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If this is your first baby, and you are having your baby at the typical hospital with a typical obstetrician, you are at considerable risk of having a cesarean for failure to progress that could have been avoided. Why? Because:

1. The typical obstetrician has unrealistic expectations of how fast first labors should progress, and,
2. The typical obstetrician’s labor management practices and policies and how the typical labor & delivery unit is set up and functions are antithetical to what best promotes labor progress.

That typical labor management in a typical hospital accomplishes the opposite of its intended goal may be hard to believe, but it’s true. Research supports this and so do the statistics.

Let’s start with them: the US cesarean rate at low-risk first births (full term, one head-down baby) is 27 percent—that’s more than one in four¹³—and it’s been this high for decades. In contrast, studies report cesarean rates ranging from 5 to 13 percent in low-risk first births beginning at home or in freestanding birth centers.⁹

Now you’ve got the statistical proof. The rest of this article will back up my contentions as to why you’re at risk. Once I’ve done that, I’ll end with “Your Takeaway,” which will be what steps you can take to protect yourself. If you don’t feel the need to be persuaded, feel free to jump ahead to that section.

Expectations of Rate of Labor Progress in First Labors Don’t Match Reality

Beliefs about how fast labor should progress in first labors and what to do when progress doesn’t meet expectations have come from a mash up of two sources. One is a study published in 1955 that graphed progress versus time in 500 first labors.⁸ That study generated the famous Friedman curve, named after its author, and that curve became the standard by which labor progress has been judged ever since. The source for how to prevent and treat labors deemed prolonged is a set of policies dubbed Active Management of Labor by the group of Irish obstetricians who developed it in the 1960s.¹⁸

According to Friedman’s graph, cervical dilation from 0 to 4 centimeters takes an average of 8.6 hours (latent labor). At this point, labor speeds up (active labor) and averages 4.9 hours to get to full dilation at 10 centimeters. Once active phase is reached, the average pace of dilation is 3 centimeters per hour, and the slowest-but-still-normal rate is 1.2 centimeters per hour, this rate being the threshold demarcating the slowest 5 percent of labors from the faster 95 percent. Once full dilation is reached, the average length of the pushing phase is 1 hour, and the cutoff for slowest-but-still-normal pushing duration is 2.5 hours.

As for managing labors, the intent of Active Management was to preemptively address failure to progress by keeping labor progress within bounds considered to be normal. Elements that have been widely adopted from it are: Track labor progress on a graph of cervical dilation versus time in the dilation phase and descent of the baby through the pelvis versus time in the pushing phase. Break the bag of waters early in labor to intensify contractions. Once cervical dilation reaches 3 to 4 centimeters, administer IV oxytocin (the hormone that causes contractions) in doses far higher than produced naturally if dilation progress falls below 1 centimeter per hour. If progress doesn’t pick up after a couple of hours of oxytocin treatment, deliver the baby via cesarean. Similarly, if the birth isn’t imminent after two hours of pushing, if the head is low enough, deliver by instruments (vacuum extraction or much less commonly forceps) or by cesarean if it isn’t.

In the early- to the mid-2010s, research began appearing that contradicted the Friedman curve—no surprise there considering the degree to which labor management today differs from the 1950s. Epidurals didn’t exist back then, and all but a few percent of Friedman’s study population labored semi- or completely unconscious under a mixture of opioid and scopolamine (twilight sleep). Also, while only 2 percent of his population had cesareans, more than half were delivered by forceps. We now know that in contemporary populations, the increase in pace occurs at 5 to 6 centimeters dilation, not 3 to 4; that the demarcation line for slower than normal pace in first labors is half a centimeter per hour, not 1 centimeter; and that a 3-hour pushing phase, not 2, is the upper limit of normal in first labors and should be increased by an additional hour if there’s an epidural in place.^{2, 22} Furthermore, not acknowledged then or now is that smooth, continuous labor progress is an artifact of plotting hundreds of labors. A graph tells you nothing about the rate at which individual labors may progress and still end in spontaneous birth to a healthy baby.⁷ As anyone who works with laboring women and birthing people knows, while some labors follow the graph, others progress slowly but steadily, make quantum leaps, or plateau for hours and then resume progress.²¹

In recent years, guidelines have been updated to reflect our new understanding,^{2, 22} but the guideline changes haven’t had much effect on the ground. The old limits are so entrenched in belief and practice that typical labor management still holds first labors to the Friedman unrealistic standard and treats them accordingly,^{1, 3, 16} much to the detriment of those subjected to it.

