The Assessment of Progress

This article was written for AIMS Journal (2011, vol. 23, no. 2) and expands on my previous post about my New Years resolution – which by the way I have kept. AIMS have kindly allowed me to reproduce the article here…

The idea that birth should be efficient originated in the 17th century when men used science to re-define birth [1].    The body was conceptualised as a machine and birth became a process with stages, measurements, timelines, and mechanisms. This belief continues to underpin our approach to childbirth today. In current midwifery texts labour is divided into three distinct stages, and further divided into phases within those stages. The first stage of labour involves regular and coordinated uterine contractions accompanied by cervical dilatation. This stage includes three phases: latent, active and transitional. The second stage of labour begins when the cervix is fully dilated and ends when the ‘fetus is fully expelled from the birth canal’ [2].  Again, the second stage is further broken down into three phases: latent, active and perineal. ‘The third stage of labour is the period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding’ [2]. This categorisation allows practitioners to measure progress through the stages and create limits and boundaries around what is considered ‘normal’.

The tool used to measure labour in hospital settings is the partogram, which is largely based on a study carried out in the 1950s by Friedman [3] where he plotted the cervical dilatation of 100 women having their first baby in an American hospital. He found that the average rate of cervical dilation was 1.2cm per hour, but that this rate was not linear. In other words, most women gave birth within twelve hours of the commencement of labour, but there was variation in their individual dilation patterns. In the 1970s Phillpott and Castle modified Friedman’s graph to provide guidance for practitioners working in a remote area of Rhodesia. Their intention was to reduce the incidence of poor outcomes associated with obstructed labour in this particular setting [4]. They added an alert line, a transfer (to hospital) line and an action (augmentation) line to Friedman’s graph. The resulting partogram is now a practice tool used in hospitals worldwide to monitor the progress of normal labour. A cervical dilatation rate of less than 1cm per hour is considered ‘abnormal’ according to most hospital policies. However, some hospitals are more generous and will consider a rate of 0.5cm per hour normal for women having their first baby.

Since use of the partogram became widespred, researchers have found that Friedman’s graph does not represent normal labour progress. In contrast, research has found that cervical dilation patterns vary widely between individual women, and the average length of labour is much longer than in Friedman’s findings [5,6,7,8,9]. A recent Cochrane review into partogram use in labour concluded that: ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’ [10]. This evidence- based recommendation is yet to be reflected in maternity care. Instead, women have their labours managed in order to follow a partogram with limits and boundaries. Fewer than 50% of women having their first baby will manage to meet the narrow criteria of ‘normal progress’ and avoid augmentation of their labour [7].    The World Health Organisation estimates that the rate of obstructed labour is between 3 and 6% worldwide [11] and so a significant number of women are experiencing unnecessary intervention during their labour.

Methods used to augment labour carry risks and alter the physiology of birth. Amniotomy (artificial rupture of membranes) does not reduce the length of labour, and may increase the chance of having a caesarean section [12]. Intravenous syntocinon can increase contractions and shorten labour, but requires careful monitoring of mother and baby because of the potentially dangerous side effects [13]. When augmentation fails to improve the progress of cervical dilatation, a caesarean section will be performed for ‘failure to progress’. Time limits on the second stage of labour result in midwives implementing directed pushing to get the baby out before they must notify an obstetrician. Directed pushing (Valsalva manoeuvre, sometimes called purple pushing because a woman is encouraged to hold her breath and push hard) does not significantly reduce the length of the second stage [14]. However, it does increase the risk of damage to the pelvic floor and perineum, and is associated with fetal hypoxia, in no small part due to oxygen starvation when mum holds her breath. If directed pushing does not improve progress, or the baby shows signs of stress due to hypoxia, the birth will be assisted using forceps or a ventouse. Most hospitals have policies regarding the length of time between the birth of the baby and the birth of the placenta. These vary from hospital to hospital, but failing to meet the deadline will often result in the placenta being manually removed.

The concept of managing women’s labours to follow a partogram relies on the premise that it is even possible to assess the progress of labour. I challenge the notion that it is possible to identify where stages of labour start or end, or to accurately predict the future progress of a labour. Physical changes in the cervix and uterus occur during pregnancy and the onset of labour is a gradual happening [15]. Therefore, identifying an exact time of labour onset is not possible. The definition of ‘established labour’ includes regular rhythmic contractions occurring at least three every 10 minutes, lasting for 45 seconds and accompanied by progressive dilatation of the cervix [16,2]. However, women’s contraction patterns are as unique as their bodies. At home births I have observed women have infrequent, irregular contractions throughout their entire labour and give birth spontaneously. Therefore, contraction pattern is not necessarily a good indication of how a cervix is dilating.

