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OBSTETRICS

Perils of the new labor management guidelines

Wayne R. Cohen, MD; Emanuel A. Friedman, Med ScD

Recent guidelines issued jointly by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine for assessing labor progress differ
substantially from those described initially by Friedman, which have guided clinical
practice for decades. The guidelines are based on results obtained from new and untested methods of analyzing patterns of cervical dilatation and fetal descent. Before these
new guidelines are adopted into clinical practice, the results obtained by these unconventional analytic approaches should be validated and shown to be superior, or at least
equivalent, to currently accepted standards. The new guidelines indicate the patterns of
labor originally described by Friedman are incorrect and, further, are inapplicable to
modern obstetric practice. We contend that the original descriptions of normal and
abnormal labor progress, which were based on direct clinical observations, accurately
describe progress in dilatation and descent, and that the differences reported more
recently are likely attributable to patient selection and the potential inaccuracy of very
high-order polynomial curve-fitting methods. The clinical evaluation of labor is a process
of serially estimating the likelihood of a safe vaginal delivery. Because many factors
contribute to that likelihood, such as cranial molding, head position and attitude, and the
bony architecture and capacity of the pelvis, graphic labor patterns should never be used
in isolation. The new guidelines are based heavily on unvalidated notions of labor
progress and ignore clinical parameters that should remain cornerstones of intrapartum
decision-making.
Key words: active phase, arrest of descent, arrest of dilatation, arrest of labor, deceleration phase, dysfunctional labor, labor curve, partogram

he seemingly inexorable increase

in the use of cesarean delivery,
and the substantial contribution that
dystocia and related diagnoses have
made to that increase, have prompted a
reevaluation of what constitutes normal
labor.1-4 As a result, new guidelines
promulgated jointly by the American
College
of
Obstetricians
and
From the Department of Obstetrics and
Gynecology, University of Arizona College of
Medicine, Tucson, AZ (Dr Cohen); and the
Department of Obstetrics, Gynecology, and
Reproductive Biology, Harvard Medical School,
Boston, MA (Dr Friedman).
Received Aug. 11, 2014; revised Aug. 20, 2014;
accepted Sept. 2, 2014.
The authors report no conict of interest.
Corresponding author: Wayne R. Cohen, MD.
cohenw@email.arizona.edu
0002-9378/$36.00
2015 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ajog.2014.09.008

Gynecologists (ACOG) and the Society

for Maternal-Fetal Medicine (SMFM)
were released.5 The new recommendations dene abnormal labor and provide
guidelines for its management that differ
sharply from those originally described
by Friedman,6-10 which have formed
the basis of the clinical management of
labor for many decades in the United
States and elsewhere. For that reason,
a thorough analysis of the proposed
standards is warranted to ensure that
changes recommended for obstetric
care during labor are justied by the
available evidence.
The guidelines are based heavily on
analytic methods used by Zhang and
colleagues11-14 to describe the patterns of
cervical dilatation and fetal descent
as functions of time elapsed in labor.
Their ndings, which have been rapidly
adopted in some parts the obstetric
community, have not yet been validated.
For the reasons we briey summarize

420 American Journal of Obstetrics & Gynecology APRIL 2015

in this commentary, we believe the

new ACOG/SMFM recommendations
provide denitions of dysfunctional labor and guidelines for its management
that, however well intentioned, are likely
to impose undue risk on mother and
fetus.

Historical background
Prior to the mid-1950s, the evaluation
of progress in labor was based primarily
on its duration. Vague admonitions such
as, Never let the sun set twice on a
laboring woman, which were based on
prevailing observations about average
labor duration and outcomes,15 were
commonly intoned. This approach was,
however, ineffective in identifying
when intervention would be appropriate
or optimal.
In 1954, the rst of hundreds of
studies of labor by, or based on the
work of, Emanuel Friedman6 was published. Friedmans work built upon previous investigators attempts to describe
the events of labor as a function of
time.16-18 Their recognition of the
practical implications of this approach
was hampered by what we now know to
have been erroneous assumptions about
labor, particularly with regard to the
role of membrane rupture. The rst
publications6-8 describing the graphic
patterns of dilatation and descent stimulated the interest of many investigators,
and led to the formulation of criteria that
made the assessment of progress in labor
objective rather than arbitrary.9,10,19-26
Unfortunately, the criteria have not always been applied appropriately, in
part because of some misunderstandings
about the curves and their proper place
in clinical care.
Misconceptions
It has often been alleged that Friedmans
seminal observations regarding the
labor curves rest on a fragile foundation
because they were never corroborated by
others. In fact, numerous studies done

