Expert Reviews ajog.

org

OBSTETRICS
Perils of the new labor management guidelines
Wayne R. Cohen, MD; Emanuel A. Friedman, Med ScD

in this commentary, we believe the

Recent guidelines issued jointly by the American College of Obstetricians and Gyne- new ACOG/SMFM recommendations
cologists and the Society for Maternal-Fetal Medicine for assessing labor progress differ provide definitions of dysfunctional la-
substantially from those described initially by Friedman, which have guided clinical bor and guidelines for its management
practice for decades. The guidelines are based on results obtained from new and un- that, however well intentioned, are likely
tested methods of analyzing patterns of cervical dilatation and fetal descent. Before these to impose undue risk on mother and
new guidelines are adopted into clinical practice, the results obtained by these uncon- fetus.
ventional analytic approaches should be validated and shown to be superior, or at least
equivalent, to currently accepted standards. The new guidelines indicate the patterns of Historical background
labor originally described by Friedman are incorrect and, further, are inapplicable to Prior to the mid-1950s, the evaluation
modern obstetric practice. We contend that the original descriptions of normal and of progress in labor was based primarily
abnormal labor progress, which were based on direct clinical observations, accurately on its duration. Vague admonitions such
describe progress in dilatation and descent, and that the differences reported more as, “Never let the sun set twice on a
recently are likely attributable to patient selection and the potential inaccuracy of very laboring woman,” which were based on
high-order polynomial curve-fitting methods. The clinical evaluation of labor is a process prevailing observations about average
of serially estimating the likelihood of a safe vaginal delivery. Because many factors labor duration and outcomes,15 were
contribute to that likelihood, such as cranial molding, head position and attitude, and the commonly intoned. This approach was,
bony architecture and capacity of the pelvis, graphic labor patterns should never be used however, ineffective in identifying
in isolation. The new guidelines are based heavily on unvalidated notions of labor when intervention would be appropriate
progress and ignore clinical parameters that should remain cornerstones of intrapartum or optimal.
decision-making. In 1954, the first of hundreds of
studies of labor by, or based on the
Key words: active phase, arrest of descent, arrest of dilatation, arrest of labor, decel-
work of, Emanuel Friedman6 was pub-
eration phase, dysfunctional labor, labor curve, partogram
lished. Friedman’s work built upon pre-
vious investigators’ attempts to describe
the events of labor as a function of
time.16-18 Their recognition of the
T he seemingly inexorable increase
in the use of cesarean delivery,
and the substantial contribution that
Gynecologists (ACOG) and the Society
for Maternal-Fetal Medicine (SMFM)
were released.5 The new recommenda-
practical implications of this approach
was hampered by what we now know to
dystocia and related diagnoses have tions define abnormal labor and provide have been erroneous assumptions about
made to that increase, have prompted a guidelines for its management that differ labor, particularly with regard to the
reevaluation of what constitutes normal sharply from those originally described role of membrane rupture. The first
labor.1-4 As a result, new guidelines by Friedman,6-10 which have formed publications6-8 describing the graphic
promulgated jointly by the American the basis of the clinical management of patterns of dilatation and descent stim-
College of Obstetricians and labor for many decades in the United ulated the interest of many investigators,
States and elsewhere. For that reason, and led to the formulation of criteria that
a thorough analysis of the proposed made the assessment of progress in labor
From the Department of Obstetrics and
standards is warranted to ensure that objective rather than arbitrary.9,10,19-26
Gynecology, University of Arizona College of
Medicine, Tucson, AZ (Dr Cohen); and the changes recommended for obstetric Unfortunately, the criteria have not al-
Department of Obstetrics, Gynecology, and care during labor are justified by the ways been applied appropriately, in
Reproductive Biology, Harvard Medical School, available evidence. part because of some misunderstandings
Boston, MA (Dr Friedman). The guidelines are based heavily on about the curves and their proper place
Received Aug. 11, 2014; revised Aug. 20, 2014; analytic methods used by Zhang and in clinical care.
accepted Sept. 2, 2014.
colleagues11-14 to describe the patterns of
The authors report no conflict of interest. cervical dilatation and fetal descent Misconceptions
Corresponding author: Wayne R. Cohen, MD. as functions of time elapsed in labor. It has often been alleged that Friedman’s
cohenw@email.arizona.edu
Their findings, which have been rapidly seminal observations regarding the
0002-9378/$36.00 adopted in some parts the obstetric labor curves rest on a fragile foundation
ª 2015 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ajog.2014.09.008 community, have not yet been validated. because they were never corroborated by
For the reasons we briefly summarize others. In fact, numerous studies done

420 American Journal of Obstetrics & Gynecology APRIL 2015

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in different parts of the world over the
course of several decades confirmed the
basic nature of the original curves, and
validated their usefulness in clinical
practice.27-43 There have been disagree-
ments over the importance of the latent
phase or even the existence of the
deceleration phase of dilatation, but the
core finding that active-phase cervical
dilatation progresses linearly, with a
lower limit of normal approximately
1.0 cm/h in nulliparas, has been re-
markably consistent among studies. It
is also noteworthy that in many in-
stitutions the introduction of labor
curves to clinical care was associated
with a decline in the cesarean rate.30,33,34
Some of the early data were collected
using a mechanical cervimeter to obviate
the potential subjectivity in clinical ex-
amination,9,44,45 and cervimetry by in-
vestigators using various tools confirmed
the sigmoid nature of the dilatation
curve.46-49 Limited data from more
recently developed techniques to auto-
mate cervical assessment also appear
consistent with the earlier observa-
tions.50,51 Sigmoid-shaped curves of cer-
vical dilatation have even been described
in cows, suggesting a common pattern of
labor among mammalian species.52
Given the large body of evidence
confirming the basic pattern of pro-
gress in normal labor, it is difficult to
believe that labor progresses very differ-
ently today from how it was originally
described. Why, then, do the labor
curves of Zhang and his colleagues differ
from those of previous observers? One
explanation was provided by Zhang
himself when he and his colleagues
applied their analytical methods to the
very same data Friedman had analyzed
from the Collaborative Perinatal Proj-
ect.14 Friedman’s analysis of those data
revealed a sigmoid-shaped dilatation
curve; that of Zhang et al revealed an
exponential curve, essentially the same
as they had found from contemporary
labors. Clearly, what had changed was
not the nature of progress in labor, but
how the data were analyzed. This raises
the question of which analytic technique
provides a more accurate model of
labor progress: that of Friedman or that
of Zhang et al?
