Evidence Based Recommendations

This increasing medicalization of childbirth processes tends to undermine the woman’s own capability to give birth and negatively impacts her childbirth experience. In addition, the increasing use of labor interventions in the absence of clear indications continues to widen the health equity gap between high- and low-resource settings.

-WHO International

ACOGs recommendations for labor:

  • Birthgivers that go into labor naturally may not require continuous intravenous fluid during admission

  • Most birthgivers should be allowed to move freely without recommending specific positions

  • Care can be specifically individualized for birthgivers with a low-risk pregnancy, in spontaneous labor, where baby is in a head down position.

  • Continuous 1:1 emotional support (ie doula) to improve birth outcomes

  • Option of intermittent monitoring of baby using a hand-held device should be available for low-risk pregnancies

  • Interventions should match the needs & preferences of the birthgiver

 

ACOG Recommendations for managing early labor:

  • If birthgiver & baby are doing well, admission to labor and delivery can be delayed

  • Use of alternative methods of pain relief that do not include pain medication

  • Frequent contact & support of birthgiver

  • Observe (not admit) birthgivers that present with complaints of pain or fatigue

  • Encourage drinking fluids, comfortable positions, and hydrotherapy

Goal: no interventions take place during early labor (if birthgiver & baby are doing fine). Interventions during early labor potentially led to multiple interventions occurring throughout the course of labor.

We will go over 2 of the most common interventions in the hospital, induction & electronic fetal monitoring (EFM). Education is key in making shared decisions with your care provider.

Background of Induction

What is induction? Medications or treatment used to either cause changes of the cervix (causing contractions) or medications that cause the uterus to contract (that start labor or move labor along).

Induction is one of the most common medical interventions used in the United States. Induction has a place in labor if it is medically necessary. Rates of induction have steadily risen over time in the United States.

*Rates of induction of labor (IOL) in the U.S:

1989 9%

2000 19.9%

2010 23.5%

2020 31.17%

Why labor may be medically induced:

  • Birthgiver has health condition(s) that affects their heart, lungs or kidneys

  • Decrease in the fluid surrounding baby (amniotic fluid)

  • Poor fetal growth

  • Uterus infection

  • Issues with the placenta

  • Diabetes (gestational or previous diagnosis)

  • Preeclampsia & eclampsia (preeclampsia symptoms with presence of seizures)

  • Ongoing high blood pressure

  • Water breaks before labor starts

  • Pregnancy at 41-42 weeks

*Per ACOG

 

Induction is done urgently or electively

  • Urgent induction normally occurs if there is a non-emergent medical reason (potentially affecting birthgiver or baby)

  • Elective induction normally occurs when induction is chosen without medical indication. Elective inductions should not occur before 39 weeks.

 

Often, the induction conversation is brought by care providers on or around 39 weeks of pregnancy, referring back to medical research, specifically the ARRIVE trial (see previous link).

You might hear one or all of the following from your care provider:

  • “You’ll need to be induced by 39 weeks” “We cannot let you go past 40 weeks”

  • Reason for using medication to move labor along: “Your contractions aren’t strong enough”—determined by electronic fetal monitoring (EFM) interpretation.

 

ACOG insight on elective induction

Before considering elective induction of labor, we should take into account:

  • ARRIVE trial findings & how it specifically applies to the birthgiver

  • Values & preferences of the birthgiver

  • Resources available in the hospital (including nurse to patient ratio).

  • In order to move forward (or not move forward), care providers & staff should have a discussion with the birthgiver and shared-decision making should take place.

  • When appropriate, OB/GYNs & other obstetric care providers should know how to use & consider using low-interventions for management of low-risk pregnancies during labor that occurs on its own.

*MCN, The American Journal of Maternal/Child Nursing 47(4):p 235, July/August 2022.

 
 
 
 
 

Induction of Labor

How is labor induced?

  • Depends on how “ready” your cervix is for labor. Have changes of the cervix occurred? Like dilation or thinning? This is determined by your care provider by using the Bishop score.

  • Bishop score ranges from 0-13.  Score of < 6 means cervix may not be ready

  • If the cervix is not ready for labor, cervical ripening agents may be used to cause cervix changes

  • The cervix is firm like the tip of your nose, as the cervix softens and thins during labor, it feels like the texture/firmness of your lips

 

Cervical ripening agents

Prostaglandins are naturally occurring hormones in our bodies. The medications, Cytotec & Cervidil, are synthetic prostaglandins that can be used to ripen the cervix & may cause contractions. These medications can be taken by mouth or vaginally.

 

Other ways of starting labor (partial dilation needed)

  • Foley catheter balloon can be used to help open the cervix,

  • Membrane sweep-separates the amniotic sac from the uterine wall.

    Finger is inserted between the amniotic sac and the uterus & gently separates the amniotic sac from the uterine wall, which can trigger the body to release prostaglandins

  • Breaking water (amniotomy) can start labor or get labor moving faster

 

Intravenous (IV) Medication

  • Pitocin-synthetic form of the hormone oxytocin

Quite frequently, Pitocin is used to start labor or to get labor moving. Some birthgivers have a pleasant experience with Pitocin. Others report not so great experiences.

