The new ACOG report on primary C-section isn’t a game changer; it doesn’t change much at all

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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%.

Now she’s come up with an equally misleading “interpretation” of the new ACOG report, Safe Prevention of the Primary Cesarean Delivery.

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.

  • rh1985

    Well, my elective c-section ended up not being so elective. I was scheduled for Friday but Thursday very early I felt very sick and could not keep anything down. I assumed this was from my acid reflux which kept getting worse. So my OB on call said I could go to hospital for IV fluids due to dehydration risk, I guess they ran more tests once I got there, and I had preeclampsia which was a total shock to me. So my CS was done ASAP and I now have a beautiful and healthy 7lb 8oz daughter. When she was born the OB told me there is no chance an induction would have worked as she was very high up still. So, yay for modern medicine!

    • Jessica S.

      Congrats!! I’m glad it turned out well!

    • Box of Salt

      Congratulations! And welcome to the little one!

    • Amy Tuteur, MD

      Congratulations!!

    • Jocelyn

      Congrats! :D

    • KarenJJ

      Congratulations!

    • Karen in SC

      Happy for you and your new baby! Yay for modern medicine indeed!

    • Maria

      Congratulations!

    • Young CC Prof

      Awesome!!! So glad your daughter is here and well!

    • anion

      Congratulations! I’ve been waiting for you to come back and let us know how it went; thrilled for you and your beautiful daughter!

    • Amazed

      Congratulations! Welcome, Baby2014!

    • Mishimoo

      Yay! Congratulations on the healthy new arrival! I was wondering how everything went, glad that you’re both well.

  • Comrade X

    “…if maternal and fetal conditions permit….”

    “…As long as fetal and maternal status are reassuring….”

    ^^THIS^^ NCBers. Fucking THIS. You make a decision on how it’s best to proceed based on WHAT’S ACTUALLY GOING ON. And in order to know what’s actually going on, you have to ACTUALLY TAKE STEPS to find out what’s ACTUALLY GOING ON. You do not guess, pray, cross your fingers, prevaricate, and keep yourself and your patient DELIBERATELY IGNORANT of the condition of their body and their child’s body in order to avoid having to ever make an informed choice.

    If there’s one thing that makes absolutely NO sense in all the NCB rhetoric (and let’s face it, there’s more than one thing) it’s this idea that monitoring is bad in itself. That choosing ignorance is the preferable option. Maybe if I stick my hands in my ears, close my eyes, and sing NA NA NA NA I CAN’T HEAR YOU then everything will be OK. It’s like in those cartoons where the Wile E Coyote or whoever runs off the edge of a cliff, but he doesn’t start to fall until he NOTICES that he’s run off the cliff. In real life it doesn’t actually work like that. Not knowing that you’ve fallen off a cliff WILL NOT SAVE YOU. Gravity will affect you, and in this case even kill you, whether you believe in it or not.

  • CanDoc

    Agree wholeheartedly! After being told about this “exciting new paradigm shift”, I pulled it up, read it and, thought, “So what?” This is exactly how we’ve been practicing. For years. (Although I note that many healthy women with an estimated fetal weight between 10 and 11 lbs will still request an elective cesarean, even if I discuss the ACOG recommendation for trial of vaginal delivery.)

  • Jocelyn

    Question for those who understand: when talking about induction, what is the difference between comparing induction to women in spontaneous labor versus comparing induction to expectant management awaiting spontaneous labor?

    The ACOG doc says: “Because women who undergo induction of labor have higher rates of cesarean delivery than those who experience spontaneous labor, it has been widely assumed that induction of labor itself increases the risk of cesarean delivery. However, this assumption is predicated on a faulty comparison of women who are induced versus women in spontaneous labor. 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.”

    Can someone explain that a little bit to me?

    • Anne

      Retrospective comparisons of outcomes of induced labour versus spontaneous labour do not compare apples with apples.

      Women who have labour induced often have risk factors for Caesarean delivery- hypertension, diabetes, fetal growth abnormalities etc.
      While a spontaneous labour cohort will almost certainly include members with these and other Caesarean risk factors.

      Computer terminology- “rubbish in, rubbish out”- sorry about the pejorative language)
      Research terminology- selection bias.
      Social terminology- not a level playing field

      This is a similar reason to why you cannot compare homebirth outcomes with hospital birth outcomes- different populations

      • Jocelyn

        Got it. Thank you!

