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Iatrogenic Norms: How Fast Do First-Time Mothers Beginning Labor Spontaneously Actually Dilate?

Iatrogenic (adjective): induced in a patient by a health care provider’s activity, manner, or therapy. An iatrogenic disorder is caused by medical personnel or procedures or develops through exposure to a health care facility.

Iatrogenic norm: a defined range of normal values for a biological process that, rather than describing actual normal physiology, instead measures the consequences of a health care provider’s beliefs, actions, or therapies or the effects of exposure to a health care facility.

Clinicians today base labor management on norms for cervical dilation rate in active phase labor (assumed to begin somewhere between 3 and 5 cm dilation in women contracting regularly) derived from research conducted decades ago by Friedman and colleagues (the famous “Friedman curve”). According to this research, in first-time mothers, the slowest 10%, an arbitrary cutoff for abnormally slow progress, dilate at a rate of 1.2 cm per hour or less. This norm has been enshrined in the “action lines” of the graphs of “dilation versus time” routinely used to manage labor. The “action” taken when women fail to progress at this minimal rate is administration of intravenous oxytocin to strengthen contractions, and such women are at high risk for cesarean surgery for labor dystocia. If this criterion is overly stringent, women with normally progressing labors will be subject to potentially harmful treatment and surgical delivery unnecessarily.

Concern over this possibility led a group of investigators to conduct a systematic review of studies analyzing active labor duration, progress rate, or both in active first-stage labor in first-time mothers, and the lead author, Jeremy Neal, presented the results at the recent Normal Labour & Birth International Research Conference. Neal began his talk with a look at the body of evidence that gave rise to this concern. I won’t bore you with the details, but suffice it to say that studies using Friedman’s norms for progress diagnose anywhere from one-quarter to one-half or more of first-time moms as requiring treatment for abnormally slow progress. If progress is abnormal in that many women, then something is wrong with the definition of normal, or, as Neal put it:

Either many nulliparous women are admitted prior to progressive (active) labor yet held to dilation expectations of “active‟ labor and/or common expectations of active labor dilation rates (e.g. 1 cm/hr) are unrealistically fast.

The group’s review pooled data from 25 studies encompassing thousands of low-risk first-time mothers with spontaneous labor onset at 36 weeks of pregnancy or more. It found that contrary to Friedman, 1.2 cm was actually the mean rate of dilation, not the rate in the slowest 10%, and the limit for the threshold of slowest acceptable progress rate fell at 0.6 cm, half that rate. (This, by the way, is not a physiologic norm because studies included women with epidurals and labor augmentation, and since all data came from hospital studies, laboring women would have been subject to policies that could affect progress rate such as confinement to bed. That being said, the review found that epidural use did not change results.)

Neal then added that active labor is assumed to progress at a constant rate, but some data suggest that rate of progress may be slower at the beginning of active phase and accelerate as it continues. In other words, the action “line” is another iatrogenic norm because it should be an action “curve.” If this is true, using an action line would put even more women progressing normally in early active phase in jeopardy of the “dystocia” diagnosis and all that follows.

Neal concluded with: “Revision of existing ‘active’ labor expectations and/or revision of criteria used to prospectively identify active labor onset is warranted and such efforts should supersede efforts to ‘change’ labor to fit existing expectations.” “From his mouth to God’s ears,” as they say—or at least to the ears of obstetricians.

Nevertheless, while revising norms to match reality would take a big step in the right direction, I would argue it doesn’t go nearly far enough because it still sticks us with the assumption that active first-stage dilation progresses smoothly. Anyone who has spent time with laboring women knows that this is often not the case. Neat graphical lines (or curves) come from averaging many highly variable individual labors, so the very expectation of how labors progress, at whatever pace, is itself an iatrogenic norm.

Moreover, the published review points out that both the old and the proposed new threshold for “abnormal” are statistically derived (e.g. two standard deviations beyond the mean). No study links a cut point for “abnormally slow” with an increase in perinatal morbidity, but averting adverse outcomes should form the basis for intervening medically because of the risks of intervention. In fact, even if a study tried to establish an outcome-based threshold, it would be hard to determine whether the increase was due to labor duration per se or to the interventions used to treat slow labor. So we have yet another iatrogenic norm, this one having to do with a definition of “abnormal” with no clinical significance.

