#253 | The ACOG Files: Exploring the Guidelines That Support Physiologic Birth

So I want to arm everyone today with some of the information a cog has published, because your doctor shouldn't have a leg to stand on to counter this stuff. This is their organization. However, a cod concluded got this, the risk increase may not be entirely related to the duration of labor, but to the health care providers actions and interventions in response to the longer labor.

There are so many statements in this one guideline that support everything that we talk about, and that obstetricians and even hospital based midwives are not necessarily following, women need to have these statements in their back pocket. So when they go to their prenatal care, or when they're in labor, they can pull it out and be like, Listen, this is what your governing body says, this is evidence based.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Big episode today

Yes. And I have no idea what it is.

It's a little overdue. Don't worry, you don't need to be prepared, you're gonna be fine. You're fine. I wanted to do and I'm excited. Yeah. Well, everyone should be excited about this one. This is basically a conversation I like to have at the end of my HypnoBirthing class with clients. Because here's why. Because it's one thing when you're listening to a podcast like ours, and getting really good evidence based research and information, or attending the classes on our Patreon platform, or reading all the good books you're reading, and then you go to your medical provider and you feel like you're getting a whole different story. And I never forgot, it's kind of funny. And I might have mentioned this before, but I never forgot years ago, right? When I was a new teacher, I had a couple who went to their doctor after the segment where I taught about the importance and the value of delayed cord clamping, and letting the baby get all of their cord blood. And they brought this to their doctor, because that is a trend that's improved in our area over the years, there is less pushback for the couples who want to do delayed cord clamping that's one thing I have noticed, improve. But anyway, back then it was a lot it was a lot harder. And they went to their doctor and said they want to do delayed. And the doctor was acting like he had no idea what they were talking about. And they said, Well, I mean, we're taking our HypnoBirthing class, and we've learned all this. And she pulled out a folder with some information she had found herself on the internet. And she was really very convinced by what I taught him by her own research. The men, I'll never forget, the doctor said I'm sorry, your Hypno who is telling you this? That's the word Hypno. Who? Well, I thought, Well, I mean, I know it's, it's just it. I think what it showed me is these couples have a real problem, too. Basically, it's one thing if a couple goes to prenatal visit, and they say Oh, well, we've learned all this stuff from our favorite podcast, and we want to talk to you about it. And it's quite another thing to go to the doctor with the exact same wishes and the exact same information but to say, look, Doc, this is coming from a cog, this is coming from your people. So I want to arm everyone today with some of the information a cog has published, because your doctor shouldn't have a leg to stand on to counter this stuff. This is their organization. So let's start with a quick statement on coercion.

This is one of the best I love this. This is one of their best statements. And we don't talk about it enough because they specifically address coercion in the way that we do. And they still do it anyway.

Yeah. It's like, the consumer doesn't know that this statement exists, and they just pretend it doesn't. So we want you to know that it's not because if you go to them and say look, ACOG says this, it has a lot more credibility to the doctor than saying your OP caster told you this, even though both sources are perfectly correct, in this case, so a quick statement on coercion, opposition to criminalization of individuals during pregnancy and the postpartum period. Now, I believe this came about because of either that one rare instance or a small handful of them where doctors had the god it's like the audacity to go get a court order mid birth for some women and there was a woman in the Northwest who wanted a VBAC. And I can't remember if she had had one C section it doesn't even matter. at her, she wanted a VBAC. She was planning a home birth, and it was a transfer. Do you remember this story? It was quite famous.

No, she, um, she got transferred. I think it was an Oregon or Washington. She was transferred to the hospital, and they flat out refused to support a vaginal birth. And there was nothing emergent. As I recall, I could be wrong. But this was a true controversy. It wasn't like, Well, her baby was in danger. It was nothing like that. They just said, we don't do VBAC. And you're having a C section and she refused. And she knew she had the right to refuse. They overrode her wishes by getting an immediate court order. It's like an ex parte motion or something. They go immediately to a judge, and they got a court order, give her a C section. Can you believe that? They put her into surgery against her wishes? Yeah. Have you ever heard any story like that? I have heard stories like that. But ya know, they are still going on stories like that.