Assessing the progression of the ‘first stage of labour’ also relies on knowing what the cervix is doing. Some hospitals no longer have a policy of routine vaginal examinations in labour, perhaps reflecting concerns about the practice [17]. Even when vaginal examination remains an element of routine management, the timing of assessments is usually four-hourly. A vaginal examination only reveals what the cervix is doing at the time of the examination. It cannot provide information about what the cervix was doing before, or what it will do in the future. For example, a woman’s cervix may be only 3cm dilated but she could birth her baby within an hour of this assessment. Another woman’s cervix may be 9cm dilated but her baby may not be born for another 6 hours. Using a vaginal examination to determine the start of the second stage is also inaccurate. If a midwife examines a woman at 3pm and finds that her cervix is fully dilated, does that mean her second stage started at 3pm? What if her cervix had been fully dilated at 2pm but the midwife didn’t know? There is only one accurate time recording that can be made during labour – the end of the second stage because the baby is born. Although a time can be recorded for the birth of the placenta, the third stage ends with ‘control of bleeding’, which is open to interpretation.

Despite the inability to accurately measure the stages of labour, maternity documentation requires this information to be recorded. Partograms, birth summaries and perinatal data forms require midwives to record the hours and minutes a woman spends in each stage of labour. The result is creative documentation and some interesting conversations between midwives. Such as: ‘What time would you say second stage started?’ ‘Umm not sure – she was making grunty noises around 5.30pm…’ ‘OK, I’ll put 6pm.’ And between midwives and women: ‘What time would you say your labour established?’ ‘I don’t know the contractions were really hurting by 7am then I came into hospital.’ ‘Hmmm well you had your baby at 9am, so you must have been doing something before 7am… I’ll put 6am.’ Midwives also manipulate the paperwork to fit policies, protect women, and avoid getting into trouble. For example, recording the cervix as being 9cm dilated rather than fully dilated to buy more time for the woman. Or ignoring an hour’s worth of spontaneous pushing before recording the start of the second stage. These strategies allow midwives to complete the required paperwork whilst protecting the woman from unnecessary interventions.

However, these strategies also support and maintain the structures that impose time limits. These fabricated times are recorded in standard maternity documentation and then sent to organisations that collect and analyse the data to provide information about labour and birth. By manipulating records midwives are helping maintain the myth that labour has distinct stages which can be measured accurately. Perhaps more importantly, though, they are re-defining women’s birth experiences, often in contrast to the woman’s own experience. For example, recording the length of a labour only from the onset of ‘established labour’ disregards the hours or days that a woman may have experienced contractions before being considered to be in established labour. Abandoning the concept of stages and the notion of accurate assessment may improve outcomes and reflect women’s experience of birth more honestly. However, individual midwives may find it difficult to practice against the cultural norm. Midwives who practice openly and autonomously within a medicalised system often experience ridicule and bullying [18,19]. Therefore it is not surprising that most midwives continue to bend the rules rather than break them.

There appears to be no simple solution to this situation. The concept of stages of labour, and assessment of progress is deeply embedded in our birth culture and practice. Perhaps change could begin with an open dialogue between women, midwives, obstetricians and policy makers regarding a move to a more evidence based approach to childbirth.
Individual midwives can also make a difference, and should support each other to do so. The content of parent education sessions can be changed to focus on what Downe and McCourt refer to as ‘unique normality’ [20] rather than descriptions of the stages of labour. Midwives can share the evidence with each other and midwifery students, and highlight the failures of the current situation rather than sustaining acceptance.
If enough midwives write ‘not applicable’ on paperwork rather than making up a time, there will be evidence that the documentation needs to change. Experience of observing non-augmented labours will assist midwives to develop their understanding of normal birth, and their ability to identify a truly obstructed labour. These changes may be challenging but the result could be a better approach that respects women’s uniqueness and embraces the unpredictable nature of birth.

References

1. Donnison, J 1988, Midwives and medical men: a history of the struggle for the control of childbirth, 2nd ed, Historical Publications, London.

2. Stables, D & Rankin, J (eds) 2010 Physiology in Childbearing: with anatomy and related biosciences, 3rd ed, Bailliére Tindall: Elsevier, London.

3. Friedman EA 1955, Primigravid labor: a graphicostatistical analysis, Obstetrics and Gynecology, vol. 6, no. 6, pp.567-89.

