Labor Day

New evidence and guidelines for laboring women: Women who are considered to have low-risk pregnancies should be allowed to spend more time in labor, to reduce the risk of having an unnecessary C-section.

Until recently, little research has been done on laboring women since 1955, when Dr. Friedman of Columbia University published a landmark study describing the average amount of time it took women to dilate during labor. Dr. Friedman studied women’s labor and plotted it on a graph. He found that the average length of time it took first-time mothers to get from 0 cm to 4 cm (known as latent labor) was 8.6 hours (± 6 hours). During the active phase of labor the rate of dilation sped up, and the average length of the time from 4 to 10 cm was 4.9 hours (± 4 hours). Once dilated to 10cm, the average length of pushing was 1 hour (± 0.8 hours). From this data the average length of time it took for a woman to dilate each centimeter could essentially be predicted. This graph became known as the “Friedman’s Curve” and for years was (and in many cases, still is) used as the gold standard for managing women’s labor and its progress.

The problem? For starters, the data is nearly 60 years old. Medicine has changed, women have changed. We no longer sedate women into a state of sub-consciousness during labor and delivery like was done in the 1950s. Instead, we commonly request epidurals. Pitocin is used much more frequently for both labor induction and augmentation. Today’s pregnant women are different, too. We are older and tend to weigh more. The methods of delivery have changed as well (vacuum assistance, fetal heart rate monitoring, supine positioning). All of these have effects on the rate of labor, either slowing down or speeding up. Suffice to say that in today’s obstetric world, all of these factors may render Friedman’s curve inaccurate.

And yet, first time moms especially, continue to be measured using Friedman’s curve. When they don’t conform, they are labeled as “failure to progress” during labor based on these [now antiquated] adopted time intervals. Failure to progress often results in a Cesarean Section (C-section). In 2013, researchers published a report that showed the overall C-section rate among first-time mothers was 30.8%, and more than 1 in 3 of these were due to a diagnosis of failure to progress.  Many of these women had not even reached 5 cm dilation before they were taken to surgery. This means that many of these women were still in very early labor.  Out of women who reach the pushing phase of labor, 1 out of 3 of cesarean deliveries for failure to progress during pushing were performed at less than 3 hours of pushing in first-time mothers.

The new guidelines released in February 2014 are based on recent, large-scaled studies and are aimed at reducing cesarean deliveries, specifically for first-time mothers, according to the American College of Obstetricians and the Society for Maternal-Fetal Medicine. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, there has been an alarming rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence that it is safer for mothers or babies. This raises significant concern that cesarean delivery is overused. A C-section is major surgery, and the procedure clearly increases complications for the mother and raise the risk during future pregnancies.

The new guidelines for the “safe prevention of the primary cesarean delivery” state that women in early labor should be given more time. The start of active labor has been redefined to cervical dilation of 6 centimeters, rather than previously used 4 centimeters. And, women giving birth for the first time should be allowed to push for at least three hours. If epidural anesthesia is used it can prolong labor, and women may push even longer. Techniques such as forceps and vacuums are also recommended to help with vaginal delivery.

NPR talked with Dr. Aaron Caughey, the chief of obstetrics and gynecology at Oregon Health Sciences University in Portland and lead author of the guidelines. The highlights from the conversation, including fetal heart rate monitors and C-section rates, can be found here.

For many women and our doctors these are huge changes. Knowing the new guidelines may help better manage expectations for mothers-to-be, especially first timers. Find comfort in knowing that women have been giving birth for thousands of years. Relax and let your body do the work. Miracles take time.



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