In the natural birth class I took with my husband when I was pregnant with our first child, the doula—who also pitched us hard on the benefits of eating placenta and doing nightly relaxation mantras—repeated over and over that if we planned to birth in a hospital (we did) and wanted to avoid a caesarean birth, we should always respond to any doctor’s suggestion of an intervention “to speed things along” with an initial request for more time. Time, the doulas assured us, was usually all birthing women really needed.
According to a new study published in the March 2016 issue of The American Journal of Obstetrics and Gynecology, that doula was on to something. The study showed that one way to help women avoid a c-section is to simply let them spend more time pushing. It found that when women were given just one extra hour in the second stage of labour—the stage from full dilation to birth—c-section rates were cut in half.
This is an important finding—c-sections involve risks for women and their babies, and have been on the rise in North America. In Canada the average total c-section rate was 27 percent in 2013, more than double the ideal 10-15 percent rate recommended by the World Health Organization.
The study looked at 78 first-time moms at Thomas Jefferson University Hospital in Philadelphia. They were randomly assigned to “usual labour” or “extended labour” groups. The women in the usual labour groups were allowed to spend three hours in the second stage of labour with epidural anesthesia, or two hours if they were labouring without an epidural. These timelines reflect those set out in the current American College of Obstetricians and Gynecologists (ACOG) guidelines for how long women should be allowed to push before forceps, vacuum or a c-section are suggested. The women in the extended labour group were allowed one additional hour (4 hours with an epidural, 3 hours without). The group of women who were given more time had a 19.5 percent c-section rate, versus 43.2 percent in the control group. The study focused on first-time moms only, since subsequent births tend to go faster and can skew the results of studies like this.
If researchers are able to back up these results with a larger trial, it could lead to the AGOC changing its guidelines for how long women should be allowed to spend in the second stage. Considering the “two-hour rule” has been around since the 1800s and, up until now, was mainly based on the doctor’s opinions on how long was long enough, evidence-based guidelines would be a step in the right direction.
The Society of Obstetricians and Gynecologists of Canada (SOGC) hasn’t published a policy on prolonged labour since 1995. Back then, it acknowledged that two hours has “traditionally” been considered the upper limit for a normal second stage for a first-time mom, and that it was usually longer with an epidural. But instead of giving hard-and-fast time limits, the SOGC policy says, “As long as there is continuous progress, measured by descent of the fetal head, and fetal and maternal status remain satisfactory, expectant management of the second stage is the preferred approach to care.” In other words, if everyone is doing fine, just wait.
Without set guidelines from the SOGC, hospitals and individual doctors are left to figure out their own approaches. Some are already routinely letting women push longer than the traditional 2-3 hours. At the Ottawa Hospital, for example, its own second stage of labour guidelines already recommend first-time moms get three hours to push without an epidural and four hours with one.
The good news for labouring women is that now if you come across an OB who is inclined to stick to the more conservative guidelines, you have some solid randomized trial data to back up a request for more time. In my experience, when it comes to asking doctors to try something new, the old “says science!” adage tends to get their attention faster than “…says my hippie doula.”
Personally, I didn’t end up having to ask for more time in either of my two births. The first was a rush-down-the-hall emergency c-section. And for my second, I had an unmedicated vaginal birth and pushed for just under an hour. And that was one incredibly long hour, which means my most important takeaway from reading this study is that any woman who makes it through “prolonged labour,” however it’s defined, is a straight-up hero.