ACOG Offers Mixed Bag of Practice Guidelines

By Rachel Walden

This year, the American College of Obstetricians and Gynecologists (ACOG) — the professional organization for U.S. obstetricians and gynecologists — has issued a number of opinions related to pregnancy and birth. For better or worse, these bulletins and opinions serve as a reference guide to the standard of care for women giving birth in the U.S. Some of the statements could encourage changes toward more evidence-based choices for women during birth, while others have generated broad criticism from advocates of birth choice.

First, in July, ACOG released a practice bulletin on continuous electronic fetal monitoring (cEFM).¹ cEFM was introduced in the early 1970s to reduce complications like cerebral palsy and fetal death, and soon became nearly ubiquitous in obstetrics. ACOG's new bulletin clearly states that cEFM does not reduce the risk of perinatal mortality or cerebral palsy. The Agency for Healthcare Reform and Quality (AHRQ) has also concluded that cEFM is not recommended for low-risk women and that there isn't enough evidence to endorse its use in high-risk pregnancies, either.²

Despite the lack of evidence for its intended benefits, cEFM was used in more than 85% of births in 2002 (up from 45% in 1980), which is highly concerning. The practice limits a woman's options for movement during labor, and increases the likelihood that she will have either a C-section or a vacuum and forceps operative delivery — both of which are more complicated and risky than vaginal birth. Yet, cEFM continues to be widely used, possibly because doctors hope it will help them avoid malpractice claims or because they have a false idea of its utility.

Overall, the new ACOG practice bulletin aligns with what women's health advocates have long been saying. It addresses the need to reduce women’s exposure to unnecessary procedures, clearly outlines cEFM's risks and lack of benefits, suggests that high-tech options are not always better, and acknowledges that providers may use cEFM data to perform unnecessary C-sections. Yet, cEFM has been so thoroughly embraced that it will require more systemic changes in how labor and delivery occur in the U.S. to foster changes in practice. It’s hard to know how ACOG can stop the routine use of cEFM, now that it’s been standard (albeit wrong) practice for over 20 years. Since AGOG members themselves wrongly adopted cEFM in the first place, however, ACOG should be more pro-active in this area than just re-stating what’s been known for decades: cEFM doesn’t help, and it sometimes makes things worse.

Second, ACOG issued a practice bulletin conceding that women in labor may be "allowed" to drink clear liquids (juice, water) instead of just ice chips.³   The restriction was intended to reduce the risk of aspiration if a woman needed general anesthesia, although the use of general anesthesia in labor is pretty uncommon now, and carries a relatively low risk of aspiration. Other providers adopted this sensible approach already: the American College of Nurse Midwives (ACNM) recommends that providers "educate clients about the small but potentially serious risk of aspiration and watch women throughout labor to identify when food and drink need to be restricted."⁴

While ACOG' s August bulletin demonstrates flexibility on liquids, ACOG maintains an annoying paternalism when it comes to food. In the press release, the chair of ACOG's Committee on Obstetric Practice suggests that women shouldn't be allowed to have any food because they won't want it, stating: "the reality is that eating is the last thing most women are going to want to do since nausea and vomiting during labor is quite common."⁵  We suggest that — lacking evidence that eating and drinking causes significant, frequent harm — this issue be left up to the woman. As one advocate wondered, "How would he ever arrive at that conclusion if he’s never allowed women to eat in labor in the first place?"⁶

Third, ACOG released an updated practice bulletin on induction of labor, which noted that induction has more than doubled since 1990.⁷  The drug misoprostol is one of the more controversial methods reviewed. ACOG noted that misoprostol has a history of safe and successful use, but also acknowledged the increased risk of complications stemming from "higher" doses of the drug, and the need for more evidence on its use for induction of labor. The National Women's Health Network believes that ACOG should not recommend misoprostol's broad use until additional research has been conducted on the drug's optimal route, dosage, timing interval, pharmacokinetics, and management of complications.

The practice bulletin also indicated that labor should only be electively induced after 39 weeks of gestation, a two-week increase from the previous recommendation (37-weeks). The March of Dimes hailed this change, noting that "infants born at 37-38 weeks have an increased risk for problems compared to infants born at 39 weeks." Other agencies have taken a different approach to elective induction; the AHRQ has stated that "the evidence regarding elective induction of labor prior to 41 weeks of gestation is insufficient to draw any conclusion."⁸

In each of these guidances, ACOG's position has become more closely aligned with women's health and birth advocates'. We believe that the benefits of cEFM may not outweigh the risks, that women should be allowed to have more than ice chips during labor, that some induction methods carry risks we need to know more about, and that inducing at 37 weeks is too early. More work needs to be done, though. Providers need to be convinced to stop using cEFM in 85% of U.S. births. Women are likely to have to advocate for themselves to get that glass of juice or to avoid pressure to have a non-medical induction. But, as they say, it's a start.

Rachel  R. Walden, MLIS is a medical librarian and blogger for Women's Health News and Our Bodies Our Blog

References:

1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins, “ACOG Practice Bulletin No. 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles," Obstet Gynecol. 2009; 114(1):192-202.

2. U.S. Preventive Services Task Force, Screening for Intrapartum Electronic Fetal Monitoring, Topic Page, Rockville, MD: Agency for Healthcare Research and Quality, 1996. Available online at: http://www.ahrq.gov/clinic/uspstf/uspsiefm.htm

3. American College of Obstetricians and Gynecologists Committee on Obstetric Practice, “ACOG Committee Opinion No. 441: Oral Intake During Labor,” Obstet Gynecol. 2009; 114(3):714.

4. American College of Nurse-Midwives, “ACOG Encourages Laboring Women to Quench Their Thirst,” Midwife Connection, 8/25/09. Available online at: http://acnm-midwives.blogspot.com/2009/08/acog-encourages-laboring-women.... See also: http://www.midwife.org/siteFile/news/ACNM_Clinical_Guidelines_on_Nutrition_in_Labor.pdf.

5. The American College of Obstetricians and Gynecologists, “Press Release: Recommendations Relax on Liquid Intake during Labor,” Washington, DC: AGOG, 8/21/2009. Available online at: http://www.acog.org/from_home/publications/press_releases/nr08-21-09-2.cfm

6. Jill ----, “The Big Push for Midwives: ACOG Wants to Keep Women Hungry in Labor,” The Unecesarean, 8/25/09. Available online at: http://www.theunnecesarean.com/blog/2009/8/25/the-big-push-for-midwives-acog-wants-to-keep-women-hungry-in.html.

7. The American College of Obstetricians and Gynecologists Committee on Practice Bulletins, “ACOG Practice Bulletin No. 107: Induction of Labor, ” Obstet Gynecol 2009; 114(2):386-397.

8. Agency for Healthcare Research and Quality, Maternal and Neonatal Outcomes of Elective Induction of Labor, Structured Abstract, Rockville, MD: Agency for Healthcare Research and Quality, March 2009. Available online at: http://www.ahrq.gov/clinic/tp/eiltp.htm March 2009.