ACOG says labor should begin naturally—When will medical practice change?

In my latest column at RH Reality Check I talk about new guidelines issued by ACOG regarding scheduled c-sections. They were addressing the practice of scheduled c-sections that have been producing pre-term deliveries, with a particular push-back on the  reasoning of a baby being too large to be born vaginally.

For those of us who’ve been tuned into the maternity care debate, these kinds of change of practice or philosophy from a group like ACOG seem like a huge turn around. So huge, that at first I thought the whole thing was a hoax.

But, thankfully, it’s not. ACOG is actually urging providers to “let nature take it’s course.” Similarly, they just released new findings regarding the impact (potentially negative) of pitocin use on newborns.

For those of use who’ve been pushing back against rising c-section rates and pitocin use for a long time, this is a victory. But the challenge remains that history tells us it will likely take a long time for these recommendations to actually influence medical practice. In my column I use the example of episiotomy to illustrate this lag:

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.

So this is both good news, and a call to action for all of us. As consumers, advocates and doulas our efforts have contributed to these recommendations, and we must remain vigilant to ensure that they get implemented. We can share these recommendations, coming from the Association tasked with governing Obstetricians, with providers who may be reluctant. And we can keep the pressure on. It’s a long battle, but I’m heartened by these incremental signs of progress.

Read the full column here.

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