  • theadequatemother

    Is there anything in this statement about the health of the mothers (other than cs are worse than uncomplicated vaginal deliveries?). I mean, have we investigate the effects of longer second stages on pelvic floor function? And sure twins can be delivered vaginally but a significant number of attempts end up as emergent cs and a not insubstantial portion of women end up with a combined vaginal cs scenario. I can’t remember the numbers off hand but I remember being surprised by the lack of vag-vag success when that multicenter rct came out last year.

    I agree with the comment below that an approach tailored to each women and her reproductive goals are in order. For some women avoiding the first cs isn’t going to make any sense.

  • moto_librarian

    I guess the 6 cm definition of active labor scares me a bit. I was at 3.5 cm., 70% effaced for 10 days with my second, and periods of unproductive contractions every damned day. After my membranes were stripped, contractions got much stronger, and I was admitted at 5 cm. I stayed at 5 for hours – CNM started pit, bit didn’t break my water until 10 hours in. After that, it was only about 90 minutes until full dilation. I wonder if I would have to keep suffering false labor under these conditions?

    • Medwife

      I hate to Monday-morning quarterback but… I would have let you get your epidural and broken your water if I was admitting you at 5cm, it being your second baby :) 5cm for hours of pit and intact membranes? That just seems unnecessary.

      • moto_librarian

        Honestly, I have been wondering about that for awhile. I had an epidural and was resting comfortably, but the baby did not like the pitocin. I remember the labor nurse coming in quite abruptly and putting am oxygen mask on my face. I wonder if that was what made him pass meconium.

  • Amazed

    A poster on SAS just said that they needed to educate moms and OBs.

    I cannot believe it.

    • Young CC Prof

      Mental image of SAS groupies wandering into an obstetrician’s conference and trying to “educate” people. Freakin hilarious.

      • Amazed

        “Dr” Amy? Would you care to rent an “office” so they can EDUCATE you?

  • Coraline

    Dr. Amy, I was waiting to hear you weigh in on this! Thank you for your perspective, it is very valuable.

    At least for me, I’m happy to see the external cephalic version (ECV) mentioned ACOG’s report; I had one just shy of 37 weeks for my daughter (#2) and it was a very pleasant experience, and ended successfully (and quickly!) Because of a family history of cephalopelvic disproportion (as in, my mom had it with me, plus the fact that my daughter was measuring much larger than my son), a vaginal breech delivery would never have been recommended, even if it had been an option. (And I wouldn’t have wanted it to be an option.) I have always been SHOCKED by how the NCB movement seems to TOTALLY gloss over the option of an ECV; they continually claim that breech is just a “variation of normal” and that a vaginal breech delivery is perfectly safe (which is ludicrous). If you have a breech baby, they’ll tell you to follow Spinning Babies’ recommendations, or visit a chiropractor trained in the Webster technique, or spend lots of money on moxibustion or acupuncture, but NEVER do they recommend or usually even mention an ECV, even though if all those “techniques” to flip a breech baby don’t work, it’s YOUR fault that you’re having a c-section because you didn’t actively search for a provider last minute who would deliver your baby vaginally.

    Anyway, I know this is long-winded, but I think it really shows their intentions that the NCB adherents don’t like recommending an ECV for breech presentation; it would decrease your odds of needing a c-section, sure, but it would put you into the hands of an EVIL OBSTETRICIAN!! and so, for them, they’d rather rely on the odds that your baby likely won’t be breech at term. And if the baby is, well, then “just deliver vaginally.” Because, you know, that’s not dangerous or anything…!

    • Therese

      I don’t know, the way I’ve seen it presented by NCBers are these are natural options you can try prior to trying ECV. Which I think is internally consistent since ECV does post risks to the baby and I don’t think that acupuncture or standing on your head does (I’m sure someone somewhere can come with a possible hypothetical for how it could but the point is it is rather remote.) Now it is probably the case that the NCB tactics don’t actually work, so they are pointless, but from their point of the view they’re thinking, here is something that might work without any of the risks of ECV so why not give it a try first?

      • Medwife

        I hate the sense of failure they get when whatever bullshit they’re trying doesn’t have any effect, and then some charlatan is a few hundred richer to boot.

        • Young CC Prof

          And the added stress through the last few months of working on turning the baby through all those stupid methods that don’t work.

          I’m so glad I knew in advance that they didn’t work, so I was able to just say, “If he stays breech, I’ll schedule the section, if he turns, he’ll probably be born in the traditional manner, and either way it’ll be fine.”

          Really, I did not have the time or energy for headstands, ice cubes and flashlights, moxibustion, chiropractic treatments or any other nonsense.

