EBB 224 – Failure to Progress or Failure to Wait with Ihotu Ali, Erin Wilson, and Rebecca Dekker

LECTURE HANDOUTS

• For lecture handouts from the webinar, click here:https://evidencebasedbirth.com/wp-content/uploads/2022/04/Failure-to-Progress-Handout-April2022.pdf

ACOG Guidelines: https://www.acog.org/clinical/clinical-guidance/ob…

EBB SIGNATURE ARTICLES

• Evidence on Failure to Progress https://evidencebasedbirth.com/friedmans-curve-and…
• Evidence on Big Babies: https://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/
• Evidence on Inducing for Due Dates https://evidencebasedbirth.com/evidence-on-inducin…
• Evidence on Waterbirth https://evidencebasedbirth.com/waterbirth/
• Evidence on Birthing Positions: https://evidencebasedbirth.com/evidence-birthing-positions/

EBB PODCASTS

• EBB 221 – The Evidence on Birthing Positions
• EBB 196 – Pelvic Biomechanics and Movement in Labor
• EBB 188 – Birthing A Posterior-Positioned Baby
• EBB 75 – Birth In Twilight Sleep-The Experiences of Rebecca’s Mom
• EBB 55 – Advocating for Evidence Based Care
• EBB 45 – How Do Peanut Balls Support Labor
• EBB 16 – Movement and Positions

Rebecca Dekker:

Hi, everyone. On today’s podcast, we’re going to talk about the updated evidence on failure to progress and factors that can influence the length of labor. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice, see ebbirth.com/disclaimer for more details.

Hi everyone and welcome to today’s episode of the Evidence Based Birth® Podcast. My name is Rebecca Dekker, pronouns she/her, and I’m the founder of EBB and the leader of the research team. And I will be hosting today’s episode, along with the rest of our research team editors, Ihotu Ali, MPH, and Erin Wilson, MPH. Today’s podcast episode is special because we are sharing with you all the audio and video from a public webinar we did this spring, all about the updated evidence on failure to progress. A lot of people who attended our webinar said they wished that their friends and family and clients could all be able to watch this content. Usually, we only keep those webinars up for about a week to be the recording, but we decided this topic is so important that we wanted to turn it into a podcast that you can easily share this content with anyone you think needs to hear it.

This webinar will also be posted on our YouTube channel in case you want to watch the PowerPoint slides that go along with the presentation. Before I get started, I’d like to introduce the two people who will be co-teaching this webinar alongside me. Ihotu Ali, pronouns she/her, is a doula, Maya abdominal massage therapist, a doctoral student in chiropractic medicine, and a research editor here at Evidence Based Birth®. Ihotu, which means love in the Idoma language, is the granddaughter of a traditional Nigerian chief of Polish, Irish farmers, and a graduate of Columbia University. Ihotu has conducted maternal health research with the United Nations before becoming a doula in 2011. Fascinated by the connections between western and traditional medicine, Ihotu spent a decade studying in Afro-Indigenous and global cultural practices for childbirth and ancestral and wound healing. Ihotu is now studying both medical training and chiropractic care, as well as the neuroscience spirituality and meditation.

Ihotu is a co-founder of the Minnesota Healing Justice Network and was featured in the Rolling Stone Magazine for their focus on rest for residents and healers through the 2020 Minnesota uprisings, and is now the director of the Oshun Center for Intercultural Healing. Erin Wilson, pronouns she/her, is a clinical researcher who’s also a doula and childbirth educator. She has an undergraduate degree in biology, a minor in English, and a master’s in public health. Erin currently lives with her family in a rural area in the mountains of Colorado, which has given her more time to spend with her daughter, Evelyn. Erin brought her unique skills to work with us on the research team as a research editor in June of 2020. And Erin all also teaches virtual perinatal education classes and works with a local nonprofit on their goal of lowering the primary cesarean rate in Colorado.

Over the past few years, Erin has switched her focus from one-on-one birth work to a more policy level change. Her overarching goal is to make quality healthcare and health education more accessible for all. Erin has long appreciated and referenced the work we do at EBB, and now, she’s involved in furthering our work of publishing clear, evidence-based scientific education. Erin is responsible for the updates on the signature article here at EBB all about the evidence on failure to progress, which we plan to publish later this summer. And she’s worked with Ihotu on making some of these updates specifically related to how racism plays a role in pelvic shape categories. So now, I’d like to turn this over to the recording of the webinar and you will not only hear us teaching, but you’ll also hear us engaging with the audience, so I hope you enjoy this recording.

All right, everyone. Welcome. Thank you so much for being here. We’re so excited to have this opportunity to share this information with you. I know we had thousands of people sign up to be here tonight and the room can only hold so many, so you can be glad that you got in. So you’re all here to continue some education with us and you’ll get to know our research team. So my name is Dr. Rebecca Dekker, pronouns she/her, and we have Ihotu Ali who is also a research editor, and Erin Wilson, one of our other research editors, and the three of us are the ones gathering and writing all the research that we publish at Evidence Based Birth®. And of course, we have an amazing rest of the team who also does valuable support work for our customers and our programs and leadership, but these are the people who are going to be teaching you tonight.

So a quick disclaimer before we begin, watching this webinar does not mean that you and I have entered into a patient-care provider relationship, nothing in this course shall be construed as medical advice. We always encourage people who are pregnant to talk with a care provider before putting this information into practice. And although we try our best, this content is not guaranteed to be a hundred percent accurate or up to date. And a content warning, about halfway through this presentation, we’ll be talking about racism and eugenics. So I would love to know how many of you were told, have ever been told personally, that you personally had a labor that was progressing that’s too slow. And I have a poll I can put up so we can find out. Have you personally ever been told your labor was progressing slowly, if it’s not applicable, just don’t answer.

And have you ever been diagnosed with failure to progress? So we just kind of want to get a feel in the room, how many of you personally experienced this while you were laboring. Wow, okay, 46% of you have personally experienced this and 20% of you have been diagnosed with failure to progress. That’s a lot of people in this room, a lot of us here today who’ve experienced this. For those of you who are birth workers, I have another question for you, and that is if you are a birth worker… So only answer this if you work in the healthcare field or the birth professional field. Have you ever seen failure to progress diagnosed with your clients? Has this ever happened to any of your clients? Let me share the results in. Okay, it looks like we’ve seen this with… Most birth workers and healthcare workers have seen this happen, so this is a pretty universal phenomenon.

And I’d also love to let you know that you are more than welcome to take a few screenshots to share on social or a very short video, if you want to do a quick video of you continuing your education with us here. You can tag us @ebbirth on Instagram, and we love to see and share people continuing their education. It’s very rewarding for us. So in this webinar, we’re going to learn the latest evidence on the diagnosis of failure to progress. And how today’s webinar will work is I’m going to do some teaching and then Erin and Ihotu will also take a turn teaching you, our team will be moderating in the chat box. Everybody who attends live will get the lecture notes at the end, so all these PowerPoint slides will be given to you at the end.