Typical Labor Management and Hospital Environments Impede Progress

This brings us to the other problem. It is not hyperbole to say that typical labor management and how typical labor & delivery units are structured and function couldn’t do better at impeding labor progress if they were designed with that intent.

To begin with, because we’re mammals, what best facilitates labor progress is an environment in which we feel safe and protected, one that is private, quiet, peaceful, familiar, and free of disturbances and interruptions.^{6, 14, 17} The typical hospital environment is none of the above. Even more important, because we’re humans, labor progresses best when we have people we trust to guide us and to provide physical and emotional comfort as we navigate the challenges of laboring and giving birth.^{6, 14} Typical L&D nursing is about monitoring, administering treatment, and assisting the doctor or midwife.

As for typical labor management, policies and practices that don’t improve outcomes with routine use and that can obstruct progress include:

• Labor induction with an unfavorable cervix¹¹
• Continuous fetal monitoring
• IV fluids¹²
• Nothing by mouth or only ice chips¹²
• Confinement to bed¹⁵
• Epidural analgesia¹⁰
• Pushing lying on the back¹⁹

As for why these factors impede labor progress, labor induction and epidurals interfere with the hormonal interactions that prepare for and orchestrate labor.⁵ Pushing while lying on the back interferes with the mechanics of birthing the baby.¹⁹ The weight of mom and baby pressing down on the bed prevents the tailbone from flexing open, and it means pushing the baby uphill.

Some of these practices are problematic because they inhibit mobility either directly, as with confinement to bed or epidural analgesia, or indirectly by tethering the laborer to tubing or wires as with induction, continuous fetal monitoring, and IVs. All of them can interfere by increasing anxiety, discomfort, or both.

Other practices and policies arise from the attempt to force labor to conform with expectations. These include:

• Rupturing membranes
• IV oxytocin, especially when administered in unphysiologic doses
• Pre-set time limits for making progress

Their use exposes women and birthing people and their babies to their potential harms such as fetal distress and postpartum hemorrhage and to avoidable cesarean and instrumental deliveries and their harms should these measures fail to have the desired effect.

Finally, we have:

• Lack of one-on-one continuous supportive care

One thing for which we have rock solid evidence is that one-on-one continuous care by a person skilled and knowledgeable in providing emotional and physical supportive care, a.k.a., a doula, decreases cesareans.⁴

Your Takeaway

So, we’ve seen that typical belief about how fast labor should progress isn’t realistic and typical labor management and the typical hospital environment inhibits rather than promotes labor progress. That brings us to what can you do to protect yourself.

During Pregnancy

At the top of the list is choosing a location for birth where the environment facilitates labor progress and care providers whose policies and practices do likewise. If you can do that, you’re home free.

• Unless there is a reason to plan hospital birth, plan to birth at home or at a freestanding birth center with professional midwives. Your home is a supportive environment by definition, and freestanding birth centers strive to provide a homelike environment because they are aware of its importance. Home and birth center births are almost all attended by midwives. To ensure they have the appropriate skills and knowledge, in the United States, make sure they are certified by either the North American Registry of Midwives or the American College of Nurse-Midwives. The former will have CPM after their name, and the latter will have CNM or CM.
• Choose (or switch to) care providers whose policies and practices promote labor progress. Here are some questions to help you determine that:
  • What are your routine policies and practices regarding IVs, eating and drinking in labor, fetal monitoring, rupturing membranes?
  • How do your practices and policies promote vaginal birth?
  • Do you have a preferred position for the birth?
  • What’s your opinion of doulas?
  • What do you consider progress delay?
  • What’s your approach to resolving progress delay?
  • Do all doctors/midwives in your practice have similar policies and practices to yours? If not, how can I ensure that I will be attended by someone who does or that the person who attends me will abide by agreements we make?
• Choose (or switch to) a hospital whose environment facilitates labor progress. Here are some questions to help you determine that:
  • What does the hospital provide to promote mobility and help me with positioning?
  • If I prefer to avoid an epidural, what non-drug alternatives and comfort measures do you offer?
  • What is the nursing staff’s opinion of doulas?
  • What are the typical management policies regarding fetal monitoring, IVs, eating and drinking, pushing position, pushing technique?
  • What percentage of your patients labor without an epidural?
  • Do you have showers or soaking tubs? How often are they used?
  • Do you have telemetry (wireless) fetal monitoring? (If you require continuous fetal monitoring, this will allow you to be mobile.)
• Hire a doula. Having a doula with you ensures you have continuous one-on-one physical and emotional labor support. A doula can also help you be comfortable at home so that you arrive at the hospital in active labor.
• Take childbirth preparation classes with your partner that prepare you to labor without an epidural. You can always change your mind in labor, but you’ll have the skills you need to avoid an epidural whereas if you don’t take a class, you won’t. As a bonus, knowing what to expect and having strategies to cope with labor can also help you remain home in early labor.