In short, forcing labor to conform to artificial, arbitrary guidelines does more harm than good. A simplistic cookbook approach to the knotty problem of labor dystocia has obvious appeal, but what is truly needed to achieve the best outcomes with the least use of medical intervention is thoughtful evaluation, individualized care, and above all, patience so long as mother and fetus are tolerating labor. Labor graphs and action lines do no more than exemplify H. L. Mencken’s truism, “For every complex problem there is a solution that is simple, neat—and wrong.”

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  1. August 25th, 2010 at 19:29 | #1

    I think Neal hit on it with both conclusions: Either many nulliparous women are admitted prior to progressive (active) labor yet held to dilation expectations of “active‟ labor and/or common expectations of active labor dilation rates (e.g. 1 cm/hr) are unrealistically fast.

  2. August 25th, 2010 at 20:08 | #2

    This post betrays two very serious misunderstandings. The first is a misunderstanding of the Friedman curve. The second is a profound misunderstanding of standard deviation.

    I know a bit about the Friedman curve because I trained with Dr. Friedman himself. He was the chief of my department at Beth Israel in Boston for the four years of my residency. He was an extremely difficult man to work with, but he was brilliant and a strong advocate for women.

    The Beth Israel Hospital OB-GYN department was one of the first to invite fathers into the delivery room and had strict rules banning elective induction and C-section for non-medical reasons. He reviewed every case and Lord help you if you so much as tried to book an induction before 42 weeks. And you need to understand that although we graphed every labor, Dr. Friedman himself did not believe in rigidly adhering to the curve.

    It helps to understand how and why Dr. Friedman defined the curve:

    Dr. Friedman did his residency in the 1950s. He was not a man to suffer fools gladly and he considered a lot of his superiors to be fools. He felt that they made medical judgments based on their intuition and not on science, and he set out to accumulate the research data necessary to give the profession a firm scientific foundation.

    During his residency, when he was on call every other night, he used his “spare” time to compile detailed observations about every laboring woman who came through the hospital. The goal was no less than to find out what normal labor looked like. Using observations from tens of thousand of women, he created a curve. Women who followed the curve were almost certain to have a vaginal delivery. Women who fell off the curve were more likely to need a C-section.

    Dr. Friedman was the first to say that you should not section a woman in latent phase because a long latent phase was not a sign that the baby doesn’t fit. He insisted that you should not section a woman in the active phase of labor unless she failed to make a certain amount of progress in a certain amount of time. Dr. Friedman used to express the utmost disgust for doctors who would say, “she looks like a C-section to me”, instead of adhering to established criteria.

    Dr. Friedman conducted his research before the advent of the epidural. It is worth investigating whether epidurals affect the curve, but the basic idea behind the curve is brilliant and he created precisely to avoid unnecessary C-sections.

  3. August 25th, 2010 at 20:17 | #3

    The concept of standard deviation has been egregiously misrepresented. NCB advocates like to claim that medical definitions of “normal” are utterly arbitrary and exist merely for the convenience of doctors. Nothing could be further from the truth. Often, “normal” is based on knowing the outcomes from previous experience. We can confidently say that having an Apgar score of 1 at 5 minutes of life is not normal, because babies who have Apgar scores of 1 at 5 minutes always have serious medical problems of one kind or another.

    Sometimes “normal” is defined as a range. That is not an accident, and it does not mean that a range was chosen arbitrarily. A normal range in medicine is almost always based on a basic and widely accepted form of statistical analysis, the standard deviation.

    There is an excellent simple explanation of standard deviation on SensibleTalk.com. It is written for journalists who have no background in statistics:

    “Let’s say you are writing a story about nutrition. You need to look at people’s typical daily calorie consumption. Like most data, the numbers for people’s typical consumption probably will turn out to be normally distributed. That is, for most people, their consumption will be close to the mean, while fewer people eat a lot more or a lot less than the mean.

    When you think about it, that’s just common sense. Not that many people are getting by on a single serving of kelp and rice. Or on eight meals of steak and milkshakes. Most people lie somewhere in between.”

    When you graph the data with calories on the x-axis and numbers of people on the y-axis, you will get a bell shaped curve. The curve is a graphical representation of all the possible things that can happen. The important point, though, is that every possible thing that can happen is not necessarily normal. How do we tell the difference between normal and abnormal? We start by calculating the standard deviation. The formula for calculating the standard deviation is complicated, but the result is relatively simple to understand. The standard deviation is a reflection of distribution of all possible outcomes.