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in different parts of the world over the
course of several decades conrmed the
basic nature of the original curves, and
validated their usefulness in clinical
practice.27-43 There have been disagreements over the importance of the latent
phase or even the existence of the
deceleration phase of dilatation, but the
core nding that active-phase cervical
dilatation progresses linearly, with a
lower limit of normal approximately
1.0 cm/h in nulliparas, has been remarkably consistent among studies. It
is also noteworthy that in many institutions the introduction of labor
curves to clinical care was associated
with a decline in the cesarean rate.30,33,34
Some of the early data were collected
using a mechanical cervimeter to obviate
the potential subjectivity in clinical examination,9,44,45 and cervimetry by investigators using various tools conrmed
the sigmoid nature of the dilatation
curve.46-49 Limited data from more
recently developed techniques to automate cervical assessment also appear
consistent with the earlier observations.50,51 Sigmoid-shaped curves of cervical dilatation have even been described
in cows, suggesting a common pattern of
labor among mammalian species.52
Given the large body of evidence
conrming the basic pattern of progress in normal labor, it is difcult to
believe that labor progresses very differently today from how it was originally
described. Why, then, do the labor
curves of Zhang and his colleagues differ
from those of previous observers? One
explanation was provided by Zhang
himself when he and his colleagues
applied their analytical methods to the
very same data Friedman had analyzed
from the Collaborative Perinatal Project.14 Friedmans analysis of those data
revealed a sigmoid-shaped dilatation
curve; that of Zhang et al revealed an
exponential curve, essentially the same
as they had found from contemporary
labors. Clearly, what had changed was
not the nature of progress in labor, but
how the data were analyzed. This raises
the question of which analytic technique
provides a more accurate model of
labor progress: that of Friedman or that
of Zhang et al?

Obstetrics
In trying to address that question it
is important to understand that the
original dilatation and descent curves
were based on and conrmed by direct
experimental observations made on
women in labor. The primacy of direct
observation over theoretical conceptualization or indirect analysis of data in
hypothesis testing has been a central
tenet of the scientic method since the
Enlightenment. When the results of an
analytic approach differ from those
derived from observation, it is important
to understand why this has occurred,
and try to adjudicate accordingly, before
declaring the direct objective ndings
invalid.
Analytical issues
The labor curves in Friedmans original
reports were not created by using complex mathematical formulae, as some
have suggested.2 The initial data were
collected by a single observer.6 Subsequently, data from multiple practitioners
in a single institution were reported.7,8
In both instances, the curves were drawn
by hand, the descriptions were empiric,
and the statistical analysis basic. Only
later was a more sophisticated method
of assessing the labor graphs by computer used to analyze >10,000 nulliparas
from multiple institutions.53-56 This
more sophisticated analysis conrmed
the initial ndings regarding the nature
of the cervical dilatation and head
descent time functions.
The computer algorithm used was
developed with the Ofce of Biometry
of the National Institutes of Health.
Raw labor data were plotted on a probit
(ie, the normal probability) scale, to
convert the sigmoid curves to straight
lines.57,58 The maximum slope data were
converted to logarithms to normalize
their right-skewed distribution. The
linearity thus achieved made the data
amenable to descriptive statistical study
for determining distributions and limits
of normal, which have until recently
stood the tests of time and clinical
applicability.
By contrast, Zhang and colleagues
used a high-order polynomial curvetting program to analyze dilatation
and descent data, and interval-censored