We will also email them out afterwards. The replay will be available through next week, Wednesday. So if you have to leave at any point, just sign off and we will probably email out the replay tomorrow, so it’ll be available tomorrow. We do have a Q&A time slot at the end. We will be able to answer just a couple questions due to time limitations, so go ahead and submit your questions as you think of them, and then our moderator will collect them and I’ll pick a few to answer at the end. All of the references to all of the studies we’re going to reference all the research and scientific studies, those are going to be in the handouts. So we will reference the first author’s name of each paper, and then you can go to the handouts and just scroll down to the very end of the handouts and you’ll see a complete list of references.

So we are going to cover the history of the failure progress diagnosis, that’s what I’ll cover. Erin will talk about recent research on this topic, and Ihotu is going to go through five really interesting factors that can influence length of labor. And then at the end, we will give you a bonus advocacy method that our research team brainstormed and we felt is a great method for you to use if you’re having a baby or that you can use as a patient advocate, if you are accompanying someone in birth. So in about an hour, we’ll be done with this presentation. We might go 10 or 15 minutes over because we do have a lot of research to share with you, we want to make sure we get through it all, so we’re envisioning that this will take about an hour and 10 minutes or so. And I’ll also be sharing with you where you can go to learn more if you’re still not satisfied after this and you’re like, “I want more research and more information.”

I’m going to, at the end of this presentation, go through a variety of different resources where you can continue your education. One more question, I want to get a sense for who is in the room. So I’d love to know if this is your first webinar with EBB, and go ahead and answer the poll question with that, because it’s always fun to see how many people are new. And it looks like we have a lot of new people, look at that team. Two thirds of you, 63%, are new to an EBB webinar, so that’s so exciting. This is your first time learning with us. I love it. And then we have some repeat people too. I also want to know who’s in the room here. So what role would you consider that you have in healthcare?

Are you a childbirth educator, doula, nurse, midwife, parent, or parent to be, physician, student, or other? If you’re something else that we don’t have, can you put it in the chat so we know? I don’t think I have lactation on there. Are you social worker? Sometimes, we have grandparents. Are there any grandparents here today? Trying to conceive, public floor PT. I think you can pick more than one in the poll. If you are currently pregnant right now, if you’re willing to share in the chat, let us know so we can congratulate you. That’s always exciting to see all the pregnant parents in here. Me, me, me, people are saying… Not me, not Rebecca, but you guys can say me, not me.

All right. There’s so many people here having babies. Congratulations. I love hearing these announcements, because to me, it’s just so much light in the world. The life that’s coming into the world is amazing. Okay, so it looks like we have a lot of doulas in the room, a lot of nurses, midwives, parents, childbirth educators, a few students and physicians, and some people who are other. Anybody here already an EBB instructor, pro member, or do you consider you’re following us because you’re parent or you’re hoping to become a parent, are you part of the general public?

Hey, nice to see some of our members and instructors in here, and a lot of people who are expecting. Okay, a lot of people here to learn. Any grandparents in the room or people who are grandparents to be? I always love it when they attend these webinars, makes me really excited. My dad, of course, is a grandpa and he is so involved at Evidence Based Birth®. He helps package your little packages that get sent out and he gets all our emails, as a grandpa. I got some grandparents in here. Any podcast listeners here before we get started? Yeah, we have a lot of people here who are podcast listeners. Super exciting. Who’s ready? If you’re ready to start learning about failure to progress, put yes in the chat and then I’ll know it’s time to go. Everyone says yes. Okay. We’re ready.

Ihotu is laughing. All these excited people, they’re like, “All right, you’ve put us in suspense. We’re going to learn now.” Okay. So with failure to progress, this is a really subjective diagnosis. And it’s diagnosed when a healthcare provider thinks labor’s taking longer than it should. It really depends on what the care provider views as normal and abnormal. And sometimes, people can feel like it was really a failure to wait, whereas sometimes, it feels like truly something was abnormal. So it’s hard to know exactly when is it abnormal, when is labor normal, plus there are different definitions around the world. And so it’s really hard to know the statistics for how often this failure to progress actually occur. We know a little bit about how often it’s diagnosed. In the United States, failure to progress is the top reason for unplanned primary cesarean. So a primary cesarean means it’s your first cesarean delivery.

Either you’ve had vaginal births before and then you have a cesarean, that would be a primary cesarean, or you’re a first time parent and you have a cesarean. So with the United States, the American Family Physician Journal said that abnormally slow or protracted labor accounts for about 25 to 55% of all cesarean deliveries. Again, it’s really hard to know for sure, but that’s kind of our best guess in the US. In the United Kingdom, it’s the cause of about 34% of cesarean. So one in three C-sections is due to failure to progress. And in Australia, it’s around 42% of cesareans. So it’s a very common cause of being told to have a C-section. Interestingly, if you plan a home birth with a midwife, failure to progress is the top reason for needing to transfer to the hospital, however, rates are very low. Only about 4% of people who plan a home birth end up transferring to the hospital because of failure to progress.

So a little bit of history and background on this topic, Dr. Friedman published a study in 1955 that kind of serves as the basis for this diagnosis. And I pulled the original article, it’s fascinating. And I took his numbers and I put them on this graph for you all. And the red line is for those giving birth for the first time, the yellow line is if you’ve had a baby before. But his main most famous study was the one using the red line with first time parents. And in this study, he followed the labors of 500 white patients giving birth at Sloan Memorial Hospital in New York City, which I believe is now the big Presbyterian Hospital in New York City. And he went around… Other people had measured the total length of labor, but what Friedman did is he went and routinely over and over measured the cervix of everyone in labor so that he could kind of graph how quickly they were dilating.

And he plotted their laborers on a curve, literally hand drew a curve in this article. This was before there were computers where you could graph things. And this graph or curve of cervical dilation over time ended up being called a partograph. So that’s what it’s called in many places around the world. So some places, they call it a partograph, some places they call it the Friedman’s curve. You can let me know in the chat what they’re calling it near you if you’ve heard of this before. In the US, it tends to be called a curve, and other countries, I think it’s called the partograph. So what did Dr. Friedman find? From the average length of time it took to get from zero to four centimeters was 8.6 hours. And I have my little dilation wheel here, if you all can still see me on the camera.

So to get from one to four to 8.6 hours, once the patients in his study reached four centimeters, labor sped up and they actually dilated on average three centimeters per hour. It took around 4.9 hours to get from four all the way to 10 centimeters. There was a little bit of a slowing down between nine and 10. And then the average length of pushing once you got to 10 centimeters dilation was one hour. And this is the study that kind of solidified the definition of active labor as starting at four centimeters. Because once you reach four centimeters, you speed up and you’re considered to be an active labor. So while I was reading those results and talking about that study, anything strike you at all about Dr. Friedman’s study? And I’ll go ahead and open up my chat so I can see what you all are thinking.