4. Philpott RH & Castle WM 1972, ‘Cervicographs in the management of labour in primigravidae. II. The action line and treatment of abnormal labour’, Journal of Obstetrics and Gynaecology of the British Commonwealth, vol. 79, pp. 592-8

5. Albers, LL 1999, ‘The duration of labor in healthy women’, Journal of Perinatology, vol. 19, no. 2, pp.114-9.

6. Cesario, SK 2004, ‘Reevaluation of Friedman’s labor curve: a pilot study’, JOGNN, vol. 33, pp. 713-22.

7. Lavender T, Alfirevic Z & Walkinshaw S 2006, ‘Effect of different partogram action lines on birth outcomes: a randomized controlled trial’, Obstetrics & Gynecology, vol. 108, no. 2, pp. 295-302.

8. Neal JL, Lowe NK, Ahijevych KL, Patrick TE, Cabbage LA & Corwin EJ 2010 ‘”Active labour” duration and dilation rates amongst low-risk nulliparous women with spontaneous labor onset: a systematic review’, Journal of Midwifery and Womens Health, vol. 55, no. 4, pp. 308-318.

9. Zhang J,Troendle, JF &Yancey, MK 2002,‘Reassessing the labor curve in nulliparous women’, American Journal of Obstetrics and Gynecology, vol. 187, no. 4, pp. 824-8.

10. Lavender T, Hart, A & Smyth, RMD 2008, ‘Effect of partogram use: outcomes for women in spontaneous labour at term (review)’, Cochrane Database of Systematic Reviews, Issue 4, Art No. CD005461. DOI: 10.1002/14651858.CD005461.pub2.

11. Dorlea, C & AbouZahr, C 2003, Global burden of obstructed labour in the year 2000, Evidence and Information for Policy, World Health Organisation, Geneva

12. Smyth RMD, Alldred SK, & Markham C 2007, ‘Amniotomy for shortening spontaneous labour’, Cochrane Database of Systematic Reviews, Issue 4. Ar t. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub2.

13. NICE 2008, Induction of Labour, National Institute of Clinical Excellence, London.

14.Martin C 2009,‘Effects ofValsalva manoeuvre on maternal and fetal wellbeing’, British Journal of Midwifery, vol. 17, no. 5, pp. 279-85.

15. Coad, J & Dunstall, D 2005, Anatomy and physiology for midwives, Mosby, London.

16. Fraser DM, Cooper, MA 2008, Survival Guide to Midwifery, Churchill Livingstone, London

17. NICE 2007, Intrapartum Care: care of healthy women and their babies during childbirth. National Institute of Clinical Excellence, London.

18. Bluff, R & Holloway, I 2008, ‘The efficacy of midwifery role models’, Midwifery, vol. 24, pp. 301-9.

19. Stewart, M 2001, ‘Whose evidence counts? An exploration of health professionals’ perceptions of evidence-based practice, focusing on the maternity services’, Midwifery, vol. 17, pp. 279-88.

20. Downe, S & McCourt, C 2008, ‘From being to becoming: reconstructing childbirth knowledge’, in S Downe (ed), Normal Childbirth: evidence and debate, 2nd ed, Churchill Livingston, London

About midwifethinking

independent midwife, lecturer and student of all things birthy
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89 Responses to The Assessment of Progress

  1. Kathryn K says:

    Marvellous. I’m am taking the ‘stages’ off my description of an undisturbed birth immediately. Thank you.

  2. A great article and lots to think about. I recently sat in on an audit meeting as a user rep for my local MSLC and the midwives were discussing the difficulties of recording observations and the pressure they are under to do so. They showed a graph to illustrate the percentage of records taken at various stages of labour. The aim was to ensure a high level of care, of course, and they were after a target of 75%. It opened my eyes to the strictures placed on the NHS midwives. Of particular concern I found the requirement to record the FHR every 5 mins in the second stage of labour (a change from the previous requirement to record after each surge). Something to do with it being easier to plt out?! This is going beyond the NICE regulations of recording FHR every 5 mins after each surge and potentially means attempting to measure FHR during a surge. And it’s one thing to observe the FHR and another to have to write it down in notes. What a lot of time the midwife is supposed to spend writing notes when surely she would rather be attending to the mother. Perhaps it is fortunate that they were reporting only about 20% of records being taken during this ‘stage’ of labour!

  3. steph says:

    Here here! The business of being born, the unnecessary intervention which leads to further intervention resulting in birth trauma for both mum and bub which is based on out dated and manipulated data to gauge normal (which by the way is a cycle on a washing machine) should be made a criminal offense and outlawed!