Expert Reviews

regression to t curves based on

centimeter-by-centimeter median traverse times. We have concerns about the
application of this technique to labor.
We do not profess personal expertise
in this area, but we are impressed by the
negative comments and strong skepticism encountered in the engineering
literature pertaining to the limitations
of high-order curve-tting methods.59
Such models do not guarantee reliable
results. Indeed, high-order curve tting
may not be appropriate or even necessary for most situations. Low-order
quadratic curve tting is preferable,
whenever possible, and yields results that
are at least as accurate. In fact, the higher
the order, the less satisfactory curvetting accuracy tends to be. This is so
because noise (ie, unstable data points,
especially if those points are spread apart
from each other or are located at the ends
of the range of data) is magnied. As a
consequence, portions of the derived
curve are distorted. In this regard a
leading authority opined that, It is
important to keep the order of the model
as low as possible.As a general rule the
use of high-order polynomials (k >2)
should be avoided unless they can be
justied for reasons outside the data.Arbitrary tting of high-order polynomials is a serious abuse of regression
analysis.59 Zhang et al used polynomial
curve-tting models of the order of 810, far in excess of the cited recommendation of no higher than 1 or 2.
Other investigators have used interval
data to create labor curves, with varying
results. Gurewitsch et al60 found a sigmoid curve of dilatation, but Chen and
Chu61 found results similar to those of
Zhang et al in terms of curve shape and
much lower rates of dilatation.
Thus, the differences alleged to exist
between the Friedman and the Zhang
curves are likely due to the different
mathematical models used to t these
curves. This is conrmed by Zhangs
nding, noted above, that the same data
Friedman and Neff62 analyzed decades
ago yielded exponential curves with the
curve-tting methods used by Zhang
and his colleagues.14
The approach by Zhang et al is likely
to have introduced an important set of

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selection biases, which also cast doubt on

the validity of their ndings. Women
with rapidly progressing labors tend to
present themselves for obstetric care and
be rst examined at more advanced
cervical dilatation than those with longer
labor. Thus, the intervals at the distal
end of the dilatation curve are likely to
have been loaded with progressively
more rapid labors. This may explain
the exponential nature of the dilatation
curve derived in this manner. It may also
explain why the descent curve, which
was unencumbered by that problem
because all patients were present and
under observation for their entire second
stage, looks very much like that originally reported.11
In addition, the labor curves of Zhang
et al were generated after excluding
women delivered by cesarean. Many of
these were undoubtedly having slow,
dysfunctional labor patterns that led to
a diagnosis of dystocia and the need
for cesarean delivery. Their exclusion is
likely, therefore, to have falsely increased
the average rate of dilatation in residual
study cases, contributing to the exponential appearance of the curves. Zhang
et al also excluded women whose cervix
was >6 cm dilated at admission, probably thus excluding many of the most
rapid labors and contributing to the
overall appearance of slow average
dilatation.
In fact, these and other biases were
acknowledged by Zhang and his colleagues.63 They stated that the fact that
their study excluded rst-stage cesareans
limit[ed] the generalizability of the
results. They also acknowledged the
probable disparity in dilatation rates
among parturients admitted at different
time points in labor, thus raising doubts
about the comparability of data derived
from these sequential points. They
further reported that their labor curves
are unadjusted for potential confounders, such as oxytocin use. While it
is technically possible to control for
confounders.it complicates the interpretation of the results.. They also
acknowledged that .time intervals for
more advanced cervical dilation were
affected to an extent by dropout of
women because of caesarean delivery for

labor arrest. Such dropouts usually are

not random. Slow progressing labors
often dropped out early, making the
average time intervals for the remaining
women appear shorter than otherwise.
The degree of bias depends on the incidence of rst-stage caesarean delivery.
Unfortunately, we have not yet recognized an easy solution to overcome this
informed censoring.
To summarize, Zhang and colleagues
have themselves acknowledged that
both the selection biases and the unadjusted confounders likely inuenced the
shape of their dilatation curve either by
slowing the early aspects of the active
phase (or the transition from latent
to active phase) or speeding the late aspects of the active phase, or both. The
combined effect of these biases probably
explains in part their nding that the
rate of active-phase dilatation increases
exponentially, rather than linearly as
Friedman and many others have previously found.6-10,25-31,35-46
Transition to active phase
One critically important way in which
the new guidelines depart from the old
is in identifying the transition from
latent to active phase during the rst
stage. It is widely, but erroneously,
concluded from the Friedman dilatation
curve that the active phase of labor begins at 4 cm. Some studies have even
used 3 cm as the denition of entry into
active phase.64-66 According to the
guidelines, the active phase begins at
6 cm. The difference is of critical
importance, because it has a dramatic
effect on whether dysfunctional labor
can be diagnosed early in the active
phase. Important labor abnormalities
(protracted active phase and arrest of
dilatation) that would be identied by
the Friedman curve prior to 6 cm of
dilatation would be classied as normal
by the new guidelines.
Why the active phase of rst-stage labor has been inferred to begin at 4 cm is
puzzling. We, in fact, have never suggested that the active phase begins at
either 4 or 3 cm of cervical dilatation; on
the contrary, we have expressly discouraged the use of any specic degree of
dilatation for the identication of the

