Labor is unpredictable. We have no way of knowing in advance when labor will begin, how long it will last, or how it will feel. Sure, there are some universal markers and generalizations about the process of labor, but every experience is different, and the variables are numerous. First-time mom vs. mom with a subsequent baby, baby's position during labor, home or birth center birth vs. hospital birth, pain med-free birth vs. heavy intervention birth, complications vs. low-risk mom... the list could go on. All of these factors influence the course of labor and birth.
Perhaps one of the most variable parts of a woman's labor is length. Healthy babies and mamas can come through a labor that lasts 3 hours, 12 hours, or 48 hours (or longer). Despite this fact, many health care providers in the United States place time limits on a woman's labor in the hospital. It is not uncommon for a doctor to recommend the use of Pitocin to speed up labor if a woman's cervix has not changed dilation in two hours. As a standard practice, obstetricians are encouraged to govern labor by Friedman's Curve, an analysis developed in 1955 by Dr. Emanuel Friedman that dictates how a woman's body should progress in a normal labor. The problem with this? According to Rebecca Dekker, PhD, RN, APRN, of Evidence Based Birth, who recently investigated this practice:
"Modern researchers have come to the definitive conclusion that we can no longer apply Friedman's curve to women of today's world. Too many things have changed since 1955. Women are no longer sedated during labor, but epidurals are commonplace; Pitocin is used much more frequently for both labor induction and augmentation, women are older and tend to weigh more, and forceps are hardly ever used. All of these things can either slow down or speed up the rate of labor."
A "abnormal" labor, according to Friedman's Curve, is one in which a woman is dilating less than a centimeter an hour. Care providers who adhere to these guidelines will often prescribe Pitocin to speed up labor, or if the stall continues (with no dilation for 2 or more hours), may call "failure to progress" and recommend a cesarean. According to Dekker's article, research published this year from a sample of 38,484 women showed that "10%, or 1 in 10, of all first-time mothers in the U.S. had a cesarean for failure to progress during the years 2002-2008 (Boyle, Reddy et al. 2013)."
So, if 1cm an hour dilation is considered too stringent and outdated, how long can you safely labor before intervention is called for? In 2012, the American Congress of Obstetricians and Gynecologists, the Society for Maternal Fetal Medicine, and the National Institute for Maternal and Child Health came together and issued new guidelines for stalled (or, "arrested") labor. Among the guidelines, as posted in Evidence Based Birth's article:
"Progress in the first stage should not be based solely on cervical dilation but must also take into consideration change in cervical effacement and fetal station. Similarly, progress in the second stage involves not only descent, but also rotation of the fetal head as it traverses the maternal pelvis.
Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit."
"1st stage arrest can be diagnosed ONLY if a woman has reached 6 cm and the water has broken, AND if there has been no cervical change for 4 or more hours of adequate contractions or 6 or more hours of inadequate contractions. If the mom is still less than 6 cm, then she needs additional time and interventions before an arrest of labor can be diagnosed, because she is still in early labor."
Stall during pushing can be "diagnosed if there has been no improvement in descent OR rotation of the baby after at least 4 hours in first-time moms with an epidural, at least 3 hours in first-time moms without an epidural, at least 3 hours in experienced moms with an epidural, at least 2 hours in experienced moms without an epidural."
Stall of an induced labor can be diagnosed if there is "failure to have regular (every 3 minutes) contractions and failure of the cervix to change after at least 24 hours of oxytocin (and if the water has been broken, if possible)."
How can you avoid unnecessary interventions due to a stalled labor? First, be sure to talk with your care provider well in advance of your birth. Find out her policies on allowing a normal labor to progress. If you are in labor and your care provider recommends Pitocin or cesarean due to stalled labor or "failure to progress," there are three questions to ask your care provider that will help you assess your situation:
- Is my baby OK?
- Am I ok?
- What's the risk in doing nothing or waiting?
- Walking, moving, changing positions
- Laboring in the shower
- Change in environment (time alone, dimmed lights, music, etc)
- Nipple stimulation