"Does 4 cm dilation constitute active labor?" interview with Dr. Emanuel A. Friedman

Emanuel A. Friedman M.D., of Columbia University, introduced the labor curve, commonly known as “Friedman’s Curve ” to depict the average amount of time it took for a labor patient to dilate each cm. Published nearly 60 years ago, the curve is still followed by a majority healthcare providers to define normal labor.

In 2012, when the National Institute of Child Health and Human Development (NICHD), the Society for Maternal and Fetal Medicine (SMFM), and ACOG held a workshop aimed at “preventing the first Cesarean.” In the workshop, it was discussed that many cesarean sections are simply performed because many women are wrongly categorized as “ failure to progress” based on Friedman’s Curve.

In 2014, ACOG and SMFM issued a consensus statement “Safe Prevention of the PrimaryCesarean Delivery ” to bring down the rising cesarean section rates. The statement redefined normal and abnormal labor and stated that Friedman’s Curve should no longer be used as the basis for modern labor management (ACOG 2014).

A critical study published by Zhang et al. formed the basis of the new guidelines. The study was based on data from the Consortium on Safe Labor and looked at labor records of 62,000 women from 19 hospitals across the U.S. The researchers concluded that “ failure to progress” should be diagnosed at 6 cm and not 4 cm as stated earlier.

ACOG also reaffirmed this statement in 2017 and again in 2018 ACOG Committee Opinion No.766: Approaches to Limit Intervention During Labor and Birth.

Here is an interview with Emanuel A. Friedman about definitions of active and in active labor. He opines that “Woman describes her own labor curve, it is irrelevant to designate a particular point in labor as a demarcation between active and in active labor.”

Vaginal cleaning before cesarean delivery significantly reduces infection: A Systematic Review and Meta-analysis.

A simple and inexpensive intervention of vaginal cleaning with an antiseptic solution before cesarean delivery brings down the rate of endometritis note the results of a Systematic Review and Meta-analysis published August 4 in Journal of Obstetrics and Gynecology.

The effect was significantly more in patients in labor or with ruptured membranes at the time of the procedure.

Claudia Caissutti, MD, from the Department of Experimental Clinical and Medical Science, Clinic of Obstetrics and Gynecology, University of Udine, Italy, and colleagues searched MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library from their inception to January 2017.

They included randomized trials comparing vaginal cleaning with any antiseptic against placebo or no cleaning at all. The final data for review came from 16 RCTs, with a total of 4,837 women in whom vaginal preparation was done immediately before the start of cesarean section.

Most of the trials used povidone–iodine (n = 11) as the cleaning agent, while rest used chlorhexidine diacetate solution n = 3) , metronidazole vaginal gel prep ( n =1), and Cetrimide ( n =1) .

The observed incidence of endometritis in women who received preoperative vaginal cleansing was nearly 50% less as compared to women with placebo or no cleaning (4.5% vs 8.7%; relative risk [RR], 0.52; 95% confidence interval [CI], 0.37 - 0.72). These group also had significantly lower incidence of postoperative fever (9.4% compared with 14.9%; RR, 0.65).

No significant difference was observed in postoperative wound infection among the groups.

In a separate planned subgroup analysis, the observed difference in rates of endometritis was only seen in women who were in active labor and for patients with rupture of membranes. Four trials stratified the data according to women were in labor or not and three trials looked into women with and without ruptured membranes.

When the data was stratified according to type of cleaning agent and prophylactic antibiotics, the results were in according to the overall analysis.

Women who received prophylactic antibiotics had a 67% decrease in endometritis incidence. The authors opined, "Surgical prophylaxis with intravenous antibiotics before cesarean delivery has been clearly demonstrated as beneficial in reducing postoperative infection morbidity, Thus, it is the standard of care and these findings could translate to current practice."

The results of study have confirmed the findings of earlier Cochrane database systematic review published in 2013.

Data is needed to assess the effect of vaginal cleaning in women not in labor and without ruptured membranes.

The authors concluded that, “Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. We recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds.”