    Mathematically, one standard deviation on each side of the mean (the average) encompasses 68% of individuals. Two standard deviations encompasses 95% of individuals. Therefore, only 5% of individuals will be outside of two standard deviations from the mean. This is always true, regardless of whether the bell curve is tall and narrow or short and extended. “Normal” is usual defined as within two standard deviations. That means that “normal” is a range, but the range is hardly arbitrary. It reflects the actual distribution of results among large populations of human beings.

    So when we look at how long a first labor lasts, for example, we can graph the labors of large numbers of women and we will get a bell curve. Ninety-five percent of women will fall within two standard deviations of the mean. It is only those women who are outside of two standard deviations that are considered abnormal. That does not mean that a woman whose labor is lasting longer than two standard deviations from the mean cannot possibly have a vaginal delivery, but it does mean that a woman whose labor is lasting longer than two standard deviations from the mean is far less likely to have a vaginal delivery.

    The bottom line is this: defining normal as a range is not arbitrary. It is a reflection of what we know about human variation. The range of normal accounts for most of human variation. Anything that lies outside the range of normal is very unlikely to be normal.

  4. August 25th, 2010 at 20:43 | #4

    Dr. Tuteur,

    Thanks you for the wonderful backstory on Dr. Friedman and the importance of the Friedman curve. Unfortunately, many of us know from personal experience that the Friedman curve is *actually* used to determine when a labor should be augmented. Changing the limits to reflect this new mis-usage of the Friedman curve seems very appropriate to this end.

    As for the “profound misunderstanding” of standard deviation, the author made no such error. Her comment was that, statistically speaking, the curve provides a label of abnormal that could be translated to mean “baby in danger.” The author’s comment that a standard deviation analysis in this situation has “no clinical significance” is related to her previous comment that there is no information on whether these babies/mothers are in a higher risk category of perinatal mortality/morbidity. The standard deviation cutoff is indeed clinically useless if it is being used to claim these mother/babies are in danger without that known link.

    Thanks for taking the time to explain the statistics, though, and thanks for your comments.

  5. August 25th, 2010 at 21:18 | #5

    Thanks for this thoughtful analysis, as ever! The thing I want to know is: how often are laboring mothers subjected to vaginal exams to determine their “progress”? I suspect vaginal exams themselves actually slow labor’s progression! It seems to me the only useful data to collect on a laboring mother are her blood pressure and the baby’s heart rate. When she’s ready to birth, she’ll know!

  6. August 25th, 2010 at 21:30 | #6

    “Her comment was that, statistically speaking, the curve provides a label of abnormal that could be translated to mean “baby in danger.” The author’s comment that a standard deviation analysis in this situation has “no clinical significance” is related to her previous comment that there is no information on whether these babies/mothers are in a higher risk category of perinatal mortality/morbidity.”

    I understand and she’s quite wrong about that.

    The Friedman curve has NOTHING to do with morbidity and mortality. That wasn’t its purpose when it was developed and it is not its purpose today. It is, however, quite important clinically because it tells us the likelihood that woman will deliver vaginally.

  7. August 25th, 2010 at 22:34 | #7

    A few additional thoughts:

    1. The Friedman Curve was developed in the 1950s and thus, during a time when women had begun to labor and birth in hospital, and therefore in a supine/inactive position (not to mention the use of Scopolomine and other sedative/amnesic agents). This certainly would have affected the curve’s outcomes and, therefore, does not represent what is “normal” for physiologic labor and delivery.

    2. Regarding the debate over significance of standard deviations: the mere fact that we, as human beings, decided that two standard deviations away from the mean = the range of normalcy when it comes to childbirth (and those people/numbers falling outside that range represent “abnormal”) is where the arbitrary nature comes in. So what if some women experience labor that lasts 1, 2, 3, 4 or 5% longer (or shorter) than the other 95% of their cohorts? Why does that occurrence necessitate the title of “abnormal”–particularly when there are no studies linking maternal/fetal safety or lack-there-of to labors sitting in the outlying time lines? It is only by our saying so, that makes those women statistically abnormal. Dr. Tuteur makes the comment that the Friedman curve has NOTHING to do with m/m. If this is the case, why does a woman’s labor falling outside the curve prompt her provider to intervene? Because of the fear of danger to mom/baby, right?