  4. infomidwife says:

    great article, the only way things are going to change is for more articles and research to challenge convention…keep up the great work Rachel

    • I think we also need a revolution in birth culture. The evidence is there but continues to be ignored which suggests to me that it is not about evidence based practice but about maintaining authoriative knowledge (ie. medical). :)

  5. Yes, challenging the mindset about labour and birth timing is the way to go, I totally agree Pauline (infomidwife). Serendipitously, Joy Johnson has a similar theme on her blog (village midwife http://villagemidwife.blogspot.com/2011/09/living-with-uncertainty.html) which fits well with your information Rachel. Joy has a link to a very interesting paper “Evidence based-practice and Affect: The impact of Physician attitudes on outcomes associated with clinical reasoning and decision-making” DUNPHY ET AL. Australian Journal of Educational & Developmental Psychology. Vol 10, 2010, pp56-64 which demonstrates clearly the variable nature of clinical decision making in medical minds. And we allow these people to make quite arbitrary decisions about our bodily functions! The reality is the best and safest judge of what’s happening and what’s needed is the informed woman.

  6. What a great summary of what happens in the hospital setting. Well done

    Unless you have managed women in close proximity during the labour process as described – you would not realise that while these systemised parameters are written in cement- they do act as GUIDE for the uninitiated. I have seen enough variations to know that individual women left to their instincts and in a relaxed atmosphere labour well – some of the documentation creates a record for the court and also gives reassurance to those who have fractured care – rostered shifts etc. . I must add that since the advent of Cardiotocography and inductions which include the rupture of membranes, chemical and instrumental intervention which leads to major surgery for birth, very few hospital practitioners recognise for example the latent or resting phases. Labour pauses and those of us who know just wait, others panic and start talking about obstructed labour. The panic results in numerous Vaginal examinations and fear for the mother. Frightening isn’t it? I once set my question before a panel of intending State obstetrician examiners of student midwives. Q What is the value of intact membranes.? Not one value was forthcoming – Why? Because they had never worked with intact membranes. I gave them a list worth 20 marks. We taught a few people that day.

  7. I will wait on someone telling me I left the woman out of the monitoring process. No I just want some critique of the benefit and harms and both sides of the story to emerge. Documentation is the protection of the carer. One can fantasise about not having charts. If you were as under threat as midwives currently are you should have the full co-operation of your client in agreeing to any written documentation. Especially agreements about care.and in many cases has put the blame for mistaken management at the feet of the midwife. I suggest this is true of hospital and home birth. There is a site which may interest you for actual cases sent to me tonight by a home birth mum who is studying law. http://www.clinicalethics.info Australian cases.

  8. Thank you for this! I am a HypnoBirthing practitioner, and our method divides labor simply into the “thinning and opening phase” and the “birthing phase.” Though I have embraced that vocab and the uniqueness of every mother’s labor, until birth attendants do the same, that vocab will be just a euphemism.

  9. Kari says:

    I was looking for more on the Downe reference and found this bibliography that you might find useful…
    http://www.ncnm.ie/files/References Evidence Course C Rhythms of Labour (1st Stage) 2005.doc

  10. Rachel says:

    Thought I’d share a couple of abstracts from some recent research:
    http://www.ncbi.nlm.nih.gov/pubmed/21099592
    http://www.ncbi.nlm.nih.gov/pubmed/20629924

    From what I can gather and from reading research, we really have very little knowledge about what constitutes a normal length of labor. I’m just curious, though, is there ever a labor that is too long? And how do we assess that? My own definition has been if either the mom or baby are in physical or emotional stress than the labor has become too long. I’m just wondering what others think.

    • Thanks for the research. Labour can be too long but how long is too long is more complex than standard timeframes. It is about a holistic assessment of mother, baby, birth journey etc. Therefore different for each woman / scenario. Not something that guidelines can comfortably accommodate. :)

  11. Ann Higson says:

    As a hospital midwife I recognise that you have to have some form of stucture when defining labour. However, I feel that we sometimes rely too heavily on these medicalised structures within hospital practice. Staff shortages within the NHS mean that time is limited with each client till we have to move on to the next. If women really understood how their bodies worked in labour it would make labours shorter and our job a lot easier. See http://painfreelabour.blogspot.com/ for why contractions in labour hurt and why they were never meant to. Ann Higson, Midwife in Manchester.

  12. Gloria Lemay says:

    I’m teaching an online class tomorrow night about how to assess dilation without doing a pelvic exam. In preparing the class, I realized that every thing that works as a “clue” to progress has exceptions to the rule. I know this from first hand experience. In practice, I find it best to create a mentality for myself that the woman is either “2 cms dilated” or “the head is showing”; there’s nothing in between. That helps me manage my own impatience and allows the birthing woman to do whatever she needs to do to give birth her way. Thanks for sharing this valuable article.

  13. Thank you for another great educational post. I always tell my HypnoBirthing parents that they may be measured against the Friedman curve but that it is an extremely rare woman who dilates at exactly 1cm per hour – especially if she is repeatedly examined!

