- Kenny Lin, MD, MPH
Two of the most important questions that pregnant women have are: 1) How can I improve my chances of having a normal (vaginal) delivery? and 2) Does where I plan to have my baby make a difference in birth outcomes? In the August 1st issue of AFP, Drs. Lee Dresang and Nicole Yonke review the management of spontaneous vaginal delivery by family physicians. The authors note that the following practices are associated with positive maternal and neonatal birth outcomes:
1) Encouraging patients to walk and stay in upright positions
2) Waiting until at least 6 cm dilation to diagnose active stage arrest
3) Providing continuous labor support (e.g., doulas)
4) Using intermittent auscultation in low-risk deliveries
5) Group B streptococcus prophylaxis
6) Active management of the third stage of labor
Guidelines from the American Academy of Family Physicians and American College of Obstetricians and Gynecologists encourage women with a previous low transverse uterine incision to consider a trial of labor after cesarean delivery, as most will be able to deliver vaginally.
Although obstetricians and family physicians remain the most common birth attendants in the U.S., pregnant women at low risk of complications have been increasingly turning to midwives practicing in birth centers or other out-of-hospital settings. A United Kingdom prospective cohort study that examined perinatal and maternal outcomes by planned place of birth in 64,000 healthy women with low-risk pregnancies found no differences in the odds of a composite outcome of perinatal mortality and intrapartum neonatal morbidities in freestanding midwifery centers compared to obstetric hospital units. Planned home births were associated with worse neonatal outcomes for women delivering for the first time, but not for women in subsequent pregnancies. As one might expect, labor interventions occurred most frequently in hospital settings.