Yeah. So that a court order can override our right to informed consent. So ACOG spoke up about this. And they issued a statement that that's why it says opposition to criminalization of individuals during pregnancy and the postpartum period. They're saying don't make it unlawful for women to refuse what you're imposing on them. So they're opposed to criminalizing women who are just there to have their babies on their terms. And this is what it says, Oh, by the way, ACOG I don't want to presume anything. A cog stands for the American College of Obstetricians and Gynecologists. How would you describe what a cog is? Trisha? ACOG is the governing body over obstetricians and gynecologist in the United States. Just like for me, it's acnm, the American College of nurse midwives, they licensed me, and they have policies. Okay.

The college opposes the use of coerced medical or surgical interventions for pregnant women, including the use of the courts to mandate medical intervention for unwilling patients. The American Medical Association also supports this premise and its statement regarding legal interventions during pregnancy. This ama statement says that judicial intervention is inappropriate when a person has made an informed refusal of a medical treatment designed to benefit their fetus their baby. Of note, coercive tactics often lead individuals to acquiesce without a court order. I think that's a very important sentence. coercive. They're saying coercive tactics often lead individuals to acquiesce without a court order. So women given just because of the pressure alone to acquiesce is to go along with without saying, Yes, fine. I agree, let's do it. to acquiesce is just to kind of quietly go along with something and they're sit there noting coercive tactics work about as effectively as a court order anyway, so they must not use coercion.

And it's so easy to do. It's just so easy for because of the power differential, and the fact that women are in the most vulnerable state when they're giving birth and they're talking about not necessarily themselves, but their baby who they would do anything in the world to protect. It's so easy to acquiesce.

And then it says the physicians duty is to provide appropriate information so the pregnant woman may make an informed and thoughtful decision not to dictate what that decision should be. A ca believes it is unethical for medical practitioners to use manipulation, coercion or threats of criminalization to compel patients toward a particular medical decision or treatment, including during pregnancy and postpartum. Implicit bias regarding race and class often influenced the decision to utilize coercive tactics or judicial intervention. That reminds me of a client I had, who was refusing the saline lock the hep lock. And the doctor I ended up reporting this and swift action was taken but the doctor she was eight centimeters and the doctor said if you don't put this in your hand right now, if you don't let me put this in your hand right now, you're gonna have to leave and go have your baby somewhere else. So not only is that against what ACOG is saying, but that is also unlawful. You can't actually kick a patient out of a hospital like that.

You can release them from your carers and provider though. Yes, you can. But once they're in the hospital and they're in medicine, someone has to take care of them. Yep, you can't adopt them. You can't kick them out of the hospital right? Either one can refuse to work with the other either one can but the hospital can't kick them out. It wasn't true. You'll have to leave and birth your baby somewhere else. That wasn't true. Okay, so anything else to say about coercion?

I mean, I think that women giving birth should print out this statement makes should carry it with them to every prenatal appointment and anytime that they feel that they are being pressured into a decision that they do not feel comfortable with. They should remind their provider of this guideline it So you're right in the United States anyway. But it's very helpful and handy that ACOG specifically has made a comment about this. And they they preemptively said don't go get a court order either. Okay, so just to add a little bit more to the statement, they go on further to say that the use of coercion is not only ethically impermissible, but also medically inadvisable, because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for an obstetrician gynecologist to attempt to influence patients toward a clinical decision using coercion. It is never acceptable.

The problem becomes that just the wrong doctor with the wrong approach, and the big enough ego is going to dispute what coercion means there's the gray area, that's the only gray area, the woman can say you're coercing me, you're telling me something horrible is going to happen to my baby, if I don't go for an induction on Monday and the doctor is going, that's not coercion, that's 24 years of experience that like, that's they're just going to come back with rhetoric, but you have to remain clear on that you have to know how to recognize coercion, and don't get into a debate about it. It's clear. And I think a cog did a really good job explaining and providing examples of what coercion looks and feels like and how women tend to respond to it. Anything else? Before we go on to the next?

No, I think we covered that pretty well. Okay,

so in August of 2022, A call came out with a statement called Safe prevention of the primary cesarean section. And I just want to share a few things here because these are also totally consistent with what you and I teach and talk about. So they do say right off the bat, the top reason versus air infection in the United States is labor dystocia, also known as failure to progress and fetal distress. And here's a quote, it may be necessary to revisit the definition of labor dystocia, because Recent data shows, actually, longtime data shows that labor progresses at a rate substantially slower than what was originally thought. Yes. What was originally fought. Trisha, how long ago was that? 80 years ago, the the freedmen? Like, the 1950s 74 years ago at this point, yeah, at least right. So fine. They again, it takes them this long to come around. It's It's unbelievable, like two generations, three, three generations to come around 18 years or something. Isn't that the right number? 13 or 17 years?

