New guidelines released by the World Health Organization (WHO) are warning maternity care providers against trying to speed up labour unless there is a medical need.

Around 140 million births occur globally every year. Most of these births are uncomplicated but leading health experts are alarmed and concerned about the increasing rates of medical interventions in recent years.

Induction, augmentation, epidural analgesia, forceps or vacuum births, and c-section births are among the interventions being performed due to labour’s being actively managed.

Obviously, women and their care providers want to achieve safe births. However, the increasing use of medical technology is interfering with women’s natural ability to give birth without assistance.

This lack of trust in birth and women’s bodies is having a negative impact on women’s physical and mental health, their baby’s health and natural adaptations to labour and birth.

What do we mean by active management of labour?

When we refer to the active management of labour, we refer to a set of processes and/or interventions that are applied with the intention to speed up labour, monitor or manage a woman’s labour and birth. This has been a topic of great debate over recent decades, within maternity care and among health care professionals.

Active management or to speed up labour goes against the concept of normal physiological labour, meaning one that is powered by the innate human capabilities of the mother and baby, enabling labour and birth to progress and unfold how it would naturally. This can also be described as expectant management.

It’s easy to confuse the terms induction and augmentation, but it’s important to know the difference.

For more information about this, read our article Augmentation And Induction | What Is The Difference?

What does the WHO say? What’s new?

The WHO has recently released the WHO recommendations: intrapartum care for a positive childbirth experience, which bring together new and existing WHO recommendations, to make sure best practice and evidence-based care are at the forefront of maternity care for women around the world.

The new WHO recommendations for intrapartum care revolutionise the way labour is managed in modern maternity care settings, dispelling older, outdated research.

A refreshing element in the new guidelines is a recognition that every birth is unique and that over-medicalisation of birth undermines a woman’s own capability and belief in her body to give birth and can negatively affect her birth experience. Attention and priority are given to the clinical safety of birth but there is also a strong emphasis on a positive birth experience; this is a critical element in ensuring high quality labour and childbirth care.

The updated guidelines disregard previous advice, based on Friedman’s Curve, which recommended speeding up a ‘slow labour’, if dilation hadn’t progressed at least 1 cm per hour during first stage labour. It was believed a prolonged dilation was risky to both mother and baby and, therefore, intervention was seen as necessary.

Friedman’s Curve – the time a woman should give birth.

In the mid-1950s, Dr. Emanuel Friedman plotted a graph of data taken from 500 first-time mothers who gave birth at full term. He calculated the average time a woman took to dilate one centimetre.

This graph is known as Friedman’s Curve and, despite more recent research that dispelled the myth of 1 cm per hour cervical dilation, the graph has been used to underpin maternity care for over 60 years!

You can read more about how this graph was designed – and about its flaws – in Friedman’s Curve | Surprised Use During Labour.

Women who don’t meet this 1cm per hour criterion for dilation are told their labour is ‘failing to progress’ and they will need ‘help’ to get things moving. This help is usually in the form of interventions, such as breaking the amniotic sac (waters) or giving artificial oxytocin.

It’s hardly surprising many women go on to have further interventions, such as epidural pain relief, forceps, and c-sections. They are the result of the long-held yet erroneous belief that every woman’s cervix dilates in exactly the same way.

Why is the WHO recommendation good news?

This updated recommendation from the world’s leading health organization is welcome news. It demonstrates to all maternity care providers the irrelevance of Friedman’s Curve, which has been used as the backbone of labour care management for many decades and was often the reason for early interventions.

It also points the way for new and experienced care providers to become fully aware of best practices and evidence-based research.

More recent studies have found that, during normal labour, women can dilate much more slowly than the widely accepted benchmark of 1 cm per hour, as described in Friedman’s curve. The use of information such as Friedman’s Curve, as the basis for decision making during labour care, is no longer relevant and is detrimental to the care of healthy women.

