Expert Opinion
org
The active phase of labor
Emanuel A. Friedman, MD, MedScD; Wayne R. Cohen, MD
Introduction
If I were to remain silent, I’d
be guilty of complicity.
Albert Einstein
De omnibus dubitandum [Doubt
everything].
René Descartes
In keeping with the theme of this
special issue on labor, we provide a
comprehensive overview of the critical
portion of labor during which the cer-
vical dilatation process is most active. It
is the period during which several major
labor abnormalities can be identified,
evaluated and managed in the interest of
preserving the wellbeing of both the
mother and the fetus. We also address
the current controversy that has arisen in
the last decade about this aspect of labor
and which has substituted newly devel-
oped concepts to replace traditional
ones.
The Normal Active Phase
Most cervical dilatation over the course
of labor takes place during the active
phase, which begins at the end of
the latent phase and continues until the
cervix is fully dilated. Identifying the
beginning of the active phase accurately
From the Department of Obstetrics,
Gynecology, and Reproductive Biology, Harvard
Medical School, Boston, MA (Dr Friedman); and
Department of Obstetrics and Gynecology, The
University of Arizona College of Medicine,
Tucson, AZ (Dr Cohen).
Received Sept. 29, 2021; revised Dec. 27,
2021; accepted Dec. 28, 2021.
The authors report no conflict of interest.
This study did not receive any funding.
Corresponding author: Emanuel A. Friedman,
MD, MedScD. eafriedman@post.harvard.edu
0002-9378/$36.00
ª 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2021.12.269
ajog.
The active phase of labor begins at various degrees of dilatation when the rate of
dilatation transitions from the relatively flat slope of the latent phase to a more rapid
slope. No diagnostic manifestations demarcate its onset, other than accelerating dila-
tation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually
short in duration and frequently undetected. Several aberrant labor patterns can be
detected during the active phase, including protracted dilatation, arrest of dilatation,
prolonged deceleration phase and failure of descent. Underlying factors may include
cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal
malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal
age and previous cesarean delivery. When an active-phase disorder is identified, ce-
sarean delivery is justifiable if there is compelling clinical evidence of disproportion. A
prolonged deceleration disorder is strongly associated with disproportion and second
stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This
review discusses several issues raised by the introduction of new clinical practice
guidelines for labor management.
Key words: abnormal labor, active phase, arrest of active-phase dilatation, cepha-
lopelvic disproportion, cervical dilatation, cesarean delivery, clinical practice guidelines,
deceleration phase, latent phase, prolonged deceleration phase, protracted active
phase, transition to active phase
is important. To do so, it is necessary to stage. Similarly, assessing uterine con-
undertake serial vaginal examinations at tractions, for example, by palpation or
least every 2 hours to determine when using Montevideo Units (sum of
the rate of dilatation increases from the amplitude in mm Hg above baseline of
negligible or absent slope of the latent contractions in 10-minute intervals as
phase to the more rapid progression of measured by internal strain gauge or
the active phase. The increased rate sig- catheter, normal said to be 200 units or
nals the conversion (ie, the inflection of more) is of limited value in deter-
the dilatation curve) into the active mining if a patient is in the active
phase. This occurs irrespective of the phase.1e4 This is because contractions
degree of cervical dilatation achieved. inconsistently increase in intensity,
The use of a simple square-ruled graph frequency, and duration over the course
of cervical dilatation and fetal descent of the first stage. No abrupt change in
against the time elapsed since the onset the characteristics of the contractions
of labor will help identify this funda- occurs to distinguish when the active
mental change in the dynamic labor phase has begun. Later, increased (and
process. painful) contractions often signal the
No other clinical change reliably de- beginning of the deceleration phase and
marcates the onset of the active phase. fetal descent. Contractile patterns have
The process of effacement, by which been studied extensively and have yiel-
the cervix is incrementally shortened ded little to facilitate differentiating real
through progressive incorporation of labor from false, let alone normal from
its most cephalad aspects into the lower abnormal.1e4 Thus, the dilatation
uterine segment, is often already pattern is alone as being reliable for
completed before labor begins, espe- prospectively identifying the onset of
cially in nulliparas. In contrast, efface- the active phase and the normality of its
ment may be delayed in multiparas progression, provided it is being
until just before the onset of the second graphed serially in labor.
MONTH 2022 American Journal of Obstetrics & Gynecology 1
Expert Opinion
FIGURE 1
Algorithm for evidence-based management of the active phase of labor
It provides a methodical clinical approach to facilitate the clinical diagnosis of abnormal labor
patterns and their safe management. AeH, Explanatory notes have been provided in the text.
Modified from Cohen and Friedman.35
Friedman EA, Cohen WR. The active phase of labor. Am J Obstet Gynecol 2022.
Defining Abnormal Active-Phase
Labor Patterns
Plotting cervical dilatation and fetal sta-
tion against time in labor aids in the
diagnosis and management of the several
definable abnormalities of labor. Identi-
fying them as they develop is critical for
selecting optimal care to avoid untoward
results for mother and fetus.5,6 Such
graphic plots have been used in widely
disparate labor-delivery settings world-
wide. They often take the form of
2 American Journal of Obstetrics & Gynecology MONTH 2022
simplified versions derived from Fried-
man’s work7e36 by Philpott and
Castle37,38 and are periodically updated
and disseminated by the World Health
Organization (WHO).39e42
Protracted active-phase labor
An excessively slow rate of dilatation
in the active phase is defined as less
than the fifth centile of the distribution
of the slope of active phase dilatation.
According to Friedman’s earlier
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observations,7e9,11,19,20,22,24 the fifth
centile was 1.2 cm/h for nulliparas and
1.5 cm/h for multiparas (Figure 1, A
and Figure 2, Curve A). The nulliparous
rate was acceptably rounded to 1.0 cm/h
for convenience by WHO in all but the
latest of the modifications39e42 of its
widely used partogram (or partograph).
For heuristic purposes, we offer an
expanded supplemental algorithm here
(Figure 1) in the form of a decision tree
for use in the clinical setting. It may
prove worthwhile for labor-delivery
personnel at all levels of expertise,
particularly when they are confronted
by the need to diagnose, assess, and
manage an abnormal labor. In addition,
Figure 2 offers visual aid for recog-
nizing those aberrant labors in the
clinical setting.