Some people are mentioning the demographics, it’s all white, only 500 people, one hospital, twilight sleep. The population doesn’t match today, too many cervical checks. Yes, can you imagine having that many cervical checks? Yeah. 1955 was very different. What are the ethics of repeating all these exams on people? A lot of good things you guys are bringing up. So I think it’s important to acknowledge that Dr. Friedman’s study took place during segregation era medicine in the United States, where there were strict rules about who could come to most hospitals. And in most places in the United States, Black patients could not be admitted to white hospitals. This was including in northern cities like Chicago and New York and Detroit. They were not allowed to be admitted. And if they were admitted, they were put in a different part of the hospital, typically the basement, and they were not given the same access to medications and treatments as the white hospitals.

The Black communities resisted this by creating their own hospitals and their own medical schools and training programs. And medicine did not start desegregating until the mid 1960s, about a decade after Dr. Friedman’s study, when Medicare was formed in the United States and federal funding was no longer allowed to go to hospitals, if they were segregated. This change was actually resisted by the American Medical Association. They did not want to desegregate hospitals, which I think most people don’t know that racist history of the AMA. So that is just kind of a little bit of background on what type of medicine was being practiced back then. Some other notes on this research include the fact that by today’s standards, this research is unethical. They were using many invasive vaginal exams on sedated and sleeping patients.

And another thing you need to know about Dr. Friedman’s study is, virtually, all of these people were given twilight sleep. Twilight sleep is when you administer morphine and scopolamine, and it does not take away your pain entirely, but what it does do is it can, in some people, if you give really high doses, you can kind of like put them to sleep for the labor. And a large percentage of these patients were what they called heavily sedated. And then the scopolamine gives you amnesia, so you don’t know what happened to you afterwards. So you feel everything, you’re experiencing everything, but then afterwards, you don’t remember anything. And this was continued going on in the United States until the late 1960s, early 1970s. And my own mother had twilight sleep twice in the 1960s. And I actually interviewed her for the podcast about her experience. And she actually knows a lot about what happened to her because there was another laboring woman on a stretcher next to her, because they just lined him up in the room and they were all giving birth together.

And her next door neighbor was a nurse who was awake and saw what happened to my mom. So she was able to tell my mom, “Yeah, they cut a large episiotomy on you and they used forceps to pull your baby out.” They were also using gas sometimes at the very end of labor to completely knock you out for the forceps delivery. There was no use of epidurals at the time. Epidurals do slow down labor because they inhibit something called the Ferguson reflex, which Ihotu will talk a little bit about later. But the Ferguson reflex is where the baby’s head is coming down onto your cervix, the top of your uterus. It puts pressure on nerves, the nerves speed back info to your brain, your brain releases more of the hormone oxytocin, which causes contractions in your body. So if you have an epidural and you’re completely numb from the waist down, you can’t transmit those signals back up to the brain.

So it does slow down labor and that was not being used. And then like my mom, almost everybody was having forceps used on their babies, where they were pulling the babies out. And that shortens the second stage. So there’s a picture of a type of forceps that would’ve been used on my mom. Today, the population giving birth is actually older and heavier. Most of the women in Dr. Friedman’s study were pretty young, kind of like my mom. She was 18 when she had her first and that was considered normal back then. That was the normal age for a first time birth. Also, people tend to be heavier now. Both your weight and your age can affect the way hormones are working in your body during labor. So our population is older, heavier, and we have way more use of epidurals. Twilight sleep is not used anymore.

Interestingly, it could be that the heavy levels of sedation were what was making labor go so quickly, because if you remove any anxiety, fight or flight response… Ihotu’s going to talk about this later. When you reduce anxiety, it can actually help relax the pelvis and improve dilation. So the sedating everybody might have made things go faster. And plus, we’re not really using forceps and episiotomy very often, depending where you live. I know in England, it’s still very common and there’s some countries where it could be as high as 40%, but in the US, in most places, it’s less than 1%.

So if so many people are being diagnosed with failure to progress, all of… There’s so many of you in the room who said you had failure to progress, right? We had a large number of people here tonight. Could it be that we’re using the wrong definitions? Is failure to progress so common that we can host a webinar and 40% of people are like, “Yeah, that happened to me?” That is a big problem. So with that, I’m going to turn it over to Erin who is going to go over the newer research for us.

Erin Wilson:

Hi everyone. Rebecca, Ihotu, give me thumbs up if you can hear me okay. If anything funky happens, let me know. I’m excited to be here and talk a little bit about some newer research. Thank you, Chanté. So we are going to talk about things that have happened since Friedman’s time. And like Rebecca has explained already, so much is different about people giving birth now as compared to in the ’50s. And so new research is necessary to figure out what is a normal labor curve now. So we’re going to go over four different studies and we’ll talk about the common themes that come up in each one of them. And spoiler alert, we’ve kind of already figured out we were using the wrong definitions. And in some cases, we really still are. So we’ll talk about that a bit more as we go through. So what led to a change in this diagnosis? In the early 2010s, there was a public health push to lower the cesarean rate, which was around 33%.

And like Rebecca mentioned, the number one reason that unplanned primary or first cesareans happen is because of failure to progress, so there was a need to revisit that. So many people were having their labor deemed abnormal, it was time to kind of figure out what the new normal was. And so what happened was that a lot of new research was done, and one of the big things that was noted is that unlike what Friedman was noticing with labor speeding up around four centimeters, more modern labor curve showed that labor was speeding up for most people around six centimeters. And so you may have heard this phrase six is the new four. There was really this push to change the definition of active labor from six centimeters to four centimeters. And I trained as a doula and a childbirth educator around this time in the early 2010s, and I heard that a lot. And it really took going over all this new research to understand why that’s really important. And so we will talk about that more.

So let’s talk about some of the evidence that led to changing the guidelines. In 2010, there was a big study of over 62,000 people that gave birth across 19 different hospitals in the United States. And this study was a really big one that was instrumental in changing things. So they saw, like we just mentioned, most people did not dilate rapidly starting at four centimeters, but labor speeding up around six centimeters. And really important, this was seen in people that were giving birth for the first time and it was also seen in people that had given birth before. And another thing that was important about this is that before six centimeters, so before that active labor time, there was this latent period that researchers observed in some people, and so their labor could be slow or they could stall out, not progress at all.

And that was normal for people in the study to have happen before six centimeters. And so just to give a little more detail, some number and some times, Rebecca mentioned in Friedman’s study that people were dilating three centimeters an hour. Well, in this population, on average, it was taking people of about 1.8 hours to go from three centimeters to four centimeters, so really big difference there. And even bigger difference in the top fifth percentile of this, it took people seven hours to go from three centimeters to four centimeters. And so that was still within the range of normal. So something important about that is all these people in the study went on to give birth vaginally to healthy babies. So having that much longer of a time, and even in that extreme upper fifth percentile was still within the range of normal. So I was saying on the last slide about learning that phrase, six is the new four, I think this really shows why that’s so important.