  14. Lauren says:

    My favourite post yet Rachel! How can anything so unique and individual be measured? And why would we want to measure it? Why can’t we just enjoy the beauty of birth for everything that it is rather than what “experts” think it is “not”? I am VERY motivated to become part of the future that changes this culture!

  15. Beautifully put and a stunning statement against the current standards of care.

  16. Daniela de Oliveira Figueiredo says:

    This is exactly the type of article we need to start changing people’s approaches. Congratulations.

  17. Rachel – I’ve been reading your blog for the past year, silently in awe. Thank-you for showing us (the passionate birthing community) how to impact the birthing paradigm one word at a time.

  18. This is by far the best text on “labour progress” for midwives. I’ll translate to Portuguese and spread here. Congratulations!

  19. Pingback: Stay. Away. From. My. Vagina! – The Peaceful Birth Project

  20. HypnoBirthers discovered early on that their mums are blowing those figures right out of the water. A woman can be opened to 3cms, which can be rather discouraging when she’s told that she still has a long way to go, and then within the next half hour she can open to 7, 8, or 9cms. We also see the reverse, where a mum has a slow restful labor, but all is well, with no cause for alarm or rushing.
    Many also just slip into that phase of being nearly complete, and the baby starts his descent literally unnoticed. Birth is not a numbers game, and we see that vaginal exams do little but tell where the woman is at the time. To continue to rely on graphs and charts just puts a woman in jeopardy of having someone introduce augmentation. Somewhere I was told that Michel Odent commented that women should be able to have babies in twenty minutes. Ive not seen that, but I’ve seen many instances where the woman’s body is laboring, and she isn’t. This needs to be a wider discussion. Numerologically, this is a “5″ year”–one of change. Why not!!!

    • Ann Higson says:

      Women today labour slowly because they are so afraid of the pain that society tels them they are going to suffer. As soon as they start to labour they become anxious and start producing adrenalin. There are receptor sites for adrenalin on the uterine cervix. Increased levels of adrenalin ‘stick’ to the cervix and prevent it from opening. The contractions then have to become stronger to pull up the resisting cervix and start producing the sensation of pain. This causes more stress and so the cycle goes on. The only way to break the cycle is to use tried and tested relaxation techniques, practiced during the pregnancy, that will reduce adrenalin levels. Only then will we see calm relaxed women, not holding their cervix shut, who can labour much quicker. For relaxation advice, see my blog at painfreelabour.blogspot.com/

      • While I agree that being able to relax aids in labor, I don’t necessarily feel like a slow labor happens because you are not relaxed enough.or are afraid. There are a lot of factors that may go into a slow labor, including fear. Other things may include the position of the baby, the position of the mom, size of both mom and baby, readiness for birth, differences between women etc. In fact, I just had a friend that was laboring for three or four days..she was not afraid, she was doing her second homebirth, her sixth baby, and very relaxed. I think what we need to realize is that a slow labor is not necessarily bad. It’s just what it is..slow. I think if we start teaching women that they aren’t doing things right if their labors are slow, then we are doing them a disservice. We need to teach the normalcy of it and ways to cope. All that changes if it becomes a medical problem, of course, but if all is well emotionally and physically for mom and baby, a slow birth is really okay.

  21. Helena Nash says:

    Love this article, just found it!. May I translate it and publish in the Swedish journal for midwives?
    Helena

  22. Michelle says:

    I just spent hours reading your blog. I do believe you have the best birth blog I have ever read. WONDERFUL information. I posted it all over facebook today as I was sharing information that all moms should know.

    It looks like you havent posted in a while. I hope things are okay and you begin posting again soon. The world needs you!

    • Thanks! And yes, I will be posting again soon :)

    • Ann Higson says:

      Hi Michelle, so glad that you read my blog. It is so difficult to get midwives to listen to ideas to help women labour cos most of the ones I work with act like obstetric nurses rather than midwives. The true art of midwifer is very slowly being lost. I have students who have never seen a birth where the woman is not strapped to a bed! It is so nice to hear from a like minded midwife. I wish you all the best, thank you for spreading the word. My book is currently with the publishers and I hope to bring pain free labours to a wider audience. Ann x.

  23. Ida28 says:

    Why do they (midwifes, doctors) rupture the membranes if it does not shorten the labour?

    • Ann Higson says:

      Hi Ida 28, we used to artificially rupture membranes all the time just for the fun of it. Things have changed now and you will only have your membranes ruptured if you do not make any progress. Progress is now at least half a cm per hour. Ruptured membranes release hormones which bind to uterine smooth muscle and open up more binding sites for oxytocin. The contractions become stronger. Research has shown that this does shorten the labour but makes it more uncomfortable. It is better to keep your membranes intact until they go on their own. Visit http://painfreelabour.blogspot.co.uk/ for advice on how to achieve a pain free first stage of labour. Ann x.