The lower limits for the rates of
cervical dilatation in the active phase
have been confirmed by diverse clinical
investigators43e48 and by those who
used objective instrumental measuring
methods.49e56 Thus, a parturient who
enters the active phase (at whatever
degree of cervical dilatation her labor
may have reached) and then progresses
in labor at less than this lower limit
(Figure 2, Curve A) can be diagnosed
dependably as having the major
labor disorder of protracted active
phase.12,15
The diagnosis of protracted active
phase12 cannot be made if the gravida is
still in the latent phase of labor, because
the latent phase is devoid of major labor
abnormalities,11,36 except for its dura-
tion if prolonged. Identifying the onset
of the active phase, therefore, is of great
importance, because if it is unrecog-
nized, gravidas will be incorrectly
deemed to be in the latent phase.
Graphing the labor while it is in progress
will reveal, even to the naked eye, the
transition from a very slow (or zero) rate
of dilatation in the latent phase to the
more rapid slope of the active phase.
That said, distinguishing a latent
phase,11 regardless of its rate of dilata-
tion, from a protracted active phase,12 is
sometimes difficult if the rate change is
small. Latent phase dilatation has been
shown not to exceed 0.6 cm/h,7e9,24,36 so
even the slowest active-phase dilatation
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should rarely, if ever, overlap the fastest
latent-phase dilatation. Moreover, if a
woman’s latent phase is progressing
rapidly, her ensuing active phase is very
likely to be normal or short and is likely
to be soon followed by a normal or fast
active phase.
Nonetheless, it is not the absolute rate
of dilatation that is relevant but the in-
crease in rate that occurs at the time of
the passage from the latent to the active
phase. Without that, entrance into the
active phase is seldom reliably recog-
nized solely on the basis of observation
of a given rate of cervical change. It re-
quires a change in rate from that of the
latent phase, and that change can occur
over a wide range of cervical dilatations.
A recommended evidence-based
sequence for the diagnosis and man-
agement of a protracted active phase is
presented here (Figure 1, BeD).12 When
this disorder is diagnosed, one should
proceed with the evaluation of the
gravida for factors associated with, and
possibly causative of (or resulting from),
the labor. Identifying them may require a
high level of diagnostic acumen. They
include the following: cephalopelvic
disproportion (CPD), which occurs at a
rate of 25% to 30% in association with
this aberration of labor12; inhibitory
factors such as a high dermatome level of
motor or autonomic neuraxial blockade
or excessive narcotic analgesia; fetal
macrosomia, hydrocephalus, malposi-
tion (occiput posterior or transverse), or
malpresentation (marked asynclitism,
brow, or face presentation); uterine
overdistention by multiple pregnancy or
polyhydramnios; and unexplained
insufficient uterine contractility.
Maternal obesity, advanced age, and
chorioamnionitis may also be relevant.
Some of these elements are correct-
able. For instance, one can enhance
contractions by careful oxytocin infusion
in cases in which they are of poor quality
or infrequent (Figure 1, D). We use the
word “careful” here to stress the need to
avoid the possible risks of uterine hy-
perstimulation.57,58 This is done by
titrating the infusion rate slowly in small
increments according to the uterine
response. A good response to the utero-
tonic agent, taking the form of effective
Expert Opinion
FIGURE 2
Plotting dilatation and descent against time depicts abnormal labors
graphically
Curves A and B are both from the same patient. Curve A displays a protracted active-phase dilatation
disorder followed by a prolonged deceleration phase in a nullipara. This combination of labor ab-
normalities is strongly associated with CPD and requires thorough evaluation and careful man-
agement. Curve B demonstrates failure of descent. The combination of this disorder with the
preceding abnormalities in dilatation makes safe vaginal delivery highly unlikely. The period of
“descent” that appears to begin in the second stage is followed by an arrest of descent for several
hours. The change in station was probably the consequence of extreme fetal head molding
mistakenly interpreted as actual descent, which is consistent with CPD. Curve C is the dilatation
pattern of another parturient. The active phase of dilatation begins normally, but progress is arrested
at 4 cm of dilatation. The arrest disorder is allowed to persist for 8 hours. A thorough evaluation for
potential causes of the arrest was warranted at the latest by hour 14 of the labor, 2 hours after the
arrest of descent became apparent. On the basis of the current guidelines for labor management, all
the labor disorders depicted in both these cases would constitute normal dilatational progress.
CPD, cephalopelvic disproportion.
Friedman EA, Cohen WR. The active phase of labor. Am J Obstet Gynecol 2022.
contractions of increasing quality and uterine infection exist, careful oxytocin
frequency with progress in dilatation, is stimulation may be beneficial without
promising for a safe vaginal delivery. A harm. If associated with evidence of
poor response to oxytocin, with CPD, however, ecbolic agents are best
continuing poor-quality contractions, avoided.
portends the likely need for cesarean
delivery (CD). Withdrawing or dimin- Arrest of active-phase labor
ishing analgesics may sometimes help Arrest of progress in cervical dilatation
improve uterine contractility. (Figure 1, G and H and Figure 2, Curve
Some conditions are not amenable to C) is much easier to identify in the active
correction without risk, particularly if phase than protracted dilatation, espe-
associated with documentable CPD cially if serial measurements of cervical
(Figure 1, E and F), so intervention by dilatation are plotted against the time in
CD is warranted. If the cephalopelvic labor. The extent of an arrest of dilata-
relationship is good, oxytocin is accept- tion that qualifies for the diagnosis is
able, provided that the response is currently a matter of debate. Fried-
improved contractions with progress in man10,14,17,26 originally determined that
dilatation. Contrary to common expec- the 95th centile of the distribution of
tation, oxytocin for a protraction disor- arrest duration in this condition was 2
der that has arisen de novo is generally hours for both nulliparas and multiparas
ineffective. When inhibitory factors such (Figure 1, G). More recently, it was
as obesity, advanced maternal age, or found59 that allowing 4 hours of arrest
MONTH 2022 American Journal of Obstetrics & Gynecology 3
Expert Opinion
decreased the CD rate while also
increasing the frequency of vaginal de-
liveries, some of which were complex,
difficult, done at high fetal station, and
hazardous. Further, 6 hours of arrest
enhanced adverse outcome even more.
We continue to recommend 2 hours
because delaying the diagnosis until the
fourth hour (or more) of arrest in the
active phase may be unsafe.
Finding other abnormal labor pat-
terns later in labor among women who
demonstrate either active-phase pro-
traction or arrest enhances risks.15,31e34
The combination of aberrant early
active-phase dilatation patterns followed
by abnormalities in the late active phase
and second stage by disorders (Figure 2,
Curves A and B, from the same patient)
is likely to be associated with high de-
grees of CPD. This requires ruling out
obstructed labor before attempting a
vaginal delivery, and caution is essential.
