How Long Is Too Long?
A new study from the University of California, San Francisco, reported in the New York Times by Catherine St Louis (Feb 5, 2014), suggests that obstetricians have been placing unrealistic limitations on the time a mother is allowed to push her baby out in the second stage of labor (the period after which the cervix is completely open and the baby descends through the birth canal) before calling it “abnormal” and moving to an operative delivery – most likely cesarean, but sometimes vacuum or forceps. The current guidelines from the American College of Obstetricians and Gynecologists are based on the Friedman curve developed in the 1950s, before epidural anesthesia was common, and long before some laboring women were allowed to continue to push beyond these restrictive limits as long as their babies looked healthy and they continued to make progress.
According to the Times article, “researchers at the University of California, San Francisco analyzed the records of 42,268 women who delivered vaginally without problems between 1976 and 2008. Roughly half had epidurals. The investigators compared the average length of the second stage of labor among women who had epidurals with that among women who did not. They also compared the upper limits of duration for both groups.
“Thirty-one percent of first births and 19 percent of subsequent labors would have been classified as abnormally long by the current ACOG definition, the researchers found. ‘It’s time to re-examine what normal and abnormal is, and revise our guidelines based on modern obstetric population,’ said Dr. Yvonne W. Cheng, the lead author of the study and an associate professor of obstetrics and gynecology at the University of California, San Francisco.”
Dr. Cheng’s study is the first to suggest that such an extended second stage may be ordinary. Midwives, who see birth as a physiological process, have known for years that “ordinary” labor may last for longer than the proscribed limitations that were set, and that it is unwise to place limitations on the length of labor as long as mom and baby are doing well and progress is being made. In settings where midwives are not restricted by protocols and policies set up by the institution or the obstetric profession, we have allowed women to labor until the baby is born or until it becomes clear that an intervention was needed, not until an arbitrary time limitation is reached. Midwives have also encouraged babies to move down the birth canal by using simple methods such as having mom squat, change her position, walk around, climb up some stairs sideways, sit on a birthing ball and rock back and forth – all with the objective of encouraging the baby to line up with the birth canal in an optimal way to bring it down and out.
Catherine St Louis, “Study Suggests Misplaced Fears in Longer Childbirths,” New York Times, Feb 5, 2014, http://www.nytimes.com/2014/02/06/health/childbirth-study-sees-longer-labor-as-normal.html?src=xps
Yvonne W. Cheng et al, Second Stage of Labor and Epidural Use- A Larger Effect than Previously Suggested. Obstetrics & Gynecology 2014;123:527-535.