  24. Ida28 says:

    Thanks for the reply! :-)

    I gave birth a few months ago. I had a long-lasting labour but didn’t go to the hospital before I felt the urge to push. ( We live very close-by! :-) ) So therefore my membranes went by themselves right before my baby was born. I am really happy about that now. My experience was positive – but very ironic that going to hospital means risks of unnecessary interventions.

    My labour wasn’t as painful as I thought in advance.

    Next time I’m pregnant I’ll consider writing in my labour letter that I don’t want my membranes to get artificially ruptured.

    Thanks for a great blog!

  25. Thank you Rachel, for raising all these difficult issues, as a 2nd year student midwife, it’s hard to see how these habits of recording can be changed now, even imagining writing N/A on a partogram makes me anxious! I want to practice independently, so that I can get away from the protocols in the hospital, and practice evidence-based woman-centred care.

    • It is heartening to know that the next generation of midwives are able to think critically and ‘get’ the essence of midwifery (being ‘with woman’). I have just spent the weekend with some lovely student midwives at my workshop who gave all of us ‘older’ midwives some hope for the future. Don’t worry about fighting the battles. Do what you need to do to become a midwife for now, protect yourself, and focus on the midwife you will become x

  26. Dpbby says:

    This is one of the best & most honest articles I have read in a long time – thank you! As a midwife that works “in the system” I do all those things you have mentioned; being “creative” with documentation to “buy” a woman time and so on. I completely understand that while it may help the individual woman at the time in avoiding unnecessary intervention, you are so right in that it doesn’t help the greater population of birthing women as it re-inforces the notion that women birth based on time-frames. I find myself torn however as to how to over-come this. The computerised documentation that I am required to complete in my current work-place does not have the option to fill in “not applicable”. It DEMANDS a time to be put in and if one does not put a time, the record is rejected & the midwife receives sternly worded emails from the ‘powers that be’ to complete one’s documentation correctly. I really do feel at times that I work in a battle-field, trying my best to “protect” women, whilst also protecting myself against “getting in trouble”. I actually suspect this will one day be what drives me out of the profession :(
    Thank you again for highlighting what really goes on, and the implications of this. A great blog that I shall continue to follow.

    • Thanks! Luckily my notification form is written and I can cross out the boxes and write ‘no appropriate’ next to them. How frustrating for you. I guess it needs to be addressed by whoever creates the software (and pigs might fly). Even if we can’t ‘do’ differently we need to speak the truth and be honest about the dishonesty :)

  27. Loved this article and everything else on this site – thankyou so much. I’m always researching and trying to get as much armour to advocate for the use of evidence based best practice when caring for women. A funny thing was said to me a couple of months ago…….it was that i am “too much with woman” what is that supposed to mean? My colleague who stated that to me wanted me to have everything “set up” right now, before night staff came on! (oops silly me, no baby label in cot!) and continued to lecture me about it once the shift was over. I explained to her that if me being “too much with woman” is her only complaint then i must be doing ok :)

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  29. “Midwives also manipulate the paperwork to fit policies, protect women, and avoid getting into trouble.”
    Oy, I think this is such a sticky topic! I agree with everything you are saying (and appreciate Gloria’s great response), but both “truth” and manipulation present dangers. This is becoming an issue for our practice in reporting MANA Statistics. On one hand, we value and honor our “truth” assessment, and in many cases they validate what you speak to. However, in VT, our MANA stats may soon become available to OB care providers…and many may be outraged by the variations in “stages” and “phases” that we support. How do you navigate this issue?
    ~ Juliana, Student Midwife, M.Ed.

    • I wouldn’t navigate it. Let them be outraged. Your understanding of birth is valid and you shouldn’t have to justify what you know to people who will probably never ‘get it’ because their world view is so different. Keep telling your truth :)

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  32. Eleanor copp says:

    Great reading Rachel, since working on a birth centre for the past 4 years I have witnessed amazing births and know there is no logic to how it goes . I also know my labour ward Colleagues do not understand this , I agree that ve’s are pants and prefer not to do them . It took me to have my 4 th child to say no thanks I don’t want one . Its loaded on many levels .

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  36. sheenabyrom says:

    Thank you Rachel for this excellent piece and so true. Well done for writing about this important topic and highlighting our crazy system so widely. I will share too. Brilliant.
    I frequently give talks about the increasing obsession with risk management in maternity and how we are drowning in paperwork. Your blog adds to the debate that we are becoming more record centred than woman centred.