422 American Journal of Obstetrics & Gynecology APRIL 2015

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active phase.23 Observations of dilatation data make it clear the active phase
can begin anywhere from 3-6 cm, and,
occasionally, earlier or later, depending
on the individual labor.23,41 Using an
arbitrary cutoff sacrices accuracy for
ease, and this unnecessary oversimplication risks incorrect diagnosis.
The transition from the latent phase to
the active phase can be correctly identied only by interpretation of serial
clinical examinations for each patient as
her labor progresses.
Consider, for example, a labor that
begins with the cervix 2 cm dilated for
several hours. It then dilates rapidly to
5 cm in 1 hour, but fails to dilate further
over the next 2 hours. According to the
new guidelines, that would be normal
latent-phase labor. To us it is an arrest of
dilatation in active-phase labor that requires thorough evaluation to search
for a cause. The likelihood that it will
resolve itself (as many arrest disorders
do) or would benet from oxytocin
stimulation would depend on the clinical
circumstances, determinable by evaluation of mother and fetus. If there were
signicant molding and a narrow pelvis,
little would be gained by further labor,
and the fetus might be exposed to unnecessary risk.67,68

Diagnosis of arrest of dilatation

Under the new guidelines, neither protracted active phase nor arrest of dilatation should be diagnosed in a nullipara
before 6 cm cervical dilatation, and the
lower limit of normal active-phase dilatation is about 0.5 cm/h, rather than the
1.0 or 1.2 cm/h reported by Friedman
and others. The guidelines do recognize
that there can be slow but progressive
rst-stage dilatation (protracted active
phase), and that it should not be an
indication for cesarean delivery, but
they conate protracted active phase and
arrest of dilatation, despite evidence
that they may be distinct disorders that
respond differently to therapy and have a
different prognosis.10,23 A protracted
active phase, unless it has been caused
by factors that inhibit contractility, such
as anesthesia, infection, and (possibly)
obesity, does not respond to oxytocin
stimulation with an increased rate of

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dilatation. Contractility does, however,
increase, thus conferring risk with no
offsetting benet.69-71
Role of contractile force
To diagnose arrest of dilatation, the
guidelines require that the cervix be 6
cm dilated, the membranes be ruptured,
and there be no progress for 4 hours
with adequate contractions, or 6 hours
with inadequate contractions produced
by oxytocin. They dene adequate uterine contractility as e.g., >200 Montevideo Units (MVU), but recommend
no alternative means of assessment.
Moreover, no upper boundary of MVU
is provided, thus condoning the potential exposure of the fetus to excessive
uterine contractility. The denition also
implies that an internal uterine pressure
transducer (IUPT) is useful to diagnose
an arrest of dilatation, but this is
questionable.
The use of MVUs is problematic for
several reasons. Intrauterine catheters
carry risk, and there is not evidence for
benet. Studies have demonstrated
that the use of IUPTs had no advantage
when compared to noninvasive means
of assessing uterine contractility during
labor.72-74 In addition, IUPT readings
may depend on patient position, or on
their location within the uterus and,
most importantly, they do not correlate well with progress in cervical dilatation70,75 or with the need for cesarean
delivery.69 Normal progress in dilatation
is achieved over a broad range of uterine
activity, and the pattern of contractions
may be as important as their strength.76
The denition of arrest of dilatation
proposed by the guidelines would, for
example, allow a labor arrested at 8 cm
with strong contractions to continue
for at least 4 hours (and an additional
4 hours if the membranes were not
ruptured until after the rst 4 hours) at
that dilatation before an arrest could
be diagnosed and the recommended
4 hours of treatment begun. This
recommendation would be inadvisable
in many circumstances, because it
fails to consider any preceding labor
abnormalities, the results of clinical
cephalopelvimetry, the presence of infection, and other factors that might be