          • Trixie

            You know, when I was waiting for mine to flip, the CNM told me it might help if I took a long bath. Harmless, and made me feel better, because what 36 week pregnant lady shouldn’t be taking a long bath, after all?

  • Jessica S.

    This is really interesting! I’m pregnant with my second, and assume I’ll have another c-section, but haven’t confirmed this with the OBs yet (my doctor only does prenatal care, but I give birth within the same medical network.) Reading this, I can see I hit several of these “limits” or what have you. I vaguely remember there being some sort of 24 hour window of sorts, and I think it was the length of time I could be given Pitocin before — and I can’t remember what came after the “before”. (Wow. That is one messed up sentence!) I think they hooked me up to the Pitocin once they realized my water had broke – it was a slow leak so I didn’t even realize it had happened until the next examination (I had already been there a day and a half). Anyhow, my contractions were never productive enough – strength and frequency, I think – to move the bub down. Also, he was 4800gs – so just a little shy of the number they listed. I really hope they recommend a repeat CS. I know it sounds crazy, but I’d rather deal with recovery from abdominal surgery than all the uncertainty of a VBAC – nevermind the odds of it not working out again. :S

    • FormerPhysicist

      I’ve had three c/s. The one without any labor was a pretty easy recovery. And so nice to have planned in advance. Lined up sitters, and everything.

      • Jessica S.

        The exhaustion was one of the hardest parts! I fell fast asleep when we returned to our room. My husband was the first one to feed and change him, etc. I was like, great! Have at it! I expect it’ll be easier this time.

        • prolifefeminist

          I can top that! :) I fell asleep on the operating table about ten minutes after my son was born (after a ten hour TOLAC). I remember looking over at him as they were warming him up and putting his ID bracelets on and whatnot, and thinking “…I just…I just can’t keep my eyes open ANY longer…zzz…”

          I woke up when they were taking my husband and baby back to my hospital room while they finished stitching me up. Then I immediately fell back to sleep for like 20 minutes. I woke up and asked my OB if I’d fallen asleep, and they all laughed and she said, “ohhh yea…you were snoring!” ha ha that must have been a funny sight!

          Anyway, yea – long labors followed by c-sections are just draining. I was wide awake for the one I had without any laboring.

          • moto_librarian

            I kept nodding off while they were repairing my tear – CNM had the attending. OB check me to be absolutely certain that my cervix hadn’t torn again, which meant she had to take out the first set of stitches to get a good look.

          • Jessica S.

            That’s funny! I’m grateful I wasn’t in a situation where I had pushed and pushed and THEN had to have a CS. That would’ve been worse. I was just tired of being in the hospital with seemingly no end in sight!

    • anion

      Congratulations!

      Oh, yeah, my second CS was definitely an easier recovery, and I loved having it all planned in advance.

      And you don’t sound crazy at all to me. My OB suggested TOL/VBAC for me; I politely but firmly told him that was Not Going To Happen. I didn’t have the slightest little bit of interest in it. I’m pretty sure that unless there was some odd complication or incision that totally contraindicates TOL, they’ll offer you the choice, and you can say that no, you are not interested in VBAC. And then there you’ll be X months later, ready to head to the hospital for a lovely, calm, relaxed c-section.

      • Jessica S.

        And the only concern on my mind will be if they can put anti-nausea drugs in my IV. Ha! Abdominal surgery, but the thing weighing on my mind is the possibility of throwing up. That’s how much I hate throwing up!! :D

  • EllenL

    The one that concerns me is #5.

    Will women be forced to accept the use of forceps or vacuum extraction? What if they would prefer a C-section? Personally, I have some fear of those techniques, and I don’t think that fear is unreasonable.

    They’ve said their use should be “in the hands of experienced and well-trained physicians.” But will that always be the case?

    I wish they hadn’t waded into that quagmire. I see the possibility of some injured babies in that recommendation. But we could brag about lower C-section rates.

