Progress At Your Own Pace
While calendars, timelines and the ticking of clocks are a pervasive part of life today, there is arguably nowhere it is more prevalent than in the life of a pregnant woman. From the moment she sees the little plus sign or predictor eagerly flashing “1-2 weeks” the next year of life for most mothers today becomes bound by the measure of weeks, dates and finally hours and minutes.
Since time immemorial, no let me correct that, since Franz Karl Naegele came up with Naegele’s Rule in the mid 1800s, mothers-to-be have been led to believe that their due date (which I spoke about here) was set in scientific stone and that being a few days off the mark was either a concern or a bodily failure.
While we know now that this estimation should be regarded by all as exactly this… an estimation… and more focus being paid to health of mother and baby and the woman’s physiological readiness for birth, rather than the date per se, there is another degree of clock-watching that women experience which adds another level of anxiety to the birth space. It’s the clock that starts ticking when physician’s and nurses start monitoring a woman in accordance with the Friedman Curve - a time check that health organisation are now recognising as perhaps the leading cause of unnecessary intervention, caesarean and emotional trauma in birth.
If you’ve ever spoken to a mother who has had an emergency caesarean you would probably have heard the following story: I was in labour, we went to the hospital… things slowed down… I wasn’t progressing… they gave me drugs to try and get things going/speed things up… it started and was so painful… I was so exhausted. At this point the story usually goes one of two ways. a) I was so exhausted I just begged them to get it over with and we had a caesarean. b) The baby went into distress and we had to have an emergency caesarean…. thank goodness the baby is ok… thank heavens for caesareans.
I’ve simplified the progression immensely. Unless you’ve spoken to a number of women who have had babies, you probably would not realise that story, after story, after story unfolds in much the same way with slight variations in the extent of drugs given. But the result remains the same, mothers believing that birth is excruciating, believing that their bodies simply could not do it, mothers believing birth is inherently dangerous and believing that women who have achieved intervention-free births are in some way superwomen.
What these women sadly aren’t aware of is that, according to studies in the last decade, the Friedman Curve and its guidelines, have in fact been one of the biggest reasons for the growing caesarean machine.
I remember chatting to a mother a few years ago. Her story brought both her, and me, to tears and at the end she said: “That’s why I always tell anyone I meet who is pregnant to just go with a caesarean. I don’t know why anyone would consider anything else.”
All I could do was listen. I could understand her trauma - her birth was nothing she had ever envisioned. I could understand her perspective - her doctor had told her her body wasn’t working and she placed complete faith in him. I could, however, also clearly see exactly why things had progressed in the way they did. But that wasn’t for me to say.
Most women simply aren’t aware. They aren’t aware of the stages of labour. They aren’t aware of how they can optimise their comfort during each stage. And they aren’t aware of how to support the progression of birth. Most importantly, they aren’t aware that despite a call for the Friedman curve to be done away with, it continues to be the standard by which most physicians continue to manage a patient’s birth. ‘Manage’ being the key word.
What is the Friedman Curve?
The assessment and diagnostic tool was created by obstetrician Emanuel Friedman in the 1950s. His study focused on 500 first-time mothers whose births varied from singleton and multiple to breech. Some births used synthetic hormones to augment labour, some used forceps. Many of the women were giving birth in a state of Twilight Sleep*. Friedman averaged the figures and came up with a graph for the progression of an “ideal” labour. It was lauded because it gave practitioners a guide that allowed them to stop relying on intuition and it became the gold standard by which every mother’s physical ability to give birth would be measured for over 60 years.
He broke birth down strictly into three stages that practitioners would expect to happen at predicable times and measurements.
Stage 1
Dilation of the cervix and descent of the fetal head into the pelvis. This stage is divided into:
a) latent labour - early labour in which a mother begins to feel uterine contractions and experience slow dilation to 3-4cm.
b) active labour - the cervix is expected to dilate at around 3cm every hour until 10cm..
First-time mothers were given about 14 hours to go from zero to 10cm and experienced mothers eight hours. Anything slower than this and the mother would get a “failure to progress” stamp in her book of life. Any birth that progressed at a rate not on the curve was, and in many settings continues to be, considered “abnormal”. Today is continues to be used and once failure to progress has been determined, doctors then normally begin intervention with artificial hormones, manual rupture of the membranes, epidural… And a result of what is now known as the “cascade of intervention” is that labours more often than not end in c-section.
Stage 2
When the cervix is fully dilated. Mother feels strong urge to bare down and the baby’s crown becomes visible. The baby is born. Friedman’s figures asserted that this stage should take about an hour.
Stage 3
The delivery of the placenta occurs.
A call to free women from the curve
In 1998, a randomised controlled trial found that when women were only admitted into birth units when in active labour rather than when in early labour they had lower rates of epidural use and augmentation of labor, had greater satisfaction, and spent less time in the labor and delivery unit.
Studies in 2005, 2014 and 2016 all found that hospital admission in the latent phase of labor was associated with more arrests of labour and caesarean births.