The principles of evaluation for the
presence of risk factors and practices for
dealing with them are much the same for
the arrest of active-phase disorder as they
are for protracted active-phase dilatation
as outlined above. What is important for
diagnosis and safe management
(Figure 1, G and H) is clearly differen-
tiating between the normal slow-to-
absent dilatational progress of the
latent phase and a true arrest of active-
phase dilatation. The former is
commonplace, benign, and requires no
action, whereas the latter demands astute
evaluation and management to prevent
harm.5,6,15,31e34
Management of the same is 2-phased,
consisting of evaluation for known as-
sociations (assumed cause or contrib-
utor to cause) and intervention
appropriate to the association found.
The clinical importance of arrested
active phase is its strong association with
CPD and the related potential risks.
Fully, 40% to 50% of parturients with
arrest of the active phase have concom-
itant CPD.14 Therefore, thorough ceph-
alopelvimetry is vital to exclude the
presence of disproportion. It is better to
err on the side of intervention by CD in
the presence of uncertainty about po-
tential harm than to allow labor in the
false hope that safe vaginal delivery may
4 American Journal of Obstetrics & Gynecology MONTH 2022
be feasible. If CPD can be ruled out,
vaginal delivery is preferable, provided it
does not prove difficult.
The optimal response to uterotonic
stimulation, if chosen for management,
is enhancement of uterine contractions
and acceptable progress in cervical
dilatation. This signals good prognosis
for safe vaginal delivery. However, one
should desist if postarrest dilatation
does not occur. Proceeding instead to
CD is a better and safer option. Most
arrest disorders will respond to
oxytocin infusion with additional
progress in dilatation within 4 hours
(though recent evidence suggests that 2
hours is safer59).
In some situations, it is preferable to
perform a CD earlier if evidence of CPD
emerges in the form of increasingly
marked molding, deflexion, or asyncli-
tism of the fetal head, all without
descent. If dilatation has been graphed
during labor, one can compare the rate
of progression before the arrest with that
which occurs after oxytocin therapy has
begun.10,17 Delivery prognosis improves
with the increment in slope after the
arrest. More specifically, if the postarrest
slope of the dilatation curve shows
improvement over the prearrest slope,
the chances of harm-free vaginal delivery
increase.
Clinicians sometimes perform artifi-
cial rupture of membranes for a pro-
traction or arrest of dilatation, but there
is no objective proof that it is a useful
treatment.16 Of course, an overriding
reason for amniotomy, say to apply fetal
monitoring scalp electrodes or insert an
intrauterine pressure transducer, makes
it acceptable. A response to rupture of
membranes with further dilatation is
unusual; if it is to occur, it can be ex-
pected to ensue promptly.
Prolonged deceleration phase
The limits of normalcy for the deceler-
ation phase on the basis of Friedman’s
work,7e9,24 that is, the 95th centiles of its
distributions, were 3 hours in nulliparas
and 1 hour in multiparas (Figure 2,
Curve A). No newer research has been
published to confirm or refute these
limits. We have, therefore, retained them
for our recommendations (Figure 1, E).
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Astute clinicians will often recognize a
potential problem even before these
limits are reached, especially if malposi-
tion or excessive molding is noted on
examination. For practical purposes, the
time from 8 cm to complete dilatation
can be used to quantify the duration of
the deceleration phase. Recently, 9 cm to
complete dilatation60 was found equally
useful and clinically acceptable for
defining and documenting the deceler-
ation phase.
The frequency of CPD in association
with a prolonged deceleration phase is
considerably greater than with a pro-
tracted active phase.7e9,30 Thus, thor-
ough cephalopelvimetric assessment is
imperative before pursuing oxytocin
infusion (Figure 1, F) or undertaking a
difficult vaginal operative delivery.
Aside from the aberrant labor patterns
as possible indicators of underlying
CPD, one should be aware of other
factors that signal concern, such as
maternal diabetes and obesity, pelvic
shape and size, fetal macrosomia,
malposition (occiput posterior and
transverse), malpresentation (brow),
asynclitism, and excess molding. As for
the last item, it is essential to differen-
tiate between molding and true descent
by means of serial suprapubic palpation
of the base of the fetal skull to ensure
that descent is actually occurring. If
evidence of CPD is found with an
active-phase protraction or arrest dis-
order, or if it cannot be ruled out with a
reasonable degree of certainty, CD is a
more prudent and safer choice. Here
again, the risks of damage to the mother
and fetus are just too great to contem-
plate an attempt at vaginal delivery,
which is unlikely to be achievable,
let alone safely. Other strong associa-
tions are essentially the same as for
active-phase protraction. When
encountered, they can be managed in
the same way, with the even stronger
proviso that CPD be ruled out before-
hand. A prolonged deceleration phase is
also a harbinger of second stage labor
abnormalities and is frequently accom-
panied by failure of descent. If vaginal
delivery occurs, it may result in shoul-
der dystocia and brachial plexus
injury.61e63 Similarly, the combination
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of a prolonged deceleration phase with
any disorder of fetal descent makes safe
vaginal delivery very unlikely.15
Uterine Contractility
Uterine contractions create the primary
driving force (supplemented in the sec-
ond stage by expulsive bearing down
efforts) that results in cervical dilatation
and propels the fetus through the birth
canal. Unfortunately, we are still largely
ignorant about the precise mechanisms
by which the uterus generates the opti-
mally timed and coordinated bursts of
contractile energy that characterize la-
bor. Although it is likely that the com-
mon causal pathway of many
dysfunctional labor patterns involves
impairment of normal contractile
events, selecting cases that would be
likely to benefit from ecbolic drugs is
often not possible, because the ability to
distinguish between adequate and inad-
equate contractility has proved
elusive.1e4
There is a very broad spectrum of
uterine contractility patterns associated
with both normal and dysfunctional
patterns of progress.1e4,57,58 Some ap-
proaches to the identification of
abnormal labor depend on continuous
measurement of uterine contractility via
an intrauterine pressure transducer.57,58
Although it may seem appealing to use
this kind of objective approach to define
the adequacy of spontaneous or
oxytocin-stimulated contractions, its
value is uncertain.1e4 Studies have thus
far failed to prove the virtue of this
approach for diagnosis and treatment.
This is an area for future sophisticated
research, but for now, we do not
consider quantitation of uterine activity
to be useful in aiding decision-making
about oxytocin administration or
dosage. Hypercontractility can be eval-
uated successfully by simple palpation,
unless obesity prevents it.