Obstetrics
In trying to address that question it
is important to understand that the
original dilatation and descent curves
were based on and confirmed by direct
experimental observations made on
women in labor. The primacy of direct
observation over theoretical conceptu-
alization or indirect analysis of data in
hypothesis testing has been a central
tenet of the scientific method since the
Enlightenment. When the results of an
analytic approach differ from those
derived from observation, it is important
to understand why this has occurred,
and try to adjudicate accordingly, before
declaring the direct objective findings
invalid.
Analytical issues
The labor curves in Friedman’s original
reports were not created by using com-
plex mathematical formulae, as some
have suggested.2 The initial data were
collected by a single observer.6 Subse-
quently, data from multiple practitioners
in a single institution were reported.7,8
In both instances, the curves were drawn
by hand, the descriptions were empiric,
and the statistical analysis basic. Only
later was a more sophisticated method
of assessing the labor graphs by com-
puter used to analyze >10,000 nulliparas
from multiple institutions.53-56 This
more sophisticated analysis confirmed
the initial findings regarding the nature
of the cervical dilatation and head
descent time functions.
The computer algorithm used was
developed with the Office of Biometry
of the National Institutes of Health.
Raw labor data were plotted on a probit
(ie, the normal probability) scale, to
convert the sigmoid curves to straight
lines.57,58 The maximum slope data were
converted to logarithms to normalize
their right-skewed distribution. The
linearity thus achieved made the data
amenable to descriptive statistical study
for determining distributions and limits
of normal, which have until recently
stood the tests of time and clinical
applicability.
By contrast, Zhang and colleagues
used a high-order polynomial curve-
fitting program to analyze dilatation
and descent data, and interval-censored
APRIL 2015 American Journal of Obstetrics & Gynecology
Expert Reviews
regression to fit curves based on
centimeter-by-centimeter median tra-
verse times. We have concerns about the
application of this technique to labor.
We do not profess personal expertise
in this area, but we are impressed by the
negative comments and strong skepti-
cism encountered in the engineering
literature pertaining to the limitations
of high-order curve-fitting methods.59
Such models do not guarantee reliable
results. Indeed, high-order curve fitting
may not be appropriate or even neces-
sary for most situations. Low-order
quadratic curve fitting is preferable,
whenever possible, and yields results that
are at least as accurate. In fact, the higher
the order, the less satisfactory curve-
fitting accuracy tends to be. This is so
because ‘noise’ (ie, unstable data points,
especially if those points are spread apart
from each other or are located at the ends
of the range of data) is magnified. As a
consequence, portions of the derived
curve are distorted. In this regard a
leading authority opined that, “It is
important to keep the order of the model
as low as possible.As a general rule the
use of high-order polynomials (k >2)
should be avoided unless they can be
justified for reasons outside the data-
.Arbitrary fitting of high-order poly-
nomials is a serious abuse of regression
analysis.”59 Zhang et al used polynomial
curve-fitting models of the order of 8-
10, far in excess of the cited recommen-
dation of no higher than 1 or 2.
Other investigators have used interval
data to create labor curves, with varying
results. Gurewitsch et al60 found a sig-
moid curve of dilatation, but Chen and
Chu61 found results similar to those of
Zhang et al in terms of curve shape and
much lower rates of dilatation.
Thus, the differences alleged to exist
between the Friedman and the Zhang
curves are likely due to the different
mathematical models used to fit these
curves. This is confirmed by Zhang’s
finding, noted above, that the same data
Friedman and Neff62 analyzed decades
ago yielded exponential curves with the
curve-fitting methods used by Zhang
and his colleagues.14
The approach by Zhang et al is likely
to have introduced an important set of
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Expert Reviews Obstetrics
selection biases, which also cast doubt on
the validity of their findings. Women
with rapidly progressing labors tend to
present themselves for obstetric care and
be first examined at more advanced
cervical dilatation than those with longer
labor. Thus, the intervals at the distal
end of the dilatation curve are likely to
have been loaded with progressively
more rapid labors. This may explain
the exponential nature of the dilatation
curve derived in this manner. It may also
explain why the descent curve, which
was unencumbered by that problem
because all patients were present and
under observation for their entire second
stage, looks very much like that origi-
nally reported.11
In addition, the labor curves of Zhang
et al were generated after excluding
women delivered by cesarean. Many of
these were undoubtedly having slow,
dysfunctional labor patterns that led to
a diagnosis of dystocia and the need
for cesarean delivery. Their exclusion is
likely, therefore, to have falsely increased
the average rate of dilatation in residual
study cases, contributing to the expo-
nential appearance of the curves. Zhang
et al also excluded women whose cervix
was >6 cm dilated at admission, prob-
ably thus excluding many of the most
rapid labors and contributing to the
overall appearance of slow average
dilatation.
In fact, these and other biases were
acknowledged by Zhang and his col-
leagues.63 They stated that the fact that
their study excluded first-stage cesareans
“limit[ed] the generalizability of the
results.” They also acknowledged the
probable disparity in dilatation rates
among parturients admitted at different
time points in labor, thus raising doubts
about the comparability of data derived
from these sequential points. They
further reported that their labor curves
“are unadjusted for potential con-
founders, such as oxytocin use. While it
is technically possible to control for
confounders.it complicates the inter-
pretation of the results..” They also
acknowledged that “.time intervals for
more advanced cervical dilation were
affected to an extent by dropout of
women because of caesarean delivery for
422 American Journal of Obstetrics & Gynecology APRIL 2015
labor arrest. Such dropouts usually are
not random. Slow progressing labors
often dropped out early, making the
average time intervals for the remaining
women appear shorter than otherwise.
The degree of bias depends on the inci-
dence of first-stage caesarean delivery.
