“6 cm is the new 4 cm” - Nguyen et all, 2014
You probably heard this before: active labour starts when your cervix is 4 cm dilated. This is part of the most common definition of active labour which is still wisely used today. Whilst we shouldn’t get too focused on centimetres, as labour progress is much more than a series of subjective measurements, it is interesting to know that recent evidence has challenged this traditional definition.
Research has shown that the active phase of labour, when your cervix starts dilating at a faster pace, doesn’t actually start until your cervix is 6 cm dilated. More importantly, researchers suggest that any interventions to speed things along should not be suggested before then. This doesn’t mean you have to wait longer for “true” labour to start. Your body will do what it needs to release your baby into the world at its own pace, no matter what definitions we use. However, changing the definition of the start of active labour means delaying the start of regular observations, charting and interruptions until things are well on their way, letting your body take its time to do what is designed to do.
Arriving on delivery suite at 4 cm of dilatation and being offered interventions a few hrs later because labour is not progressing “fast enough” based on set, outdated criteria is way too common of a story in modern midwifery. We know each labour is different and dilatation rarely follows a neatly designed curve as the textbooks would have us believe. It is very reassuring to see sound evidence reflect this and it would be great if more services showed more flexibility in their assessments and definitions, supporting birthing people in their individual journey.
"Failure to progress"
This is one of the most unfortunate terms used in maternity today.
You and your body cannot fail at labour!
In fact, the only failure involved in labour progress is the inability of modern maternity services to recognise that each journey is unique and will take its own time based on many factors.
Failure to progress, or labour dystocia, is a term used to define prolonged or arrested progress in active labour. This diagnosis represents one of the main reasons for birth interventions. In the UK, failure to progress causes over 30% of caesarean sections, yet only 3-6% of labours seem to be truly arrested. That’s quite a discrepancy!
But how do we know when labour has stopped progressing? In many countries, including the UK, we are still relying on an outdated model (Friedman’s curve) that sets a very specific expectation: every birthing person’s cervix should dilate at least 2 cm every four hours, and all babies should be born within 1-2 hours of pushing. Friedman’s curve was developed in the 50 s, drawing an average “normal” pace for labour by observing 500 Caucasian women in a single hospital. Friedman’s findings have been challenged over the last 50 years, and recent evidence recognises modern birthing people may need longer to birth their babies.
The expectation that all labours should follow this set standard is a bit mad, don’t you think? There’s no other physiological function in our bodies that is measured and evaluated like this. Each labour is unique and there are many different factors that are known to potentially lengthen your labour: epidurals, induction of labour, giving birth for the first time, baby’s position (back to back or head tilted sideways), lying on your back, advanced maternal age, being overweight, fear or anxiety, being a survivor of sexual or birth trauma, your waters releasing before labour.
Labour progress should be a holistic assessment, taking into consideration the whole picture. Our bodies work in marvellous and mysterious ways and the “one-size fits all” approach simply isn’t good enough for our birthing families. As long as the birthing person and baby are well, simple measures with little or no risk should be offered to correct any suspected delay, before introducing high risk medical interventions.
"Labour is taking too long"
If you’re offered interventions because your labour is “taking too long”, remember you can always ask for more time. If you or baby are becoming unwell your birth professionals will let you know that urgent action is needed, but in the vast majority of cases it is safe for you to take some time to consider your options and take action to improve things without the need for high risk interventions.
Here are some things you could try if you feel your labour has slowed down:
Environment – dim lights, relaxing sounds and visuals, privacy, being surrounded by people you feel safe with. This will boost the release of birthing hormones and help things move along. Your birthing partner can be a great help with this.
Moving and changing position – if baby is trying to find a better position, moving and shifting your pelvis will help them find their way.
Sit on the toilet – a full bladder can get in the way of labour progress. Sitting on the toilet for a few surges can also help relax your pelvic floor, helping baby rotate and come down.
Birthing pool – if you’re feeling tense or anxious, getting in warm water can relax you and help your labour move along. If you’ve been in a pool for some time, get out for a bit, stand, move, use the toilet. Your body may just need something different for a little while.
Drinking and eating – water or isotonic drinks will keep you well hydrated as long as you drink to thirst. You may not feel hungry, but a few bites of high-calorie foods will give you a nice energy boost to give your body the fuel it needs.
Whatever turn your journey takes, trust your body and your baby, both of you were beautifully designed to do this. Medical interventions are a blessing when needed, but can’t be removed once introduced, alongside the risks they carry. So if you and baby are well, why not try to move things along with more holistic and effective measures? Drugs will be readily available if you need them, but why not try some hugs first?
