[OzMW]

We are looking at our policies and am wondering what your minimum acceptable dilation rate in active labour is before resorting to ARM or oxytocin infusion? We are trying to get ours dropped to 0.5cm per hour from 1 cm per hour!

[Elvish]

Ours is 1cm/hour, if I'm not mistaken. (I don't do L/D.) I'm not the world's biggest fan of this, esp for primips. Most women don't know there's a curve they're 'supposed' to be following in labor. Many many times I've seen (and I'm sure you have too) somebody stay at a certain dilatation for several hours then all of a sudden, BAM! They're complete & ready to push. Without any help. I wish our policy would change too.

[Jolie]

I've been out of practice for awhile, but I have never heard of a policy setting minimum acceptable dilation rates. That boggles my mind! In the absence of risk factors such as PROM, s/s of infection, or non-reassuring FHR, I would have a hard time supporting such an arbitrary policy.

[Elvish]

Originally Posted by Jolie

I've been out of practice for awhile, but I have never heard of a policy setting minimum acceptable dilation rates. That boggles my mind! In the absence of risk factors such as PROM, s/s of infection, or non-reassuring FHR, I would have a hard time supporting such an arbitrary policy.

I totally agree with you! I should clarify to say, I don't think we have a set 'policy' in place; but this is what is pretty well accepted that our docs like, according to those nice little labor curves. If you have someone staying at the same dilatation, a lot like to hurry things along even if there's no good reason to.

[CEG]

I was speaking with a Norwegian midwife a few months ago. They have a new "Labor Curve" that has resulted in wonderful outcomes. For the first six hours they do nothing. No matter how fast/slow mom is dilating. Then for six hours they will observe more closely/ perform exams and consider interventions. After the second six hours they have the option of intervening and a decision tree for that. I don't have the exact details on it but you could probably google it. It has been very succesful at reducing unnecessary interventions. Of course, in Norway they have national healthcare and are not trying to turn a profit the way we are here, so a slow labor would not be looked down upon so much.

Here's an interesting article that breaks down Friedmans curve and discusses why it is not accurate http://www.birthsource.com/scripts/a...?articleid=120

[SmilingBluEyes]

No set policy, although the "magic" formula rounds about to 1 cm per hour. I have been know to fudge (aka lie) about dilation in some rare cases in order to buy more time with a very impatient OB and it worked out. I hate to see anyone go under the knife due to impatience with what should be a healthy process anyhow. I know there is great controversy over the Friedman Curve and similar such measurements. I just think having a lot of experience has taught me, many, many women "fall off the curve" and only rush way ahead in good time. I trust their bodies as much as I possibly can. How many women have we seen, as in the above example, who did "nothing" for hours, only to "take off" in due time? Esp multips---they have their OWN timetable and it should be respected!'



May I also add, our attitudes and energy do a lot to either take away or add to the situation. I have told many a mom positive things, any positives I could find, to "keep the faith" and it worked! I think our attitudes as their trusted health care professionals are HUGELY important and effect outcomes a lot.

[Spidey's mom]

Ah, this is making me feel so very good about not having to be an OB nurse anymore.

There was no set policy, as others have said .. .. but 1 cm an hour is what most of the docs wanted . . regardless of the SCIENTIFIC EVIDENCE that pushing up the rate of pitocin does nothing if the time is just not right for dilation.

(Deb - I did the same thing - fudging).

steph

[almost a cnm]

This is what I learned in midwife school about abnormal labor patterns.

Nullip first stage greater than 24.7 hours is abnormal.
Nullip protracted dilitation is less than 1.2cm/hr.
Nullip arrested dilitation is no change for 2 hours.

Multips are:
Duration - should be less than 18.8 hours.
Protracted dilitation is less than 1.5cm/hr.
Arrest is no change in 2 hours.

Second stage nullip:
Arrest of descent (epidural)- greater than 3 hours
Arrest of descent (no epidural)- greater than 2 hours

Second stage multip:
Arrest of descent (epidural)- greater than 2 hours
Arrest of descent (no epidural)- greater than 1 hour.

[OzMW]

Wow...some passionate responses! Thank you. I must give you more info tho. We don't routinely involve doctors in normal labours and midwives do the hands on care (like you guys). So we have guidelines that say a woman needs to progress at 1 cm per hour and if she doesn't then we have a set of actions we are to consider, and obviously if they don't work we consult the obstetrician. This is a clinical guideline written by clinicians. Its not some form of policy written by managment!

[OzMW]

There is research around that supports the fact that Friedmans stuff was crap and that women can labour more
slowly and the outcomes are good.

J Perinatol. 1999 Mar;19(2):114-9.


The duration of labor in healthy women.

Albers LL

University of New Mexico Health Sciences Center, College of Nursing, Albuquerque 87131-1061, USA.

OBJECTIVE: To measure the duration of active labor (first and second stages) in low-risk women whom received intrapartum care from certified nurse-midwives in nine hospital settings in the United States in 1996. Clinical factors and morbidity indicators associated with longer labors were also examined. DESIGN: An observational study was conducted with healthy women at term who did not receive oxytocin or epidurals (n = 2511). Descriptive statistics are reported for the duration of the active phase--first stage (4 cm to complete cervical dilatation) and second stage (complete to delivery)--by parity and for subgroups of women according to race/ethnicity, age, insurance, activity in labor, type of fetal heart monitoring, and narcotic analgesia. Logistic regression was also used to assess the contribution of each variable to longer labors with simultaneous adjustment of the other variables. RESULTS: The mean length of the active-phase, first stage was 7.7 hours for nulliparas and 5.6 hours for multiparas (statistical limits of 2 standard deviations from the mean were 17.5 and 13.8 hours, respectively). The mean length of second stage was 54 minutes for nulliparas and 18 minutes for multiparas (statistical limits 146 and 64 minutes, respectively). Variables associated with longer labors were electronic fetal monitoring, ambulation, maternal age over 30 years, and narcotic analgesia. Morbidity was not increased in longer labors. CONCLUSION: Normal labor in healthy women lasted longer than many clinicians expect. The criteria for distinguishing normal from abnormal labor, based on time, need revision.