    • thepragmatist

      I really, really do not see the value in operative vaginal delivery at the point where we are now. I see it if a woman is not a good candidate for c-section for whatever reason, but if she IS, I personally cannot see a good enough reason to put anyone through that, knowing a few women personally who had terrible operative deliveries. One told me she would have rather just died and was deeply depressed because had such serious issues post-partum with both her sex life and a prolapsed rectum. Another tore up into her clitoris. I keep thinking about some of the stories I’ve heard and thinking: really? At what point are we going to value women’s sexual selfhood enough to give the honest truth about the options. Sure, the pain may be well controlled (or not) at the time, but I would rather be told the truth. Some very scary things happen during operative vaginal deliveries and they can be avoided, both for mum and baby, by a prompt c-section. Yes, c-sections are surgeries but what happens to women who have very difficult vaginal births and then the reconstruction that happens… it is very traumatizing. My one friend told me that the damage to her cervix was so severe she was offered c-section that next birth and that the c-section was a “dream” compared to the first delivery. So I read the same lack of concern for a woman’s sexual future in that, too. It’s dangerous for babies, and it causes trauma to a woman’s sexual organ, whereas a c-section is safer for the baby, and safe for a healthy woman. Women should at least get the option. I would want my OB to lay it out for me: we can either do this or we can go to c-section. I told my OB/GYN straight out, when I was still considering a vaginal delivery, that if it came to an operative vaginal delivery, I wanted to go to c-section.

  • Amy Tuteur, MD

    When will we see all the NCB, doula and homebirth organizations acknowledge the validity of the other 90% of the recommendations in the new ACOG report, not merely the 10% that they like?

    For example, how quickly will NCB organizations retract their faulty claims that pitocin increases the risk of C-section or that induction before 42 weeks increases the risk of C-section?

    I’m betting never.

    • Young CC Prof

      Hmm, yes, I did like the way Sense and Sensibility quoted the recommendation against inducing before 40W6 unless necessary, but left out the other half (of that same sentence!) that recommended FOR inducing right away once you get to 41 weeks.

      • thepragmatist

        Cherry picking ain’t just in the summer.

    • thepragmatist

      It was very good to see that. Maybe it will shut up the “Babies aren’t library books” crowd. I doubt it. But this was already in the NICE guidelines when I was planning my c-section and the data was already there, it still didn’t prevent all the post-dates nonsense to float around and harm a friend of mine, who probably would’ve had a boring, non-eventful delivery of a fifth child (by induction) but bought into the woo and instead went post-dates with GD and ended up in a scary situation with an emergency section and no help at home for her two toddlers… and of course the doulas and NCB advocates urging her on BLAMED HER for the c-section! OF COURSE. When I saw photos of the baby, all I could think of how lucky she was she didn’t have a still birth: that baby was far past the point of “baked”, if you will. He had long nails and fingernails and wrinkled skin and was 11+ pounds. For shame.

      • Jessica S.

        11+! That’s crazy! And as a post-date, totally unnecessary for baby AND mom. Every day past 40 wk must feel like an entire week. And all over ideology. Crazy.

  • Young CC Prof

    OK, read the whole thing. I admit I don’t entirely understand the guidelines on progress vs lack of progress and THIS fetal heartbeat alteration is actually fine but THAT one is scary. If I was an obstetrician I’m sure all that would be totally clear. One thing I did take away from those sections though:

    This is what we needed. The only safe way to reduce “unnecessarians” is to develop better ways for doctors to tell when a fetus is actually in distress or when labor is really stalled versus when it isn’t. If these newly refined guidelines can actually lower the NNT, the number of urgent c-sections necessary to prevent one case of instrapartum stillbirth or hypoxic brain injury, that would be a major win.

  • Trixie

    If ACOG is going to endorse doulas (and I think the idea of doulas is generally good), then maybe there should be some sort of movement to train labor support people within the hospital network who don’t try to sell BS placenta encapsulation services or tell patients dangerous NCB woo.

    • Rochester mama

      Love that idea. I was two weeks early with my first and none of the grandparents are within a six hour drive so it was a few days before real help arrived. Also because I wad early my husband had to be at work the next day for a meeting. Thanks to Rooming In I was left to take care of the baby by myself with a horrible 3b tear. The nurses were great and gave me help when ever I needed to use the bathroom etc… But I hated having to “bother” someone.

    • Danielle D

      I had the impression that things are headed in that direction. For example, Johns Hopkins has a birth companions program that pairs doulas-in-training with patients.

      • Trixie

        Wow, well that’s great.

    • antigone23

      Great point. From my perspective considering a doula for my first, I thought having an experienced support person with me at all times would have been nice, but in the end I didn’t want someone who was going to try and dissuade me from getting pain relief should I want it, or try and tell me that my doctor/nurses were wrong and just trying to foist unnecessary interventions on me. Unfortunately most doulas are simply going to be feeding NCB woo to patients which could strain the relationship between the patient and her OB or CNM.

      • Medwife

        Doulas can actually be good moderators of extreme NCB demands. For instance, some women have told me when I meet them in labor, “I’m not getting an epidural and my husband knows that even if I ask for one, he’s not supposed to let me get it!” Um yeah no. If a woman asks for pain meds that I can safely get for her, she’s gonna get them. A good doula/childbirth educator could have straightened that out beforehand.