Because if there’s this group of people that are having these longer labors, giving birth vaginally and to healthy babies, we have to redefine what’s normal and recognize that active labor didn’t start as early as we thought it did. And also that it’s okay not to have a lot of progress or to stall out when we’re still in early labor, so really big difference there. So this study was one of the big studies that led to this new labor guideline being published. So in 2014, the American College of Obstetricians and Gynecologists, along with the Society for Maternal-Fetal Medicine, published this new labor guideline and the goal, just like it sounds, was safe prevention of the primary cesarean. And so this is just a little screenshot of what the guideline looks like. You can look it up online and read the full thing, but in this guideline, the new normal is longer.

That’s helpful already, but there’s also more room for flexibility. So if somebody has medications on board like an epidural, or if a patient’s being medically induced, there’s more room for flexibility. And a couple of people have asked things about terminology in the chat that I’ve seen, and so this is something that changed too with this guideline. Rebecca mentioned about how failure to progress is a really vague diagnosis. It can mean a lot of different things, be diagnosed for different reasons. So some more specific terms are introduced with this guideline. One of them is labor arrest, which means that the dilation phase of labor is abnormally slow or prolonged. So we see here that looking at this new data, if we continue to apply Friedman’s curve to birthing people today, we are saying, and we’ve seen this right here in our group today in the webinar, half of people are having abnormally slow labors.

And so if such a large proportion is abnormal, we may just be using the wrong definition. And using Friedman’s curve creates this expectation for people giving birth for the first time to dilate much faster than today’s average. And I think that’s something we talk about here at EBB a lot, in different aspects of our work, is the mental impact of things that can happen in labor. And so I think that’s really important to mention here that creating this expectation to labor more quickly, and then having that not happen, it sets people up for feeling like they are failing or that something is wrong with their labor. And so we really want to reframe this and stop people from feeling that way. So next, we’re going to talk about some new research that’s happened since 2014, since that guideline came out. And so most of the things we’re going to talk about now are basically about whether or not that guideline is being followed. And when it is being followed, what is happening? So several different studies have looked at that.

So this one in 2018, Al Reyes and colleagues did a labor records review of unplanned cesareans that happened because of a failure to progress or arrest of dilation diagnosis at a single academic medical center. And so they’re specifically looking at whether or not the 2014 guidelines that we just talked about were being followed. And so what they saw was of the cesareans that occurred because of a failure to progress diagnosis, over half of them did not meet the new guidelines. They also saw that care providers were less likely to follow the new guideline if they were attending a birth on a weekend versus a weekday. And so that so illustrates what Rebecca was talking about with this idea of being impatient or a failure to wait. If the care provider was more rushed, they were more likely to not use the new more lenient guideline.

They also saw, and this is really important, in the cesarean births where the new definitions were used, there was no increase in adverse outcomes for the birthing person or the baby. And so at least at this hospital, there was no major safety issue with the guidelines that allow for longer of labors. People could labor longer and not have a negative impact on the birthing person or the baby. So here’s another study that I want to go over. This is one of our favorites. This is a 2016 study that happened in Italy. And you’ll see it’s a much smaller group of people, 400 participants, but it’s very different because it’s a perspective study. It’s not a medical records abuse. So in this study, researchers approached patients, enrolled them, and followed them throughout their labor.

And the patients were split into these two groups. So half the patients had Friedman’s curve, they had standard of care based on that older curve, and they were just treated with an older protocol in general. So they were mostly confined to bed, they couldn’t eat or drink when they were in labor. And the other half of the patients had the newer model of care based on the 2014 guidelines. So not only did they have longer to labor, but they also were treated with a more modern protocol where they were encouraged to move around and they could eat or drink when they were in labor. So we all know what group we would rather be in, and let’s see what happened.

So those that were in the old model of care group, they had slightly over twice the cesarean rate as compared to the newer model of care group. So 22% in the old model of care, versus 10% in the newer model of care. They also saw that those in the newer model of care group had less interventions overall. And then I found this crazy, the average length of labor was about the same in both groups. And so it’s really interesting to see that the length of labor was the same. Unfortunately, the older model of care group, they just had way more interventions. They got messed with more and they had more cesareans, even though their labors were really not different. So let’s look at one more study. This one’s the most recent, it’s from 2020. And this one is really focused on medical induction. So when failure to progress happens, following a medical induction of labor.

And Rebecca mentioned at the beginning, we’re working on redoing our signature article, it’s all about this topic. And in that paper, we have a separate section that’s about induction and we talk about a few different studies, but let’s focus on this one for now and you’ll see the other ones when the new paper comes out. So in this, investigators looked at medical records of 591 primary cesarean, so first cesareans that occurred after medical inductions of labor. And what they saw was that about 80% of the failed inductions that were diagnosed were not adhering to the new guidelines. And care providers were not waiting long enough to diagnose failure to progress before calling that and sending the person to an unplanned cesarean. They also saw that cesarean deliveries were inversely correlated with how the care provider was adhering. So in other words, the lesser provider was following the new guidelines, the higher their cesarean rate was.

And then again, both groups, regardless of which guideline had been followed, had the same health outcomes. So similar to the other studies that we’ve talked about before, care providers could wait longer, have a lower cesarean rate and not have negative health outcomes for the birthing person or the baby. So what’s the bottom line here? What are the common themes? I kind just said them, but I’m going to say them again. There’s two big things that we noticed when going over these studies. First, care providers are not always following the new guideline, but when they do, the cesarean rate is lower without negative impacts on the birthing person or the baby. So really showing how important it is to follow these new, more lenient definitions and guidelines. So with that, I’m going to pass it off to Ihotu. And she is going to talk about five factors that can influence the length of labor.

Ihotu Ali:

Thank you so much. Hi, I’m Ihotu. Hi everyone. Dr. Dekker, I’d love to start with a poll of the audience please. So because I am a massage therapist and a student chiropractor, we’re going to use our fingers a little bit in this section. So if everyone can hold up their fingers, whew, you know. Wiggle it, get that blood flowing a little bit, and then use those fingers to write in the chat, what reasons do you think that the length of labor and birth could be different for different people? Whatever comes to mind, this is a no judgment zone. There we go. Great. Beautiful. Pop them in, what comes to mind first. And Rebecca can read some of those out for us.

Rebecca Dekker:

Yeah. I mean, it’s going really fast, but a lot of mental health concerns, like fear and anxiety, age, movement, position of the baby, racism, a couple people have mentioned, oxytocin levels, feeling safe, movement, body type, environment. So a lot of kind of like physical and emotional factors, what people are mentioning, I think.