    3. I can’t help but relate the points made in this analysis to the question of prodromal labor–another sticking point during which I have seen a lot of potentially unnecessary intervention occurring. How do we define a “normal” complete length of labor and birth when early labor can last anywhere from hours to days? I believe that because we are an impatient society with many quick fixes available to us, many have lost their ability to truthfully judge “normal” from “abnormal”–whether discussing active labor, prodromal labor, second or third stage, etc.

    As I go along in life, I believe more and more that stopwatches are better saved for the kitchen when baking bread and the gym when working out…not in the labor and birth setting.

  8. August 26th, 2010 at 06:51 | #8

    @Allison
    The thing I want to know is: how often are laboring mothers subjected to vaginal exams to determine their “progress”?
    From what I’ve read and heard, most women have VEs every hour while in labor, although the World Health Organization’s “Safe Motherhood” standards say that mothers shouldn’t be checked more often than every 4 hours.

  9. avatar
    Carol Van Der Woude
    August 26th, 2010 at 09:33 | #9

    My perspective on the progress of labor changed when I began attending homebirths. For the first time I saw a woman move freely throughout labor. The mothers position changes, intuitive desire to stand and rock her hips affected the postion and angle of the baby moving down and into position for birth. Some babies need to adjust their position. Sometimes the circumference of the baby’s head ( a larger head) takes longer to find that right angle. My daughter labored at home with home birth attendants and stalled at 5-6 cm for six hours. Her bag of waters was still intact when she transferred to the hospital. At the hospital she was given intravenous fluids (no pitocin) and allowed to continue in labor while the baby was monitored. Six hours later she gave birth vaginally to a baby with 9/9 apgars and 14 and 1/4″ head circumference.
    I agree with Kimmelin–Dr. Friedman’s observations were limited and skewed by viewing labor within hospital practices.

  10. avatar
    B
  11. August 26th, 2010 at 19:26 | #11

    No study links a cut point for “abnormally slow” with an increase in perinatal morbidity, but averting adverse outcomes should form the basis for intervening medically because of the risks of intervention.

    I’m simply a mother of five (all birthed in the hospital with no interventions, with carefully chosen, patient doctors), so I’m hesitant to jump into these deep waters, but this topic is of particular interest to me. The above point is frustrating to me; I cannot understand why this hasn’t been studied, especially when doctors DO, most certainly, use the Friedman Curve. Its usage has become so standard that when a doctor chooses to deviate from it, it’s cause for celebration from the natural-birthing world! Virtually all of my friends who have labored & delivered in a hospital setting, and three of my friends who are L&D nurses, agree that mothers are, indeed, bullied with the standard of 1cm/hr.

    I’m not nulliparous, obviously, but to my surprise, the birth story of my youngest was recently chosen by the Mother’s Advocate blog as anecdotal support, I suppose, of how avoiding unnecessary interventions very often has a positive result. I was “failure to progress”, staying at 7cm for nearly seven hours, before spontaneously entering transition and birthing a healthy baby in 15 minutes’ time. http://mothersadvocate.wordpress.com/2010/08/16/the-birth-of-baby-fiala/

  12. August 27th, 2010 at 00:51 | #12

    @Karen Joy
    Enjoyed your birth story. It was great to read about your persistence and prayer–and the patience of your doctors!

  13. August 27th, 2010 at 16:34 | #13

    @Carol Van Der Woude
    Thank you, Carol! I realized, at the time, that my doctor was patient (even the impatient nurse assured me that he was, indeed, likely the most patient doctor with whom she was familiar). But, the more I study about natural birthing, and the better I acquaint myself with standard birthing practice in the U.S., the more I am thankful that he was my doctor.

    (By the way, I just subscribed to your blog, and put a request for your novel via inter-library loan, as my library does not have a copy. I’m always on the hunt for books that are good art + good message — it’s hard to find that combination!)

  14. avatar
    IndianaFran
    August 29th, 2010 at 12:00 | #14

    @Amy Tuteur, MD
    It’s seems you have chosen to interpret this post as a “smear” on the reputation of your former colleague. It’s clearly nothing of the sort.
    In the context of the contemporary practice of obstetrics (and midwifery), Dr Friedman’s original motivations in researching and developing his “curve” are quite irrelevant. (just like Margaret Sanger’s motivations and Dr Dick-Read’s motivations are irrelevant to a contemporary discussion of birth control or physiologic birth).
    If the original purpose of the Friedman curve was to prevent unnecessary cesareans, then over the decades of its use, it has clearly failed in execution, if not in principle.