    • http://safermidwiferyutah.wordpress.com/ Safer Midwifery Utah

      I took a doula training course and really- they could teach family members or volunteers in the useful stuff pretty easily. A booklet would probably be fine.

      • Trixie

        The useful thing about a doula IMO is that it’s sort of an impartial person to make sure you remember to bring the hospital bag, run around with sips of a drink in between contractions, getting a snack for dad, holding a leg during pushing, keeping track of mom’s glasses, a cold washcloth on the brow, or, IDK, a hundred other little things that come up that the dad or other family labor support person might be too stressed out to think about and do proactively. I had a doula for that kind of stuff and she was really useful. But they should be limited to that stuff and not the kind of woo they usually get into.

        • fiftyfifty1

          This is a lot of the stuff the nurses used to do many, many years ago before their labor became more expensive. Now they are encouraged (or only allowed) to “work at the top of their training”.

          • Trixie

            Sure. So I think there legitimately is a gap to fill there, and it could be filled with a person without the same skill level and training as a nurse (and at a lower cost than a nurse), but who ideally still had some familiarity with the hospital and their policies and the things that help laboring women and their families be more comfortable.

      • AmyP

        A paid doula can be very helpful when family is far away.

    • OBPI Mama

      The doula training course I took in Indiana had 6-7 doulas on staff in the hospital (they were part of the hospital employees). This was 9 years ago at a hospital in South Bend. Some of the doulas were bilingual which was a big help to Hispanic women who were far from their families. It was a cool program!

      • moto_librarian

        Was this at Memorial or St. Joe? I grew up in SB.

        • OBPI Mama

          Memorial and that’s where the doula training was as well. It was great training and very well taught and they said the hospital program was a hit.

    • thepragmatist

      I REALLY want to be an EBM duola. Someone who could demystify the process for women and accompany women who were single, or who had husbands who were serving away or working in camp. I would love that. I could NEVER be a duola with the ways things are around here: I’d have no crunchability with most of them. There are a couple who work for the government who are really pragmatic, but the rest are terrible. They’ve since cloistered themselves in a private group so that the rest of us can’t read their posts anymore, because we had a heyday tearing apart the misinformation they were feeding women. In a sense I guess that was a win because it limited their audience by about 200 women, but at the same time, there are still women being drawn into the woo who are now unreachable. The thought leaders in that camp KNOW that they are not practicing in an evidence-based way and are misleading others, but are doing it willfully. I know because they’ve told me in private! I would love to walk a woman through a scary c-section and know that I helped to make it easier for her, for example. I would especially love to help women survivors.

  • Jen

    I thought latent phase arrest was an indication for a c-section. Four days into an induction and I was still at 5 centimeters, and it seemed pointless to try to go any further.

    • Mel

      From the following excerpt:
      “With few exceptions, the remainder either will cease contracting or, with amniotomy or oxytocin (or both), achieve the active phase.”

      I think you were one of the few exceptions….

  • anon13

    NCBer: I’ll only be your patient if you practice according to these new guidelines from ACOG. (hands over print out from Science & Sensibility.
    OB: Okay
    The end.

  • manabanana

    MANA is remarkably silent on the fact that the American Association of Birth Centers just endorsed a policy regarding birth centers following specific standards.

    Well, I think we all know where MANA stands on following guidelines and adhering to standards. So this should be no surprise.

    • Guesteleh

      Do you have a link?

      • manabanana

        http://www.birthcenters.org/about-aabc/position-statements/birth-center-quality

        I got an email from the AABC this morning – notifying me of this position statement.

        • Trixie

          You know, how many CPM practices or CPM birth enters could even clear half of the administrative stuff, like adherence to GAAP and semi-annual financial statements?

          • manabanana

            Few, good point. I don’t care so much about the administrative stuff. I care about the risk-out criteria.

            I think the AABC is the only organization that is making a statement that breech, twins, preterm and postterm deliveries are inappropriate for OOH birth center deliveries.

            Granted, they are not making this statement very forcefully – you have to rummage around in the standards to find these statements, but they are saying this.

            So…. why are all the midwifery organizations ignoring this little detail? This is a non-issue?

            MANA won’t even defend it’s position that supports every crazy possible thing attended by an ‘expert-in-normal’ CPM in an out-of-hospital setting?