The goal of oxytocin therapy for
dysfunctional labor is to produce regular
strong uterine contractions at intervals
of 2e3 minutes, with a maximum of 5
contractions in a 10-minute interval and
with individual contractions <90 sec-
onds in duration. If the patient is having
spontaneous strong contractions in this
pattern, increasing the infusion rate for
uterotonic stimulation is inadvisable lest
unsafe uterine hyperstimulation oc-
curs.57,58 With safety in mind, one may
discontinue the infusion altogether; if
the good contraction pattern persists, the
gravida’s own intrinsic myometrial con-
tractile mechanism has ameliorated the
problem. If not, restarting the infusion
(at a lower infusion rate) is acceptable,
again provided that CPD is not present.
If in doubt about the fetal-pelvic rela-
tionship, it is preferable at this point to
reconsider CD. Evidence of fetal
compromise demonstrated by the FHR
pattern is cause for concern, but whether
the absence of nonreassuring moni-
toring is sensitive enough to ensure fetal
safety is still unclear.5
Current Controversies
An overview
Over recent decades, authoritative
modifications in the form of clinical
practice guidelines for the management
of labor (or simply guidelines, for short)
were issued by the American College of
Obstetricians and Gynecologists—Soci-
ety for Maternal-Fetal Medicine (ACOG/
SMFM)64,65 and then modified, adop-
ted, and disseminated by the WHO.39e42
They were based in part on the findings
of Zhang et al,66e73 whose analysis of
cervical dilatation data asserted that la-
bor followed a hyperbolic pattern quite
different from the sigmoid curve that
had been traditionally accepted since the
mid-1950s when introduced by
Friedman.7e9,23e25 The labor pattern
described by Zhang et al66,68,71,72 was
also longer in duration and had no
discernible inflections into the active
phase before 5e6 cm, contrasting with
Friedman’s findings of an S-shaped
(sigmoid) curve with variable transitions
into the active phase over a wide range of
dilatations.
The main objective for creating the
guidelines was to reduce the insupport-
ably high CD rate, which is an under-
standable goal. Cumulative data since
the guidelines were issued,81,83e90 how-
ever, seem to show that this aim is
inconsistently achievable87,88 on the one
hand and possibly unsafe59,83,87,89 on the
other.
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Opinion
The choice between which of the 2
dissimilar views of labor progression to
adopt in practice is mistakenly viewed by
some as one between 2 mathematical
models that interpret cervical dilatation
data differently. That is just not so. It is
instead a choice between accepting
painstakingly obtained observational
data7e34—verified independently by
other clinical investigators
worldwide49e54 and confirmed by
objective electromechanical and ultra-
sonographic cervimetry55e62—as con-
trasted with a curve-fitting statistical
model66e73 that has little resemblance to
the real course of labor.
Conflicting data among comparative
investigations
Studies addressing the value, including
the benefits and risks, of the new
guidelines have varied considerably in
design and results. Only 1 investigation
was based on a randomized controlled
trial (limited to second stage duration),81
but it was disputed82 for its underpow-
ered size and marginal results.
Others85,88 used cluster randomized trial
designs comparing data from different
groups of cases being cared for in
randomly assigned sites. Cluster ran-
domized trials have been shown to be
difficult to standardize, control, main-
tain, and complete.92e94 Other in-
vestigators compared cases from
different time intervals, that is, cases
from time periods before and after the
guidelines were introduced,84,85,89 and
another used a caseecontrol format
(study cases with [ostensible] dystocia vs
controls without dystocia).83 One “sys-
tematic review”90 did not meet the
demanding standards set for such pub-
lications.91 The investigators reported on
7 sets of labor data, 6 of which followed
Zhang’s methods closely; not unexpect-
edly, therefore, the results derived from 6
of them were similar to those of Zhang,
both individually and when pooled.
Comparative investigations showed a
broad range of CD rates. Among those
reporting a reduction, the impact was
good,81,84,89 mixed,85 or marginal.86
Another found no change at all in the
CD rate,88 and one encountered an in-
crease.87 This inconsistency may reflect
5
Expert Opinion
differences in the acceptance frequency
of the guidelines. Indeed, resistance to
adopting new guidelines is a common
impediment in all disciplines.95e97
Of fundamental importance is the
possibility that maternal and fetal harm
could accrue from the guidelines to
counterbalance any benefit in reducing
the CD rates. Some studies did not
address this issue at all. Among those
that did, some found no change in the
short-term adverse perinatal conse-
quences to mother and fetus,81,84 one
reported mixed results,85 and still others
saw an increase.59,83,89 No long-term
evaluations5 were undertaken for
neurologic fetal damage that developed
later in childhood. The same applied for
late maternal anatomic or functional
damage.6 Friedman provided data on the
adverse impact of major labor disorders
disclosed by his approach.21,32-25 If more
current long-term studies were to yield
information that such distant injury was
associated with the labor management
guidelines, those findings would signal
the clear need for a course correction.
Given the disparities among the results
thus far, we cannot confidently conclude
that the guidelines have achieved their
objectives or done so safely. Indeed, our
overall impression is not encouraging.
We concur with those calling for well-
conducted randomized controlled tri-
als,81,87 provided they are ethically
devised and methodologically
trustworthy.
A composite overview of changes in
the CD rate or adverse outcomes
resulting from the introduction of
guidelines is difficult to state definitively,
because data collection methods, data-
base sizes, study designs, and analytical
approaches differed, as did results. Given
the diversity of results, additional details
on some of the more probing and
perceptive investigations may provide
relevant insights.
Bernitz et al,88 for example, under-
took a cluster randomized trial
comparing location-specific results in
labor-delivery units using the WHO
partogram (control cases) against those
using the Zhang method (study cases).
Although they encountered significant
reduction in the CD rates overall in the
6 American Journal of Obstetrics & Gynecology MONTH 2022
study cases after the guidelines were
introduced, they also unexpectedly
found a near-identical CD decline in
both the study and the control cases.
They, therefore, attributed this observa-
tion of equivalent benefit more to the
increased attention paid to carefully
assessing labor than to an advantageous
influence of the guidelines.
Chaillet et al85 found a small but sta-
tistically significant diminution of the
CD rate that was probably of little or no
practical clinical relevance. Further, the
reduction was limited primarily to the
low-risk group in their study. The
question not addressed was, why was
that reduction also not encountered
among high-risk gravidas? A logical
answer is that it may have reflected an
aggressive mindset toward intervention
among healthcare personnel because of
the high-risk status of the gravidas, or
perhaps it was just another aspect of the
aforementioned resistance to accept
guidelines, albeit limited to that group of
parturients.