Obstetrics
contributing to the dysfunction, some
of which might not be surmountable.
Of even more concern, the recommendations in the guidelines implicitly deny
the possibility that the fetus could be
put at risk by prolonged exposure to
strong uterine contractions during an
arrest of labor.67,68,77

Treatment of arrest of dilatation

We have always taught, based on objective ndings, that arrest of dilatation
should generally be treated with oxytocin infusion unless there is compelling
clinical evidence of disproportion or
another contraindication to oxytocin
use.23 Although the duration of oxytocin
treatment should be tailored to the individual situation, a trial of about 4
hours was recommended as early as
1963.9,78 This approach was conrmed
as appropriate more recently by other
investigators.65
Several analyses of arrest of dilatation
made it clear that the disorder will
sometimes resolve spontaneously, but
that oxytocin stimulation is often
necessary, and usually effective.10,24,78
When oxytocin is used, about 90% of
labors that will respond with further
dilatation will have done so after 3-4
hours; 7 hours may be necessary before
all cases have responded. Rupture of
membranes seems to be effective in
provoking further sustained dilatation
in only a small proportion of cases.10,66
Given the risks associated with rupture
of membranes (infection, abnormal
fetal heart rate patterns, increased head
compression66,68,79) we do not recommend amniotomy as a treatment for arrest disorders, but it should be used
if there are other potential benets,
such as better quality fetal heart rate
monitoring or more effective clinical
evaluation.
The deceleration phase
During the terminal portion of the active
phase of labor (the deceleration phase),
uterine contractions remain strong,
and the patient may perceive pain of
increasing intensity. The graphic
appearance of dilatation at this time,
however, seems to slow. This results
from the cervix being retracted in a

Expert Reviews

cephalad direction (relative to the

mother) around and alongside the fetal
head. As it nears full dilatation, the cervix is no longer opening in a primarily
transverse plane relative to the mothers
pelvis. Because our examination only
measures dilatation accurately in that
plane, dilatation appears to decelerate,
even though the cervical rim is still
being retracted at about the same speed
as before. The deceleration phase is
often quite short in normal labors and
is easily missed if examinations are
not done with sufcient frequency to
identify it.
The labor patterns reported by Zhang
et al11,12 failed to show a deceleration
phase, but they did acknowledge that it
was present in cases delivered by cesarean that they had excluded from their
analysis. In other words, its absence in
their average curves was a consequence
of patient selection. They excluded the
very labors most likely to manifest prolonged deceleration. The presence of the
deceleration phase has been conrmed
by others.43,49,60,80-83 Despite the articial nature of the deceleration phase of
the dilatation curve, it reects a critically
important time in labor. Deceleration
generally marks the beginning of fetal
descent, and its prolongation portends
signicant problems for the labor.
Frequent careful examinations during
this portion of labor can yield important
prognostic insights regarding the risk
of shoulder dystocia, abnormal secondstage descent, and the likelihood of the
need for cesarean delivery.82-86

The second stage

The new guidelines dene normal limits
for the second stage by elapsed time
after full cervical dilatation, and take
no account of the rate of fetal descent.
Using only elapsed time makes it
impossible to distinguish among protracted, arrested, and failed descent, each
of which has a different prognosis for
the labor ending in a safe vaginal delivery.10 Moreover, there is evidence
that morbidity associated with a very
long second stage is largely conned to
those with abnormal descent patterns.87
If this is conrmed, the approach
recommended by the new guidelines

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will result in increased maternal and