13 years? I believe? I don't know where I know, this is said I just don't know the original source. So I don't talk about a lot because I just hear people say it. So I don't know if it's true. But I don't know who would have done this. One of those. They it's one of those right. But they say it takes an average of 17 years for a hospital to implement a policy after updates are made. Yeah, I don't know the source of that. I heard Karen on pain, free birth say that. But I didn't see a source and I, I don't want to repeat it unless I find the source. We should have asked her that lesson we talked to her would have been good. But that's an I believe it. I see that I've been in business for 18 years. And I absolutely see that. And I agree with it. I just I don't know who would have been able to do that study.

Do you remember when the guidelines came out about allowing women to eat and drink and labor when they? Yeah, what year was that? 2015. Okay, so we're nine years in and still not seeing that change in the hospital. So we know it's at least nine years.

Yeah, we're not. And they're also starting to backpedal about it too, which is interesting. I was just reading about that in recent days. And it said, there was one one study showed there was one single case of aspiration out of 1.4 million births. And of course, that only happens in the event of general anesthesia. And 1000s of women had that there was one single case of it. And here we are still depriving women of food, and often fluid, when the research actually shows that depriving her leads to these top two reasons of cesarean section failure to progress and fetal distress. So we're putting all those women at risk, supposedly, to save that one woman. But that's baloney. That's not what's going on. It's just more of the unnecessary control tactics, because that's not justifiable by any reasonable person's estimation. We don't even know why that could have happened with that one woman. We don't know if she weighed 625 pounds. We don't know what kind of condition she was in. We didn't know anything. We didn't know if she was allergic to the last meal. We don't know that it had anything to do with anything she ate, right? We don't know.

That's right. That just happened. Somebody actually said that. That's absolutely correct. And it actually said that they don't even know if it's attributable to the fact that she ate. Thank you for I mean, people who are in accidents of any kind who need immediate general anesthesia, they don't tend to concerned about when they last ate or drank. They just treat them and you don't hear of a lot of No. Well, if it were really a problem, it would be happening a lot more in emergency situations. Absolutely. It just doesn't. Alright.

Now, the next thing it said is increasing women's access to non medical interventions during labor, such as continuous labor support has been shown to reduce the zerene rates. Yes, we know. And then I think back to my doctor saying You sure you spend all that money on a doula? Just make sure she remembers who's in charge. So they know. They know they're better outcomes. Okay, the next one this is another quote for most pregnancies is Erin appears to pose appears. We also know this conclusively for most pregnancies, this area appears to pose greater risk over vaginal delivery. And their data shows it to be nearly five times the risk to the mother. So yes, it appears to is that factoring in the long term risk or just the risk of that current cesarean because we know the risk of future? I'm sure it's just the perinatal risk for that pregnancy, right and there and the risk is even bigger for her future.

Yes, and I don't know who's ever going to do the research or care about that at all. Like now all of these women who had zero hands are now looking at VBAC situations. And were they given less VBAC support because they had one initial cesarean and now I don't think anyone wants to do that research for what happens to their future pregnancies if they have multiple sis Aryans, right? How risky those pregnancies can become. Yep. In fact, the World Health Organization has been publishing data supporting this since the 80s. First time, moms active labor is 14 to 20 hours on average, a prolonged labor of greater than 20 hours should not be an indication for cesarean section, what did my doctor tell me in 2005, you get 10 hours. They're saying, Don't even say that to a woman when she is looking at 20 plus hours? Hallelujah. What statement is this? What guideline is this ACOG August 2022, safe prevention of the primary C section. And that's this is what I this is how I kind of end my class with my couples because they listen, you now know so much, you know more about birth, probably than anyone you'll ever meet the rest of your life. But now you have to go partner with these medical providers who might not be on board. So I say this is what ACOG says this is going to really help you in that relationship with that doctor. So I read these and I was like, Oh, thank God really helps couples, because if it was contrary to the evidence, and sometimes it is, yes, that's, that's very difficult. Alright. And of course, we must remember and you and I have always said this, there is no correlation between the duration of a woman's labor and the outcome whatsoever. And here's another quote, that's great. adverse outcomes have not been associated with the duration of the second stage of labor, crushing. And then it goes on to say that when women have pushed for five hours or more, none of the following outcomes have been found one low Apgar in baby, two umbilical cord issues, they listed various or three the need to go to the neonatal intensive care unit. They did see slightly worse outcomes in moms as far as obviously increased tearing and increased C sections however them a cod concluded got this. However, the risk increase may not be entirely related to the duration of labor, but to the healthcare providers actions and interventions in response to the longer labor. Meaning she wasn't more likely to have a SI session because she pushed for five hours. As the doctor got tired of waiting and said, That's it, we're going to see section. So the women who pushed for five hours were more likely to have a C section than the women who pushed for 90 minutes of that's, that's less common sense.

