By Janelle Durham, Kim James, Tracy McPhillips, Audrey Miles Cherney, Sharon Muza, Katie Rohs, Penny Simkin and Katherine Steen

When ACOG released the "Safe Prevention of the Primary Cesarean" bulletin - it was hailed as a serious game changer. We covered this article on Science & Sensibility here. Many childbirth educators, doulas and others simply changed their materials and teaching content to indicate early labor was now was considered 0 cm to 6 cm and called it good! In reality, nothing could be further from the truth! Families working through "early" labor were finding things to be quite intense and at times very difficult. Educators need to do everything possible to prepare families for the coping and comfort measures that will help them to get to "active" labor. My colleagues and I, as part of the Education Committee at Great Starts, a program of Parent Trust for Washington Children, recently discussed this topic and prepared an inservice for our educators on how to adequately address strategies to cover this shift in identifying active labor. We would like to share this information with you now. How are you preparing families for potentially working longer at home to get through "early" labor before checking in at their birth location? What are you seeing with the families you work with? - Sharon Muza, Community Manager, Science & Sensibility

Childbirth educators, we have a problem. When the American College of Obstetricians and Gynecologists (ACOG) changed the definition of the start of active labor from 4 cm to 6 cm of dilation (Caughey, 2014), we failed to change our collective thinking about how we interpret and teach the phases of labor in our childbirth classes.

In trying to be up-to-date, childbirth educators adjusted their teaching aids (posters, videos, and parent hand-outs) to reflect the changes: Early labor is now 0-6 cms, active labor from 6-8 cms and transition from 8-10 cms. For just a couple easily viewable examples, please see: "Six Essential Labor and Birth Charts" and "Phases of Labor - Set of 3 Posters".

Unfortunately, these teaching aids simply expanded early labor to 6 cm but, kept the original emotions and expectations of the previous definition of early labor: This implies that early labor (all the way to 6 cm) will be experienced as mild contraction intensity.

Katherine Steen, LCCE recalls, "When I first learned about this change, I simply adjusted the times and dilation measures on my teaching materials and went on with things. Because I do not regularly attend births, I was also under the mistaken assumption that hospital admission would be delayed to 6 cm. I was so excited about the possibility of these new recommendations to lower intervention rates, it took me awhile to internalize what this shift really meant for my students and to adjust my teaching strategies to provide the realistic expectations and additional coping skills needed to deal with longer labors."

Let's review what "6 is the new 4" really is.

In the Safe Prevention of the Primary Cesarean bulletin (Caughey, 2014), it states "Cervical dilation of 6 cm should be considered the threshold for the active phase. Before 6 cm of dilation is achieved, standards of active phase progress should not be applied. Further, cesarean delivery for active phase arrest ... should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change." Active labor is an important obstetrical benchmark for identifying slow labors that require attention and arrested labors that require action.

Janelle Durham (MSW, LCCE) reminds us: "As childbirth educators, we want to focus on the '6 is the new 4' as the reason we shouldn't MESS with you until you're at least 6 cm. If you're less than 6 cm, it's not prolonged labor and you don't need a cesarean. I want my students to know that if interventions are proposed for slow progress before 6 cm they should be asking questions..."

The new definition of active labor beginning at 6 cms requires different thinking about the phases of labor and how we teach parents to recognize and cope with each phase.

For most laboring parents, their experience of intense contraction pain and the need for comfort measures and emotional support starts well before 6 cm of dilation.

Please consider the advice from the Great Starts Education Committee members:

Katie Rohs CD(DONA), LCCE: "In addition to the traditional "early", "active", and "transition" phases of the first stage, I teach a 4th 'phase' of labor called 'Early Getting Into Active' which is approximately 3 or 4 to 6 cm. There are such clear emotional & physical changes that happen in this phase that I find it to be critical to teaching realistic expectations."

Janelle Durham: "The important message is that laboring parents have to do really hard work to get from 4 - 6 cm, and they shouldn't be discouraged if that phase is really challenging and it takes a while - that's normal. I think it's almost as if we're adding a fourth phase to 1st stage: early labor is the warmup - then there's the intense-but-slow-progress of "getting into active" - the intense-but-at-least-there's progress of active labor - and then transition."

Tips for Accurately Teaching "6 is the new 4"

Use AV aids that realistically show what parents experience in each phase of labor.

This graphic shows a more realistic view of how parents experience the phases of labor and helps parents understand that they will likely feel intense pain before the active phase of labor.

One of the best teaching graphics may still be Penny Simkin's Road Map of Labor depicting parents' coping at all phases of labor. (Please note, the Road Map of Labor also appears in the appendix of the new edition of Pregnancy, Childbirth and the Newborn.)

Teach parents that the ability to cope is independent of cervical dilation.

Ability to cope varies depending on numerous factors, including pain intensity, speed of labor progress, knowledge of comfort measures, understanding what is going on with the baby and cervix, having good support and patient caregivers and companions.

Teach realistic expectations about when to arrive at the birth location.