Ihotu Ali:

The whole gamut. Beautiful. Well, we’ll dive into five factors. Many of you have covered these in different ways. So we’ll go into if you had a prior vaginal birth, I don’t know if I saw that one quite yet. We’ll talk about that. Medications and labor. I saw epidural flying through there. Position of the baby in the pelvis, as well as mobility and movement of the person in labor, so we’ll talk about that. And then pelvic mobility and shapes. And so my little spoiler alert here is that we’ll talk about pelvic mobility in the context of stress and how much that pelvis is able to open in a safe place. And then we’ll finish up with a bonus advocacy method on how you can actually have conversation with your provider in the moment to address some of these factors that are within our control.

So let’s dive in. All right. So first, let’s talk about the history of a prior vaginal birth. So this is the factor that has the most clear evidence on it, but it’s also the one factor that’s unfortunately not under our control in the moment, right? Numerous studies have shown that active labor progresses faster on average for people who’ve given birth before, vaginally. This is reflected in the 2014 guidelines, also in the 2010 study that’s been mentioned a few times. And Friedman’s original 1955 study showed an actually completely different curve for first time birthing people versus those who had given birth before. So this means that if you have not birthed vaginally before, even if you birthed in other ways, or you’re not yet in active labor at six centimeters, so you’re still in early labor, you can expect slowness, right? This is how this factor plays out in our own individual kind of curve.

It’s perfectly okay and this should not count against you on the clock, right? So let’s look at medications. Research also shows us that epidurals and medical inductions can slow in length and labor. Rebecca, I think, mentioned this earlier as well, because of the lack of Ferguson reflex. So especially if the baby’s high in the pelvis, as in has not yet engaged, right? It’s kind of still floating, or if there’s little cervical change, depending on the Bishop score, and there’s more information the Bishop score in some of our papers, you can expect an induction to be two or three days, that can be normal. And so we share this just so that you can be prepared, mentally prepared for that time. On the other hand, Pitocin can stimulate and speed up labor. So this is a different medication that’s used. When it’s according to clinical guidelines, it can help in cases when labor slows too much, or it can be used hand in hand with an epidural, with an induction, to kind of keep labor moving.

So you can talk with your providers about how to use these different types of medications. Remember, inductions and epidurals will slow labor, and then Pitocin will speed, or they use the term augment it. So then fetal positioning, right? Where is the baby in the pelvis? This is becoming a real hot topic. More birth workers are speaking more about this and teaching more about this. From a research perspective, it does show that position of the baby in the pelvis does matter, right? We call it fetal positioning because the baby can change positions, right? That can be estimated, here we go, can be estimated by… Manually, a provider can manually feel, or on the outside, and kind of guess where is the bottom of the baby, where is the head, where are limbs, to guess where the baby might be positioned. If you want to know for 100% certainty, you would need an ultrasound.

And so each baby’s navigating the space available inside the uterus, and it has to do some acrobatics, right? Has to descend into the top or the inlet of the pelvis, move through the mid pelvis and pass out of the bottom, or what we call the outlet of the pelvis. And you think about the baby has to move around the hard spine, around the pelvis bones, around organs like the bladder, which may or may not be full in labor, so it’s important to keep that bladder empty, and it has to move possibly through really tired and tight abdominal and pelvic floor muscles. If you think about what might be going on with those muscles during labor. So another factor is that the baby’s head is not a perfect sphere. It has areas with kind of longer and wider widths, and also, areas with shorter widths, which many birth workers will know, if you want the baby to kind of tuck their head so that this diamond shape that’s a little bit smaller width appears at the top of the head.

And that’s when the Ferguson reflex can really do work when that tucked head is pressed on the cervix and releasing those hormones back up to the brain to release more oxytocin. So many midwives, OBs, doulas, even chiropractors and specialized body workers like myself have trained in all of this in more detail. And actually for years, from my training with midwives, I’ve offered prenatal myofascial release massage that can help with fetal positioning. And I’ve had a lot of anecdotal success, but also there’s not a lot of research yet or large randomized control trials to know if there’s kind of a standard benefit from some of these techniques. Okay. Let’s bring back the fingers and get into some of these positions like OP and OA and asynclitic. So fingers, wiggly fingers, and then let’s bring them to the back of our neck, along the hairline and the base of the skull, and let’s just give ourselves a nice massage, because we’re doing a lot.

It’s a Wednesday night, we’re using our brains and y’all keep going, but I’ll say that the cranial bone behind your fingers right now is called the occiput, that’s a medical term for it. When occiput, the back of the head of the baby, is touching the front side of the pelvis, here, right? We call that an occiput anterior position. When the occiput of the baby is on the backside, we call that the posterior position. So you can go back to the two images that I have the there that show the baby just a little bit more clear. So the occiput anterior positions can be called OA for short, or LOA for right or left. And these are considered more ideal positions because the soft parts of the baby, as you can see, are cradling the hard spine and the sacrum of the birthing person, right?

And we’ll get to asynclitic in a minute, and there’s a lot of questions about that one. Then you can guess that when the occiput of the baby, that hard part, is against the back of the birthing person’s pelvis, you’ve got rigid parts, hard parts up against hard parts. And that, for many reasons, can cause slower labor or more painful or more challenging labor. So those positions can be called posterior positions, OP, LOP, ROP. And so there is this research from Senecal and colleagues that speaks about the OP positioning as slowing down labor. Then a 2015 study by Mel Vasi and colleagues also found that slow or stalled labor can result from an asynclitic position, which means that the baby’s head is tilted, or the baby’s head is pushing in the direction, actually, into the side of the pelvis, rather than straight down into the cervix.

Again, reducing the strength of that Ferguson reflux, right? So you can see how that would be not as ideal. All those constructions are pushing it in the wrong direction. So let’s turn now from the baby’s position to look at the birthing person. So we actually have an entire EBB signature article on birthing positions, which highlights the research on upright positions when our friend gravity is helping us out all the way through, right? And impact that has on labor and birth. So there’s a whole history that’s really interesting, actually, I think, and sad and also illuminating on how it started that birthing people in hospitals were confined to the bed, on our backs, why that was and how that can make birth longer, more painful. So when I first became a doula about 10 years ago, one of my favorite questions to ask a new client was this.

So how do you get off a ring that’s too tight and stuck onto your finger? How would you get it off? So we talk about when you pull and pull and pull, it won’t budge, but it’s not until you twist slowly and over time that you can finally nudge that ring off. So with that same idea, really popular evidence-based birthing positions to keep on your shortlist can include swaying where you get in kind of that twist, that movement over time, slow dancing with a partner, lunging on a small stool or hip circles on a birth or physio ball is one of my favorites, just that twisting, turning, twisting, turning the whole way through, right? Even if you’re in bed, even if you have an epidural, you can still raise up the back part of a hospital bed and raise down the bottom part in this kind of throne position that I love to use, that still keeps gravity working for you, right?

