At the 2019 Lamaze Conference, Deborah Amis presented a Research Update. I watched it today – it is available at that link for $20. It is an excellent review of the most important research and research-based guidelines issued between 2015 and 2019. I will list here some of the items she covered, with links and a few notes, but I’d encourage you to watch the recording for all the details.
Here are the key research and guidelines you should be aware of – just listed in the order she covered them in her presentation.
WHO Statement on Cesarean Section Rates (2015) – “at a population level, caesarean section rates higher than 10% are not associated with reductions in maternal newborn mortality rates.” Here is a companion FAQ.
California Maternal Quality Care Collaborative (CMQCC) Toolkits. Each includes best practice tools and articles, care guidelines, and implementation guides. Toolkits include: Substance Exposure; Maternal Sepsis; Venous Thromboembolism, Cardiovascular Disease in Pregnancy, Obstetric Hemorrhage, Preeclampsia, Reducing Elective Deliveries before 39 weeks, and Toolkit to Support Vaginal Birth and Reduce Primary Cesareans and Implementation Guide, 2016
AJOG April 2019 – Safety Assessment of a Large Scale Improvement collaborative to reduce nulliparous cesarean delivery rates. Study of CMQCC efforts to reduce primary cesareans. Data from 119,000 births. NTSV cesarean rate fell 29.3 to 25% between 2015 and 2017, with no increase in poor maternal or neonatal outcomes.
AIM – Alliance for Innovation on Maternal Health – Patient Safety Bundles – “… a small, straightforward set of evidence-based practices … proven to improve patient outcomes.” Not new ideas, but a standardized approach for delivering well-established, evidence-based practices to be implemented for every patient, every time. Topics include: Safe Reduction of Primary Cesarean; Reduction of racial disparities; Obstetric Hemorrhage, Severe Hypertension in Pregnancy, Obstetric Care for Women with Opioid Use Disorder, Cardiac Conditions; Postpartum Discharge Transition, and more.
Lancet: Optimizing Caesarean Section Use – 2018 series. Reviews the global epidemiology and disparities in caesarean section use, as well as the health effects for women and children, and lays out evidence-based interventions and actions to reduce unnecessary caesarean sections.
AWHONN Save your life: get care for these POST BIRTH warning signs. Patient handout.
ARRIVE Trial. Study with 6000+ participants showed elective induction at 39 weeks yielded a cesarean rate of18.6% vs. expectant management rate of 22.2%, a 16% reduction in relative risk. Leads to ACOG Guidelines that “it is reasonable… to offer elective induction of labor to low-risk nulliparous women at 39 weeks gestation.” Also read Rebekka Dekker’s article on this in Evidence Based Birth, which includes a link to a one-page patient handout, which includes other ways to reduce c-s risk: midwifery care, continuous labor support, intermittent auscultation, etc. Dekker also links to responses to the ARRIVE trial and ACOG guidelines from ACNM and CMQCC. Summaries of the AWHONN response and SOGC response are on this Talking Points handout from Amis’ The Family Way.
JAMA 2018 – Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia. Shows no difference in perineal lacerations, endometritis, severe hemorrhage, transfusion, NICU, neonatal morbidity. Immediate pushing group had shorter second stage (mean 102 minutes vs. 134 minutes), decreased chorioamnionitis, decreased hemorrhage, decreased neonatal acidemia, decrease suspected sepsis. Delayed pushing had less 3rd and 4th degree tears; active pushing was 75 minutes vs 84. ACOG Committee Feb 2019 – “data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia”.
AWHONN’s Second-Stage Labor Practices Reduce Cesarean Births and Newborn Harm (2019) has 13 evidence-based, second-stage labor practices. (Article on Implementing Guidelines.) Provide info about both immediate and delayed, but a key guideline is respecting spontaneous urge to push.
ACOG – Approaches to Limit Intervention During Labor and Birth – 2017 and 2019. Also read Sharon Muza’s follow-up articles on these guidelines: Sharing ACOG’s Guidelines with Clients and her Research Update – ACOG Advises No Longer Laboring Down and Support of Family-Centered Cesareans. Guidelines include: laboring at home till active labor; doulas, intermittent monitoring, reducing AROM, using coping techniques and positions; oral hydration; pushing with urge to push, immediate pushing at 10 cm with epidural, and family-centered cesareans.
Physiologic basis of pain in labour and birth – Bonapace… Buckley. (SOGC) “…scientific literature supports the use of nonpharmacological approaches to pain management … due to benefits for the mother and child, including a reduction in the need for obstetrical interventions, labour augmentation, or Caesarean section.” Addresses Gate Control, Diffuse Noxious Inhibitory Control (counter-irritants), Central Nervous System control, continuous labor support, and the hormones of labor.
International Childbirth Initiative – 12 steps to safe and respectful motherbaby- family maternity care. Includes: affordable care, midwifery model, continuous support, non-pharmacological first option, benefit/risk considerations, and baby-friendly practices. (It’s similar to the Ten Steps of the Mother Friendly Childbirth Initiative from CIMS, from 1996.)
WHO update 2015 – Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice. Includes 56 recommendations for labor and birth. Many are same as 1996 – midwifery, intermittent, food and fluid; mobility & upright positions, following urge to push, skin-to-skin. New: active labor begins at 5 cm; during active, may progress more slowly than 1 cm/hr; no interventions to speed up labor before 5 cm; delay cord clamping at least one minute; delay bath 24 hours.
AIMM study – Vedam et al 2018 – Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. States with a better integration of midwives into the health care system had more spontaneous births, VBACs, breastfeeding and at 6 months; less interventions; less preterm birth, LBW, neonatal deaths.
Consortium for Safe Labor? I didn’t get the full citation on this… but Amis summarized that hospitals with physicians AND midwives had lower rates of induction, augmentation, c-s; had birth at a later gestational age, more NICU admissions; no differences in adverse neonatal outcomes or Apgars.
Listening to Mothers in California 2018 – survey of 2539 participants. Summarizes survey result data, but also includes quotes from parents who describe their maternity care experiences. Asked about choice of care provider and birthplace, maternity care preferences vs. care received, respectful and disrespectful treatment, and racial disparities. Here are a couple of interesting visuals from Listening to Mothers.