Most hospitals prefer admitting laboring parents at 4 cms dilation or beyond and parents need to understand reaching the active labor threshold for most first-time parents will take between 15 - 24 hours. The greatest areas of influence childbirth educators have is teaching parents to cope confidently with a long early labor, recognize the signs of labor progress, and understand the signs and signals of when to appropriately leave for the birth place. In Washington State, the Washington State Hospital Association (Wagner, 2015) recommends laboring parents arrive at the hospital when contractions are 3 minutes apart or if the bag of waters breaks. Additionally, WSHA recommends discharge home if:

• Cervix 4-5 cm without change x 2 - 4 hours
• Less than 80% effacement
• Membranes intact
• Reactive NST/FHR category I (if uterine contractions present)
• Contractions less than 3/10 minutes

Tracy McPhillips PCD(DONA), LCCE: "The instructor is key to helping parents understand what it's like to progress from early labor into active and when it's time to leave for the birth place or call the midwives to come. Ideally, class members develop patience for how labor unfolds and appreciate the need to learn and use skills to cope with a longer early phase of labor.

Focus on teaching coping skills and comfort techniques to increase parents' ability to confidently cope with labor pain intensity, regardless of the phase of labor.

Instead of creating false expectations that the latent phase of labor will be the easiest phase of labor and last until 6 cm, childbirth educators must prepare parents to confidently cope with whatever intensity they feel whenever they feel it.

Says Penny Simkin (PT), "If we don't prepare people to cope with early-to-active labor, we are not doing our job."

Penny recommends: "We should go into detail about the emotional and physical challenges that come with "getting into active labor,"" and tie them in with cervical changes and the "6 Ways to Progress", which we have already covered in class. (i. e., the contractions intensify before the cervix responds with dilation, as it continues thinning, moving forward, and ripening). The cervix tends to resist dilation until it becomes very thin. This causes an emotional struggle for the laboring person, who may feel overwhelmed and anxious, especially if they think the contractions are very intense and doing "nothing"

They struggle with "control," and may decide it's too hard and request an epidural, or they may release control ("I can't do this. It's too hard. My body will have to do it!"). (I've wondered if the well supported laboring person releases control about the same time that the cervix lets go -- just a thought!) When she does release control, she often becomes more instinctual and discovers her own spontaneous ritual.

From my experience, I've learned that when in this instinctual state, "coping" seems to consist of spontaneous behavior, which includes the "Three Rs:" 1) Relaxation between contractions (if not during contractions); 2) Rhythmic behavior (breathing, vocalizing, moving; or rhythmic mental activity, such as counting, a mantra, a song); and 3) Ritual, which is the repetition of these rhythmic behaviors for many contractions in a row. After that, labor becomes more manageable, not because the contractions are less intense, but because the laboring person has discovered how to work with the contractions. A key point is that in order to get through this challenge, the laboring person really benefits from freedom to move around to seek comfort, and "emotional safety," which I define as unconditional acceptance by others of the way they discover to cope -- sounds, movements, etc.

The laboring person shouldn't be criticized (even though the intention of the criticism to be helpful: "You're breathing too fast" "Try to stay still during your contractions or you'll exhaust yourself" "Those high-pitched sounds aren't doing any good. Try to lower your pitch." This translates to the laboring person as, "I'm doing it wrong. They disapprove." The laboring person is likely to remember, "I was awful in labor. I did it all wrong," rather than, "I found a way to cope!" We should teach that these 3 Rs (Relaxation, Rhythm, and Ritual) indicate that the laboring person is coping, and teach the partners to match the laboring person's rhythm in some way (head or hand movements; stroking the laboring person's arm or back, vocalizing with them, etc.)"

In addition to Penny Simkin's 3 R's, Audrey Miles Cherney, Great Starts Program Manager and Childbirth Educator, talks about "labor P.A.I.N." and really emphasizes the need to relax during the contractions, releasing any muscles not needed to support oneself during a labor contraction, as well as the "other 3 R's" that are important during the "resting time" between contractions.

Audrey explains, "As many educators do, I teach families about the acronym for labor P.A.I.N. as a way to transform a word with which we otherwise have negative associations. "Pain" is a word that is often assumed as meaning "suffering" or that something is wrong that has to be put right and healed, but there are many ways to experience pain and the sensations of labor without suffering and to work with it, instead of fighting or resisting it. When I explain the acronym, I talk specifically about how labor is "Powerful" as well as "Purposeful". It is the laboring person's inner power and strength at work signaling what we need and when we need it when birthing the baby. In one such way, it is a signal to be in their "safe place" and to be surrounded by the people who make them feel safe, if not also loved and respected, and help them be comfortable during this process. Early on, their safe place may be in their neighborhood going for a stroll, then a little later at home actively coping with partner and/or doula. And then even later still, either at the hospital with their medical team, or at the birth center or at home with their midwife. And while we can "Anticipate" what will work for coping, such as with Penny Simkin's "3 R's", we can also anticipate that the strong sensations of labor are "Intermittent"--that there will be a peak with each powerful surge and then it subsides and allows time for the "other 3 R's" to happen: Rest, Rehydration/Refuel, and Reconnect as a couple (or Regroup as a team, and ask questions, or Re-strategize if something is not working).

