First, let me start off by thanking you for clicking and reading this.   Whether you are pregnant or not, you more than likely know someone who is. It is important to note that last year the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely^® campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question.   Although the Choosing Wisely^® campaign addresses many medical societies, I was most interested to read about the decisions made about obstetric care in the U.S. 

Using the findings of the Choosing Wisely^® campagin,  the American College of Obstetricians and Gynecologists (ACOG) and  American Academy of Family Physicians (AAFP) released a list this month of "Five Things Physicians and Patients Should Question" in obstetrics-gynecology. This list contains five evidence-based recommendations that can support ob-gyns and their patients in making smart choices about their care. All five recommendations are noteable, and I found myself focusing on two of the five standards of care:

1.  Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age. 

Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.

Ideally, labor should start on its own whenever possible.  Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable.  Health care practitioners should discuss the risks and benefits of their patients before considering inductions of labor without medical indications.

A favorable cervix is one that is already thinned out and starting to dilate (sometimes called 'ripe'), and the baby is settling into the pelvis.  OB's and and midwives use a system called the Bishop Score to give a measurement of cervical ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally. 

Amy Romano from Childbirth Connection questions if this new recommendation will still lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe.  Romano acknowledges that Choosing Wisely^®, ACOG and AAFP have made powerful statements that scheduled delivery is unwise if the baby or the woman might not be ready for birth.  She further states "that although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women."

I believe that an integrated approach to pregnancy and birth, a beautiful balance of trusting a womans innate birthing ability and appropriate use of technology.  Sometimes medical intervention is needed to help our body and baby.  I also believe sometimes we are too quick to run to medically manage birth and lose sight that labor does not always need help to 'move along'.  It's time to take a stand to bring childbirth back into the hands of parents, where it truly belongs.  Hiring the right professionals in this process is necessary and essential. But the responsibility of birth needs to be taken on by by Mom and Partner.  Find joy in this responsibility. Find liberation in educating yourself about birth and medical choices. Discuss your preferences of care with your OB or midwife and determine their readiness to support your beliefs and choices. 

If you don't have a plan for your birth, you will just be following someone else's.......is that ok with you?

Evidence-based links:

Problems and Hazards of Induction of Labor

Induction, C-Section & VBAC Facts

Risks of Cesarean Section