 

Oxytocin & Pitocin

Pitocin is a synthetic form of our hormone, oxytocin.

Quite frequently, Pitocin is used to start labor or to get labor moving.

Oxytocin is a naturally occurring hormone (chemical messenger) in our body. Oxytocin plays a large part in the labor cycle. Even though Pitocin is a synthetic form of oxytocin, it does not interact with our body the way oxytocin does. Pitocin can potentially break the natural cycle of labor. The natural cycle of labor provides support for both the labor process and the post-birth period.

 

Oxytocin puts in a lot of work. Let’s shout-out some of the great work it does:

  • Hormone of love & feel-good vibes

  • Communicates with the brain

  • Causing contractions of the uterus (which causes changes of the cervix)

  • Allows the uterus to take a “break” from contractions

  • Causes contractions after birth that return uterus to its normal size & tone

  • Prevents excessive bleeding from the wound bed, where the placenta lived.

  • Let down reflex during breastfeeding

  • Maternal-child bond after birth

  • Triggers endorphins, our natural pain relievers, to be released

 

Pitocin may lead to:

  • Sporadic, irregular, painful contractions

  • Back-to-back contractions

  • Minimal rest between contractions

  • A break in the labor cycle

  • A lot of contractions can be stressful to baby, potentially affecting their heart rate, which may lead to other inventions

  • Need for electronic fetal monitoring

  • Decreased levels of oxytocin after birth

 

Pitocin may be beneficial in specific situations, such as its post-birth use to enhance uterine contractions when they are insufficient to control excessive bleeding. In this context, the administration of Pitocin is medically indicated.

Let’s be honest:

If the cycle of labor is broken, our bodies will compensate, by why should our body work harder when it doesn’t have to? Who does cartwheels when their boss hands them more work at 5:01 PM.

If induction is brought up during your pregnancy or labor and is not medically necessary (you are low-risk and you & baby are doing well) then it is best that you weigh your options. If you do opt for induction, it should be a shared decision between yourself & your care provider. Please make sure you do your research during pregnancy as you prepare for birth.

 
 
 

Electronic Fetal Monitoring

Another frequently used medical intervention in the hospital setting involves the use of continuous electronic fetal monitoring. Our specific focus will be on continuous external monitoring.

Continuous external electronic fetal monitoring (EFM) has become the standard for many hospitals across the United States. EFM is not always an accurate tool & may lead to subsequent medical interventions.

 

What is EFM?

External Electronic Fetal Monitoring (EFM) consists of 2 bands across your belly, each has a sensor. Bands are connected to wired lines that lead to the EFM monitor. One sensor detects contractions of your uterus, the other sensor monitors your baby’s heart rate.

 

*History of EFM:

  • EFM use started experimentally in the 1970s

  • When introduced in the 1970s, birthgivers were not aware EFM was being used experimentally

  • No research was done to demonstrate its safety or efficacy during labor

 

Over the years, research has shown:

  • EFM may increase the chance of having a C-Section

  • When used during labor for low-risk pregnancies, it has not been shown to significantly affect adverse outcomes of neonates, such as perinatal death or cerebral palsy.

 

“In the U.S., ‘non-reassuring fetal heart tones’ (on EFM) is the second most common reason for first-time Cesareans (23%) after Failure to Progress (34%)”

-ACOG/SMFM 2015

 

Why EFM irks our soul

  • Attention moves from birthgiver to a machine

  • EFM sensor may not detect fetal heart rate in certain positions, may have limited positions to move into

  • EFM may hinder your ability to get out of bed

  • Increased perception of pain due to limited movement.

  • EFM may provide inaccurate findings leading to interventions (overtreatment)

  • EFM has loud alarms that many families find disturbing

  • Distractions during labor can move the mind from focus, increasing perception of pain

  • Can lead to stress, distraction, fear, stalling labor progress

 

What research, care providers, and guidelines recommend:

Hands-on, intermittent listening for those without known complications, low-risk pregnancies.

Issues with implementing hands-on listening in hospitals:

  • Training staff to use this device effectively (not enough time to do this)

  • Staffing issues (due to provider shortages or patient ratios)

 

When hands-on listening should not be used: pregnancy with multiples, breech, high body mass index (BMI), prior Cesarean, post-term pregnancy, pre-term labor, premature rupture of membranes, and the use of Pitocin (Bailey 2009), due to a lack of evidence of EFM vs hand on listening in these groups*.

*Evidence Based Birth (see previous links)

 
 
 
 
 

In Summary

In knowing our bodies, we not only strengthen the foundation of our own existence but also lay the groundwork for the lives of our children.

-AJ

The journey of pregnancy and childbirth etches both physical & emotional imprints upon your being. The birth of your babies will be a memory you carry for the rest of your life. We want all families to have a solid foundation & the happiest birth experience possible.

In summary, when preparing for childbirth, it's essential to thoroughly research your options and make informed decisions. Consider taking a childbirth education class, communicate your preferences with your care provider, and ask questions about potential risks and benefits of proposed treatment(s). Be aware of your provider's stance on medical interventions and inquire about the sources they reference. Although the process can seem overwhelming, understanding your choices can ease the journey. For more details on these topics, please refer to the provided links.

Until we meet again :)

Anjanette

Perinatal Resources

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