Neal et al83 not only encountered
higher adverse effects in study mothers
and fetuses in their caseecontrol study
but found that fully half of the CDs for
active-phase dystocia had normal dila-
tation curves. If true, this unusual
manifestation of diagnostic error might
reflect either resistance to accepting the
guidelines, or an imperfect understand-
ing of what constitutes a dystocic labor,
or both. As the primary goal of the
guidelines for labor management was to
reduce the CD rate, this seeming indif-
ference to the documentation of
abnormal labor progress before under-
taking aggressive intervention may be an
area worth focusing on for future
guidelines on labor management in their
role of educating obstetrical personnel
more effectively. If half of the CDs un-
dertaken for dystocia were done in
women with normal labors, as Neal et al
showed, they would constitute a moth-
erlode for achieving the aim of the
guidelines, that is, bringing the current
high CD rate down somewhat, all
accomplished without changing long-
held views of the labor process or
introducing a disputable set of guide-
lines. It is important, moreover, that
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these errors in diagnosing aberrant la-
bors where none exist may have resulted
from inherent problems with interpre-
tation of either (or both) the Friedman
or the Zhang method, an area ripe for
enhanced clinical training and probing
analyses.
The most recent changes in the WHO
partogram42 have some acceptable
modifications, such as eliminating the
“alert” and “action” lines and intro-
ducing graphic representation of the
fetal descent process. However, some
new problems were introduced. One is
that the new blank partogram form
limits entering dilatation measurements
to those at 5 cm. This projects a mes-
sage to labor-delivery providers that all
smaller measurements are of no intrinsic
clinical importance by relegating all of
them to oblivion (or to recording on a
less important or impermanent docu-
ment). It essentially forces labor-delivery
personnel to deny the possibility of an
active phase beginning at a smaller dila-
tation and ignoring it if it should arise
before labor progress has reached 5 cm.
In this way, gravidas who do advance
into the active phase earlier in labor will
not have the opportunity to have an
abnormal labor disclosed in timely
fashion, thereby possibly subjecting
them and their fetus to risk from delayed
diagnosis and management. WHO also
provides recommendations on its new
partogram for ostensibly normal
centimeter-by-centimeter progress
derived from the work of Zhang
et al.70,71 These last 2 modifications may
prove counterproductive. The guide-
lines64,65 do essentially the same, but fix
the onset of the active phase to 6 cm or
more instead.
The latest WHO partogram42 also
offers a concession to Friedman by
acknowledging that the onset of the
active phase is highly variable, thus
countering both Zhang et al68,69,71 and
the guidelines about the existence of a
fixed inflection point to mark the
beginning of the active phase. Nonethe-
less, the WHO contradicts itself by
effectively fixing the lower limit for entry
of active-phase dilatation observations at
5 cm. This creates a practical problem,
because recordings of dilatation below 5
ajog.org
cm may constitute important informa-
tion to clearly show an earlier and more
precise onset of the active phase and
thereby allow for the prompt diagnosis
of a developing labor disorder.
Further, important new research by
De Vries et al74 has exposed serious
problems in the statistical methodology
used by Zhang et al68e74 to revise cervi-
cal dilatation curves. Zhang’s approaches
were shown to modify the pattern of
progress in labor in ways that could
make it difficult to diagnose dysfunc-
tional labor patterns, delay treatment,
and possibly cause maternal and fetal
harm.59,87,89 Several issues related to the
guidelines64,65 and to the research from
which they were derived66e73 are of
particular relevance to the management
of the active phase of labor. These relate
especially to the correct identification of
the onset of the active phase, to whether
the deceleration phase exists, and to
what is the acceptable lowest normal
range of dilatation rates in active phase
progression.
Selection biases
Zhang et al69,71 undertook their retro-
spective investigations of the labor
course by selecting cases from a large
electronic database. The method for
choosing cases had a substantial selec-
tion bias, principally with a marked
overrepresentation of women admitted
late in labor. Zhang et al67,69,71
acknowledged this nonrepresentative
case selection. For example, all women
who had a CD in the first stage were
summarily dropped from the study, a
clear limit on generalizability as
conceded by Zhang et al.67 Multiparas
were included in the database if cervical
dilatation had reached 3e5 cm on
admission and were excluded if their
dilatation was 6 cm or greater when they
first arrived. Whether nulliparas were
also subject to such exclusion criteria is
unclear. Women who are admitted late in
labor tend to have more rapid labors
than those with an average orderly labor
who are admitted earlier.13 Although the
hyperbolic dilatation pattern undoubt-
edly resulted primarily from the regres-
sion analysis, it is unclear what the
impact of the selection bias was. De Vries
et al’s findings74 suggest that it prolonged
several aspects of the hyperbolic dilata-
tion pattern. Given the disparate
composition of Zhang et al68,69,71,73
cases, moreover, their analytical results
may not be generalizable to other gravid
populations, as is even acknowledged by
Zhang’s group.69
The excess number of women with
advanced dilatation on admission may,
in turn, have resulted in what
appeared—and was interpreted by
Zhang et al68,69,71,73—to be a high rate of
transitions from the latent to the active
phase at 5—6 cm dilatation. Because of
the prevalence of advanced labor at the
time of admission and with most cases
already well into the active phase, it
should not have been possible to deter-
mine accurately when that inflection to
active phase had actually occurred as
they had not yet been admitted for cer-
vical examination. The rapid dilatation
so prominent at and after 6 cm indicates
that many, if not most, had already
entered the active phase before they were
admitted. Thus, the assertion by Zhang
et al68,69,71,73 that the transition from the
latent to the active phase occurs at 5 and
6 cm was probably the result of distor-
tion by computer assessment (ie,
particularly polynomial regression, as
intuited above and now documented by
De Vries et al74) or selection bias.
Consequently, their study findings
deserve more careful reconsideration for
their use in clinical practice and as the
basis, in whole or in part, for the labor
management guidelines.64,65 As the
guidelines state that active phase labor
should be considered to begin at 6 cm
based in large measure on
Zhang’s questionable conclusion, it must
follow that this declaration requires
reevaluation.
Can a fixed dilatation demarcate
transition into active phase?
Misperceptions are common among
clinicians and investigators, especially
those who have been led to assume that
the active phase always begins at some
fixed degree of cervical dilatation.
Experienced labor-delivery personnel,
however, recognize that transition hap-
pens over a wide range of dilatations.
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Opinion
Serial observations of dilatation and
descent, with careful documentation of
closely spaced, timed measurements,
verify this.
The choice of 6 cm or more64,65 to
designate the onset of the active phase in
the guidelines was on the basis of data
assembled by Zhang et al.68,69,71,73 They
claimed that advancing active phase
cervical dilatation followed a hyperbolic
curve with no inflection points until
dilatation reached or exceeded 5e6 cm.