  • KT

    I’d be interested in what the “new” criteria for fetal distress is. My daughter was a c-section due to fetal distress (PROM with heart rate decelerations whenever my rare contractions would kick in and decelerations during any pitocin-induced contractions once they started the pit). I trusted my doctor and was glad I did when she had meconium in her fluid during the c-section. However I’d still be interested to know what the guidelines for distress are, as I plan to attempt a VBAC should my provider be in favor.

    • Amanda

      Our c-section was for similar reasons and is something that has weighed on my mind. I would be interested in hearing if there are any new ideas or evidence about how dangerous it was for my son – it wouldn’t change the c-section but it might alleviate some guilt at how long I let it go before the c-section.

    • Karen in SC

      I’m sure there are some guidelines, but I recently read an account on here a week or so ago when the OB noticed some things and had a “gut feel.” Chalk that up to the art of medicine, I suppose.
      A few years ago, I read a story where a mother who really really wanted a HBAC, but had a week of contractions and couldn’t sleep. She went in to the hospital (on her midwife’s recommendation) for an epidural so she could rest. I believe she was planning to go back home for the birth. However, the OB on call got an EFM going, showed them the decels and she consented reluctantly to a C-section. They did get pathology on the placenta and it showed chorio infection. There were no indications except the failure to progress, no temperature had been recorded. Even then, reading her account, she had trouble processing the fact of getting a second C-section.
      I think trusting your OB / CNM is key.

    • Medwife

      Fetal heart monitoring standards have not fundamentally changed. Some decels are ok, some are not, and it’s possible to have no decels at all and identify a baby who needs out 5 minutes ago. It’s a big topic but no changes.

  • fiftyfifty1

    The reason this ACOG report is important is not because there is much new in regard to these best practices, but because there is wide variation among OBs in whether these best practices are followed.

  • Sue

    So ACOG are the good guys now, NCBers?

    So confusing.

    • Jules

      From what I’ve been reading on TFB page, not exactly. Just taking the findings out of context, twisting them to fit their own agenda, glossing over or downright ignoring anything that doesn’t fit their rigid thought process, and saying, “NYAH! NYAH! TOLD YOU SO!”.
      In other words, same old, same old.

      • thepragmatist

        Yes, in the same way the WHO is when it recommends breast-feeding, but NOT when it recommends the dread vaccine.

        • Jessica S.

          I know, I hate that so much!!

  • Karen in SC

    Number 7!! Induction does NOT increase the c-section rate!! That should be an entire post.

    • Young CC Prof

      Especially post-dates induction! It’s been proven than induction at 41 weeks means fewer c-sections than waiting to 42.

      With modern technology, there is no reason why babies should ever go more than a few days past their due date. It endangers the baby and is occasionally dangerous and always unpleasant for the mother.

      And as for induction before the due date, often there’s a medical reason. “Well, we need this baby out within the next few days. Continuing the pregnancy is just too dangerous for one or both of you. We can book a c-section, which has a 100% chance of ending in a c-section. Or we can do an induction, which has a less than 100% chance of ending in a c-section.”

      • Meredith

        I am forever grateful to my OB, who offered to induce me at 40 wks 4 days. I took him up on the offer, because I was miserable. Radial nerve compression (in my dominant hand), sciatica, poor sleep due to inability to take medicine, hip pain… I’m glad you include pregnancy being “unpleasant to the mother” as a valid consideration when thinking about post-dates induction.

        • Young CC Prof

          Yup. There’s this idea that sure, going post-dates is miserable, but it’s just something you have to put up with. In fact, just putting up with it makes about as much sense as just putting up with those annoying 3am asthma attacks.

        • moto_librarian

          I had SPD during my second pregnancy. Even rolling over in bed caused me to weep from the hip pain. I started having prodromal labor right when I hit 37 weeks. At 38 + 5, after yet another day of unproductive contractions, my CNM swept my membranes. I was admitted to the hospital in active labor two hours later, and our son was born very early the next morning. I felt like I was going to lose it. I cannot imagine going through that for 2 or even 3 more weeks.

          • Meredith

            Thank goodness your CNM helped things along. I didn’t have any actual health risks during pregnancy, but the “harmless” side effects were misery. My husband got a vasectomy when our daughter was 9 months old, because he said, “Never again!”

          • Prolifefeminist

            I had SPD during my fourth pregnancy. It’s a pain unlike any other. It felt like my pelvis was splitting in two. I remember laying on my side in bed and having my husband SIT on top of my hip to press them together just for a few moments of relief. Truly horrible. And this was the pregnancy I went to 42+2 with! I ended up with a CBAC anyway…and I sure wish I’d had that c-section a few weeks earlier! The SPD pain was worse than the post-c/sec pain. At least I had drugs for that!