Unfortunately, we have not yet recog-
nized an easy solution to overcome this
informed censoring.”
To summarize, Zhang and colleagues
have themselves acknowledged that
both the selection biases and the unad-
justed confounders likely influenced the
shape of their dilatation curve either by
slowing the early aspects of the active
phase (or the transition from latent
to active phase) or speeding the late as-
pects of the active phase, or both. The
combined effect of these biases probably
explains in part their finding that the
rate of active-phase dilatation increases
exponentially, rather than linearly as
Friedman and many others have previ-
ously found.6-10,25-31,35-46
Transition to active phase
One critically important way in which
the new guidelines depart from the old
is in identifying the transition from
latent to active phase during the first
stage. It is widely, but erroneously,
concluded from the Friedman dilatation
curve that the active phase of labor be-
gins at 4 cm. Some studies have even
used 3 cm as the definition of entry into
active phase.64-66 According to the
guidelines, the active phase begins at
6 cm. The difference is of critical
importance, because it has a dramatic
effect on whether dysfunctional labor
can be diagnosed early in the active
phase. Important labor abnormalities
(protracted active phase and arrest of
dilatation) that would be identified by
the Friedman curve prior to 6 cm of
dilatation would be classified as normal
by the new guidelines.
Why the active phase of first-stage la-
bor has been inferred to begin at 4 cm is
puzzling. We, in fact, have never sug-
gested that the active phase begins at
either 4 or 3 cm of cervical dilatation; on
the contrary, we have expressly discour-
aged the use of any specific degree of
dilatation for the identification of the
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active phase.23 Observations of dilata-
tion data make it clear the active phase
can begin anywhere from 3-6 cm, and,
occasionally, earlier or later, depending
on the individual labor.23,41 Using an
arbitrary cutoff sacrifices accuracy for
ease, and this unnecessary over-
simplification risks incorrect diagnosis.
The transition from the latent phase to
the active phase can be correctly identi-
fied only by interpretation of serial
clinical examinations for each patient as
her labor progresses.
Consider, for example, a labor that
begins with the cervix 2 cm dilated for
several hours. It then dilates rapidly to
5 cm in 1 hour, but fails to dilate further
over the next 2 hours. According to the
new guidelines, that would be normal
latent-phase labor. To us it is an arrest of
dilatation in active-phase labor that re-
quires thorough evaluation to search
for a cause. The likelihood that it will
resolve itself (as many arrest disorders
do) or would benefit from oxytocin
stimulation would depend on the clinical
circumstances, determinable by evalua-
tion of mother and fetus. If there were
significant molding and a narrow pelvis,
little would be gained by further labor,
and the fetus might be exposed to un-
necessary risk.67,68
Diagnosis of arrest of dilatation
Under the new guidelines, neither pro-
tracted active phase nor arrest of dilata-
tion should be diagnosed in a nullipara
before 6 cm cervical dilatation, and the
lower limit of normal active-phase dila-
tation is about 0.5 cm/h, rather than the
1.0 or 1.2 cm/h reported by Friedman
and others. The guidelines do recognize
that there can be slow but progressive
first-stage dilatation (protracted active
phase), and that it should not be an
indication for cesarean delivery, but
they conflate protracted active phase and
arrest of dilatation, despite evidence
that they may be distinct disorders that
respond differently to therapy and have a
different prognosis.10,23 A protracted
active phase, unless it has been caused
by factors that inhibit contractility, such
as anesthesia, infection, and (possibly)
obesity, does not respond to oxytocin
stimulation with an increased rate of
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dilatation. Contractility does, however,
increase, thus conferring risk with no
offsetting benefit.69-71
Role of contractile force
To diagnose arrest of dilatation, the
guidelines require that the cervix be 6
cm dilated, the membranes be ruptured,
and there be no progress for 4 hours
with adequate contractions, or 6 hours
with inadequate contractions produced
by oxytocin. They define adequate uter-
ine contractility as “e.g., >200 Mon-
tevideo Units” (MVU), but recommend
no alternative means of assessment.
Moreover, no upper boundary of MVU
is provided, thus condoning the poten-
tial exposure of the fetus to excessive
uterine contractility. The definition also
implies that an internal uterine pressure
transducer (IUPT) is useful to diagnose
an arrest of dilatation, but this is
questionable.
The use of MVUs is problematic for
several reasons. Intrauterine catheters
carry risk, and there is not evidence for
benefit. Studies have demonstrated
that the use of IUPTs had no advantage
when compared to noninvasive means
of assessing uterine contractility during
labor.72-74 In addition, IUPT readings
may depend on patient position, or on
their location within the uterus and,
most importantly, they do not corre-
late well with progress in cervical dila-
tation70,75 or with the need for cesarean
delivery.69 Normal progress in dilatation
is achieved over a broad range of uterine
activity, and the pattern of contractions
may be as important as their strength.76
The definition of arrest of dilatation
proposed by the guidelines would, for
example, allow a labor arrested at 8 cm
with strong contractions to continue
for at least 4 hours (and an additional
4 hours if the membranes were not
ruptured until after the first 4 hours) at
that dilatation before an arrest could
be diagnosed and the recommended
4 hours of treatment begun. This
recommendation would be inadvisable
in many circumstances, because it
fails to consider any preceding labor
abnormalities, the results of clinical
cephalopelvimetry, the presence of in-
fection, and other factors that might be
Obstetrics
contributing to the dysfunction, some
of which might not be surmountable.