In 2010. Dr Zhang released the results of his studies, calling for this outdated model of medicine to be rethought. In a nut shell, Dr Zhang found that what had previously been considered slow labour/failure to dilate by obstetricians was in fact NORMAL progressive labour.
2014 saw ACOG (The American College of Obstetrics and Gynaecology) concur with Zhang’s studies and replaced Friedman’s guidelines with new standards which have already seen a reduction in c-section rates. and in 2017, ACOG again released new guidelines to limit intervention in birth and avoid primary caesarean sections.
In a study looked at by Evident-Based Birth comparing the births of mothers using the new model of care versus the old Friedman guidelines, the results were significant. “Women who received the old model of care had a Cesarean rate more than twice as high as the women in the new model of care group. Those in the new model of care group also had fewer interventions overall; fewer women had Pitocin or had their water artificially broken. The percentage of newborns with low Apgar scores or low umbilical cord pH was higher in the old model of care group. The average length of labor was the same in both groups.”
The issue with using the friedman curve
1. Any practitioner adhering to the curve is not simply following a curve and a clock. They will be using vaginal examinations as their prime source of information to gauge a woman’s progress. We now know that this is not only unreliable and not evidence-based. The curve assumes that all woman dilate at 1 cm an hour and that birth occurs at 10cm. In reality, some women may take longer during early stages while rapidly dilating towards the end. Some women go from 1 to 10 cm in minutes. Some births may, in fact, occur before a woman has reached 10cm. The process of forcing a mother to have to undergo internal examinations when her body is deeply in need of privacy is in fact a major factor in stalling labour.
2. A mother being repeatedly told that she has not dilated any further than her last check, is left feeling defeated, depressed and as though she is failing. These emotions alone are enough to deplete energy needed for birth and inhibit any further progression . A case of negative reinforcement producing the undesired outcome.
3. The curve fails to consider prodromal labour. This is labour that can start and stop for days as a woman’s uterus “warms up” and attempts to shift a baby into a more optimal position. While the idea of “being in labour for days” sounds awful to most women today, an extended first stage of labour can/should in fact be a peaceful time in which she builds up oxytocin and endorphins (natural analgesics) for a women in an environment where she is supported to rest, refuel herself and move her body freely in ways that support the progression. Once the baby is in its optimal position, birth usually happens very quickly in a matter of hours or even minutes. For a women forced to lie in a bed, hooked up to monitors and IV drips in a clinical setting, the experience is vastly different and indeed painful.
4. The curve fails to consider that each woman brings a unique emotional history to her birth and having a history of trauma or fear of birth can inhibit labour. Creating an environment in which she feels safe and supported can alter the time and experience of birth in ways that no clock can understand.
5. The biggest flaw with Friedman’s guidelines lies in the assumption that dilation is even a sign of labour. A doctor using this curve may assess a patient at around 38 weeks and see she is slightly dilated and tell her she call her partner to bring the bags as labour is imminent. Dilation, however, is not an indicator of imminent birth. Dilation can, in fact take place slowly over a number of weeks before labour itself initiates.
6. The curve works alongside a formalised and rigidly applied theory that birth follows distinct stages. The reality, however, is that birth is birth. It unfolds in a time of its own that modern medicine insists on trying to control and we are realising now that this does not improve birth outcomes. Friedman, in his determination to get intuition out of the birth room and streamline things with strict scientific guidelines neglected to consider all the factors that can inhibit progression and what we can do to prevent this.
What inhibits progression of labour?
1. An atmosphere of fear. We know that any creature exposed to stress will stall the birth of its young until it believes danger has passed. As it goes into a state of fight, flight or freeze to protect itself, energy is diverted to muscles needed for this purpose and away from other muscles, including the uterus. The reality is that medical settings are indeed the very place that elicit a fear/stress response in most people, and pregnant mothers who are in a deeply intuitive state are arguably even more sensitive to the smells, sounds and energy of the environment, making it less than conducive for optimal uterine muscle function. When this happens oxytocin production stops, endorphins are reduced and catecholamine takes over. The circular muscles at the base of the uterus constrict and are unable to open, creating painful contractions. Instead of being told she needs to hurry up, what a mother most often simply needs is the chance to relax and have privacy or rest to get her oxytocin and endorphins going again and dilation can then continue.
2. In some births women’s cervixes have even been found to even reverse their dilation simply because they felt that uncomfortable. Ina May Gaskin’s article, Going Backwards: The Concept of Pasmo, she highlights how, while it might be considered normal or understandable in some cultures, in western medical settings it is considered a defect.
3. For birth to unfold smoothly, a synergistic flow of hormones is required: oxytocin, endorphins, serotonin and melatonin. Thanks to the work of renowned obstetrician Michel Odent it is now known that oxytocin production is strongly supported by melatonin. Melatonin is produced when the body goes in to rest and restore state in a.dark and cozy environment. In most hospital settings, however, bright fluorescent or LED lighting is a glaring reality. With regular shift changes and frequent clock watching, even in a hospital where a mother is able to dim the lights in her suite, lights will be frequently turned on as staff pop in to perform the the routine examinations they use to chart her progression.