During Labor

Of course, you may not have control over who attends you in labor or have the ideal environment for giving birth. Here, then, are some decisions that are under your control.

• Unless there is reason to do otherwise, delay hospital admission until active labor. Stay home until you are having regular contractions for at least an hour that occur no more than 5 minutes apart counting from the beginning of one to the beginning of the next, that last about a minute, and that are strong enough that you can’t walk or talk while you’re having one, a.k.a., the “5-1-1” rule. Ask to be checked when you arrive at the hospital and decline hospital admission unless you are at least 4 centimeters dilated and have a strong, regular contraction pattern. If you’re still in early labor, return home. If you’re feeling that things might be picking up, hang around the hospital or somewhere close by for an hour or so and then go back and get rechecked. If there hasn’t been a change, again, go home.
• Make the labor room your own. Wear your own clothes in labor. Bring several comfortable tops or gowns that are long enough for modesty and that you won’t mind if they get stained. (I packed several breastfeeding-friendly nightgowns.) Bring your bed pillow without changing the pillowcase. Having it next to your face will smell of home. Wear noise cancelling headphones or listen to music. Keep the door to the labor room closed and tape a sign to it asking people to please knock and announce themselves before entering.
• Have patience. Time is your friend and impatience your enemy. Most problems with labor progress can be resolved with giving it time and with DIY remedies. In fact, strong evidence supports that lulls in labor are normal, may be beneficial, and may occur at any point in the process.²¹
• Reject the routine use of restrictions and procedures that research shows inhibit progress:
  • Decline routine continuous fetal monitoring in favor of intermittent listening.
  • Decline a routine IV.¹²
  • Continue eating and drinking.¹²
  • Stay mobile and change positions periodically if you are in bed.
  • Push in positions other than on your back.¹⁹
  • Decline a cesarean or instrumental vaginal delivery based solely on exceeding a preset time limit.

With today’s lighter epidurals, you can still change positions during the dilation phase and push side lying or even on hands and knees or squatting if you have spotters.

What If You Need a Medical Intervention that Can Affect Progress?

If it happens that your labor requires medical intervention or restrictions, here are some ways to minimize their potential adverse effects:

• What if labor is being induced? If the cervix is unfavorable, ask if you can wait for cervical readiness. This is measured by the Bishop score, an evaluation made during a vaginal exam. A Bishop score greater than 7 predicts high probability of induction success, and as the number decreases below 7, it becomes progressively more likely that induction will end in cesarean delivery even when agents are used to ripen the cervix.²⁰ According to guidelines jointly published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, you should be allowed up to 24 hours to achieve active labor, and IV oxytocin should be administered for at least 12 to 18 hours after membrane rupture before declaring the induction a failure and proceeding to cesarean.² Decline having membranes ruptured until you are in established labor and making progress in dilation. Having intact membranes allows for an induction in which labor isn’t progressing to be paused and restarted after a respite or on another day.

• What if I need to be admitted to the hospital in early labor? Have patience. Decline medical intervention for slow progress before achieving 5 to 6 centimeters dilation.

• What if I need continuous fetal monitoring? If the hospital has telemetry (wireless) monitoring, this will enable you to be mobile. If you find the sounds and lights of the monitor distracting, ask for the sound to be turned off and cover the monitor with a towel.
• What if I need to be tethered to equipment? Don’t allow the need to stay close to or in bed to inhibit you from moving around and changing position. In bed, you can sit up, lie on your side, get on hands & knees, or squat. You can also sit in a chair, stand upright or lean over the bed and do pelvic rocking, or slow dance—rock from foot to foot—in your partner’s arms. Be creative. And don’t let the nurse’s need to readjust the monitoring sensor inhibit you.

References

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