Or more likely to have a vacuum or a force up delivery, which would then lead to worse outcomes for her.

That's true, too. Yeah, that's exactly right. Another indirect reason, but not specifically because pushing was long. Right? Okay. On fetal distress, they said it's often overdiagnosed I'm sure you agree with that wholeheartedly. Trisha. That's the kind of thing you understand very well, right?

Well, not only is it over diagnosed, but it's induced in women through the use of Pitocin. What's the actual leading cause of fetal distress

position on oxygen deprivation? Pitocin, the use of Pitocin.
They said it's often the over diagnosed and providers shouldn't jump to C section. Can you believe that? Everyone listened to that? I mean, if if they are getting fetal distress, don't jump to C section. It says providers should try other measures first, such as position changes there you go to improve fetal heart rate patterns. The first thing they should say before this is let's start by saying women shouldn't be continuously monitored. They shouldn't be continuously monitored, and they shouldn't be forced. Just to be on their backs, if that isn't the position that they're choosing, because she's going to feel out the best position. So yeah, the fact that they even have to say position changes is kind of interesting to me. If women weren't on their backs to begin with fetal distress wouldn't be diagnosed so often. And of course, I love this because big babies is a topic very close to my heart, as you know, they say this suspected fetal macrosomia. You know, the word I don't use, but they say it suspected fetal macrosomia, which they just described as babies over 813 is not an indication for delivery. And is rarely an indication for a C- section is not an indication for delivery. What is that? When they do an ultrasound and say, Gosh, you've got founder, and they're not an indication for induction? No, no, no, okay. Meta analysis was done on this. And when women had a late pregnancy, ultrasound, and they found quote, big babies in there, they were actually wrong about it. By the time all was said and done. But when they saw big babies, which they found in one of three women, they told a third of them to go straight to scheduled C section. So immediate deliveries with their son, they told 40% of that third, that they didn't have a choice. So 12% of all the women in total, were told, You're having a sick scheduled C section now and you don't have a choice. The remaining two thirds were told to be induced with Pitocin. And 20% of them were told they didn't have a choice. But even in the best case scenario, the women who were told, Go get Pitocin not a C section, and they weren't told you don't have a choice. Just think of the distress on that woman. Gosh, your baby's big. We really think you need to go be induced. Look, it's up to you. It's up to you. We can't make you do it. But yeah, it's what we said, I've planted the practical version. Exactly.

They've planted the seed of fear that every day she waits, her baby's getting bigger and bigger and less likely to fit through her pelvis, which we know is complete nonsense. And why the fear of a big baby is actually more harmful than the big baby itself because it leads to unnecessary interventions. Yes, and there were significantly worse outcomes in the category of women whose babies were suspected to be large as compared to the women who actually Earth large babies, but it was not suspected. And then the statement goes on to say patients should be counseled that estimates of fetal weight, particularly in late gestation are imprecise. Ultrasound performed late in pregnancy has been associated with the unintended consequence of increases during delivery with no evidence of neonatal benefit. third trimester ultrasound for estimated fetal weight in third trimester should be used sparingly and with clear indications. In other words, for a clear purpose we just talked about

ACOG is ACOG is singing our song.

Exactly. Say that's why this episode is so important. It's exactly what we said when we had the conversation with Stu. I said, I told my clients only get one if you have a reason to and it's hard to convince women back because they want to see their babies excited to see their babies.

But almost no obstetricians are following that guideline. Because right, everybody's doing third trimester ultrasounds. That's right. That's right. And they're making money for doing it.