4. Even when a woman is not aware of the Friedman’s curve being used, the awareness of time ticking is huge. At each check doctors detail how long they’ll give until their next check and how long it’s been since a mother arrived. We all know that nothing moves slower than a watched clock. The reality is that in most instances, nothing moves slower than a watched woman in labour.
NEW guidelines
According to the Consortium on Safe Labour, the active stage of labour should only be seen to start at 6cm dilation rather than 4. More time and less pressure is the new order of the day with current studies showing that dilation happens much quicker once a women has reached this stage of dilation. If labour does slow at 6cm a mother should be given at least 6 hours at 6cm before a diagnosis of arrested labour is made.
Some of ACOG’s 2017 guidelines also saw a move away from the Friedman Curve to reduce intervention in labour. They were the following:
Women should only be admitted once in active labour. If they have to be admitted during early/latent labour because of fatigue or discomfort, non-pharmalogic pain relief such as water immersion and massage should be offered, along with oral hydration (rather than movement-limiting IV drips). Women should also be encouraged to move freely or be in whatever position they choose, to encourage optimal positioning of the baby and optimal comfort for the mother.
Continuous one-to-one emotional support provided by support personnel, such as a doula is preferable. This is associated with improved outcomes for a number of reasons. Beyond the obvious reason that birth hormones flow optimally when a women is surrounded by familiar faces she trusts, having continuous care means that a mother does not have constant staff changes. Frequent changes result in staff focusing on, and being guided by, a woman’s chart rather than the state of the woman herself.
The traditional supine position during labor has known adverse effects such as hypotension and more frequent fetal heart rate decelerations. Therefore, for most women, no one position needs to be mandated or proscribed. Friedman’s research was based on women who were in the supine position.
Stop recommending valsalva pushing. Friedman’s research was done in a time when women were forced to start pushing once they’d reached what he called active labour. Allowing women to listen to their bodies and go with spontaneous rather than forced pushing improves outcomes and reduces immediate and long-term pelvic damage. Friedman believed that the final stage using forced pushing should happen in a set time. While spontaneous pushing may take a bit longer than forced, it is a process in which the woman’s body is naturally nudging the baby down which facilitates a natural numbing of perineal tissue and slow unfolding that prevents chances of tearing. It also supports steady compression of the baby which squeezes amniotic fluid out of the lungs and enables a gentle transition to life earth side.
In 2018, The World Health Organisation corroborated this information and brought out recommendations that drugs should not be given to speed up labour unless there is a genuine risk of complications.
These guidelines, however, do not mean that every physician or even hospital is on board and it therefore remains the responsibility of mothers to be informed.
What can you do to support progression of your birth?
1. Learn techniques with a trained childbirth educator to support optimal flow of birth hormones and remove anxiety and fear from your birthing environment.
2. Be aware that it is not unusual for labour to slow down, particularly at the point between active labour and birth. During this transition time birth may slow either as the body pauses to rest or because it is relaxing to allow the baby to rotate into its final optimal position. If vitals are normal, take the time to rest to regain your energy for the final “push”. Requesting privacy to be alone with your partner or support team in a quiet, safe, nurturing environment and using natural techniques to boost oxytocin production should be enough to stimulate the flow of labour again.
3. Ensure continuity of care so that you are familiar and comfortable with your care provider. Ask your care provider beforehand how they measure progression of labour and under what circumstances they would call for intervention.
4. If your cervix shows no sign of being “ripe” ie initiation of labour being imminent, mothers should avoid induction unless medically necessary.
5. Know that there is no one-size-fits-all measurement for “successful” labour ands relaxation techniques to free yourself of performance pressure.
6. Be aware that physicians sticking to the idea that birth should progress the same way in every woman are operating on a conveyor belt type system, perhaps out of time constrains and other pressures placed on them, but also largely perhaps for their own convenience. In a low-risk pregnancy, giving yourself time to enjoy (yes it is entirely possible) early labour in the comfort of your home away from these external pressures and only checking in when you know you are in established labour will negate this.
7. Remember that the clock on any wall, watch, app or smartphone is never biological. Taking the time during pregnancy to tune in to your body, your baby and your intuition is priceless and will always put you ahead of the curve.
* a morphine and scopolamine-induced state which couldn’t have been further from nap-like as the de-inhibiting effects often led to women thrashing around out of control necessitating that they be strapped down or put into straight jackets. Babies were delivered by forceps and very often had breathing difficulties due to the drugs that were still in their systems. Nevertheless, the fact that the drugs erased all memory of this left it touted by feminists of the time as a gift to women. Sources:
https://www.ncbi.nlm.nih.gov/pubmed/12388957
Colwyn Murphy is a journalist and childbirth educator. Any information presented here is educational and is not intended to replace the advice of your medical practitioner.