LOUIS ó Women planning to deliver at some birth centers are
being encouraged to stay at home when their labor begins. They
are advised to rest, eat, walk around and not to time every
tell the mom not to spend all her labor energy in early labor.
We donít expect a lot of progress," said Jessica Henman,
a certified nurse midwife who directs the Birth and Wellness
Center in OíFallon, Mo. "We remind her things are going
to go slowly."
month, national obstetrician organizations together released
new guidelines aimed at reducing the spiraling cesarean rate
in the U.S. A big change was allowing women much more time in
labor, based on new research.
changes include: providing continuous labor support, letting
women attempt to deliver twins, not using the fetusí weight
as a reason for surgery and doing more to understand
electronic fetal heart rate readings.
health advocates said the guidelines developed jointly by the
American College of Obstetricians and Gynecologists and the
Society for Maternal-Fetal Medicine could completely change
how women approach birthing options.
consensus statement has the potential to be a game-changer in
ongoing efforts to improve the quality of maternal health
care, and maternal and child health outcomes," the
National Partnership for Women and Families said in a
doctors acknowledge barriers. Changes are slow to take effect
in massive hospital systems and in private practices where
doctors have been doing things a certain way for decades.
guidelines say that although national organizations can set
the agenda to safely lower the cesarean rate: "Ö such
an agenda will need to be prioritized at the level of
practices, hospitals, health care systems, and, of course,
patients. Changing the local culture and attitudes of
obstetric care providers regarding the issues involved in
cesarean delivery reduction also will be challenging."
hospitals need to have rooms available for longer? Will they
urge women to stay home until they are in the later stage of
labor? Will they bring back doula (labor coach) programs? Will
they limit use of fetal heart rate monitoring?
are great questions," said Dr. Alison Cahill, chief of
the maternal-fetal medicine division at Washington University
School of Medicine, who helped develop the guidelines.
"Could these change obstetrics in the U.S.? We donít
can look to midwife-led birth centers at their homelike
facilities to see how care can be done differently.
released in January of more than 15,500 women who received
care at birth centers in 33 states showed that fewer than one
in 16 (6 percent) required a C-section, compared with nearly
one in four (24 percent) similar low-risk women planning a
the C-section rate in the U.S. has climbed to one in three
births ó a 60 percent increase since 1996 ó the rate at
birth centers has stayed the same for more than 20 years.
are associated with increased maternal mortality and
morbidity, and those risks significantly increase with
subsequent C-sections. Death and intensive-care stays also
become more likely for babies.
most women who have C-sections end up having repeat C-sections
in subsequent pregnancies, the new guidelines focused on
practices that could prevent the surgery in healthy first-time
biggest reasons first-time mothers have cesareans are
subjective: Doctors consider labor "stalled" or
determine the electronic fetal heart rate readings are "nonreassuring."
But the latest evidence shows that labor lasts much longer
than long thought, and little information exists on how to
interpret questionable but common heart rate patterns.
heart rate monitors ó which are tied around the womanís
belly and keep her immobile ó are used in 85 percent of
hospital births, but they arenít to be seen at the OíFallon
birth center. Henman said midwives use a hand-held doppler to
occasionally monitor the babyís heart rate during the active
phase of labor, when the womanís cervix dilates rapidly.
the active phase was considered to start when the cervix
dilates to 4 centimeters, the new guidelines say 6 centimeters
is more accurate. The active phase can also last twice as
long, and women should be allowed to push for up to three
hours. No time limit should be placed on a woman before she
reaches the active phase.
said that rather than watching the clock, she watches whether
the cervix is thinning, contractions are strong and the baby
is dropping down. "Our standard is to recognize early
labor vs. active labor," she said. "Once she turns a
corner, we expect progress."
STORY CAN END HERE)
are encouraged to seek comfort in a large tub in two of the
centerís birthing rooms and use whatever positions feel most
comfortable. Women transfer to a hospital if more intervention
is necessary, Henman said, such as an epidural anesthesia,
medication to strengthen contractions or a cesarean section.
is really needed. Thatís where itís important for a woman
to have support she needs, that this might be a really long
process and that is totally normal," Henman said.
"Nothing is wrong because you donít have your baby in
an hour like you see on TV."
the two midwives, a birth assistant and whoever the woman
wants with her provide support throughout the labor, which has
been shown to help women avoid C-sections.
guidelines say cesareans should not be performed because of a
big baby, unless the baby is estimated to weigh more than 11.2
pounds. Henman said the biggest baby she had delivered was 10
pounds 10 ounces. The mother pushed twice and didnít need
stitches. "You canít make a judgment based on the size
of the baby," she said.
International, which studies and promotes healthy birth
practices, said the new guidelines were an important step in
closing gaps between evidence and day-to-day care that women
receive in labor. But systemic change is hard, and women
should not wait, said Lamaze president Michele Ondeck.
is why itís critical for women to have the education,
resources and support they need to push for evidence-based
care now," Ondeck said, "rather than waiting for
providers to change their practice."