They're coming up with an indication. The latest is that your baby's not growing properly. But the best case scenario they say let's check on things. Let's see how your baby's doing. They just they use it the way they used to use a Doppler. I'm to check on your baby. Okay, last thing on this statement was about twins. Another great segment that we're going to like hearing, quote, women with twins are now having C sections 68% of the time, even with both babies head down. It goes on to say Severian delivery has not improved outcomes. vaginal birth is recommended when the first baby is head down regardless of the position of Baby B. Is that great?

I love it. I mean, there. There are so many statements in this one guideline that support everything that we talk about and that obstetricians and even hospital based midwives are not necessarily following or hospital policies aren't following. And women need to have these statements in their back pocket. So when they go to their prenatal care or when they're in labor, they can pull it out and be like, Listen, this is what you're licensed licensing board governing body says this is what I want. This is evidence based. And your people are saying this not my hypno-who. You know what I? I've learned a lot about HypnoBirthing since working with you and I have to say when I was in midwifery school and when I was pregnant, I was a little turned off by the HypnoBirthing myself because it does sound a little woowoo I wish they would have given it to you First name, because it's it's so it what it's actually about is so important and so real and true. But it is a little Hypno woohoo. First

of all, I just want to start by saying, You're the one who posted everyone's tarot card readings on New Year's. And you're the one who gave me crystals, which I love, by the way to have next to me when I sleep at night, you have them on your nightstand and you gave me them for Christmas for my nightstand. So it's pretty funny hearing you talk about Lulu, you're talking to someone who's like, Look at me. I'm such a research person. I've lived my mind. No, no, I know. And I know you. But now you understand how easy it is to discredit other people because you yourself never even knew about it. And it does sound strange. And that's why I always laugh that the father's end up loving my class because they show up just because they love their wives, they want to be supportive. And then they're just like, oh my gosh, this is it's so rational. It's so much evidence. And every single technique and HypnoBirthing is exactly the techniques taught in yoga, every single one. Its physiology, its breath, its visualization. And we know factually, that these things work and you take the most type a people and they love HypnoBirthing and they love yoga, because they need to access that part of themselves.

Yeah, it's actually right up my alley. I mean, I you know, I was all into the I read spiritual midwifery and all that in my midwifery training, but for some reason HypnoBirthing just never caught my attention.

Well, Hypno means calm, focused. That's what hypnosis stands for. But a lot of people like I can't say a lot. But I mean, I've had so many couples, it's in the 1000s now, but I've had like three or four people say to me over the years, they need to have a different name, though, I really had the wrong impression of this. And I thought really, I don't I didn't get I didn't the name didn't turn me off the first time I heard it when I had no idea what it meant. But it didn't turn me off. But now I know, it just simply stands for relaxed and focused. And that right there means your your conscious mind is focused and your subconscious is receptive. It should be called

embodied birthing.

Well, I like that. Okay. And then finally, this is from ACOG guidelines of 2017. And to my knowledge, none of these have been overwritten or changed. But I do want to get the date out there. Because, you know, it's important to know when each of these is published, I'm just going to tick off some of the things they have here that I think are so important one routine amniote me isn't necessary. Now that one, I have mixed emotions around because they're their language is purposefully soft. It's kind of like they said, it appears What did they say? Right? It appears that they're not as good of outcomes. It's rather it's a routine me out amniote Me is harmful, it's harmful.

And they're careful because they know if the doctors are in a litigation, they don't want to have damning language that is going to be used against the doctor. So they're very soft, but we can read between the lines, routine, Amjad me isn't necessary. Okay, we'll take it. The continuous use of electronic fetal monitor has not improved outcomes for low risk women. Everybody knows this. But ACOG is finally saying it. You don't need electronic fetal monitor if you're especially if you're low risk. And then there's the whole debate about what low risk and when high risk even means, because there are so many women called the high risk you and I wholeheartedly disagree with. Look at how they look at how softly they put this one, Trisha. No one position for birthing needs to be mandated or prescribed. When it should just say let women choose their own position.

It should say for the health of the mother and baby a woman should be free to choose her position and move freely throughout labor and rewrite it for them. Yes, you

should reread it. Labor and Delivery. Yeah, because a lot of times doctors are like, Oh, sure, you know, but when the baby's coming out, I'm going to need you on your back. And it's you know, I

would really help. Here's what would really help. Somebody needs to go into hospital labor rooms and redesign the rooms and the bed needs to be not upright. Actually, this just get rid of the bed really. It's the focal point of the room. So the woman ends up in the bed and when she's in the bed, she doesn't have a lot of position changes and position options. The back is going to be the most natural especially since the beds are upright. You know the beds I mean when they fold up. Yeah, they're set that way. They're not set flat, they're set at an incline. So the position that she automatically assumes when she gets in bed is on her back.

