New Recommendations Say Labor Should Begin Naturally—When Will Medical Practice Change?


A recent blog post on the American Congress of Obstetrics and Gynecology’s (ACOG) website gave me such pause I had to inquire about its validity on Facebook. The language seemed like such a departure from ACOG’s positions and rhetoric that at first I believed it was a hoax—someone posing as ACOG’s president and releasing statements that contradict their ideology. Quickly, though, it was proven that the statement is indeed from ACOG President James T. Breeden. The post, headlined “With Delivery Times, Defer to Mother Nature,” outlines what seems like a radical new philosophy for the organization: We should allow labor to begin on its own, with limited use of inductions and cesarean sections.

It’s important that ACOG, a dominant group in determining obstetric practice, would come out so strongly against these practices. However, it can take decades for these kinds of changes to take effect, even with clear recommendations from groups like ACOG. And that delay could have implications for many pregnant people both in the United States and abroad.

“Let Nature Take its Course”

“Let nature take its course,” writes Breeden in his blog post for ACOG. He continues: “Over the years, I’ve found this saying particularly applies to the process of giving birth. My personal experience as an ob-gyn and reams of scientific research demonstrate that Mother Nature knows best when a child is ready to be born. The start of natural labor is the main sign, but we’re not always patient enough to wait for it.”

Breeden goes on to note that inductions are at an all-time high and that “many of these births occur before the pregnancy is considered ‘term’ at 39 weeks.” This is one of the most extreme examples of the detriment of intervening in the labor process; labor is often induced before full fetal development is complete, increasing risks for all sorts of medical problems for those children. The New York Times reported on this trend in 2008 (emphasis added):

A study of single births from 1996 to 2004 found an increase of one percentage point in premature deliveries, to 10.7 percent from 9.7. Ninety-two percent of those premature deliveries were by Caesarean. Most were “late preterm,” born after 34 to 37 weeks of pregnancy, instead of the normal 38 to 42 weeks.

Essentially, we are producing infants born prematurely through our own practices of c-section and induction. And that prematurity has serious risks and implications for the health of the child, outlined in ACOG’s new guidelines:

Early-term infants have higher rates of respiratory distress, respiratory failure, pneumonia, and admission to neonatal intensive care units compared with infants born at 39 to 40 weeks gestation. Infants born at 37 to 38 weeks also have a higher mortality rate than those born later.

In particular, the new guidelines respond sternly to the practice of inducing labor or scheduling a c-section because of fears of fetal size. From the statement:

There are certain medical indications that require early delivery, including preeclampsia/eclampsia, fetal growth restriction, placental abruption, multiple fetuses, and poorly controlled diabetes. However, suspecting that a baby is macrosomic (large) is not an indication to induce or deliver by cesarean before 39 weeks.

How Long Must Pregnant Individuals Wait?

Unfortunately, it could take years for these changes to go into effect. Just look at the history of episiotomies. In the 1950s and ’60s, episiotomies, a cut in the perineum (the region between the anus and vagina), were recommended as routine practice during labor. At the time it was believed that an episiotomy was preferable to the natural tearing that is very common during vaginal delivery, and that the straight incision of an episiotomy was easier to repair. A 2012 Huffington Post article outlines this history, and how the practice came to dominate by the 1980s, occurring in more than 60 percent of deliveries.

It was only then that clinical trials were conducted to examine the impacts of episiotomy in comparison to natural tearing, and the results were staggering:

Clinical trials conducted in the ’80s and ’90s found that episiotomy cuts can, in fact, turn into even deeper lacerations during delivery, damaging the area around the rectum. Then, in 2005, a sweeping review published in the Journal of the American Medical Association found no benefits to routine episiotomy. A year later, the American Congress of Obstetricians and Gynecologists issued new guidelines, saying that episiotomy during labor should be restricted because doctors had previously underestimated the risk of bad outcomes later on, such as painful sex and possible incontinence.

Decades after those clinical trials, and seven years after the new ACOG recommendations, it’s unclear exactly how the new recommendations regarding episiotomy are being implemented. In 2005, the year before the ACOG recommendations, a study in the Journal of the American Medical Association (referenced in the Huffington Post article) estimated that 25 to 30 percent of vaginal deliveries still involved episiotomy. The 2010 National Hospital Discharge Survey reported that roughly 320,000 episiotomies were performed in the United States that year.

These practices don’t just affect the United States, but also other countries that often follow U.S. medical protocol but that might not adapt to new standards and reversals in practice as quickly. In 2004 I spent a semester studying abroad in Ecuador, where I had an internship at a public maternity ward. Every single vaginal birth that occurred in that hospital involved an episiotomy, even though the medical students and residents studying there told me they knew it was no longer standard practice in the United States. As a nation that often has significant influence on medical practice abroad, the imperative is great to ensure that our recommendations are fact-based and clinically proven.

The point is that it can take a really long time for recommendations from groups like ACOG to actually change the course of obstetric practice in the United States, particularly when those recommendations are trying to address common practices. This is because of how medical education works, how challenging it is to change one’s routine practices after long-established practices take hold, and even the time and attention paid by current practitioners to the most recent research and recommendations.

So I’m glad to see ACOG taking such a bold stance in supporting “mother nature’s” role in the beginning of labor, but I know that it may take a long time for these recommendations to actually affect the use of inductions and pre-term c-sections as parts of standard obstetrical practice. That’s a huge challenge, because these practices very clearly put the health and wellbeing of babies and parents at risk.

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  • http://www.facebook.com/Feral.9.Hex Carla Clark

    Um, this should be the choice of the woman. You see, this is part of the reason why I don’t want to be pregnant. Because we are telling physicians to not interfere during labour, not telling them to inform women of the risks and get their explicit consent before going ahead. Ugh.