These elements between contractions work in compliment to what is happening during contractions since the resting time is at least as important to the support happening during the contractions when it comes to maintaining one's ability to reasonably cope and achieve better outcomes overall. And, of course, barring any medical complications, the sensations of pure labor are "Normal." Our bodies are designed to give birth, just as it is designed to breathe and digest food. We certainly do not give birth every day, but it is still a normal physiological process we are designed to do. According to WHO estimates, every second there are 4-5 babies born, so literally, there are hundreds of people worldwide giving birth to babies any given minute. As has been noted by many others before, the human race would not have survived this long, or been so successful breeding if our ability to birth was inherently flawed."

Building parents' confidence in their ability to cope takes time. There is no way around it: Mastering self-comfort coping skills is reached through repetition and practice. Educators should aim for 35% - 50% of their class time teaching and practicing physical and emotional/mental coping skills for labor and self-advocacy skills for shared medical decision-making.

Conclusion

The new guidelines, "6 is the New 4" will lower cesarean rates for failure to progress, but they require laboring persons to be able to endure longer labors, and potentially more emotional distress if they have not found ways to cope. Even those with an epidural find the longer duration of labor to be stressful. Labor is as much an emotional experience as a physical one for the laboring person and their team. Our job as childbirth educators is to present them with accurate information, help them develop realistic expectations and practice the skills they will need to cope successfully with this challenge.

References

Caughey, A. B., Cahill, A. G., Guise, J. M., Rouse, D. J., & American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.

Wagner, C., Zabari, M., Handel, S., & Director, I. C. (2015). Best Practice Recommendations for Labor and Delivery Care.

About the Authors

Janelle Durham, MSW, LCCE has been a childbirth educator since 2000, is a parent educator for Bellevue College, co-author of Pregnancy, Childbirth and the Newborn, and author of the blog Transition to Parenthood - resources for parents and childbirth educators.

Kim James BA, BDT(DONA), CD(PALS), ICCE, LCCE, is an ICEA and Lamaze certified childbirth educator teaching at Parent Trust for Washington Children/Great Startswhere she sits on the Education Committee. She owns and operates www.DoulaMatch.net and is a DONA International and PALS Doulas certified birth doula as well as a DONA-approved birth doula trainer working at the Simkin Center/Bastyr University. Her daughters are 11 and 18 years old. Kim and her family live in Seattle, Washington.

Tracy McPhillips, PCD(DONA), LCCE is a Lamaze certified childbirth educator. She serves on the Education Committee for Great Starts, a program of Parent Trust for Washington Children. She is also a Postpartum doula, certified through DONA International and serves on the DONA certification committee. Tracy also guest lectures for the Simkin Center's Postpartum Skills workshop.

Audrey Miles Cherney is Great Starts Program Manager. She's been a Great Starts Childbirth Educator, Lactation Educator, and birth doula since 2009. Audrey served on Jefferson Healthcare's BFHI Task Force Team (2012-2013), helping it to become the second hospital in WA State to earn this designation. In addition, she is a HypnoBirthing Practitioner, scientific illustrator, a partner-for-life, and mother to two very active daughters.

Katie Rohs, CD(DONA), LCCE, is a DONA certified Birth Doula and Lamaze® certified childbirth educator and teaches for the Great Starts program of Parent Trust for Washington Children. Katie also works as Penny Simkin's office manager, and is President of PATTCh, a non-profit bringing awareness to traumatic childbirth.

Sharon Muza, BS, CD(DONA) BDT(DONA), LCCE, FACCE has been an active childbirth professional since 2004, teaching Lamaze classes and providing doula services to thousands of couples through her private practice in Seattle, Washington. She is an instructor at the Simkin Center, Bastyr University where she is a birth doula trainer. Sharon is also a trainer with Passion for Birth, a Lamaze-Accredited Childbirth Educator Program and a consulting instructor for the Great Starts program of Parent Trust for Washington Children.

Penny Simkin, PT, is a physical therapist who has specialized in childbirth education and labor support since 1968. She is the author of many books and articles on birth for parents and professionals .Co-founder of DONA International, and member of the editorial staff of the journal, Birth, she recently was honored to be made the namesake for Bastyr University's Simkin Center for Allied Birth Vocations, which provides training for Birth and Postpartum Doulas, Childbirth Educators, Lactation Educators, and Perinatal Massage Therapists. She is married, the mother of four, and grandmother of eight.

Katherine Steen, BS, MAIS, LCCE has been teaching childbirth classes since 2012. She currently teaches for the Great Starts program of Parent Trust for Washington Children in Seattle, WA. Prior to the birth of her daughters, she spent 10 years working as an educator in zoological parks. In addition to teaching birth classes, she loves to cook, garden, read and spend time outdoors.

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