Of even more concern, the recommen-
dations in the guidelines implicitly deny
the possibility that the fetus could be
put at risk by prolonged exposure to
strong uterine contractions during an
arrest of labor.67,68,77
Treatment of arrest of dilatation
We have always taught, based on objec-
tive findings, that arrest of dilatation
should generally be treated with oxy-
tocin infusion unless there is compelling
clinical evidence of disproportion or
another contraindication to oxytocin
use.23 Although the duration of oxytocin
treatment should be tailored to the in-
dividual situation, a trial of about 4
hours was recommended as early as
1963.9,78 This approach was confirmed
as appropriate more recently by other
investigators.65
Several analyses of arrest of dilatation
made it clear that the disorder will
sometimes resolve spontaneously, but
that oxytocin stimulation is often
necessary, and usually effective.10,24,78
When oxytocin is used, about 90% of
labors that will respond with further
dilatation will have done so after 3-4
hours; 7 hours may be necessary before
all cases have responded. Rupture of
membranes seems to be effective in
provoking further sustained dilatation
in only a small proportion of cases.10,66
Given the risks associated with rupture
of membranes (infection, abnormal
fetal heart rate patterns, increased head
compression66,68,79) we do not recom-
mend amniotomy as a treatment for ar-
rest disorders, but it should be used
if there are other potential benefits,
such as better quality fetal heart rate
monitoring or more effective clinical
evaluation.
The deceleration phase
During the terminal portion of the active
phase of labor (the deceleration phase),
uterine contractions remain strong,
and the patient may perceive pain of
increasing intensity. The graphic
appearance of dilatation at this time,
however, seems to slow. This results
from the cervix being retracted in a
APRIL 2015 American Journal of Obstetrics & Gynecology
Expert Reviews
cephalad direction (relative to the
mother) around and alongside the fetal
head. As it nears full dilatation, the cer-
vix is no longer opening in a primarily
transverse plane relative to the mother’s
pelvis. Because our examination only
measures dilatation accurately in that
plane, dilatation appears to decelerate,
even though the cervical rim is still
being retracted at about the same speed
as before. The deceleration phase is
often quite short in normal labors and
is easily missed if examinations are
not done with sufficient frequency to
identify it.
The labor patterns reported by Zhang
et al11,12 failed to show a deceleration
phase, but they did acknowledge that it
was present in cases delivered by cesar-
ean that they had excluded from their
analysis. In other words, its absence in
their average curves was a consequence
of patient selection. They excluded the
very labors most likely to manifest pro-
longed deceleration. The presence of the
deceleration phase has been confirmed
by others.43,49,60,80-83 Despite the artifi-
cial nature of the deceleration phase of
the dilatation curve, it reflects a critically
important time in labor. Deceleration
generally marks the beginning of fetal
descent, and its prolongation portends
significant problems for the labor.
Frequent careful examinations during
this portion of labor can yield important
prognostic insights regarding the risk
of shoulder dystocia, abnormal second-
stage descent, and the likelihood of the
need for cesarean delivery.82-86
The second stage
The new guidelines define normal limits
for the second stage by elapsed time
after full cervical dilatation, and take
no account of the rate of fetal descent.
Using only elapsed time makes it
impossible to distinguish among pro-
tracted, arrested, and failed descent, each
of which has a different prognosis for
the labor ending in a safe vaginal de-
livery.10 Moreover, there is evidence
that morbidity associated with a very
long second stage is largely confined to
those with abnormal descent patterns.87
If this is confirmed, the approach
recommended by the new guidelines
423
Expert Reviews Obstetrics
will result in increased maternal and
neonatal morbidity.
The studies that purport to show that
the traditional second-stage labor data
are incorrect demonstrate a similar
pattern of descent to that described
by Friedman, but the lower limits of
normal are slower, about 0.5 cm/h for
nulliparas.11,88 The new guidelines
indicate that an “arrest of labor in the
second stage” can be diagnosed only af-
ter a nullipara has been pushing for at
least 3 hours and a multipara for 2 hours.
If epidural anesthesia is used, an addi-
tional hour is permissible, but then only
as long as progress is being documented.
Otherwise stated, 3 hours of maternal
bearing-down efforts with no progress in
descent are acceptable. We are concerned
that this practice may expose the fetus to
harm from excessive head compression.
A recent influential report4 further
indicated that no progress in rotation
during these time periods also consti-
tutes an arrest of labor in the second
stage. The proposal that lack of rotation,
independent of descent, should be used
as a diagnostic criterion is heterodox and
has not been substantiated. Rotation in
the second stage cannot occur without
descent, and a normal second stage can
occur without rotation. (For example,
an occiput posterior-positioned fetus
descending in an anthropoid pelvis may
never rotate, and yet descend at a normal
rate.) Therefore, we urge that the pres-
ence or absence of rotation not be used
for the diagnosis of descent disorders.
There is no doubt that epidural anes-
thesia can lengthen the second stage,
probably by inhibiting the mother’s
ability to push or by relaxing pelvic floor
musculature. The degree of inhibition
may be minimal or considerable. It var-
ies among patients, and probably de-
pends, among many factors, on the type
and dose of analgesic and anesthetic
agents used. It is, therefore, reasonable
to consider epidural anesthesia as a cause
of or contributor to a descent disorder.
Its inhibitory effects can generally be
overcome with oxytocin; but it is wise
to remember that the presence of an
epidural block does not mean other,
potentially insurmountable, causes of
abnormal descent are absent. Ignoring
424 American Journal of Obstetrics & Gynecology APRIL 2015
that fact and depending solely on dura-
tion of pushing risks making labors un-
necessarily long and adds risk. A recent
study of the effects of epidural medica-
tion suggested that the inhibition of la-
bor progress might be considerably
greater than has been assumed.89
Whether that observation is generaliz-
able remains to be seen, but it underlines
the fact that using duration as the sole
indicator of second-stage progress can
lead the practitioner astray.
We have long opposed the American
tradition of limiting the second stage to 2
hours, and of encouraging intense and
sustained pushing with each contrac-
tion, which may not always be in the
best interests of fetus or mother.19,23,90
Most, but not all, studies of the effect of
second-stage length found little effect
of duration per se on early neonatal
outcome for second stages up to at least 3
hours,90-92 but there is little information
on long-term maternal or neonatal
morbidity. Maternal infection and
hemorrhage risk does tend to increase
after very long second-stage labors, due
in part to the associated high likelihood
of cesarean or operative vaginal delivery.
Unfortunately, most studies of the effect
of second-stage labor duration have not
stratified cases according to whether the
rate of descent was normal, and this may
be a relevant factor.87 The consequences
of the very long second stages advocated
in the new guidelines could be detri-
mental, especially when there is no
descent of the fetal head. Absent more
information about the consequences of
such labors for the maternal pelvic
floor or for the fetus exposed to enor-
mous intracranial pressures sufficient
to impair brain blood flow,67,68,93 the
new recommendations seem, at best,
incautious.