You can use a peanut ball in between your hips to keep your knees into an open knees position or a closed knees, open feet position, if you so choose. So let’s talk more about these positions. So there’s actually a need for more research in this area, but speaking from a clinical perspective, we know some things are true about the pelvis, right? Many people… And you can spot kind of the pelvis movements here. Many people think of the pelvis as solid and inflexible, not moving, but the pelvis is a joint. It can move, it can open. And with the help of a hormone called relaxin that’s released in pregnancy, these strong ligaments that are holding the three joints of the pelvis, so the SI joints in the back connecting the sacrum to the iliac bones and also the pubic synthesis, this relaxin hormone actually soften the ligaments that are holding these joints.

So this can be bad news in pregnancy in that you feel so unstable that you might have pain, but it’s good news in labor in the sense that the amount of pelvic mobility you have on the regular is actually increased. And you can actually get into positions that really open different parts of the pelvis. So you can open the top part of the pelvis, this inlet that actually gives more space, maybe a centimeter or two or more, for that baby to engage in the top, if that is part of the struggle. You can actually open the outlet of the pelvis, for that baby to crown and to working along with the positioning and what the directionality and the width of the head of the baby is. So let’s bring back our wiggly fingers another time to find our own personal form of evidence on this topic.

So this technique was taught to me by Gil Tali. And if you’re able, I invite you to bring your fingers to your sitz bones. I will hold this pelvis here to kind of show, but also, there are pictures on the slides, so we can kind of… You can all see this, these are ischial tuberosities. So if you bring your hands under your bottom, move your fleshy, glute muscles to the side and kind of find those bones that set into your hand. Awesome. And hold your hand steady right on those bones, take a breath and open your knees up to this position that I’m in on the top, like a seated squat, just notice, do those bones move? And you can bring your knees back together. And then this time, keep your knees together and open your feet and ankles wide, but keeping the knees together, do those bones move?

Do they move in different direction? Kind of play with that. Are folks finding that the bones move, they kind of slide off of your fingers? So that’s our pelvic mobility lesson in real time. Seeing that even with simple movements, even if you’re not pregnant as you’re watching this, you will find that the pelvis does open. You can also imagine that other factors might limit how much the pelvis joints move, right? Based on past scar tissue, based on tailbone injuries, muscle tension, how much you sit all day versus how active you are. And then we were talking about stress as well. So many birth and body workers speak about how we store emotions, trauma, ancestral stories in our pelvis, in our hips, how the nervous system has an impact there. If we’re in a fight or flight response in that moment, if we sense danger or microaggressions in the birthing room, and physiologically, we’re ready to run and get out of there, or in a total free state, that will affect pelvic mobility.

So hopefully, there will be more research to come on these factors, more understanding about it, more people talking about it, including the effectiveness of solutions that are already popular, already being widely used, which might be chiropractic care, acupuncture, specialized massage, energy work and healing and releasing, and also, deep rests and naps. Maybe not sedation, but maybe naps to understand that that will help open the pelvis in birth. Yes. Pelvic health PT, absolutely, add that to the list. Many integrative care specialties can help with this. So let’s reel back, in terms of a little bit of history, I’d love to clue you in a little history with pelvic shapes and pelvic mobility. Since the 1930s, long time ago, healthcare students around the world have been leading four standard pelvic shapes, right? The problem with this research that we’d love to sound an alarm at EBB is that this research is flawed.

It was not blinded, and they could only assume pelvic shape from external measurements, right? There were no ultrasounds to actually confirm 100%. So this was very close to the time when face and nose measurements were being used to identify someone’s race in Nazi Germany, and very similar methods of measuring skulls and brain size were used to justify child slavery, right? So today’s teachers might not know any of this history, but if you look back at Caldwell and Moloy’s papers, they chose names for these four shapes very intentionally, and in ways that today we would call racist, sexist, and just plain inaccurate. For example, some shapes are assumed to birth vaginally like the gynaecoid shape, which is the bottom left here, which comes from the Greek word for womanly. While other shapes like the anthropoid shape in the top right here are considered near impossible to birth vaginally.

So anthropoid comes from the Greek word for ape or animal, or you might see humanlike, which means not actually human, but just humanlike. And this category was also considered common in “primitive races” in the papers. So according to Caldwell and Moloy, you don’t actually have the option of five factors influencing your birth and this complexity. You’re either assumed to have an easy labor and perhaps have no opportunity to get help or additional medications or support if you need, or you’re not even given the chance to try. So we’ve put red Xs through these outdated categories that oversimplify the picture of labor progress. And we wanted to sound this alarm because studies have shown how these outdated categories have led to forced sterilizations, mandatory cesarean sections in times when the cesarean sections were actually dangerous to perform. We wonder if these theories, theories like these and kind of stereotypes around this, stemming from the ’30s and Caldwell-Moloy were a part of why the VBAC calculator included being Black or Brown as a factor that counted against you in your likelihood of having a trial labor after cesarean.

But then that factor was removed recently, which was great because it came up that there was no evidence behind it. So what something like this is called is scientific racism, right? Using poor science and manipulating data to justify racism. This can also be called eugenics, just thinking that some of us are better suited to reproduce while others should not. And in fact, interesting new research in 2015 came out that actually debunks the entire Caldwell-Moloy theory by plotting the shapes of pelvis confirmed by CT scan into a scatter plot.

So if the shapes were true, they should have clustered into four main areas of similarly shaped pelvises, right? Kind of four areas. Instead, the scatter plot formed what researchers called a “nebulous cloud of variation,” so no major trends. And the researchers call into question the usefulness of continuing to use this outdated theory. So what’s the bottom line? I’ll close this up by just saying, can anyone remember the impact on labor of each of these five categories, right? Yeah. We’ll just leave it right there. And if anyone has questions, Dr. Dekker, you can take it from here for our bonus advocacy technique on how we put all these into practice.

Rebecca Dekker:

Awesome. Okay. Here’s our bonus advocacy method. If you find yourself in the situation where you’re being told labor is taking too long, you can ask outright, is this an emergency where minutes count? If it is not an emergency where minutes count, you have time to think and plan and figure out your course of action. So most of the time, the answer’s going to be no, minutes do not count. In which case, you can pull out your handy dandy handout from EBB on the evidence on failure to progress. Somebody was asking, how do we teach our residents the definitions? Well, you can have the ACOG guidelines printed off. Anybody can Google the guidelines on normal labor from ACOG. You can also have this handout, which in the right hand column, we have a quick summary of the diagnosis of labor arrest in the first stage and labor arrest in the second stage.

And this information can be really empowering. We’ve had countless emails from families who’ve discovered this handout or in this article on failure to progress while they were in labor, and they downloaded it, looked at it, and realized, “Actually, things are abnormal. I need the definition of labor arrests and I need medical intervention.” Or they’ll be like, “Oh, actually, I don’t qualify for this diagnosis yet, so we can try other things first, or I might just need more time.” Then we suggest asking for time. If you think it’s appropriate to ask for time, you can ask for more time with yes, and statement. So you listen to what the healthcare worker is telling you about how labor’s taking too long, failure to progress, blah, blah, blah. You’ve looked at the definitions, you’ve had time to think.