There is also a large body of evidence to show the rate of cervical dilation actually begins to pick up after 6 cm, rather than 4 cm, which was when Friedman considered active labour to begin.

This newer research and new recommendations acknowledge the flaws in Friedman’s evidence and recognise that labour practices and birthing populations have changed greatly since the 1950s when he undertook his research. This was the era of ‘twilight sleep’, where many women were sedated during labour, and the average age of women included in the study was 20, whereas today, the average age for someone having her first baby is considerably closer to 30.

Modern maternity care practices include increased rates of epidural analgesia; rates of inducing labour have also increased dramatically, and the average body size and shape has changed too. All of these factors are known to affect labour and birth.

How long does it take to dilate from 1 cm to 10 cm?

We know that every labour is unique; these new recommendations, however class ‘latent’ (or early labour) up to 5 cm. It’s noted that women should be advised that a standard duration of the latent phase has not been established and that it can vary widely.

The ‘active’ stage of labour is classed from 5 cm onwards, and usually doesn’t exceed 12 hours (from 5-10 cm) for first labour’s and 10 hours for a subsequent labour (women who have had a previous pregnancy and birth).

How Long Does It Take To Dilate From 4cm To 10cm?

How to speed up labour

Although medical intervention to induce or speed up labour might be appropriate in some circumstances – for example, when there are certain pregnancy complications, such as high blood pressure – more attention should be given to holistic methods, such as complementary therapies or alternative techniques.

Some care providers and units providing midwifery-led care offer therapies such as acupuncture, massage or reflexology, so it’s a good idea to check what’s available in your area or whether your doctor or midwife offers anything similar.

If not, don’t worry; there are still plenty of things you can try yourself to help calm and relax your mind and body during pregnancy and labour to help naturally ‘induce’ or speed up your labour.

Some things you can try are:

Relaxation exercises and breathing techniques
Mindfulness exercises
Music or hypnobirthing
Massage
TENS machine
Birthing pool or warm bath
Staying active and mobile during labour
Nipple stimulation
Eating dates
Nutritional elements, such as evening primrose oil, red raspberry leaf tea (herbal tea), pineapple or spicy foods.

Some of these tools and techniques can be used as effective alternatives to pharmacological pain management.

You can learn more about natural methods of induction by reading our article How To Bring On Labour Naturally – 11 Natural Methods.

Positions to speed up labour

Various maternal positions can be used during pregnancy, or at any stage, to help get your baby into the best position for birth and to make contractions more manageable and comfortable for you.

Generally, forward learning or upright positions help create more space in the pelvis and help to get your baby’s head in the optimal position before entering the birth canal. Optimal fetal positioning is important to make sure your baby enters the pelvis and birth canal in the most effective way. Poor fetal positioning in active labour can create an increased risk of stalled labour (labour dystocia) and creates a higher risk of assisted vaginal births and c-sections.

The most obvious way to treat dystocia in the hospital setting is to use interventions, such as breaking your waters to release the amniotic fluid around your baby or using a hormonal (oxytocin) drip to try to start labour again by bringing back contractions.

The use of a birthing ball, either to sit on or lean on, can provide a comfortable position to experience contractions. Either position involves leaning forward slightly, in order to balance, and keeps the back of the pelvis free to allow for slight movement and more space, enabling your baby to move through more easily.

A hands and knees or all-fours position can also have a similar effect for most babies and can help you to stay calm and feel more relaxed during your birthing process.

What does this mean for birthing women?

The new guidelines from the WHO highlight the importance of maternity care providers acknowledging the individual women they are caring for. This creates a more positive and empowering birth experience.

The recommendations overturn the incorrect advice and practices that have been responsible for removing women’s autonomy with regard to their birth experiences.

Pregnant women can refer to these new guidelines as they discuss their maternity care with their care provider, doctor or midwife. They can make sure they are not being put ‘on the clock’, which increases the risk of interventions for both mother and baby.