Take as an example the case of a fetus
in an occiput posterior position and
marked cranial molding at the onset of
the second stage, and with the leading
surface of the head at the level of the
ischial spines in a funnel pelvis. The
suggestion that the mother should
remain in the second stage pushing for 3
hours before intervention, even without
any progress in descent, seems to us
to invite peril. The new guidelines also
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recommend manual rotation of the fetal
head in cases of malposition to avoid
cesarean delivery. We agree that manual
rotation (which requires skill and expe-
rience to perform safely) can sometimes
be a useful tool. However, the recom-
mendation that manual rotation be
employed without careful assessment of
the pelvis is not responsible. Do we really
want to rotate an occiput posterior
fetus to an anterior position in an an-
thropoid pelvis with prominent ischial
spines, narrow forepelvis, and a deep
sacral hollow? If such a fetus were to
deliver vaginally, would it not do so more
safely and easily in a posterior position,
rather than being forced to accommo-
date to a pelvis less well suited to its
further descent?
Implementation
It is simplistic and wrong to expect that
any labor curve abnormality will neces-
sarily signal that cesarean delivery is
required. The clinical evaluation of labor
is essentially a process of serially esti-
mating the likelihood of a safe vaginal
delivery.23 Graphic labor patterns are
an excellent tool for that purpose, but
they should never be used in isolation,
because many other factors contribute to
the probability of safe delivery. These
include the degree of cranial molding,
head position and attitude, and the
bony architecture of the pelvis, all of
which can be determined clinically. In
addition, the response to oxytocin, the
fetal heart rate pattern, and factors such
as fetal weight and sex, maternal body
mass, and the presence of infection are
important in this regard.
The average parturient in today’s
industrialized world is older, more
obese, and more likely to have epidural
anesthesia, induced labor, and a larger
baby than in generations past. That these
factors may make dysfunctional labor
more common is valuable information
for the clinician, and should help guide
decision-making, but should not neces-
sarily result in more cesarean deliveries
for dystocia. A labor disorder merely
tells us something about the labor
that should prompt extra scrutiny and
reasoned analysis.
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Arguably, the most important virtue
of the approach to labor we have en-
couraged is not in the numerical details
of the curves, but in the way they can
inform a logical and safe system of
care during labor and delivery. We
have advocated a method that allows a
systematic measure of labor progress,
provides an unequivocal language for
communication about it, and encom-
passes a consistent and logical guide
to decision-making.23 Furthermore, in-
formation derived from the curves
has revealed clues to the risks inherent
in certain aspects of labor and
delivery.23,62,80,82-85
In aiming to restructure our funda-
mental understanding of normal labor
progress, the guidelines raise a more
general question about the incorpora-
tion of new research findings into prac-
tice. New observations are generally slow
to enter professional guidelines and even
slower to become common practice.
This restraint allows new approaches to
be confirmed by further study. Consid-
ering the conservative nature of that
process, should we uncritically accept
the recommended paradigm shift in la-
bor management at this time, or should
we await further confirmation of its
value? We urge a cautious and consid-
ered approach. Adoption of uncorrobo-
rated new practices can have all sorts of
unanticipated consequences, including
harm to patients.
Conclusions
The stated goal of the ACOG/SMFM
Guidelines is to provide safe clinical
strategies to prevent primary cesarean
delivery. Whether the recommendations
will achieve widespread acceptance re-
mains to be seen. Our specialty has pre-
viously attempted to curtail the rising
cesarean rate. Although success has
been achieved in some individual in-
stitutions,94,95 the rising overall rate has
not been significantly affected by the
introduction of new guidelines. The rec-
ommendations of a national consensus
conference on cesarean delivery in 198196
were, for example, largely ineffective.
This is not surprising, given the difficulty
of changing established practice in
most areas of medicine.97-99
Obstetrics
Perhaps the pursuit of a desirable ce-
sarean delivery rate will not bring us
down the most worthy or productive
path. The current cesarean rate is
merely a symptom of a multifaceted and
poorly understood process. Treating
symptoms is rarely as satisfactory as is
modifying or eliminating their source.
If we direct our clinical and basic science
investigations to the goal of practicing
obstetrics in a manner that optimizes
maternal and newborn outcomes, the
ideal cesarean delivery rate, whatever it
may be, will follow.
The use of new databases, prospective
designs, and new statistical methods to
reassess data derived many years ago is
quite reasonable. Novel findings deserve
our respect and invite constructive scru-
tiny. Our overriding concern about the
ACOG/SMFM recommendations is that
they do not offer an encompassing
paradigm for management. Friedman
provided a nosology for dysfunctional
labor, and, based on it, a system of care
that is logical, reproducible, and easily
applied. Failure to apply principles
correctly can lead to specious diagnoses
as well as untimely and inappropriate
intervention.86
To adopt sweeping new guidelines
for the assessment of labor that largely
ignore antecedent obstetric practice is
premature. One could infer from them
that cultivation of the physical diagnostic
skills necessary to become an astute
obstetrician is no longer important.
The guidelines never mention the need
for measurement of fetal station, un-
derstanding the implications of the
mechanism of labor, or any aspect
of clinical cephalopelvimetry. They en-
courage considerably longer labors in
first and second stage than generally
practiced today, but they provide no
evidence that such lengths would be
safe for mother or baby. In fact, the
guidelines regarding management of
arrest disorders ignore the potential
for any maternal or fetal risk. We do not
know nearly enough about the associa-
tion of long labor with chorioamnioni-
tis, neonatal ischemic encephalopathy,
birth injury, and maternal pelvic floor
injury to abide the extended labors rec-
ommended by the guidelines.