Yet, inflection points occurring at various
dilatations along the dilatation-time
curve demarcating the onset of active
phase were described by Friedman7e36
and verified by others.43e48 Not finding
them runs counter to these long-
established, published observations and
supports our contention that the meth-
odology used by Zhang et al69,71 was
likely to have yielded dilatation curves
that are not a true reflection of the pat-
terns of labor progression.
Even though polynomial regressions
are often used in scientific research, their
limitations are not necessarily well-
known. For example, admonitions exist
in the literature warning about the lim-
itations of high-order polynomial
regression, defined as at or above 3,
contrasting with 8e10 used in Zhang’s
method. Such high-order regressions
can yield curves that may be “unstable,
distorted, and misleading.”76,77 More-
over, even lower-order polynomial re-
gressions, by their very nature, can be
expected to yield hyperbolic curves.
Therefore, when applied to curve-fitting
where the process being studied is not
basically hyperbolic in nature, the tech-
nique will try to force the data into a
hyperbolic form, albeit without a
particularly good fit.78 Similarly,
interval-censored regressions have been
shown to obscure the precise time when
a given cervical dilatation occurred so
that traversal times from centimeter to
centimeter of dilatation were consis-
tently prolonged.74 They were relied on
in developing the dilatation curves pro-
posed by Zhang et al,69,71 making them
suspect. The insightful new evidence by
De Vries et al74 robustly corroborated
the likelihood of serious errors in
Zhang’s approach.
7
Expert Opinion
The assertion that all labors with a
dilatation of <5 to 6 cm are in the latent
phase runs counter to well-documented
clinical observation.45e50 Peisner and
Rosen100 analyzed data from direct
sequential cervical examinations and
showed that many but not all labors in
nulliparas were already at or well beyond
transition to active phase by the time
they had attained 5e6 cm dilatation,
leaving a sizable residual still left in the
latent phase at larger dilatations. These
observations verified that there was an
admixture of latent and active phase la-
bors among gravidas before and after 6
cm dilatation. Combining disparate
cases in this way biased the findings of
Zhang et al,68e70 as they pertain to the
durations and rates of dilatation in the
groups designated as either latent phase
or active phase, respectively. Only plot-
ting individual dilatation courses against
time can provide reliable information
about when the active phase actually
begins in any given case.7e9
Analysis of the labor assessment
process used by Zhang et al66e73
Doubts about the methods of Zhang
et al67,69,71 are highlighted by the recent
report by De Vries et al74 that identified
major missteps in Zhang’s approach to
labor progress assessment. De Vries
et al74 created simulated labor curves to
build 2 large databases of 500,000 each,
consisting of the range of patterns of
cervical dilatation comparable to the
databases used by Friedman20,22 and
Zhang.66e73 The simulation process is
valuable in statistics,78 providing a
means for corroborating or invalidating
a given methodology, that is, whether the
process is acceptable for the purpose to
which it is addressed. A simulation study
thus allowed De Vries et al74 to appraise
Zhang et al’s66,69,71,72 statistical methods
for their ability to accurately replicate the
“true” underlying pattern of cervical
dilatation and found them wanting.
Both the databases were then sub-
jected to all but one of the steps of the
Zhang method, encompassing repeated-
measures high-order polynomial
regression and interval-censored regres-
sion to form centimeter-by-centimeter
dilatation traversal times. The omitted
8 American Journal of Obstetrics & Gynecology MONTH 2022
step was the interval-censoring of the
dilatation data, which was superfluous,
because the data simulation process
created “true” data points. Analysis with
the Zhang method converted all the
Friedman modified sigmoid curves to
hyperbolas and prolonged them.
Furthermore, the Zhang hyperbolas
retained their shape but were changed by
prolonging the original curves consid-
erably. Detailed findings by De Vries
et al74 exposed the following concerns
regarding the Zhang statistical approach:
The acceleration of dilatation marking
the inflection from the latent to the
active phase was not identifiable by the
Zhang method.66,69,72,73 Moreover, the
method markedly overestimated the
lengths of labor progression, especially at
small cervical dilatations. All the high-
order polynomial regression results
were substantially longer than the “true”
underlying labor durations. An extreme
example was found in dilatation curves
obtained with 2-hourly cervical exami-
nations, where it took 20.8 hours for
dilatation to increase from 1 cm to 7 cm,
which is more than double the actual
median duration of 9.2 hours in the
simulated dilatation curves. This clearly
misrepresented the underlying “true”
data and invalidates the method. On the
basis of these and other similarly dis-
turbing findings, De Vries et al74
concluded that “repeated-measures
polynomial regression and interval-
censored regression should not be
routinely used to define labor progress
because the resulting curves did not
accurately reflect the underlying data.”
They also showed that “repeated-mea-
sures polynomial regression was unable
to detect the rapid increase in the rate of
cervical dilatation in labor at transition
from latent to active phase and consis-
tently produced abnormally prolonged
labor curves.”
Practical consequences result from the
recognition that the data supporting the
new guidelines for labor management
are imprecise. For example, the guide-
lines64,65 admonish against diagnosing
protracted or arrested dilatation before 6
cm. This is on the basis of the postula-
tion that all such parturients are neces-
sarily still in latent phase labor (clearly
ajog.org
not so in at least 11%e15%79), where
such disordered labor patterns are not
expected to occur.11,36 Not detecting and
properly managing such important labor
disorders when they do develop before 6
cm is potentially serious.
Is the basis for the new labor
management guidelines trustworthy?
Given the issues we have raised about
Zhang’s database selection and curve-
fitting methodology, we feel that the
guidelines disseminated for labor man-
agement by ACOG/SMFM64,65 cannot
be fully justified for general clinical us-
age. Parts of the controversy were
dealt with in previous opinion
papers.87e93 We summarize the major
issues here in the interest of clarity and
concision:
1. The database is probably defective
because of several instances of selec-
tion bias.
2. The Zhang method step in which the
data are interval-censored may
introduce error, leading to invalid
inferences.80 It could, for example,
augment the known observer error
inherent in the clinical measurement
of cervical dilatation.
3. Interval-censored regression analysis
does not provide precise timing that a
given cervical dilatation is achieved,74
thereby making the traversal time
from centimeter to centimeter of
dilatation and subsequent curve
fitting open to question. The traversal
times determined by this method are
also markedly prolonged relative to
the underlying “true” curves.