neonatal morbidity.
The studies that purport to show that
the traditional second-stage labor data
are incorrect demonstrate a similar
pattern of descent to that described
by Friedman, but the lower limits of
normal are slower, about 0.5 cm/h for
nulliparas.11,88 The new guidelines
indicate that an arrest of labor in the
second stage can be diagnosed only after a nullipara has been pushing for at
least 3 hours and a multipara for 2 hours.
If epidural anesthesia is used, an additional hour is permissible, but then only
as long as progress is being documented.
Otherwise stated, 3 hours of maternal
bearing-down efforts with no progress in
descent are acceptable. We are concerned
that this practice may expose the fetus to
harm from excessive head compression.
A recent inuential report4 further
indicated that no progress in rotation
during these time periods also constitutes an arrest of labor in the second
stage. The proposal that lack of rotation,
independent of descent, should be used
as a diagnostic criterion is heterodox and
has not been substantiated. Rotation in
the second stage cannot occur without
descent, and a normal second stage can
occur without rotation. (For example,
an occiput posterior-positioned fetus
descending in an anthropoid pelvis may
never rotate, and yet descend at a normal
rate.) Therefore, we urge that the presence or absence of rotation not be used
for the diagnosis of descent disorders.
There is no doubt that epidural anesthesia can lengthen the second stage,
probably by inhibiting the mothers
ability to push or by relaxing pelvic oor
musculature. The degree of inhibition
may be minimal or considerable. It varies among patients, and probably depends, among many factors, on the type
and dose of analgesic and anesthetic
agents used. It is, therefore, reasonable
to consider epidural anesthesia as a cause
of or contributor to a descent disorder.
Its inhibitory effects can generally be
overcome with oxytocin; but it is wise
to remember that the presence of an
epidural block does not mean other,
potentially insurmountable, causes of
abnormal descent are absent. Ignoring

that fact and depending solely on duration of pushing risks making labors unnecessarily long and adds risk. A recent
study of the effects of epidural medication suggested that the inhibition of labor progress might be considerably
greater than has been assumed.89
Whether that observation is generalizable remains to be seen, but it underlines
the fact that using duration as the sole
indicator of second-stage progress can
lead the practitioner astray.
We have long opposed the American
tradition of limiting the second stage to 2
hours, and of encouraging intense and
sustained pushing with each contraction, which may not always be in the
best interests of fetus or mother.19,23,90
Most, but not all, studies of the effect of
second-stage length found little effect
of duration per se on early neonatal
outcome for second stages up to at least 3
hours,90-92 but there is little information
on long-term maternal or neonatal
morbidity. Maternal infection and
hemorrhage risk does tend to increase
after very long second-stage labors, due
in part to the associated high likelihood
of cesarean or operative vaginal delivery.
Unfortunately, most studies of the effect
of second-stage labor duration have not
stratied cases according to whether the
rate of descent was normal, and this may
be a relevant factor.87 The consequences
of the very long second stages advocated
in the new guidelines could be detrimental, especially when there is no
descent of the fetal head. Absent more
information about the consequences of
such labors for the maternal pelvic
oor or for the fetus exposed to enormous intracranial pressures sufcient
to impair brain blood ow,67,68,93 the
new recommendations seem, at best,
incautious.
Take as an example the case of a fetus
in an occiput posterior position and
marked cranial molding at the onset of
the second stage, and with the leading
surface of the head at the level of the
ischial spines in a funnel pelvis. The
suggestion that the mother should
remain in the second stage pushing for 3
hours before intervention, even without
any progress in descent, seems to us
to invite peril. The new guidelines also

424 American Journal of Obstetrics & Gynecology APRIL 2015

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recommend manual rotation of the fetal
head in cases of malposition to avoid
cesarean delivery. We agree that manual
rotation (which requires skill and experience to perform safely) can sometimes
be a useful tool. However, the recommendation that manual rotation be
employed without careful assessment of
the pelvis is not responsible. Do we really
want to rotate an occiput posterior
fetus to an anterior position in an anthropoid pelvis with prominent ischial
spines, narrow forepelvis, and a deep
sacral hollow? If such a fetus were to
deliver vaginally, would it not do so more
safely and easily in a posterior position,
rather than being forced to accommodate to a pelvis less well suited to its
further descent?

Implementation
It is simplistic and wrong to expect that
any labor curve abnormality will necessarily signal that cesarean delivery is
required. The clinical evaluation of labor
is essentially a process of serially estimating the likelihood of a safe vaginal
delivery.23 Graphic labor patterns are
an excellent tool for that purpose, but
they should never be used in isolation,
because many other factors contribute to
the probability of safe delivery. These
include the degree of cranial molding,
head position and attitude, and the
bony architecture of the pelvis, all of
which can be determined clinically. In
addition, the response to oxytocin, the
fetal heart rate pattern, and factors such
as fetal weight and sex, maternal body
mass, and the presence of infection are
important in this regard.
The average parturient in todays
industrialized world is older, more
obese, and more likely to have epidural
anesthesia, induced labor, and a larger
baby than in generations past. That these
factors may make dysfunctional labor
more common is valuable information
for the clinician, and should help guide
decision-making, but should not necessarily result in more cesarean deliveries
for dystocia. A labor disorder merely
tells us something about the labor
that should prompt extra scrutiny and
reasoned analysis.