APRIL 2015 American Journal of Obstetrics & Gynecology
Expert Reviews
While the goals of the ACOG/SMFM
Guidelines are admirable, their recom-
mendations for the assessment of labor
depart substantially from accepted
norms, and no data yet exist to support
the superiority or even the equivalence
of the proposed paradigm for labor
assessment and management to that
which has served our patients well for
many decades. Absent such data, It
seems unwise to jettison 50 years of
corroborated work with what Sir Robert
Hutchison100 referred to as “too much
zeal for the new and contempt for what is
old.” Perhaps we should temper our
enthusiasm and seek to verify what really
constitutes best practice. The last thing
anyone wants is for a new system to do
a disservice to the women and babies
entrusted to our care. -
REFERENCES
1. Millen KR, Kuo K, Zhao L, Gecsi K. Evidence-
based guidelines in labor management. Obstet
Gynecol Surv 2014;69:209-17.
2. Cahill AG, Tuuli MG. Labor in 2013: the new
frontier. Am J Obstet Gynecol 2013;209:531-4.
3. El-Sayed YY. Diagnosis and management of
arrest disorders: duration to wait. Semin Peri-
natol 2012;36:374-8.
4. Spong CY, Berghella V, Wenstrom KD,
Mercer BM, Saade GR. Preventing the first
cesarean delivery: summary of a joint Eunice
Kennedy Shriver National Institute of Child
Health and Human Development, Society for
Maternal-Fetal Medicine, and American College
of Obstetricians and Gynecologists Workshop.
Obstet Gynecol 2012;120:1181-93.
5. American College of Obstetricians and
Gynecologists; Society for Maternal-Fetal Med-
icine. Safe prevention of the primary cesarean
delivery. Obstetric care consensus no. 1. Obstet
Gynecol 2014;123:693-711.
6. Friedman EA. The graphic analysis of labor.
Am J Obstet Gynecol 1954;68:1568-75.
7. Friedman EA. Primigravid labor: a graph-
icostatistical analysis. Obstet Gynecol 1955;6:
567-89.
8. Friedman EA. Labor in multiparas: a graph-
icostatistical analysis. Obstet Gynecol 1956;8:
691-703.
9. Friedman EA. Labor: clinical evaluation and
management. New York: Appleton-Century-
Crofts; 1967.
10. Friedman EA. Labor: clinical evaluation and
management, 2nd ed. New York: Appleton-
Century-Crofts; 1978.
11. Zhang J, Troendle JF, Yancey MK. Reas-
sessing the labor curve in nulliparous women.
Am J Obstet Gynecol 2002;187:824-8.
12. Zhang J, Troendle J, Mikolajczyk R,
Sundaram R, Beaver J, Fraser W. The natural
425
Expert Reviews Obstetrics
history of the normal first stage of labor. Obstet
Gynecol 2010;115:705-10.
13. Zhang J, Landy HJ, Branch DW, et al.
Contemporary patterns of spontaneous labor
with normal neonatal outcome. Obstet Gynecol
2010;116:1281-7.
14. Laughon SK, Branch DW, Beaver J, Zhang J.
Changes in labor patterns over 50 years. Am J
Obstet Gynecol 2012;206:419.e1-9.
15. Williams JW. Obstetrics: a text-book for the
use of students and practitioners. New York: D.
Appleton and Co; 1903.
16. Wolf W. Der unzeitige Blasensprung. Stutt-
gart: Wissenschaftliche Verlagsgesellschaft;
1946. p.103.
17. Koller T. Versuch einer graphischen
Darstellung des Geburtsverlaufes. Gynaecologia
1948;126:227.
18. Zimmer K. Die Muttermundseröffnung bei
den Schädellagen im Wegzeit-Diagramm. Arch
Gynaekol 1951;179:495-513.
19. Cohen WR, Acker DB, Friedman EA, eds.
Management of labor, 2nd ed. Rockville, MD:
Aspen Publishers Inc; 1989.
20. Cohen WR. Normal and abnormal labor. In:
Reece EA, Hobbins J, eds. Clinical obstetrics:
the fetus and mother, 3rd ed. London: Blackwell
Publishing Ltd; 2007:1065-76.
21. Cohen WR, Friedman EA. The assessment
of labor. In: Kurjak A, Chervenak FA, eds. Text-
book of perinatal medicine, 2nd ed. London:
Informa; 2006:1821-30.
22. Cohen WR. Controversies in the assess-
ment of labor. Prog Obstet Gynecol 2006;17:
231-44.
23. Cohen WR, Friedman EA. Labor and de-
livery care: a practical guide. Oxford: John Wiley
and Sons Ltd; 2011.
24. Bottoms SF, Hirsch VJ, Sokol RJ. Medical
management of arrest disorders of labor:
a current overview. Am J Obstet Gynecol
1987;156:935-9.
25. Sokol RJ, Stojkov J, Chik L, Rosen MG.
Normal and abnormal labor progress, I: a
quantitative assessment and survey of the liter-
ature. J Reprod Med 1977;18:47-53.
26. Duignan NM, Studd JWW, Hughes AO.
Characteristics of normal labor in different racial
groups. Br J Obstet Gynecol 1975;82:593-601.
27. Hendricks CH, Brenner WE, Kraus G. Normal
cervical dilatation pattern in late pregnancy and
labor. Am J Obstet Gynecol 1970;106:1065-82.
28. Ledger WJ. Monitoring of labor by graphs.
Obstet Gynecol 1969;34:174-81.
29. Ledger WJ, Witting WC. The use of a
cervical dilatation graph in the management of
primigravidae in labor. 1972;79:710-4.
30. Evans MI, Lachman E, Kral S, Melmed H.
Predictive value of cervical dilatation rates in
labor in multiparous women. Isr J Med Sci
1976;12:1399-403.
31. Melmed H, Evans M. Predictive value of
cervical dilatation rates, I: primipara labor.
Obstet Gynecol 1976;47:511-5.
32. Kwast BE, Lennox CE, Farley TMM. World
Health Organization partograph in management
of labor. Lancet 1994;343:1399-404.
426 American Journal of Obstetrics & Gynecology APRIL 2015
33. Poma PA. Use of labor graphs in a com-
munity hospital. Int Surg 1979;64:7-12.
34. Studd J, Clegg DR, Sanders RR,
Hughes AO. Identification of high risk labors
by labor nomogram. Br Med J 1975;2:545-7.
