The media recently reported on the complications tennis champion Serena Williams faced after the birth of her daughter. Williams has a history of blood clots, but was not taking her anti-coagulant due to her C-section. She began to experience shortness of breath and immediately assumed—given her medical history and her medications—that she was having a pulmonary embolism. She brought her concerns to a nurse who assumed that the new mother was having an adverse reaction to her pain killers. Williams insisted on a CT scan and blood thinners, but it took persistent advocacy to get the care that she needed.* Since Williams has shared this story, a multitude of other women have come forward to share similar stories of precarious birthing and post-birth experiences. These experiences highlight the awareness of a deficit in the care that women receive during and after labor and delivery and, if taken seriously, may permit a path forward to more nuanced care.
(*Nowhere does it say that her medical team outright refused to care for Williams. It appears that there was a course of action that her doctors needed to take before administering the CT scan and IV, but the reports stress that Williams’ understanding of her own medical needs were not immediately acknowledged.)
Labor and delivery practices have largely been guided by the research of Dr. Emanuel Friedman. One of the most influential results of his work came from the graphical analysis of labor progression in the 1950s which generated the “Friedman curve,” an S-shaped curve that tracks cervical dilation to the duration of labor. The parameters set by the Friedman curve maintain that a woman’s cervix will dilate by a minimum of 1 cm/hr as labor progresses. The problem with this expectation is that Friedman’s work was limited to women in the United States, and rests on the assumption that the experience of labor progression is consistent for all woman. It does not take into account unique individual factors such as age, number of children, weight, fetal weight, etc. A paper published in PLOS Medicine reports that for many Nigerian and Ugandan women labor progression for vaginal births is actually slower than expected when these factors are considered. It is a recent addition of a previously unstudied group to the growing body of research that assesses labor experiences of women within the context of nationality and culture, and well, themselves.
Reliance on the Friedman curve may mean that labor progression is incorrectly assessed and that labor interventions are undertaken prematurely, this includes administering pitocin, and rupturing or sweeping membranes. In other words, just because a woman isn’t dilating at 1 cm/hr doesn't necessarily mean that her labor isn’t progressing normally for her. In the women observed, cervical dilation occurred at less than 1 cm/hr through much of early labor (up to 5 cm of cervical dilation) regardless of whether they were experiencing labor for the first time or had multiple vaginal births. While there were some cross-cultural parallels in labor progression for first time mothers, the labor curves that resulted from this work were overall significantly different from the Friedman curve.
Generally, the average time needed for cervical dilation to advance by 1 cm was more than 1 hour until 5 cm was achieved for women in this population for whom this was their first labor and for women who had experienced labor previously, and labor progression became more rapid from 7 cm. In fact, labor was so slowed that for some first time mothers, it took more than 7 hours to advance from 4 to 5 cm and over 3 hours to advance from 5 to 6 cm.
Despite the break from the Friedman curve, the authors maintain that the standard curve they shared did not reflect the individual variations in labor that the women they observed experienced. Thus, they caution, the rate of labor progression should not by itself be the determining factor in whether labor interventions are undertaken. Healthcare continues to be a hotly contested point of discussion in the United States with the experience of healthcare itself being a central point. The research presented here does beg the question of what the overall norms may be within Nigerian and Ugandan hospitals regarding labor time and who guides this understanding. This mounting body of evidence may ultimately help women advocate for changes in the way American hospitals in particular view and treat them during labor. It may not happen overnight, but perhaps we can move out of the 1950s into present day.
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Oladapo OT, Souza JP, Fawole B, Mugerwa K, Perdoná G, Alves D, et al. (2018) Progression of the first stage of spontaneous labour: A prospective cohort study in two sub-Saharan African countries. PLoS Med 15(1): e1002492. https://doi.org/10.1371/journal.pmed.1002492
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