            Anyone who scoffs at c-sec or induction for mom’s discomfort maybe hasn’t been through the intense pain or other reasons moms have for choosing to get baby delivered.

      • Trixie

        There are certainly times when people don’t have an accurate due date to begin with. My OB was fine with 41 or 42 weeks with NSTs starting at 41 weeks.

        • Young CC Prof

          True. If your due date is rough, waiting to 42 weeks might make sense. But an awful lot of pregnant women nowadays know their due dates very precisely for one reason or another.

          • fiftyfifty1

            Yes, if you know your due date precisely, waiting past 41 weeks has ZERO benefits and lots of risks.

    • Meredith

      Yes, please do post on that! I felt guilty for a couple of years about having an induction, because I figured it “caused” my c-section. (Remind me to kick the NCB activists in the teeth later for that guilt.)

      • Jessica S.

        When in reality, the induction may have been increase the chance of a vaginal delivery, in you happened to be someone who would not have started into labor without a csection. (Essentially what Young CC said below.) I was in the same boat, CS after induction, but again, if they would’ve just waited until a CS was the only course, the first course of action, then I would’ve had no chance of a vaginal delivery. I guess it depends which side we’re coming from, how we view it!

        • Meredith

          Huh, yeah, I see your point! I never thought of it that way. :)

    • slandy09

      Amen! I have a friend who announced on facebook that she had scheduled an induction for 41 weeks and oh my goodness, she had people telling her to cancel it because it would increase her “risk” of a c-section!

      Well, she actually did end up needing a c-section, but it was because her baby (her FIRST baby, mind you) ended up weighing 11 pounds!!!!

    • Meredith Watson

      Agreed! I was absolutely shocked when I heard this several years ago because I was so mired in the NCB philosophy. I would love to see more evidence-based ways to avoid c-section in general. There are women who want large families and who live in dread of that first c-section because then they are faced with difficult choices – VBAC or several repeat C-sections. It is so easy for them to be lured in by NCB promise of lower C-section rates.

      • fiftyfifty1

        ” I would love to see more evidence-based ways to avoid c-section in general. There are women who want large families…”

        Yes, this would be my ideal: Different management plans for women who want small families vs. those who want larger families. Some of this of course goes on already, but it’s not as explicit as it could be. In my ideal world, the risks and benefits of both planned trial of labor AND planned CS would be discussed with each woman. For some women (e.g. older, planning only 1 or 2 babies etc.) a planned CS would likely be a frequent choice, and this should be fully allowed and paid for. For other women (e.g. young and planning large families) trying very hard for a vaginal birth is the best choice. The women in this second group might be very willing to accept a higher relative, although still low absolute, risk to each baby in order to avoid a scarred uterus and the future risks of that. These are women who might be willing to accept a long and uncomfortable prodromal labor, a less than perfect strip, the added risk of a mid-forceps etc. In an ideal world, these women should be accomodated, AND THEIR OBS PROTECTED FROM LEGAL CONSEQUENCES when the inevitable occurs on occasion.

        • Sue

          That sounds like the ideal approach, fiftyfifty1.

          Application of these principles could certainly be behind part of the increase in section rates over time, as there are more and more older first-time mothers wanting (or only able to have) smaller families.

          The ideal outcome, then, would be the best match of technique to individual situation – not an arbitrary section rate.

          • thepragmatist

            Yes! This! As a patient, I felt like my OB/GYN did exactly this… she asked me a lot of questions about what I wanted in the future, about what I was going to be comfortable in during labour, and I felt like we tailored a birth plan to meet my needs. This is why guidelines need to be guidelines and not taken absolutely. For example, she told me I was going to want an early c-section. I had already read that c-section before 39 weeks carried slightly increased risks. But we had a good early U/S and I was already showing signs of a separated pelvis at only 5 or 6 months in… she knew what I did not know… that my pelvis was going to get much, much worse. By the time I was wheeled into a c-section at 38 weeks, I couldn’t care for myself any more, I couldn’t walk and my pelvis was not holding the baby. It was awful. I was so glad I didn’t have one schedule for a week later and my son was a healthy weight and discharge 2 days later with no issues other than an initial drop in blood sugar that I can’t find any evidence of having anything to do with the c-section. He had no breathing issues. I felt like she really took the time to plan an individualized careplan for me.

          • Jessica S.

            That sounds so painful. Anyone I’ve talked to who has had that problem says it’s one of the most extreme types of pain they’ve experienced.

    • Jessica S.