  15. avatar
    IndianaFran
    August 29th, 2010 at 12:28 | #15

    @Amy Tuteur, MD
    As far as the standard deviation discussion, the statistical definition of normal (within 2 standard deviations of the mean) may or may not have any actual clinical significance.
    Ask your primary care provider whether your blood pressure is normal, and I doubt that s/he would use a definition that includes 95% of the population. Instead, the range of normal is defined by its clinical significance – the threshold where blood pressure impacts the likelihood of having an adverse affect on health. That threshold is somewhat arbitrary (and has been revisited several times), but it is at least based on actual observed outcomes.
    As far as labor observation and management, what is needed is not a more recent estimate of where the 95% cutoff lies, (since this has nothing to do with mortality or morbidity), but evidence-based guidelines based on outcomes.
    When a clinician recommends either augmentation or surgical delivery, that recommendation ought to be based on clear evidence that such action is likely to have a better outcome than no intervention.

  16. August 29th, 2010 at 12:34 | #16

    @Karen Joy
    My daughter-in-law’s recent story was very much on my mind as I wrote my blog post. Her first baby, she was induced at 42 weeks for postdates. She hung up at 6 cm for many, many hours. Thanks to the watchful patience and excellent care by the staff at Kaiser Santa Clara–which included taking a break from the Pitocin for a shower and a rest (which allowed a restart at a lower dose), an epidural eventually, time to “labor down” before beginning pushing–and the knowledgeable assistance and support of her doula, my daughter-in-law gave birth spontaneously to an 8 lb 15 oz boy in the occiput posterior position. I am sure that at any hospital adhering to the conventional cookbook approach, she would now be recovering from her cesarean surgery. In fact, that would probably have been true a few years ago at this same hospital, but a new, progressive ob who graduated from resident to attending physician has been influential in changing the culture.

  17. avatar
    cathi
    August 30th, 2010 at 10:18 | #17

    @Henci– Congrats to your family, and Kudos to that doc/staff! I hope this amount of patience will become the norm! How wonderful! :)That’s a good size baby for an OP one! :)

  18. August 31st, 2010 at 08:09 | #18

    “My daughter-in-law’s recent story was very much on my mind as I wrote my blog post. Her first baby, she was induced at 42 weeks for postdates. She hung up at 6 cm for many, many hours.”

    Why?

    Do you suggest that people stop wearing seat belts because your daughter-in-law drove cross country without one and didn’t get hurt? Do you suggest that people refuse breast biopsies because your friend ignored a lump for 3 years and it turned out to be benign?

    The recommendation to wear a seatbelt and the recommendation to biopsy all breast lumps are based on statistical analysis. Sure, you can get away with not wearing a seatbelt or with ignoring a breast lump. But that doesn’t mean it’s a good idea. Similarly, you can get away with a protracted labor, but that doesn’t mean it’s a good idea.

    Telling “just-so” stories tike that of your daughter-in-law, and pretending that medical management should be based on them is just the kind of scientific nonsense that leads people to ignore NCB advocates.

  19. avatar
    Emalee Danforth, CNM
    August 31st, 2010 at 17:38 | #19

    I just read the Neal article in the July/August issue of the Journal of Midwifery and Women’s health in its entirety. I think some of the salient points that Ms. Goer does allude to include a) many labors will stall for greater than or equal to 2 hrs in the active phase and b) As dilation is progressively closer to 10 cm, the rate of dilation speeds up. So yes, labor does not typically proceed in a linear fashion and doing interventions in the 4-6 cm range in particular may not take into account a potentially normal physiologic variation in many nulliparous women.

    I would comment, in regard to the penultimate paragraph, I don’t think that it can be assumed to be clinically insignificant when a woman’s labor length is in the far reaches of the norms despite the lack of a cutoff point at which is is known a poor outcome would result should labor continue. When a labor is truly prolonged, with or without intervention, there is often an identifiable reason. For example a larger baby, poor fetal positioning, dehydration or fatigue may be at the root. A prolonged labor demands that the provider look more closely to discover what might be holding up progress, and interventions may take many forms including or not including pitocin augmentation.