That's so true. She's not going to be as likely to go on her hands and knees because she'll only have half the bed at her disposal to do or her side right which would require laying the bed down which is effort well require somebody else to do so the way hospital rooms are designed is a big part of the problem. The bed should be like an accessory in the corner. The room should have a birth stool and a birth ball as the focal point Yeah, that's great. Be a mattress on the floor. Anyway required Whole new yoga mats, all sorts of things, anything but the bed in that position being the focal point of the room and crystals on a table next to the bed.

I mean, that would just change birth completely.

Okay, the next one, this one I really appreciate because a pretty in depth segment of my course where I talk for probably 20 to 30 minutes is around membranes releasing because so many women end up unnecessarily rushing off to the hospital, invariably then getting pressured into Pitocin. Because their memory is released, and they think they're in labor. And really they're not. And women have to learn when to go to the hospital and when not to go to the hospital, if and when their membranes release at the onset of labor, which is the minority of women, but it's still millions of women a year. So look at what they say here. This is great. When membranes rupture at term, that means your full term not premature before the onset of labor. So that proves that when your water breaks your membranes release, it doesn't mean labor just began. When membranes rupture at term before the onset of labor, approximately 80% will go into labor spontaneously, within 12 hours. It could be that long, it could be 12 hours before Labor even begins. And 95% within 28 hours.

In term means 37 completed weeks.

That's right. So not a premature baby. And that is not 40 weeks, you you you can be earlier. And this is still okay.

Oh yeah, right, correct. But if it's a premature baby, that's a different situation. If your group B strep positive, that's a different situation. There are there there's a whole segment of details around this that we're not going to get into today. Because the one thing that's going to cast the widest net and help the most women is simply to understand if you remember his release, it does not mean labour just began. And so many women are on their way to the hospital with that seat belt on calmly sing well, so far, it's not so bad, I feel fine. They check in there one centimeter at most. And those are the women, by far most likely to be pushed down that track to Pitocin electronic fetal monitor C section. And

I wonder how many women give the OB or midwife a call and are actually told, Don't worry, you've got 24 hours and there's a 95% chance you're going to be in labor on your own. So I feel it's back after 24 hours right? Now they're told come in, and we should check on the baby. And we should admit you. Yep.

And earlier research before they came out with this in 2017. I was teaching the research prior to this. And it doesn't contradict this, but it's still worth mentioning. It was about 82% of women went into labor within 24 hours that doesn't contradict this, it just shows that maybe there's a foreign five chance you'll go into labor within the first day. They're saying it's a little higher than that. They say 80% within 12 hours. But it's really a long time. It's a long day for women to stay calm, cool, relaxed, eat well drink, well take your time, trust labor is going to start. If it doesn't, if it really still doesn't start it is still possible to go days with your membranes released. Actually, let me keep reading almost positive that's coming up. Induction versus expectant management. That means you're waiting until Labor begins on its own, was studied with no apparent difference between the two. Can you believe that? And you believe they're saying this is my great induction versus expectant management was studied with no apparent difference, waiting 10 hours up to four days was studied. And for informed women, the choice of expectant management may be offered and supported. Now I just want to say Nancy Waner as told me for years, and she's had 1000s of women as she was there midwife she's had she has told me for years she had women who with membranes released for days. She told them what to do, how to stay hydrated, but she said you don't intervene. That is not a reason for induction. And I'm so happy to see took ACOG long enough but in 2017 there they set it. They studied up to four days, and they're coming around to agreeing with what she's been doing for decades.

They also we are not seeing it in practice. That's right.

And then they added for women who are GBS positive, however, antibiotics should not be delayed while awaiting labor and for both.

Sorry to interrupt you. I just want to clarify, antibiotics shouldn't be started. But that does not mean you need to induce labor, right? That can go get a course of antibiotics and go back home but for all of our for all of our information on that we've got our GBS episode. So everyone can listen to that because that's a very in depth conversation and I believe we provided all of the research that can be found on it so it was very, very worthwhile episode. In fact, I wrote that what you just said I wrote in parentheses to myself note this does not mean induction though it means heading to to hospital and important distinction. I just wrote that on the side myself.

