Minimizing Unnecessary Interventions During Labor and Birth

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During labor and birth, a wide variety of potential interventions are available. A number of these interventions are not necessary for all healthy low-risk women. Some routine interventions may be of little benefit or lacking scientific merit. Some create conditions in which other interventions are perceived to be needed such as epidural analgesia leading to artificial oxytocin to augment labor, or the reverse, labor induction with oxytocin producing contractions of such frequency and duration that the woman can no longer tolerate labor without epidural analgesia. Well-intentioned interventions can lead to unintended emergencies or even harm, such as elective amniotomy to speed labor progress followed by prolapsed umbilical cord, cesarean under general anesthesia, and birth of a depressed baby. Fortunately, interventions such as enemas and pubic hair shaving are no longer ordered for women during labor and birth. Other procedures should be likewise eliminated as routine, and rather used sparingly on an individual as needed basis, such as episiotomy, bedrest, “visitor control,” and stirrups. No doubt this list could be much longer.
It is important to note that some interventions can be lifesaving for mother or baby, for example, emergent birth for placental abruption, uterine rupture, or prolapsed umbilical cord. Some interventions can be very helpful and desired by the laboring woman such as frequent repositioning, hydrotherapy, epidural analgesia, or use of the peanut ball. What may be perceived as beneficial by some women may not be viewed as acceptable by others. There is a broad spectrum of desires of laboring women from those who have firm plans to labor and give birth “naturally” with no pharmacologic pain relief measures to others who are upfront with their hopes to “feel nothing” and “get it over with as soon as possible.” Given sometimes unforeseen circumstances, these plans often change over the course of labor, but should be respected and honored as safely as possible. Making sure the woman is a true active partner in the care team who has enough accurate data to make an informed decision is essential in the process of determining which interventions, treatments, techniques, or technology are appropriate.
In January, the American College of Obstetricians and Gynecologists (ACOG, 2017) issued a committee opinion about ways to limit unnecessary interventions during labor and birth for low-risk women in spontaneous labor. It was endorsed by the American College of Nurse-Midwives and the Association of Women's Health, Obstetric, and Neonatal Nurses. The lead author was a nurse midwife. I encourage you to read the entire document, as it is well developed and comprehensive with supportive evidence as available for each of the topics presented. There is acknowledgment that the evidence could be more robust for some practices.
Avoiding routine admission in latent labor, options for term prelabor rupture of membranes, providing continuous support during labor, avoiding routine amniotomy, and considering intermittent auscultation rather than continuous electronic fetal monitoring are discussed as possible strategies to minimize unnecessary interventions. Hydration and oral intake during labor, maternal positioning, and second-stage labor management including timing of initiation of pushing and pushing techniques are presented in detail as well. Much of this content is well known to labor nurses who are up-to-date on the most recent literature (Simpson & Lyndon, 2017), nevertheless a committee opinion by our colleagues at ACOG fully supporting limiting interventions to those that are needed, appropriate to the individual clinical situation, or desired by the laboring woman is welcomed and affirmed.

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