      Yes!! I had no idea, and I don’t buy into any of the natural nonsense. Yet I’ve been spouting off untruths. For shame! I can’t wait for the next opportunity to say “Actually, did you know…?”

      • thepragmatist

        This was in the NICE guidelines from the UK a few years back and I’ve been trying to tell people but they keep telling me I’m full of it. Ha! I can’t wait for this to come up again in debate elsewhere… ;)

  • http://safermidwiferyutah.wordpress.com/ Safer Midwifery Utah

    contrast with NCB, where no amount of data leads to a change of practice. How can they criticize acog at all?

    • KarenJJ

      It will be interesting to compare when MANA releases its practise guidelines.

      Oh. Hang on a minute…

      • Amazed

        … or an hour, at least. That’s about the time the baby is supposed to hold his/her breath in until a life-saving c-section can be performed in the hospital that’s only 5 minutes away…

    • Amazed

      That’s because they don’t practice medicine. Shameon. They practice “birthkeeping”, as they say. No need to follow data or anything.

  • AlisonCummins

    I don’t understand the reccomendation in 9. C-section should not be attempted until the fetus weighs at least 11 or 10 lbs?

    • Dr Kitty

      If the SOLE indication for the CS is foetal macrosomia the guidance is that the EFW should be > 4500g for GDM and >5000g for non diabetics (the 500g difference is because the GDM babies will have proportionally bigger tummies and be at higher risk of shoulder dystocia).

      Of course, if your patient is a 4’9” Asian lady married to a 6’6” NFL player and the foetal head circumference has been consistently measuring on the 90% centile with an EFW at term of 4400g you may decide that you’re not happy to adhere strictly to that guideline…which is called using clinical judgement about the individual risk of CPD and severe tears.

      • AlisonCummins

        Ah, ok. That clarifies a lot. Thanks.

      • Jessica S.

        I’ll never forget, as long as I live, what the doctors and nurses said as they pulled my 10 lb 10 oz son out: “Whoa, he IS a big boy!” “And I’m not even done pulling him out yet!” :D I was glad I didn’t buy any newborn sizes!

        • Dr Kitty

          Part of why we opted for the CS was because of the very real chance that even at 6lbs 3oz my pelvis wasn’t big enough for my daughter to fit through.
          When you have a high and free foetal head at term in a very petite primip with known pelvic abnormalities the chances of CPD are not low.

          I had never intended to have a large family, wouldn’t want to VBAC, so opting for the CS was an easy choice for me.

          • Jessica S.

            I think that was the case with me, too. I’m “petite” in that I’m 5″4″ and (I think) have a smaller bone structure (doesn’t mean I’m skinny, but that’s another entirely!) and my meager contractions, at full Pitocin levels, weren’t bring the boy down. I wonder if that’s why my doctor said they’ll most like offer an elective CS, b/c those factors are somewhat static.

            I’m amazed at how little I remember and/or remembered to ask back then!! :)

  • Young CC Prof

    I might be wrong about this, but I get the impression that EFM has actually made the pros MORE patient with the normal labors that just take significantly longer than average. As in, “Well, she’s progressing slower than we like, but she’s progressing, and she and the child are both tolerating labor. Let’s wait and see.”

    (This doesn’t mean that 5 hours of pushing with no doctor even consulted and only the occasional fetal heartbeat check is a good idea, NCB folks.)

    • KarenJJ

      I wonder about that too. After the EFM was done when I was first admitted to hospital in labour my obgyn gave me the option to continue or go straight to c-section. I opted for the c-esction, but without the reassurance from EFM I don’t know I’d have been given a choice.

    • Elizabeth A

      Yeah, without EFM, I think you either have to cut earlier or get your head around losing more babies.

      I pushed for 5.5 hours with my first, and I sort of think that much pushing is inhumane, but I was really scared of c-section at the time, and it was clear that I was progressing… slowly… and DS was handling it fine.

    • Jessica S.

      That was partially true with me, although I wasn’t even beyond 6cm after almost 18 hours of Pitocin, and 24 hours after my water broke. They could tell me son was great, not in any rush to move down, that’s for sure. (First signs of trademark stubbornness!) In fact, when they came in to discuss the CS and after we agreed to go ahead, they said the OBs who would be performing the section “called it” a few hours before, but let the doctors try a little longer if they (and myself, I guess) wanted. I was so relieved by the time they made the decision.

  • Ceridwen

    The recommendation for induction isn’t brand new but it’s rather more strongly in favor of induction (particularly before 42 weeks) than what I’ve seen previously. Interesting that they don’t really address that on the science and sensibility site…