35. Philpott RH, Castle WM. Cervicographs
in the management of labor in primigravidae.
J Obstet Gynaecol Br Commonw 1972;79:
599-602.
36. Van Bogaert L-J. The partogram’s result
and neonatal outcome. J Obstet Gynaecol
2006;26:321-4.
37. Drouin P, Nkounawa F. The value of the
partogram in the management of labor. Obstet
Gynecol 1979;53:741-5.
38. Cibils LA, Hendricks CH. Normal labor in
vertex presentation. Am J Obstet Gynecol
1965;91:385-95.
39. Juntunen J, Kirkinen P. Partogram of
a grand multipara: different descent slope
compared with an ordinary parturient. J Perinat
Med 1994;22:213-8.
40. Lekprasert V. Monitoring of labor by graph.
J Med Assoc Thai 1972;55:647-53.
41. Peisner DB, Rosen MG. Transition from
latent to active labor. Obstet Gynecol 1986;68:
448-51.
42. Duncan GR, Costello E. The partogram: a
graphic guide to progress in labor. N Z Med J
1975;82:193-5.
43. Incerti M, Locatelli A, Ghidini A, Ciriello E,
Consonni S, Pezzullo JC. Variability in rate of
cervical dilatation in nulliparous women at term.
Birth 2011;38:30-5.
44. Friedman EA. Cervimetry: an objective
method for the study of cervical dilatation in
labor. Am J Obstet Gynecol 1956;71:1189-93.
45. Friedman EA, Von Micsky LI. Electronic
cervimeter: a research instrument for the study
of cervical dilatation in labor. Am J Obstet
Gynecol 1963;87:789-93.
46. Zador I, Neuman MR, Wolfson RN. Contin-
uous monitoring of cervical dilatation during
labor by ultrasonic transit time measurement.
Med Biol Eng 1976;14:299-305.
47. Kok FT, Wallenburg HCS, Wladimiroff JW.
Ultrasonic measurement of cervical dilatation
during labor. Am J Obstet Gynecol 1976;126:
288-90.
48. Eijskoot F, Storm J, Kok F, Wallenburg H,
Wladimiroff J. An ultrasonic device for contin-
uous measurement of cervical dilatation during
labor. Ultrasonics 1977;15:183-5.
49. Richardson JA, Sutherland IA, Allen DW.
A cervimeter for continuous measurement of
cervical dilatation in labor: preliminary results.
Br J Obstet Gynaecol 1978;85:178-84.
50. Sharf Y, Farine D, Batzalel M, et al. Contin-
uous monitoring of cervical dilatation and fetal
head station during labor. Med Eng Phys
2007;29:61-71.
51. van Dessel HJ, Frijns JH, Kok FT,
Wallenburg HC. Ultrasound assessment of
cervical dynamics during the first stage of labor.
Eur J Obstet Gynecol 1994;53:123-7.
52. Breeveld-Dwarkasing VNA, Struijk PC,
Lotgering FK, et al. Cervical dilatation related
ajog.org
to uterine electromyographic activity and
endocrinological changes during prostaglandin
F2a-induced parturition in cows. Biol Reprod
2003;68:536-42.
53. Friedman EA, Kroll BH. Computer analysis
of labor progression. J Obstet Gynaecol Br
Commonw 1969;76:1075-9.
54. Friedman EA, Kroll BH. Computer
analysis of labor progression, II: distribution of
data and limits of normal. J Reprod Med 1971;6:
43-8.
55. Friedman EA, Kroll BH. Computer analysis
of labor progression, III: pattern variations by
parity. J Reprod Med 1971;6:179-83.
56. Friedman EA, Kroll BH. Computer analysis
of labor progression, IV: diagnosis of secondary
arrest of dilatation. J Reprod Med 1971;7:176-8.
57. Bliss CI. The method of probits. Science
1934;79:38-9.
58. Finney DJ. Probit analysis. Cambridge
(United Kingdom): Cambridge University Press;
1952.
59. Montgomery DC, Peck EA, Vining GG.
Introduction to linear regression analysis, 5th ed.
London: John Wiley and Sons; 2012:7.1.
60. Gurewitsch ED, Diament P, Fong J, et al.
The labor curve of the grand multipara: does
progress of labor continue to improve with
additional childbearing? Am J Obstet Gynecol
2002;186:1331-8.
61. Chen HF, Chu KK. Double-lined nomogram
of cervical dilatation in Chinese primigravidas.
Acta Obstet Gynecol Scand 1986;65:573-5.
62. Friedman EA, Neff RK. Labor and delivery:
impact on offspring. Littleton, MA: PSG Pub-
lishing; 1987.
63. Vahratian A, Troendle JF, Seiga-Riz AM,
Zhang J. Methodological challenges in studying
labor progression in contemporary practice.
Paediatr Perinat Epidemiol 2006;20:72-8.
64. Rouse DJ, Owen J, Savage KG, Hauth JC.
Active phase labor arrest: revisiting the 2-hour
minimum. Obstet Gynecol 2001;98:550-4.
65. Rouse DJ, Owen J, Hauth JC. Active phase
labor arrest: oxytocin augmentation for at least 4
hours. Obstet Gynecol 1999;93:323-8.
66. Rouse DJ, McCullough C, Wren AL,
Owen J, Hauth JC. Active-phase labor arrest: a
randomized trial of chorioamnion management.
Obstet Gynecol 1994;83:937-40.
67. Schwarcz RL, Strada-Saenz G, Althabe O,
Fernandez-Funes J, Alvarez LO, Caldeyro-
Barcia R. Pressure exerted by uterine contrac-
tions on the head of the human fetus during
labor. In: World Health Organization. Perinatal
factors affecting human development. Wash-
ington, DC: Pan American Health Organization;
1969:133-43.
68. Schifrin BS, Deymier P, Cohen WR. Fetal
neurological injury related to mechanical forces
of labor and delivery. In: Zhang L, ed. Stress and
developmental programming in health and dis-
ease: beyond phenomenology. Hauppauge,
New York: Nova Science Publishers; 2014:
651-88.
