The new guidelines from ACOG

Recent changes in defining active phase of labor from 4 cm to 6 cm. This change is intended to help first time mothers avoid being given a cesarean when labor is simply slower than what was considered normal. Longer labors can certainly be normal. So when the question is asked, “How far dilated is she?” or “How far dilated am I?” the pressure for progress is extended to 6 cm now.

Active labor was considered 4 cm and a changing cervix. A long stall at 4 cm, meaning the labor is not progressing past 4 cm though contractions are regular may be a reflection of the distraction to the mother. A social gathering that seemed supportive before labor began may actually be the delaying factor for a woman who is waiting for privacy to enter the active labor phase. Tension or distrust in the environment or people in the immediate area may keep a woman from “relaxing into” labor. Or, she may simply be waiting to arrive at her birth place upon when her labor may take off quickly once she feels safe to open.

ACOG had long stated that doing a cesarean before active labor for length of labor alone (and not health indications) was unfounded. In a move to reduce the unhealthy and high cesarean rate, ACOG has taken another step. Moving the start of active labor to 5 cm for an experienced birthing woman and to 6 cm for a woman’s first labor gives women more time to labor.

The better question is, “Where’s baby in the pelvis?”
The woman and baby may need this time to help baby engage if engagement hadn’t happened yet. The baby is high, at “-3” station. Often a mother hears that baby needs to come down more and the nurse or midwife doesn’t explain station. Its OK to ask. An approximate station is helpful information even if there is a little variation in the number.

Another way to ask is, “Is the baby in the pelvis? Is the baby ballotable or well engaged?”
Answers like, “The baby is high,” or, “The baby isn’t in the pelvis yet,” also mean “-3” station.

Engagement in labor is often due to the mother choosing a position that opens the brim, and is less likely in the first time mother to be by chance or time. Opening the brim with Abdominal Release, or an Abdominal lift and tuck (not at all a tummy tuck, ladies!) can help the baby enter the top of the pelvis in about ten contractions time.

During the phase of labor near 5 cm, the first baby would often be already engaged and moving onto the pelvic floor in the midpelvis. The fetal station would be “0” or nearly “0” at “-1” or “+1”.

Giving extra hours for those women having a longer labor whose baby is near “0” station may give time to help baby rotate through the pelvic floor.
Easing this time is often helped with the Sidelying Release. Choosing a myofascial release is choosing the first Principle of Balance. Labor may pause an hour as the uterus has a short rest and then will resume. Sometimes, though, baby comes quickly so be where you want to have the baby. If labor doesn’t proceed when baby is in the midpelvis, a lunge will give room for the bones and for the tighter pelvic floor to open on one side. Do the lunge through a contraction for 3 contractions on each side and then repeat.

Waiting for a labor to progress that is holding at 6 cm, or 5, hour after hour may reflect a misunderstanding of labor progress. First attend to the soft tissues and alignment (or balance) of the pelvis. That’s why Spinning Babies first principle is Balance. Then open the brim or open the midpelvs depending on how far down baby has gotten with the Principles of Gravity and Movement. That’s where were find the techniques and moves to open the pelvis.

Understanding the rotation needs of the baby and the levels of the pelvis, we can support labor progress more smoothly and save a woman many hours of waiting. Sometimes, as in lack of engagement, or transverse arrest waiting can take days and still not lead to progress. Let’s increase our observation skills and ask the right questions to find out where baby is and what baby needs to make the next turn on the journey.

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