Unless you're having a home birth, then your midwife can come and give your antibiotics at home. That's right.

All right. And here they go again, emotional support provided by doula is associated with improved outcomes. Benefits found in randomised trials include shortens labor, decreased need for epidural, your severity rates, fewer reports of dissatisfaction with the labor experience. Apgar rates were also higher with a doula, a review of 15 studies now they're getting honest, changing the subject, a review of 15 studies found Amjad me did not shorten the duration of labor, or lower the incidence of cesarean births. I just want to say it increases the incidence, so scissoring births. And I want to say that even if it did show that it shortens labor, who cares because the risks are not worth a shorter labor, I think that is still soft language. There's just a couple more continuous electronic fetal monitor was introduced to reduce the incidence of perinatal death and cerebral palsy. However, the widespread use of continuous EFM has not improved these outcomes in low risk women. Low Risk here is defined as no meconium no bleeding, or abnormal fetal test results during pregnancy. I wrote that in parentheses so that we would know what they're talking about. Next, to facilitate the option of heart rate monitoring OBGYN should consider adopting protocols and training staff to use handheld Dopplers, who desire such monitoring. You and I did an episode very early in 2021, with Amy Romano, called interim in auscultation. And it shows that global research shows that Dopplers intermittent auscultation results in safer birth outcomes and continuous monitoring. Can you explain why?

The main thing is that nobody can come to consensus on what heart rate pattern actually indicates that a baby is in danger. So when you're continuously monitoring a baby, and watching every heart rate variation, and seeing some patterns that look concerning, we're intervening too soon, and those babies are not always in distress. So intermittent monitoring, you don't see everything. And you know, when a baby's truly in distress, it becomes apparent in intermittent monitoring as well, you see it. So I think it's just it's like, looking for the problem. With continuous monitoring, you're sitting there watching the screen, non stop, and picking up on things that might otherwise still be normal. We just that after so many years of evaluating fetal heart rate strips, there still is not good consensus about with a category one versus two versus three. Real category three tracings are are pretty indicative of fetal distress, but it's really the middle ground Category Two is like, is that baby really in distress or not?

Yeah. And years ago, you taught a really good workshop on my business called Ask the midwife. And I remember years ago, you talked about this and said that fetal distress is far more indicative when not when the heart rate falls, as long as not a drastic low level, because that's a whole other story. But it's normal for the heart rate to dip but what you're looking for is for it to recover. So when you're watching it all the time you see it Oh, my God, you don't know and especially if they want to pounce on that opportunity with a category heart rate tracings are categorized into various types of decelerations. There's prolonged, there's variable, there's early and they all sort of have different meanings, some more ominous than others, but it is these ones that sort of are in the middle where we have a problem that we're potentially putting a baby and a mother in surgery unnecessarily for a heart rate pattern that may actually be okay for that baby. Okay.

Next, during the first stage of labor, water immersion consistently has been found to lower pain scores, relaxation techniques, that's like HypnoBirthing. That's what that's the primary technique, method and HypnoBirthing acupuncture, and massage have all demonstrated statistically significant reductions in pain in numerous studies. Shout out to Barbara Harper. We've got three episodes with her worth their weight in gold. She's been right about water birthing since the 80s. But they fall short. They say during the first stage, they're still not caught up, they're still wrong about that.

They are still not supporting actually birthing the baby in the water, because they're not informed and that's why she spends her life traveling to hospitals around the entire world from here to China. Middle East, she goes everywhere to train hospital staff and water birthing.

Well, hospitals aren't set up for it. Babies are not taught it. So they have no experience with it. Right? You know, a hospital with 10 labor rooms might have one tub or none, and it's usually out of serve It's or it hasn't been cleaned or it's, you know, it's become a storage room.

Yeah, most have none. There we go.

The hospital room should have a tub as the central focal point, not the bed. Can't believe I didn't think to say that before.

Our own local hospitals. We have tons of them in Fairfield County, but Stanford and Greenwich must be five miles from each other. And Greenwich boasts its lobster dinner and champagne. After you have a baby. And Stanford, they renovated a few years ago, and my clients were telling me you walk in and there are these opulent crystal chandeliers in the lobby. It's just like the richest it's like dripping in wealth. They don't have tubs, and they disallow midwives from practicing. So there's seducing women with this fancy who like a lobster dinner and champagne after you give birth. You kidding me?