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Arguably, the most important virtue
of the approach to labor we have encouraged is not in the numerical details
of the curves, but in the way they can
inform a logical and safe system of
care during labor and delivery. We
have advocated a method that allows a
systematic measure of labor progress,
provides an unequivocal language for
communication about it, and encompasses a consistent and logical guide
to decision-making.23 Furthermore, information derived from the curves
has revealed clues to the risks inherent
in certain aspects of labor and
delivery.23,62,80,82-85
In aiming to restructure our fundamental understanding of normal labor
progress, the guidelines raise a more
general question about the incorporation of new research ndings into practice. New observations are generally slow
to enter professional guidelines and even
slower to become common practice.
This restraint allows new approaches to
be conrmed by further study. Considering the conservative nature of that
process, should we uncritically accept
the recommended paradigm shift in labor management at this time, or should
we await further conrmation of its
value? We urge a cautious and considered approach. Adoption of uncorroborated new practices can have all sorts of
unanticipated consequences, including
harm to patients.

Conclusions
The stated goal of the ACOG/SMFM
Guidelines is to provide safe clinical
strategies to prevent primary cesarean
delivery. Whether the recommendations
will achieve widespread acceptance remains to be seen. Our specialty has previously attempted to curtail the rising
cesarean rate. Although success has
been achieved in some individual institutions,94,95 the rising overall rate has
not been signicantly affected by the
introduction of new guidelines. The recommendations of a national consensus
conference on cesarean delivery in 198196
were, for example, largely ineffective.
This is not surprising, given the difculty
of changing established practice in
most areas of medicine.97-99

Obstetrics
Perhaps the pursuit of a desirable cesarean delivery rate will not bring us
down the most worthy or productive
path. The current cesarean rate is
merely a symptom of a multifaceted and
poorly understood process. Treating
symptoms is rarely as satisfactory as is
modifying or eliminating their source.
If we direct our clinical and basic science
investigations to the goal of practicing
obstetrics in a manner that optimizes
maternal and newborn outcomes, the
ideal cesarean delivery rate, whatever it
may be, will follow.
The use of new databases, prospective
designs, and new statistical methods to
reassess data derived many years ago is
quite reasonable. Novel ndings deserve
our respect and invite constructive scrutiny. Our overriding concern about the
ACOG/SMFM recommendations is that
they do not offer an encompassing
paradigm for management. Friedman
provided a nosology for dysfunctional
labor, and, based on it, a system of care
that is logical, reproducible, and easily
applied. Failure to apply principles
correctly can lead to specious diagnoses
as well as untimely and inappropriate
intervention.86
To adopt sweeping new guidelines
for the assessment of labor that largely
ignore antecedent obstetric practice is
premature. One could infer from them
that cultivation of the physical diagnostic
skills necessary to become an astute
obstetrician is no longer important.
The guidelines never mention the need
for measurement of fetal station, understanding the implications of the
mechanism of labor, or any aspect
of clinical cephalopelvimetry. They encourage considerably longer labors in
rst and second stage than generally
practiced today, but they provide no
evidence that such lengths would be
safe for mother or baby. In fact, the
guidelines regarding management of
arrest disorders ignore the potential
for any maternal or fetal risk. We do not
know nearly enough about the association of long labor with chorioamnionitis, neonatal ischemic encephalopathy,
birth injury, and maternal pelvic oor
injury to abide the extended labors recommended by the guidelines.

Expert Reviews

While the goals of the ACOG/SMFM

Guidelines are admirable, their recommendations for the assessment of labor
depart substantially from accepted
norms, and no data yet exist to support
the superiority or even the equivalence
of the proposed paradigm for labor
assessment and management to that
which has served our patients well for
many decades. Absent such data, It
seems unwise to jettison 50 years of
corroborated work with what Sir Robert
Hutchison100 referred to as too much
zeal for the new and contempt for what is
old. Perhaps we should temper our
enthusiasm and seek to verify what really
constitutes best practice. The last thing
anyone wants is for a new system to do
a disservice to the women and babies
entrusted to our care.
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