    Finally, in regard to Ms. Tuteur’s comments, I did go to your blog to read the full flesh of your comments that you posted here. I found your tone to be spiteful and ill-willed when I read your posts in entirety. I would prefer a kinder approach in these professional discussions and debates.

  20. August 31st, 2010 at 18:07 | #20

    Amy Tuteur, MD :
    “My daughter-in-law’s recent story was very much on my mind as I wrote my blog post. Her first baby, she was induced at 42 weeks for postdates. She hung up at 6 cm for many, many hours.”
    Why?
    Do you suggest that people stop wearing seat belts because your daughter-in-law drove cross country without one and didn’t get hurt? Do you suggest that people refuse breast biopsies because your friend ignored a lump for 3 years and it turned out to be benign?
    The recommendation to wear a seatbelt and the recommendation to biopsy all breast lumps are based on statistical analysis. Sure, you can get away with not wearing a seatbelt or with ignoring a breast lump. But that doesn’t mean it’s a good idea. Similarly, you can get away with a protracted labor, but that doesn’t mean it’s a good idea.
    Telling “just-so” stories tike that of your daughter-in-law, and pretending that medical management should be based on them is just the kind of scientific nonsense that leads people to ignore NCB advocates.

    Your analogy doesn’t work. From my perspective the seat belt is careful observation of mother and baby. Fetal heart tones are a measure of the baby’s tolerance of labor. The Friedman curve cannot be compared to a seat belt. If I followed your logic and fear-mongering I would never get in a car.
    @Amy Tuteur, MD

  21. September 1st, 2010 at 09:06 | #21

    A perspective from another OB –

    The Friedman curve was the product of some brilliant research from a dedicated man, who put a great deal of work into defining the norms of term active labor. The data did show us 5th and 95th percentiles for typical labor, for term spontaneous labor. There is nothing wrong with this data, and it is somewhat useful, but one needs to consider changes that have occurred since Friedman collected his data.

    Since that data two major things have changed:
    1) inductions have become common, and Friedman looked at only term spontaneous deliveries
    2) average BMI has increased substantially, and obesity is associated with slower labors (and shoulder dystocias)

    Subsequent data to Friedman has been published has suggested that a ‘modern’ labor curve may be slower than what Friedman described, likely for the reasons noted above.

    In my opinion, we must individualize care. If a patient is way off the curve, it may be that she truly will not deliver the infant vaginally, but if the strip is reasurring and the mother wants to continue the labor, it is in the best interest of the mother to give her more time.

    A number of comments have taken issue with the idea of someone being at the 5th or 95th percentile being ‘abnormal’. I think these folks need to note take these terms so personally. Ultimately we are trying to identify women who will not deliver vaginally, or who will not deliver vaginally without injury to baby or mother. Most likely, all of these mothers will eventually be contained within the 5% outside of two standard deviations of the mean(true positives), but some of the women two standards from the mean will go on to deliver a healthy infant if given enough time (false positives). The concept of ‘abnormal’ or ‘normal’ in this case is purely a statistical definition, not a value judgement.

    As for statistics being a creation of man, I would argue that if anything is a creation of something other than man, it would be the truth of mathematics. We didn’t create mathematics, we discovered it.

    I think Henci’s example is a good one of how the Friedman curve can lead us astray. Her daughter in law had two issues that might push her off the curve 1) she was an induction and 2) her infant was OP. The patience of her physician, the staff, and the mother allowed the ‘false positive’ to be revealed and for the baby to deliver vaginally. As long as the fetal heart rate strip was reasurring, waiting that situation out did not bring additional risk, and ultimately was crucial in allowing a vaginal delivery. I disagree with Dr Tuteur here, in that this story illustrates good and patient labor management, rather than flaunting of some proven rules.

  22. avatar
    MAmomma
    September 1st, 2010 at 12:26 | #22

    I agree with you Dr. Fogelson. There are so many factors that can influence how quickly or slowly labors progress, and Henci’s example was perfect… and I don’t believe that she was giving that example so that we can all forget about wearing “seatbelts”. Duh. Caregivers need to take these factors into consideration when using the curve and making decisions, and not use them as excuses to immediately jump to a c/s. This is also the reason that as patients, we need to explore these factors and how they can affect labor so that we can advocate for ourselves if needed. There may be women who don’t know that they may have a stalled/slow labor if baby is OP for example.

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