And you say, “Yes, I understand what you’re saying, and we’ve decided we’d like more time,” or, “Yes, I hear what you’re saying, and we’d like to try getting in the shower,” or, “Yes, I hear what you’re saying, and I want to try the peanut ball.” So instead of saying yes, but, if you say, “Yes, I hear what you’re saying, but we’re not going to follow your…” It just introduces this conflict, which can make the atmosphere more difficult for you. So we let the yes, and trick. And then, obviously, if you’re in the person who’s in the labor land mindset where you’re focusing on your contractions and having a baby and you can’t have these conversations, can be very difficult, then make sure your support team, if you have a doula, a birth partner or birth partners, whoever your support team is, make sure they know this strategy and that they understand the handout and that they can ask for more time for you and ask is this an emergency for you?

So just make sure everybody on your support team knows the plan in case this happens to you, which, obviously, it happens to a lot of people. So it’s a great idea to have this plan in your back pocket. So I’d love to know, before we get to resources and questions, if you could put your number one takeaway in the chat, I want to hear what is the number one thing that either surprised you or perhaps you’re like just can’t stop thinking about one thing that you learned tonight, or one thing you’re going to go tell somebody, what’s the one thing for you? The studies, the racist history, six is the new four, people aren’t following the guidelines.

The pelvis is bendy, someone says. Ihotu, I love it. The pelvis is a joint, no more pelvic stereotypes. The ring twist, I love that. Some people had never heard of the racism, they didn’t realize the research was based on twilight sleep. Eugenics, relaxin, birth takes time. Somebody says, “Now I know why it’s called a sitz bath.” Yeah. Those are your sitz bones, which makes sense, because you sitz, you sit on them, right? I don’t think I ever realized that either until recently. All right. The people love the pelvic information and the new research, so awesome job. Where did you get the pelvic, the flexible pelvis?

Ihotu Ali:

Actually borrowed this from a local birth worker. So I will do some research and let you know.

Rebecca Dekker:

Awesome. Okay. So today, we covered the history, the recent research, and the five factors. And there are more factors than those five. We just wanted to highlight five that have a lot of information, evidence-based information. Okay. So some resources for you, before we get to the Q&A. We do have an article on birthing positions. I’m in the process of updating it. I’m actually putting the final touches on my update this week. So we also had a podcast today about that, which is based on all the latest research. So check out our podcast today. We have an article on water birth, it’s a great option for lots of mobility, encouraging mobility during the labor and pushing phase. We have an article on induction or cesarean for a big baby. Big babies can also influence the length of labor, so there’s an article about that.

And I know some of you are asking about what about if you’re being induced and how long does that take and what’s the evidence for that? So we have several articles on induction, but the one related to due dates is at that address. And all these will be in the handouts you get. Also, if you have any questions about have we covered something, you can always go to our blog and search the blog. Also, at the top, you’ll see that there is some different tabs you can click on, to get to our signature articles. So the signature articles are all of our peer-reviewed, science based articles. So you can click on that and you’ll get… I think we have 24 of them now. I wanted to highlight a few podcasts episodes where you can go learn more.

Like I said today, I released a brand new episode on birthing positions. I don’t even know if Ihotu and Erin have listened to it yet, but it’s one of my favorites. We had a guest come on and talk about the pelvis in episode 196, that’s Brittany McCollum, and I know she teaches workshops on that. 188 is a OP posterior birth story. 75 is my mom’s twilight sleep experience, which you might find interesting. And then there’s some more episodes down there that I listed. And a lot of podcast apps will only show the most recent 100 episodes. And now that we’re up to 221, if you want to find the older episodes, just go to evidencebasedbirth.com/podcast, and we have a directory of all of them that you can listen to there. For those of you are expecting, we do have that EBB child birth class that can be taken virtually or hybrid, in person and virtually with an instructor.

And you can check that out and see if there’s a class that fits your schedule. And then I am excited to announce that the EBB professional membership is on sale starting tonight and going through next Tuesday. So the professional membership is a community of pros who want to make a true impact in your community and have a supportive interprofessional environment where they can continue their education. So we have a lot that’s included in your membership, all of our continuing ed courses, tons of contact hours, we do a live monthly training like this. And so each month you get access to this. It’s a smaller group, so you can have your questions answered. We did a private showing yesterday for our members, and we were able to get to all of the questions that were asked, unlike when we have a thousand people at these live public ones, and you get the recordings and contact hours.

So our members yesterday watched this and got a contact hour for it. We also have a private community, library of all of our PDF handouts, including the full length PDFs, we do weekly interactive videos, you get sneak peeks of different articles and topics. And we also started support groups. So we have a peer to peer support group meeting every month and we do specialty group meetings. Last month, we did one with doulas and we have one coming up next month, I believe, as midwives or student midwives, one of those two. Chanté can let you know in the chat. And our continuing education is good for people from a variety of fields. Our courses are all approved for nurses and most doulas and childbirth educators can use them. We also have a certain number of hours that are approved for midwives. So to get in at the reduced rate, Chanté’s going to put the link in the chat.

We have monthly or annual rates. You can cancel at any time and you are locked in at sale rates. So if you purchase during the sale, you get the 20% off for the lifetime of your membership as long as you stay with us. The membership fees go to support the free work that we do at Evidence Based for all of the research we publish and our team. So we don’t accept outside funding or advertisers or anything like that, it’s all comes from our programs and other services that we offer. So to join, you can just click on the link that Chanté puts there and we’ve already applied the coupon code, so it should be pretty simple for you. Coupon code is listed there though. And we’ll email it out later as well, the code, if anybody needs it later. So again, this is available through next week, Tuesday, and it’s a great opportunity to join at the reduced rate.

So question and answer, I’m going to pull up the questions that you all have been submitting, and we’re going to answer a few. And Ihotu and Erin, if you think of one… Here’s a great question about home birth transfers. I’ve heard maternal exhaustion is the number one reason for home birth transfer. Would this be considered a part of failure to progress? And I think maternal exhaustion goes hand in hand with failure to progress. I know Ihotu and Erin, both of you as doulas, have probably seen this, right? It’s probably hard to separate the two exhaustion and along labor. So I think often, those diagnosis are kind of vague and so you’re going to see a lot of overlap. Another question that I love-

Ihotu Ali:

Rebecca, I would just add to that, maternal exhaustion probably has an impact on pelvic mobility too, that everything is just kind of tired and done and strained. So it could be some of those factors that we’re currently looking at, all kind of dovetail with that too. And then you might be too tired to move anymore, and so when you can’t do all those factors, then it will slow down labor.

Rebecca Dekker:

I mean, it’s a really good point because there brings up so many different things that are connecting, like the whole concept of an epidural. Some people were saying in the chat if you get one early, it seems to slow it down, but if you get one later, it doesn’t seem to have an effect. But often, when someone with exhaustion and a very long labor gets an epidural further into the process, they really need to rest. And the baby’s probably already engaged in the pelvis, so that helps. But we’ve talked a lot about this, I know the pro members, how the need for rest can be so great and the need for adequate pain control at that point, if you’re starting to suffer. So getting an epidural can allow you to rest, take a breathe, breather and sleep. Some people who sleep find that they wake up and things are moving really quickly.