  37. Jackie says:

    As a doula, I sometimes work with clients who have doctors as their care providers. I find it really difficult to articulate to a woman birthing in a hospital that “average” does not equal “normal”. I’m looking for a go-to sentence (or two) that expresses this idea more clearly. Mothers birthing in the hospital with doctors tend to think that average is more safe, and I can’t quite figure out how to break that barrier.

    • It is very difficult… I’d like a one sentence solution too! I facilitate sessions on ‘navigating the hospital system’ which includes explaining: how hospital organisations work and how individuals fit into it (public or private); the politics and overall aim of the system without fear mongering or blaming those working in it; the ‘job’ from the perspective of the ‘professionals’ ie obstetricians and midwives (that they are not intending harm and have protocols to follow and their own backs to cover); that these systems are not focussed on her as an individual, but that they are accountable to her and she is paying for them (one way or another); why the stats are as they are and that the ‘norm’ is intervention; that she must take responsibility for leading her own care and making her own decisions… or hand over responsibility and accept the ‘norm’.
      Here is a quote from an interview I did regarding the term ‘normal’ which may help with dealing with ‘normal and average’:
      In Australian hospitals nearly 80% of women have their labour induced or augmented and over a third of women have caesarean sections. Therefore intervention is the ‘norm’ and many women who experience intervention consider their birth to be ‘normal’. I prefer to use the term ‘physiological’ – ‘being in accord with, or characteristic of the normal functioning organism’ – to describe an undisturbed, healthy birth. ‘Natural’ is also a useful term but sometimes nature becomes pathological and requires intervention to ensure a healthy outcome. Back to the question… Physiological birth is almost extinct in Australia. (http://www.baby-birth.com/uk/articles/84-childbirth-professionals/816-rachel-reed.html#.UNuQ06Up8so)
      If you come up with a sentence let me know :)

  38. Pingback: Three Stages or Bust? | Birth Matters

  39. rain0021 says:

    I did read that Friedman studied cervical dilatation of 100 African women at term in their first labour. The women were given frequent rectal examinations and their progress was recorded in centimetres of dilatation per hour. I tried to locate a copy of the original paper but Google scholar and Pub Med were not forthcoming. I wonder what those poor women thought as a man with a clipboard repeated examined their cervix through their anus. I wonder how may came back the next time? Never having done a rectal examination in labour I wonder how well you may actually feel the cervix?

    I work as a rural GP who helps women have their baby in the bush, supported by a small group of in a state-run hospital. We are permitted to do low risk deliveries, no VBACs, BMI under 40 etc. I certainly see the benefit of allowing a couple to experience the birth of child in a supported environment.

    Like most doctors I was trained by obstetricians in a busy teaching hospital. I can see why a “normal” has been defined. Most big city units wouldn’t have enough birth rooms to serve their population to allow a birth to continue for an indefinite period. Of course it would be different if low risk mothers had their baby at home and hospitals were left for those who were more likely to need an obstetrician’s care. Excuse me for not wanting to get any further into birth politics here.

    Thankfully the country hospital I work at doesn’t have that pressure with 40 to 60 deliveries a year and so the Friedman’s “rules” are often allowed to become more elastic. The midwives still fill in the partogram, as per other rules. And I will still consider a Caesarean in consultation with the mother should I not see any progress over the hours. And I do sometimes wonder what the outcome would have been if I hadn’t intervened.

    • I doubt that Friedman would get his study through an ethics board today!
      Country hospitals are often great places to birth… away from the hustle and bustle and timeframes imposed by the big city hospitals. I also hear great feedback from midwives working with rural GPs too – some have told me that they learned the best ‘midwifery’ from rural gp/obs :)

  40. Jewel Hernandez says:

    I have no disagreement with tossing out the graphs and times, but I’m in school and having to write a “limits in labor” protocol…..maybe I’ll print out my template and write “not applicable” across it! But in thinking about it, is labor ever too long? should there be limits? or perhaps those limits are dictated not by the clock, but by other factors, ie fhr, well-being of mom and her wishes

    • Ann Higson says:

      In my experience, women who have long labours are usually very stressed. Calm relaxing women have much shorter labours. Stressed women secrete adrenalin. Receptor sites have been found on the cervix for adrenalin. It is a survival trait from way back, if there is danger then you secrete adrenalin to stop baby coming out till the danger has passed and it is safe to give birth. Today, women are afraid of labour because society teaches them that it will be painful. Uterine smooth muscle was never designed to cause the sensation of pain when contracting under normal conditions. Therefore, if women are anxious in labour the the labour will be longer and much harder. http://www.painfreelabour.blogspot.com/ Look at the posts Why Labour Hurts. and Evidence to Support a Pain Free Labour.

