New guidelines preach patience in the delivery room
WASHINGTON – Show more patience in the delivery room: That’s the prescription being given to the nation’s obstetricians.
New guidelines say doctors should give otherwise healthy women more time to deliver their babies vaginally before assuming that labor has stalled.
“Labor takes a little longer than we may have thought,” said Dr. Aaron Caughey, who co-authored the guidelines for the American College of Obstetricians and Gynecologists.
The recommendations were published jointly by two groups of pregnancy specialists – ACOG and the Society for Maternal-Fetal Medicine – amid growing concern that C-sections are overused.
Nearly 1 in 3 women in the U.S. gives birth by cesarean. Yes, C-sections can be life-saving for mother or baby. But they also can be done for convenience or fear of lawsuits, and the surgery can bring some serious health risks. And having one cesarean greatly increases the chances that a next pregnancy will end in one, too.
One of the main reasons for a first-time C-section is labor that’s progressing too slowly, ACOG’s analysis found.
How long should labor take? There’s no clear-cut deadline, and every woman is different, stressed Caughey, obstetrics chairman at the Oregon Health and Sciences University.
“My patients ask this every day,” he said. He tells them it can “run the gamut from six hours long, start to finish, to three and four days” at the other extreme.
Whether labor is too slow is assessed at different time points – and what doctors were taught in medical school about the different stages may not be the most up-to-date.
A 2012 study from the National Institutes of Health found that one particular stage takes up to 2½ hours longer now than it did in the 1960s, when many labor definitions were set. Partly, that’s because today’s mothers-to-be tend to be older and weigh more. But it’s also because of some changes in obstetric practice, such as more use of painkilling epidurals that can slow labor.
Among the recommendations for otherwise low-risk mothers and babies:
• Don’t order a C-section just because the first and longest phase of labor is prolonged. Historically, doctors considered it stalled if it lasted longer than 20 hours for a first-time mom or 14 hours for other mothers.
• “Active labor” begins later than once thought, not until the cervix is dilated 6 centimeters. Active labor is when contractions become stronger and more frequent, and the cervix begins to dilate more rapidly until the woman is ready to push. Doctors once thought active labor began when the cervix was dilated 4 centimeters, but recent research shows that dilation remains pretty slow until reaching the new threshold.
• If women aren’t too tired, allow them to push at least two hours if they have delivered before, three hours if it’s their first baby. They may push longer if they had an epidural as long as the doctor can see progress.
• Forceps can offer a safe alternative to certain cesareans if used by an experienced, well-trained physician.