.  In the committee opinion, they encourage labor and delivery units to train staff on intermittent monitoring using a hand-held Doppler.  I see two issues.  One, what is low risk?  Data has shown that continuous fetal monitoring has not improved outcomes in LOW RISK patients.   Some examples of high risk are given in the document, but the list is not all-inclusive.  I believe this sets up a slippery slope.  If we begin doing this with some regularity, patients will start demanding this.  Given that there is no acceptable definition of low risk and high risk, I can see this as a major issue.    Two, intermittent auscultation is not possible for every labor patient and will set up nurses and physicians for failure.  Labor and deliveries are busy places.  Intermittent auscultation will require a large staffing increase; an increase that most hospitals will not be able to afford.  If a short-staffed labor and delivery unit is attempting this intermittent auscultation, disaster will ensue.  A busy nurse will not be able to listen as often as recommended and outcomes will be affected. 

Overall, ACOG’s heart was in the right place.  The organization has seen the shift in attitude regarding obstetricians and inpatient medical care.  Yet, implying that OBs are overtreating or even mistreating, is not the way to mend fences.  Appeasing the “anti-medical establishment” patients by offering intermittent auscultation with Doppler and expectant management for PROM is irresponsible in my opinion.  What is next?  Although patient satisfaction is important, is it not near as important as a healthy mom and baby.