You don’t have to have an epidural to sleep in labor. I know that I have slept with the help of listening to Hypnobabies tracks in my ears. I don’t know if anybody else has any experience with sleeping in labor, but it is possible to rest. And some people need an epidural in order to do that. Okay. Here’s a question. Ihotu and Erin, maybe you can answer. This is being my first pregnancy, I’m trying to gain as much knowledge as possible. How long can one be in the early stages of labor before six centimeters, and is that painful to have a long, early labor? One of you want to answer, because I know you’ve probably been at those births.

Erin Wilson:

You want to go Ihotu?

Ihotu Ali:

I was just going to say that the chat was talking all about that in the beginning.

Erin Wilson:

Yes. I saw that too.

Ihotu Ali:

For days, they had been at four or five centimeters and not with any pain in some cases.

Rebecca Dekker:

And sometimes, it’s not painful. Okay.

Ihotu Ali:

That’s what people were saying.

Rebecca Dekker:

Oh, people are saying when they’re not having contractions, but they’re walking around dilated. Okay. Yeah. And you can find out that you’re four or five centimeters and you haven’t even had a single labor contraction. That’s why –

Ihotu Ali:

Yeah. That’s not everyone’s story, but-

Rebecca Dekker:

Yeah. Measuring cervical dilation is not always going to tell you when things are going to happen. I had a friend who I think was five centimeters dilated for like two weeks, but it was an incidental finding. She would’ve never known if she hadn’t had a cervical check at a prenatal visit. So Erin, what were you going to say?

Erin Wilson:

Oh, I was just going to say, a research-y answer, according to this guideline, I think that’s one of the big points. It’s okay to be in early labor. Obviously, that’s assuming the birthing person, the baby are coping okay, but there’s not a definition for that, right? You can hang out in early labor for a really long time. We know it can happen in real life, but also, according to this guideline, it’s okay, right?

Rebecca Dekker:

Yeah. And somebody said in the chat that our automatic transcriptions at one point said that you could be in early labor for 600 years. I love it. 600 years of early labor that’s an adventure.

Ihotu Ali:

It’s too much. Maybe too…

Erin Wilson:

Yeah. Biologically impossible.

Rebecca Dekker:

Yeah. But I was thinking too, early labor, that’s something that… It’s really important you educate yourself as a first time parent, ways to stay comfortable. I, actually, every Friday I work with pregnant teens at the local high school for pregnant teenagers. And I love teaching them the stuff. They just soak it up and they’re so excited to learn. And we talk about they didn’t realize that you could be in early labor for 12 to 24 hours before you even need to go to the hospital. And that’s mind blowing for them. And like, “Wait, I don’t go to the hospital with the first contraction?” And it’s like we talk about how it’s actually more comfortable to be at home. And most people can manage early labor in a calm, safe home environment. Now, if you start to feel like you can’t cope anymore, that’s a sign you should go to the hospital.

But think about all the things you all were listing in terms of what influences labor. The environment, the people who are around you, your mobility, eating and drinking, being exposed to microaggressions or not. A lot of people, not always, but most people feel safer in their home environment with laboring, and so that’s pretty normal. And you can actually be pretty comfortable at home because you can get in the tub and you can take showers and get on the birth ball. And once you get to the hospital, it can be a little bit more difficult to use those comfort measures. So people worry about having early labor at home, but there are strategies you can use. And a good child birth class will teach you ways to stay comfortable before you have to seek help. So what about short stature and pelvis size? Erin, do you want to talk a little bit about that? Because you and I were kind of like starting to investigate that for the update of the article.

Erin Wilson:

I don’t know if I have a ton to say on that. I know that that is something I heard a lot when I was practicing as a doula more regularly, that care providers, nurses, people would walk in and kind of make comments like, “Oh, you’re tall, it’s okay. The baby will turn, they have more room to get into a good position.” And on the flip side for people that were of smaller stature. So I mean, that’s definitely a stereotype and a thing that gets said. I don’t have a tangible thing to say about a study about that. I don’t know if I’ve read one lately. Have you, Rebecca?

Rebecca Dekker:

Yeah. So there is a lot of research, at least on the stereotypes, that shorter people have more difficult births. But as far as I know, there’s no evidence to back that up. It’s just a stigma and a prejudice against short people. And I’ve met people as young as like 19 or 20 who’ve never had been pregnant, but would like children someday, and they’re already worried about giving birth because their doctors have made disparaging comments to them about their size and their shape. And so I think that is… Yeah, if somebody said shoe size, that is a big belief in some parts of the world that if you measure someone’s shoe size, that will tell you if they can birth a baby vaginally. And it just goes back to those stereotypes against about pelvic shapes and how some people are prejudiced against and thought that they should not reproduce because of certain characteristics.

But if you think about it, just because you’re short doesn’t mean your pelvis is going to be narrower. It doesn’t have anything to do with your size of your pelvic openings just because your legs are short. So I think that is something that a lot of parents face. A lot of people here are saying that they’ve heard this, so this is very common and we are going to make sure we have a section in the updated signature article. So I think that wraps it up. We’ve covered a lot tonight. I wish we could have gotten to everybody in these questions. Chanté, can you make sure that the handout link is dropped in there for everyone? And thank you again so much for joining us tonight. We probably could have talked about this topic for like four or five hours. I think you guys noticed we went a little bit over, but that’s okay.

I think you all wanted to be here. Most people ended up staying with us through the whole hour and 20 minutes, so we appreciate your time. Feel free to tag us with your posts on Instagram. And we look forward to just continuing to teach. And we’ll have another showing on Sunday, so if you have any friends or family who you want to watch this, you can direct them to evidencebasedbirth.com/webinar to sign up. And we’ll, of course, send this recording out to all of you tomorrow. So have a wonderful evening or more morning, wherever you are in the world. And we’ll see you later. Bye everyone.

Ihotu Ali:

Bye.

Erin Wilson:

Thanks everyone.

Rebecca Dekker:

Well, that brings us to the end of this podcast, and I hope you enjoyed the recording of the webinar. Keep in mind that if you are a birth worker or a healthcare worker, and you’d like ongoing access to trainings like this one, along with contact hours for continuing education for your profession, you can get that and so much more and our community inside the Evidence Based Birth® professional membership. You can learn more at evidencebasedbirth.com/membership. Please pass on the word that this webinar is available, both on our podcast and our YouTube channel. And we have hope that this information reaches a lot of people since this is a global topic of a lot of importance. Thank you so much for listening to our podcast episode all about the evidence on failure to progress and we’ll see you next week. Thanks everyone. Bye.

Today’s podcast was brought to you by the Evidence Based Birth® professional membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.