4. Interval-censored high-order poly-
nomial regression analysis has been
shown to be prone to instability.76,77
The Zhang process, which used or-
ders of 8e10 for this step,68,69,71,73
uniformly converted dilatation pat-
terns to hyperbolas.74 Polynomial
regression was designed and expected
to do exactly that. Especially when
applied at high orders of regression
analysis, the process may approxi-
mate curves to fit other varieties of
curvilinear functions such as those
that occur commonly in nature and
in science, sociology, business, and
ajog.org
engineering but not necessarily with
a fit good enough for practical clin-
ical use.76e78
5. Reports about the impact of the
guidelines on labor management
published since they were issued
showed inconsistent impact on CD
rates, ranging from good75,77 or small
decrease73,78 to dubious change76,80
or increase.78
6. Some studies found that introduc-
tion of the guidelines for labor
management may increase maternal
and neonatal risks.68,74,76
7. Evidence of long-term infant dam-
age, seemingly related to intrapartum
events, has been found5,18,31e35 and
may yet be unrecognized perinatally.
This complication has not been
addressed in any studies to gauge
whether practicing according to the
guidelines on labor management
could induce later harm.
Does the deceleration phase exist?
Zhang et al66,69,71,72 asserted that the
deceleration phase does not exist, con-
troverting the findings of Friedman and
others.7e9,19,20,79 This misinterpretation
is understandable and widely held. On
the one hand, if vaginal examinations
in the late active phase are done infre-
quently, normal deceleration phases are
often undetected, because they are
likely to fall between sequential exami-
nations. In contrast, a prolonged
deceleration phase is more readily
detectable, given the greater opportu-
nity for one or more cervical exami-
nations to be done when the
deceleration phase is in progress.
It is curious that Zhang et al69 argue
that the deceleration phase is an artifact
caused by a delay in diagnosis of full
cervical dilatation. It constitutes a
turnabout for the Zhang group to
accept interval-censoring in all their
publications (ie, projecting the interval
between observations of dilatation as if
there were no progression, thus yielding
a “staircase” effect) for all measure-
ments of dilatation as if that interval
progress is unknown and assumed not
to occur (even though such progression
is the usual expectation and encoun-
tered if examinations are continuous or
done more frequently). Further, this
contradicts Zhang et al’s66e69 own
acknowledgment of seeing such de-
celerations (deemed artifactual). Para-
doxically, they provided several self-
contradictory observations about the
deceleration phase in one of their pa-
pers66: (1) “No deceleration phase was
observed,” (2) “The majority of women
in our data did not have a deceleration
phase” [frequency not provided]. (3)
Based on this finding, they explained
“Therefore, the average labor curve
shows no deceleration at the end of the
first stage.” (4) “However, we found
that patients who had a cesarean de-
livery for dystocia at the second stage of
labor often had a pattern similar to
deceleration (not shown), suggesting
that if a patient has a deceleration in
late active phase, she may be at risk for
dystocia at the second stage.” Subse-
quent publications did not repeat,
elaborate on or refute these statements,
except to reiterate that deceleration
phases were not observed.67e69,71,72
They even prominently displayed a
prolonged deceleration phase as
illustrative of an abnormal labor
process (eg, Curve C in their staircase
Figure 4 shown in the study by Zhang
et al68).
An observant clinician should be able
to verify with confidence that the
deceleration phase does exist, and it is
widely misunderstood. Its proper
assessment is an important part of la-
bor evaluation. Advancement in cervi-
cal dilatation is in fact probably
continuously linear from the end of the
acceleration phase to full dilatation,
reflecting the incorporation of the cer-
vix into the lower uterine segment over
time. However, the nature of our clin-
ical examination technique creates
apparent slowing (Figure 3). During
most of the dilatation process, the cer-
vix is being retracted along the rela-
tively flat surface of the presenting fetal
part. From the transition into the active
phase and beyond to the beginning of
the deceleration phase, active-phase
dilatation occurs along the transverse
plane of the presenting fetal part
(Figure 3, A), which is usually the ver-
tex of the well-flexed head. As the
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Opinion
cervix dilates against the fetal skull, the
examining fingers can detect and mea-
sure cervical dilatation from one edge
of the external cervical os to the other.
However, when nearing full dilatation,
retraction of the external os proceeds in
a more cephalad direction relative to
the mother (Figure 3, B) in a manner
analogous to turning a corner. As
retraction continues cephalad, the side-
to-side dilatation does slow (even
though the cervix is being pulled up at
a steady rate by contractile forces), ac-
counting for the deceleration phase
(Figure 3, C). Then it seemingly halts
entirely when the second stage is
reached (Figure 3, D), having been fully
incorporated into the lower uterine
segment. This usually (but not always)
occurs at 10 cm. The actual dimension
depends on the diameter of the fetal
head, which determines the diameter
that the cervix reaches at full dilatation.
For example, it is much smaller than 10
cm in premature births and consider-
ably larger in association with fetal
macrosomia or hydrocephalus.
The importance of the deceleration
phase is that the terminal events of cer-
vical dilatation will generally not occur
unless fetal descent also takes place and
vice versa. Thus, attaining complete
cervical dilatation is an important mile-
stone in the fetal descent process. If fetal
descent is delayed or the deceleration
phase is prolonged at this point in labor,
one should suspect CPD and anticipate
abnormalities of the second stage and
shoulder dystocia if vaginal delivery
ensues.61,69,73
What is the normal lower range of the
active phase dilatation rate?
As noted previously, Friedman found the
lower limit of normal dilatation on the
basis of the fifth centile on the distribu-
tion curve in the nulliparous active phase
to be 1.2 cm/h. A convenient lower
rounding limit of 1.0 cm/h became the
worldwide norm propagated by the
WHO.39e42 Zhang et al66e73 challenged
this standard and proposed 0.5 to 0.6
cm/h instead. We have proposed that this
is likely to have resulted from mixing
gravidas still in the latent phase among
those who had already entered the active
9
Expert Opinion ajog.org

whose cervix is dilating as slowly as 0.6

FIGURE 3
cm/h is in the active phase of labor,
Changing directional dynamics as mechanism for producing the let alone having a normal active phase, as
deceleration phase recommended by the guidelines. Such
dilatation rates do occur, though infre-
quently and exclusively in latent phase
labor where they are quite normal,
particularly in multiparas. However, it
would be considered an unusual and
extremely dilatory rate for the active
phase. If it did exist, it would be difficult
to confirm and, under these rare cir-
cumstances, might represent either a
protracted active phase or an arrest of
dilatation. Both labor disorders may
carry risks to mother and fetus17,18,31e34
that could be mitigated by prompt
evaluation and interventive treatment.
Given that Zhang et al66,69,71,72 were
unable to identify when the active phase
actually began in individual cases
because of the limitations of their data-
base and their analytical method, the
aforementioned admixture of latent and
active phase labors was unavoidable.

Do clinical patient guidelines for labor

management impact on cesarean
delivery rates?