      • Ann – there are very good physiological reasons for sensations of pain during birth – I might write my next blog post about it to tackle the misinformation that uterine smooth muscle should not = painful contractions.
        I agree that too much adrenalin can slow labour down early on… however, once labour is established and the birth is close adrenalin can speed things up.
        “Today, women are afraid of labour because society teaches them it will be painful”… this statement worries me and reflects the patriarchal approach of Grantly Dick-Read. Across all societies and cultures women have experienced pain during birth… in our society we teach them either that they shouldn’t if they have the right mindset… or that they don’t have to if they use the right medication. Either way is not very empowering. Women are amazing and are perfectly capable of journeying through the deeply challenging experience of childbirth.

    • I think the well-being of the mother and baby set the limits. Also taking into account the full picture… strong, powerful contractions for hours and hours without any signs of progress is not normal and I would be wondering why.

      • Ann Higson says:

        If a woman is having strong, powerful contractions for hours and hours without any signs of progress then the first thing I would do is assertain if the baby is presenting in a flexed OA position. If this was the case then I would teach her relaxation techniques, if she was not already relaxed, to stop the flow of adrenalin. There are receptor sites on the cervix for adrenalin and so when a woman is anxious or stressed she will secrete adrenalin which will ‘stick’ to her cervix and try and prevent it from opening. It is an ancient survival trait then modern women simply do not need anymore. In my experience it is the single most prevalent reason for delay in labour. An epidural is often helpful just to break the stress/pain barrier that hinders some labours. See http://www.painfreelabour.blogspot.com/ for posts on making labour simple: stay upright and relax.

      • I experienced this with my first labour – strong, regular contractions for 40 hours, but dilation only to 8 cm, then back to 5cm….

        On my 4th pregnancy, I now know that this was caused by my baby being in a difficult position with his head tilted and not firmly engaging my cervix, due to ligament issues in my pelvis. 3rd labour was very different, with lots of help from spinningbabies :)

        I do wish sometimes that my midwives at that first labour had thought to link it to baby position and explain, at the time I was scared and in a lot of pain, and not knowing made it worse :(

  41. Thank you for a well-written, well-researched post. It makes me think of my first labor & delivery job at a high risk maternity hospital in Boston -1985. There was one particular doctor who totally subscribed to the Friedman curve approach of assessing labor. If a woman did not dilate 1 cm per hour, she would be delivered by c-section within 2 hours of that “failure to progress”. I witnessed many horrific tragedies of birthing there, as residents practiced their skills on unwitting women, but this particular doctor who could not see real life unfolding beyond his mathematical linear idea of progress, repetitively took the cake. As a perinatal massage specialist, and former OB nurse, I support the idea of natural birthing as an important rite of passage, and I have been hearing stories of women who have “fired the doctor” or sued the doctor if necessary, to prevent or fight against the loss of their empowered birth experience.

    • Ann Higson says:

      Wow, I cannot believe that we have put up with this treatment for so long. Women today are supposed to have gained equality though a struggle that has lasted centuries. OK, some cultures still see women as second class people but for the western world this is surely a thing of the past? I was so shocked when I read about the poor women who had their cervix examined through their anus. What! If that is not sexual abuse then I do not know what is. Enough. We need to free women from the medical model of care unless they are so high risk that they would not be able to birth without it. Birth is the last great battlefield of the genders. Their days are numbered. Keep fighting sisters, you are doing a wonderful job. Ann x

  42. Jewel Hernandez says:

    Unfortunately it is not a thing of the past and as long as women are being oppressed anywhere—we all are. I know you mean well Ann, but “last great battlefield of the genders”? You’re right the struggle must continue through change and beyond, but I think we need a different image.

  43. Pingback: Labor Progress and a call to discard the Cervical Dilation Exam

  44. Pingback: The Assessment of Progress This article was written for AIMS Journal (2011, vol. 23, no. 2) MidwifeThinking mothers, birth, babies and midwifery - Birth Balance

  45. Valle says:

    Hi Rachel!
    my name is Valle and I am a midwife who recently decided to become independent working in Spain. I love your blog and really got me thinking! I am writing you because I am trying to create my own documentation as carefully as I can to reflect the process in a simple and clear way and avoiding ticking boxes. I have in my hands the very useful but very square minded documentation used in UK. So I thought, and provably it is too much to ask but worth a try, that it would be great to have a look at your documentation to add ideas. Thanks for every single one of your posts!

  46. Valle says:

    Thank you ever so much! Hug :)

  47. Pingback: Assessment of Labor | Esali Birth Blog

  48. Admiring the hard work you put into your website and detailed information you provide.
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  49. Pingback: Home, hospital or birth centre? | MamaCafe

  50. Pingback: 5 Ways to Prepare Your Mind and Soul for Natural Birth | Baby & Blog

  51. Jenn says:

    Fabulous paper!

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