6 is the New 4: Changes in the ACOG Guidelines

From “The Birth Series,” circa 1975

In March of 2014, the American College of Obstetricians and Gynecologists (ACOG) released a statement called “Safe Prevention of the Primary Cesarean Delivery.” In that statement, they outline some ways to decrease cesareans, including:

  • Letting early (latent) labor progress without time limits.
  • Changing the definition of active labor from 4 cm to 6 cm.
  • Not diagnosing “failure to progress” (no adequate contraction or cervical change) during active labor before four hours without oxytocin and six hours with.
  • Letting those who have delivered vaginally before to push for at least two hours, three hours if they haven’t, and even longer in some situations, like an epidural or posterior baby, before a cesarean is recommended.
  • Using instrumental delivery, for example vacuum extraction or forceps, to help with vaginal delivery and avoid cesarean. This includes ensuring new doctors are learning these skills.
  • Counseling patients to avoid gaining over the recommended amount of weight during pregnancy.

I became a doula the year these changes were implemented, although I had attended several births before my career change. It wasn’t until I participated in an online webinar through GOLD Learning’s Online Symposium on Childbirth Education with Penny Simkin, entitled, “The Tipping Point(s) in Childbirth Education & the Consequences of Ignorance,” that I really understood how these changes were affecting my practice as a birth worker and impacting the experiences of the clients I served.

According to Simkin, time and patience are allies of the parent and baby, but our job as childbirth educators, doulas and advocates, is to convince birthing women that these things are important! Since “Longer labors are harder on women,” Simkin says, “motivation, incentive and know-how are essential” and that “when people understand why and how to avoid a c-section and are assisted along the way, the odds of success improve.”

When I consider my recent experience as a childbirth educator and doula, her wisdom really resonates with me. Birthing people are often sent home, multiple times, after being told they are not yet in “active labor,” which can be discouraging when their bodies are giving a different message. Preparing them for this possibility begins with educating them about the high rates of cesareans and how ACOG guidelines defining 6 as the new 4 for active labor is a positive change to help them achieve the birth they desire. Next, providing strategies for staying home as long as possible can put them in a better mindset for the long-haul ahead of them.

Along with realistic birth preparation, childbirth educators and doulas can provide strategies that can be used during labor to help increase endurance: nourishment, movement, relaxation and rest. Encouragement is also key, so believe in the birthing person and their body’s ability to birth from beginning to end and let them know you do!

Waterbirth – What’s the Big Deal?

While attending the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in January of this year, I had the pleasure of hearing Joanne Bailey, PhD, CNM, speak on “Hydrotherapy and Waterbirth: Evidence, Outcomes and Challenges.”

According to Dr. Bailey, the first documented waterbirth occurred in France in 1803. It wasn’t until the 1970’s and 1980’s that waterbirth started to become more popular in Europe and Russia. In 1983, Michel Odent described 100 stories of waterbirth, mostly positive. In 1989, Barbara Harper, who had studied waterbirth in Russia, held the first waterbirth conference in the U.S. She later went on to found Waterbirth International.

Despite such a long, successful history, there are only three options for someone who wishes to have a waterbirth in West Michigan today. The first is to deliver at home. Those choosing a homebirth may rent or purchase a pool that can be set-up in their home and in which they may labor and/or give birth in. The second option is to choose to give birth in a free-standing birth center. The Simply Born Birth House, in Grand Rapids, has deep tubs to labor and birth comfortably in. The third option is for rebels. If a provider is knowledgeable about how to safely manage a waterbirth, the birthing person may refuse to get out of a hospital tub and deliver underwater.

Why is waterbirth so difficult to access within a hospital? Rebecca Dekker of Evidence Based Birth asked herself that same question while delving into the research and case studies that led to the 2014 joint ACOG (American Congress of Obstetricians and Gynecologists) and AAP (American Academy of Pediatrics) statement against waterbirth. Her conclusion was that they based their decision on limited, isolated cases and not on the larger body of evidence suggesting that waterbirth is safe.

While all West Michigan hospitals have policies against waterbirth, this is not the case everywhere. In fact, Dr. Bailey tells the story of how the first waterbirths occurred at University of Michigan Health System in 1996 as the result of a consumer-driven effort. Currently, 16.4% of the births there occur underwater.

How about you? Did you have a waterbirth and if so, how did you achieve it? Please share your story!