Since the ACOG-SMFM published its
guidelines for labor management for
purposes of reducing the CD rates, more
than 8 years have passed. The guidelines
have been disseminated widely, although
not necessarily accepted uniformly.
Some institutions have been successful
in diminishing their CD rates, mostly by
Pictorial representation of the postulated mechanism for the development of the deceleration phase. means of intense surveillance and edu-
A, linear retraction of the cervix along the coronal (transverse) plane of the fetal head during the linear cation, seemingly unrelated to any
maximum slope of the active phase. B, as dilatation approaches the deceleration phase, the cervix changes in obstetric practices as recom-
“turns the corner” as it retracts cephalad (relative to the mother) along the fetal head. C, cephalad mended in the guidelines.105 A large new
retraction continues at the same pace, but with progressively less additional increment in cervical cluster randomized control trial is pub-
dilatation, giving the appearance that the dilatation rate is slowing. D, second stage is reached when lished in this Journal issue.106 It involved
the cervix is fully incorporated into the lower uterine segment at full cervical dilatation; at this point, nearly 89,000 deliveries at 26 Canadian
the cervix can no longer be perceived by palpation. hospitals about evenly divided between
Friedman EA: Labor: Clinical Evaluation and Management, 2nd ed. Appleton-Century-Crofts, New cases following the guidelines and those
York, NY, 1978.22 that did not. The study showed strong
contradictory evidence that the guide-
Friedman EA, Cohen WR. The active phase of labor. Am J Obstet Gynecol 2022.
lines had no discernible impact toward
lowering the primary CD rates.
phase.79,98e104 Doing so would be ex- literature. Nevertheless, the guidelines The overall CD rate has grown
pected to alter the lowest range of for labor management also recom- remarkably since before the turn of this
normal distribution downward (ie, mended the use of 0.6 cm/h as the lower century from 20.7% in 1996 to 32.9% in
below 1.2 cm/h to as low as 0.5e0.6 cm/ limit of normal active phase.64,65 2010, a 58.9% increase according to data
h) and alter the median accordingly. This It is important to stress that one emanating from the CDC.107,108 In the
contention has not been countered in the should not assume that a parturient ensuing decade (2010-2019), the swift

10 American Journal of Obstetrics & Gynecology MONTH 2022

ajog.org
growth rate abated as it fell slightly to
31.7%. This was followed recently by
resumption of the CD rate increase from
31.8% in 2020 to 32.1% in 2021. The
annual primary CDs were also exam-
ined, although limited to the time when
national data on primary CDs began to
be parsed out from repeat CDs in 2016.
The annual primary CD rates in 2016
and 2017 were 21.8% and 21.9%,
respectively; they fell slightly in 2018 and
2019 to 21.7% and 21.6%; but rose back
to 21.9% again in 2020 and still further
to 22.4% in 2021. This occurred while
the repeat CD rates were falling; dis-
counting these repeat cases yielded a still
more rapid growth of primary CD rates.
Given the total numbers of births in
the United States, averaging just under 4
million annually, and primary CDs at
about 700,000, these data are particularly
robust. Early trends up to 2009 preceded
the promulgation of the labor manage-
ment guidelines in 2014; therefore, the
prior CD rates could not have been
affected by the guidelines. The latest data
showing continued increases in primary
CD frequency do not bode well to sup-
port a contention that the guidelines
have the ability to achieve their sought-
for benefit of lowering the CD rate, let
alone curtailing its ascent.
Research questions
1. Are properly designed randomized
controlled trials feasible and ethical
to undertake for the purposes of
resolving apparent discrepancies be-
tween the Zhang method or current
guidelines vis-à-vis the previous
traditional approach to labor
management?
2. Can newer objective measures to
assess labor progress and abnormal-
ities of contractility be developed and
applied to elucidate issues related to
various aspects of myometrial
contractility and cervical resistance
or elasticity. For example, is it
possible to develop more sophisti-
cated tocodynamometry, myokinetic
studies, electrohysterography, ultra-
sonography, magnetic resonance
imaging, electromagnetic investiga-
tion, cervical biochemical and
cellular characteristics, electrolytic
shifts, etc. for finding objective and
undisputed information about the
labor process and its abnormalities to
help clinicians better manage labor?
3. Can neural pathways, both inherently
operative and under experimental
stimuli, be studied to determine
whether the component parts of the
nervous system control, regulate, and
synchronize myometrial function?
Can those pathways be modified to
enhance myometrial contractility in
clinical conditions associated with
suboptimal contractility or to stop
contractions associated with preterm
labor?
4. Is it feasible to assess for possible
CPD with greater sophistication, ac-
curacy, and nuanced clinical inter-
pretation by using advanced 3- or 4-
dimensional sonography or other
imaging techniques to determine the
spatial relationship between the fetal
skull and the dimensions of the
maternal pelvis?
5. Similarly, can more critical evalua-
tions of fetal head molding and dis-
tortions of head shape be developed,
particularly as indicators of CPD and
the risks of intracranial damage by
excessive degrees of molding? Is there
a way to determine objectively when
such excesses are likely to be haz-
ardous, that is to say, how much
molding is too much?
6. Is it feasible to take advantage of the
new developments in soft molding
under investigation for robotic use,
say to create a temporarily implanted,
but minimally invasive, functional
electromechanical cervimeter to
measure cervical dilatation, and a
comparable instrument for assessing
fetal station continuously during
labor?
Conclusions
We have undertaken a carefully detailed
review of the traditional concepts of la-
bor progression and the more recent
research findings of Zhang et al66e73
pertaining to the course of dilatation in
the active phase of labor. We have
elucidated what we perceive as the
several weaknesses of research by Zhang
et al.66e73 Their findings were used as
MONTH 2022 American Journal of Obstetrics & Gynecology
Expert Opinion
part of the basis for the guidelines for
labor management promulgated by
ACOG/SMFM64,65 and the latest version
of the partograph by the WHO43 for
wide distribution and adoption. The
cited support for the new set of guide-
lines for managing labor does not meet
the required standards of objective
research. Strong new evidence recently
published by De Vries et al74 serves to
substantiate our arguments. Their find-
ings indicate that Zhang’s description of
labor progression68,69,71,73 does not
comport with what is expected of
normal labor. Concern is also expressed
about the possibility that use of the
current guidelines may adversely affect
the wellbeing of the mothers who place
their care and the care of their fetuses in
our hands. We, therefore, urge the
ACOG, SMFM, and WHO to reconsider
their recommendations for labor man-
agement. We renew our petition to uti-
lize preexisting guidelines that were
successfully used for decades, unless
their clinical efficacy and applicability
are repudiated by reliable, illuminating,
and trustworthy research. -
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