Why do professional natural childbirth advocates have such difficulty relating the results of scientific papers honestly?
First, following the lead of the executives of the Midwives Alliance of North America (MANA), Judith Lothian attempted to hide the fact that their data showed that homebirth increases the risk of perinatal death by a whopping 450%.
According to Lothian, the new report “change[s] the game.”
Sharon Muza, Editor of the Lamaze blog Science and Sensibility introduces the piece with her own bizarre spin:
I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down. Be prepared to be blown away. ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end. I feel like this blog post title could be “ACOG and SMFM adopt Lamaze International’s Six Healthy Birth Practices.” (Okay, that may be a little overenthusiastic!) I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented. Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement.
There’s just one teensy, weensy little problem. The report says very little that is new.
I ought to know. Nearly 30 years ago, I trained with Dr. Friedman himself (creator of the eponymous Friedman Curve). There very little in the new report that is different from what Dr. Friedman said back then and the standards that he set for our department.
Let’s take a look at the actual report itself, and you will see what I mean.
The report starts with a caveat:
The information … should not be construed as dictating an exclusive course of treatment or procedure.
ACOG isn’t changing the game, because ACOG starts with the premise that the correct treatment plan for an individual patient is best determined by the doctor caring for her in consultation with the patient, not by reports.
Let’s look at the recommendations in the report:
1. “Prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery”
Prolonged latent phase has NEVER been an indication for C-section.
Most women with a prolonged latent phase ultimately will enter the active phase with expectant management. With few exceptions, the remainder either will cease contracting or, with amniotomy or oxytocin (or both), achieve the active phase.
That’s the same thing that Dr. Friedman said decades ago, and that’s the way that I was trained to practice.
2. …“[A]s long as fetal and maternal status are reassuring, cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor . Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied.”
I was taught the the active phase typically begins at an earlier dilatation, especially for women having their second or subsequent child. However, I was also taught that the diagnosis of active labor should be made not by assessing dilatation, but by assessing the strength and frequency of contractions. It was recognized 30 years ago, and even before, that some women will not reach active phase until later than other women and that NO decision for C-section can be made before active labor begins, regardless of dilatation.
3. “Further, cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.”
This is the one thing that is different and its different because authors recapitulated what Dr. Friedman did and found that in current practice, vaginal delivery can be achieved by waiting longer.
Dr. Friedman never set out to create hard and fast rules about labor. Quite the opposite. Dr. Friedman did the research that led to the curve because he was angry that obstetricians would make decisions based on nebulous criteria (e.g. “that woman looks like a Cesarean to me”). Dr. Friedman set out to define parameters that generally led to successful vaginal delivery. Before the Friedman curve, obstetricians DID perform unnecessary C-sections in latent phase; they DID perform unnecessary C-sections for supposed “arrest” of labor or “arrest” of descent when they simply hadn’t waited long enough to see what would happen. Dr. Friedman NEVER said that anyone who deviated from the curve needed prompt C-section or couldn’t ultimately have a vaginal delivery. He just defined the way that most successful labors progressed. If a woman deviated from the curve substantially, her chances of vaginal delivery were substantially lowered, but not zero or even close to zero.
Over the succeeding generations, the way that most successful labors progress has changed. Therefore, the recommendations OUGHT to change to reflect that.
Have some obstetricians converted the original Friedman curve into hard and fast rules? Yes, some have, but that was NEVER Dr. Friedman’s intention.
4. “… [B]efore diagnosing arrest of labor in the second stage and if the maternal and fetal conditions permit, at least 2 hours of pushing in multiparous women and at least 3 hours of pushing in nulliparous women should be allowed . Longer durations may be appropriate on an individualized basis (eg, with the use of epidural analgesia or with fetal malposition) as long as progress is being documented.”
Nothing new there, either. I routinely cared for women who pushed 3 or 4 hours, and as long as they were making progress, there was no need for any intervention.
5. “Operative vaginal delivery in the second stage of labor by experienced and well trained physicians should be considered a safe, acceptable alternative to cesarean delivery.”
Nothing new there. Forceps and vacuum have always been used and are still being used. Both have a greater potential to harm the baby, though, and that is a critical factor in determining how to proceed.
6. There are new methods for detecting and categorizing fetal distress, but the basic principle remains the same. If there is evidence of fetal distress, a C-section is the appropriate response.
7. “Studies that compare induction of labor to its actual alternative, expectant management awaiting spontaneous labor, have found either no difference or a decreased risk of cesarean delivery among women who are induced. This appears to be true even for women with an unfavorable cervix.”
Contrary to the claims of natural childbirth advocates, induction does NOT increase the C-section rate.
8. “Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned…”
C-sections are safer than vaginal delivery for breech babies.
9. “To avoid potential birth trauma, the College recommends that cesarean delivery be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes …”
This is not news. The research on which these recommendations are based was performed when I was in training.
10. “Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalic-presenting twins should be counseled to attempt vaginal delivery.”
That’s what I was taught and that’s how I practiced.
11. The recommendation for C-section in the presence of active genital herpes is unchanged.
12. ACOG offers a nod to NCB proponents by recommending doulas.
I don’t see much that is new in this paper. In fact, I see much that harks back to Dr. Friedman’s initial recommendations and to the way he taught his residents and ran his department.
The one substantive change is the emphasis on waiting longer in active phase for making a diagnosis of arrest. That is likely to have an measurable effect on the C-section rate. The rest is old news.
Of note, ACOG is strongly in favor of fetal monitoring and recommends no alterations at all in standard labor and delivery care. ACOG mentions no support for 5 of Lamaze’s “Six Healthy Birth Practices.” ACOG offers no support for the notion that childbirth is inherently safe, that epidurals should be avoided, that interventions are “bad,” or just about anything else that is the hallmark of contemporary natural childbirth advocacy.
The new report reinforces one of the chief virtues of obstetrics. As a scientific discipline, it is always open to new evidence, always looking to improve outcomes, and always willing to change practice to reflect the latest research. Unlike natural childbirth and homebirth advocacy organizations, obstetrics doesn’t depend on unchanging beliefs, does not value process over outcome, and makes no value judgments about the “best” way to give birth.
If Lamaze wants to pretend, contrary to all the evidence, that they have changed minds at ACOG, it isn’t going to hurt any mothers or babies. The only thing their pretending hurts is their own credibility.