69. Bugg GJ, Siddiqui F, Thornton JG. Oxytocin
versus no treatment or delayed treatment for
ajog.org
slow progress in the first stage of spontaneous
labor. Cochrane Database Syst Rev 2011:
CD007123.
70. Steer PJ, Carter MC, Beard RW. The effect
of oxytocin infusion on uterine activity in slow
labor. Br J Obstet Gynaecol 1985;92:1120-6.
71. Friedman EA, Sachtleben MR. Dysfunctional
labor, II: protracted active-phase dilatation in the
nullipara. Obstet Gynecol 1961;17:566-78.
72. Bakker JJ, Janssen PF, van Halem K, et al.
Internal versus external tocodynamometry dur-
ing induced or augmented labor. Cochrane
Database Syst Rev 2013;8:CD006947.
73. Bakker JJ, Verhoeven CJ, Janssen PF, et al.
Outcomes after internal versus external toco-
dynamometry for monitoring labor. N Engl J Med
2010;362:306-13.
74. Chua S, Kurup A, Arulkumaran S,
Ratnam SS. Augmentation of labor: does inter-
nal tocography result in better obstetric outcome
than external tocography? Obstet Gynecol
1990;76:164-7.
75. Jacobson JD, Gregerson GN, Dale S,
Valenzuela GJ. Real-time microcomputer-based
analysis of spontaneous and augmented labor.
Obstet Gynecol 1990;76:755-8.
76. Oppenheimer LW, Bland ES, Dabrowski A,
Holmes P, McDonald O, Wen SW. Uterine
contraction pattern as a predictor of mode of
delivery. J Perinatol 2002;22:149-53.
77. Towner D, Castro MA, Eby-Wilkens E,
Gilbert WM. Effect of mode of delivery in nullip-
arous women on neonatal intracranial injury.
N Engl J Med 1990;341:1709-14.
78. Friedman EA, Sachtleben MR. Dysfunctional
labor, V: therapeutic trial of oxytocin in secondary
arrest. Obstet Gynecol 1963;21:13-21.
79. Caldeyro-Barcia R. Adverse perinatal ef-
fects of early amniotomy during labor. In:
Gluck L, ed. Modern perinatal medicine. Chi-
cago: Year Book Medical Publishers; 1974.
Obstetrics
80. Nguyen T, Handa VL, Hueppchen N,
Cundiff GW. Labor curve findings associated
with fourth degree sphincter disruption: the
impact of labor progression on perineal trauma.
J Obstet Gynaecol Can 2010;32:21-7.
81. Kushtagi P. Pattern of descent of fetal head
in normal labor. J Indian Med Assoc 1995;93:
336-9.
82. Gross T, Sokol RJ, Williams T, Thompson K.
Shoulder dystocia: a fetal-physician risk. Am J
Obstet Gynecol 1987;156:1408-18.
83. Hopwood HG. Shoulder dystocia: fifteen
years’ experience in a community hospital. Am J
Obstet Gynecol 1982;144:162-6.
84. Weizsaecker K, Deaver JR, Cohen WR.
Labor characteristics and neonatal Erb’s palsy.
BJOG 2007;114:1003-9.
85. Deaver JE, Cohen WR. A prediction model
for brachial plexus injury. J Perinat Med 2009;37:
150-5.
86. Garrett K, Butler A, Cohen WR. Cesarean
delivery during second stage labor: character-
istics and diagnostic accuracy. J Matern Fetal
Neonatal Med 2005;17:49-53.
87. Cohen WR, Mahon T, Chazotte C. Very long
second stage of labor: characteristics and
outcome. In: Cosmi EV, ed. Labor and delivery:
the proceedings of the second world congress
on labor and delivery. New York: Parthenon
Publishing Group; 1998:348-51.
88. Graseck A, Tuuli M, Roehl K, Odibo A,
Macones G, Cahill A. Fetal descent in labor.
Obstet Gynecol 2014;123:521-6.
89. Cheng YW, Shaffer BL, Nicholson JM,
Caughey AB. Second stage of labor and
epidural use: a larger effect than expected.
Obstet Gynecol 2014;123:527-35.
90. Cohen WR. Influence of the duration of
second stage labor on perinatal outcome and
puerperal morbidity. Obstet Gynecol 1977;49:
266-9.
APRIL 2015 American Journal of Obstetrics & Gynecology
Expert Reviews
91. Laughon SK, Berghella V, Reddy UM,
Sundaram R, Lu Z, Hoffman MK. Neonatal
and maternal outcomes with prolonged second
stage of labor. Obstet Gynecol 2014;124:
57-67.
92. Cheng YW, Hopkins LM, Caughey AB. How
long is too long: does a prolonged second stage
of labor in nulliparous women affect maternal
and neonatal outcomes? Am J Obstet Gynecol
2004;191:933-8.
93. O’Brien WF, Davis SE, Grissom MP,
Eng RR, Golden SM. Effect of cephalic pressure
on fetal cerebral blood flow. Am J Perinatol
1984;1:223-6.
94. Sanchez-Ramos L, Kaunitz AM,
Peterson MD, et al. Reducing cesarean sections
at a teaching hospital. Am J Obstet Gynecol
1990;163:1081-8.
95. Meyers SA, Gleicher N. A successful pro-
gram to lower cesarean rates. N Engl J Med
1988;319:1511-6.
96. National Institutes of Health. Cesarean birth
task force development report. Obstet Gynecol
1981;57:537-45.
97. Oppenheimer LW, Holmes P, Yang O,
Yang T, Walker M, Wen SW. Adherence to
guidelines on the management of dystocia and
cesarean section rates. Am J Perinatol 2007;24:
271-6.
98. Grol R, Dalhuijsen J, Thomas S, Veld C,
Rutten G, Mokkink H. Attributes of clinical
guidelines that influence use of guidelines in
general practice: observational study. BMJ
1998;317:858-61.
99. Lomas J, Anderson G, Domnick-Pierre K,
Vayda E, Enkin M, Hannah W. Do practice
guidelines guide practice? The effect of a
consensus statement on the practice of physi-
cians. N Engl J Med 1989;321:1306-11.
100. Hutchison R. The physician’s prayer. BMJ
1998;317:1687.
427