Right. They're completely backwards about it. It is not about the chandelier and the delicious food, it is about supporting women in relaxing through labor, with having the right tools in the room to help that.

Okay, last one that they say is observational studies of maternal position during labor have found that women spontaneously assume many different positions over the course of labor. Who knew? Wow, good, whoa, rumor has it people do the same thing during sex. I always make analogies to sex, because I think there's like tons of analogies between birth and because they're very closely aligned. They're they're very closely aligned. There is little I'm continuing there's little evidence that any one position is best, although many were encouraged a supine position during labor. This position has known adverse effects.

Hello, hallelujah, a cut, including hypotension and fetal distress, low blood pressure, so decreased oxygenation to the baby of There you go, you know, distress, I,

it's the best went off your back, right? Therefore, no single position should be mandated or prescribed. Again, they're, they're being very careful with their language. And you can see this is the same sentence from their statement in 2022 that I read earlier. Okay. Um, further, women are unlikely to stay in one position during the course of labor and cannot be expected to maintain one position, it was found that upright positions shortened the duration of labor by approximately 90 minutes, they were also less likely to have a cesarean section, a cog. Good. But we've all known this for a lot longer than the date of this publication. And that's what worries me, what are they not publishing today, that we're talking about today? And they're going to come out and say, hey, look, what we just found out, right?

All the things that we're still talking about, we'll see published five or 10 years from now, or 15,

or 20. Because these took them decades, most of the stuff was available information in the 80s. And then in February of 2019, they released what they call approaches to limit intervention during labor and birth. And this one says, when not coached to breathe in a specific way women flush with an open glow glottis.

That means women push spontaneously and generally with an open mouth letting sound out as opposed to holding their breath closing their mouth, bearing down the what people refer to as purple pushing, which we know is totally harmful and inappropriate. The spontaneous pushing allows sound to come out low, guttural sound to come out with pushing. It doesn't have to you can also be quiet but most women will make a low sound with spontaneous pushing.

This goes on to say in consideration of the limited data regarding superiority of spontaneous versus Valsalva capital V pushing. What is that pushing? What is that purple pushing her publishing Valsalva with a capital V I wonder who that's named after whatever that means. Each woman should be encouraged to use her preferred and most effective technique Valsalva the definition of Valsalva is the performance of forced exploration against a closed glottis. Any activities of our daily lives such as straining during defecation or playing the saxophone entail performance of the valsalva maneuver, don't push like you're playing the saxophone. Right? the glottis is the glottis is the part of the larynx consisting of the vocal cords and the opening between them It affects voice modulation through expansion or contraction. So open glottis pushing basically means allowing your larynx to be relaxed and your your your voice to be open and expanded rather than contracted.

Okay, conclusion, quote, many common obstetric practices are of limited or uncertain benefit for low risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. satisfaction with one's birth experience is related to support from caregivers, quality of the patient caregiver relationship, and the patient's involvement in decision making. Therefore, OBGYN should be familiar with and consider using low intervention approaches. Mic drop. Thank you, ACOG.

Well, we better start teaching it in medical school, then, yeah, get some midwives in there and start teaching these babies like Barbara harbor is doing, how to have low intervention birth, or stay out of it, and focus on high risk birth, because that's what you're trying to do. All they had to do was go look at the midwifery guidelines over the years. And they they could they would have seen a lot of this. Yeah, they would have seen this all already been this is what midwives have been saying forever. I do wonder if we go look, though, if they've become a little more medical if they've had creep as well in the other direction? Because of the influence hospital based midwives? Yeah, in nurse midwifery? Yes. Yeah. Because what I've seen over the years is the very midwives that I attend, that attended my birth in my first birth, they've gotten more medical, they're doing third trimester ultrasounds, they're talking about big babies. Now, they didn't do that when I was pregnant. They were doing that they're doing on stress tests. Now, no one did that with me. Yeah, but still coming from the acnm. If you look at their protocols for practice, you will see all of this, they're good. So the takeaway, whether we like it or not, is you the pregnant woman, you and your partner, you're responsible for making sure you get the care that you need to get that you deserve. And that is theoretically supported by the American medical system but not supported in practice. It's going to come down to you, making sure you get the care that you know you're entitled to. Because unfortunately, we can't do it for you. They're not going to do it for you. The only way the system is going to change is with all of us one Earth at a time. Anything else?

What am I supposed to say after that?

Another mic drop.

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