Preventing primary cesareans: implications for laboring women, their partners, nurses, educators, and doulas.

New evidence-based guidelines for Safe Prevention of the Primary Cesarean Delivery call for extensive modifications of many long-standing obstetric practices that have collectively contributed to large increases in cesarean rates and worsening outcomes (1). The document also calls for the resurrection of some skills and beneficial practices (such as external cephalic version and manual rotation of the fetal head) that have largely fallen out of favor. The most dramatic and revolutionary change, however, is the revision of long-held norms of labor progress that have guided obstetric management for many decades. The conclusion of recent extensive studies (2) of labor progress of tens of thousands of women who had normal healthy outcomes might be summed up in this catchy slogan: “6 is the new 4” (or “six centimeters is the new four centimeters”) (3). In other words, the threshold for the active phase, which until now had been defined as 4 centimeters may be as late as 6 centimeters (as it normally can require up to 6 hours to progress from 4 to 6 centimeters). Labor management should include a greater tolerance of longer labors and avoidance of a cesarean delivery for arrest of labor until there has been no cervical change for several hours, even with augmentation. The guidelines also recommend allowing nulliparas to push for 3 hours, and multiparas for 2 hours (plus another hour if an epidural is in place) before diagnosing second stage arrest. Many other “sacred cows” of obstetrics are challenged in this document, including current approaches to management of elective induction of labor, abnormal or indeterminate fetal heart rate tracings, fetal malpresentation and malposition, multiple gestation, suspected fetal macrosomia, and others (1). Such sweeping reforms will likely encounter resistance or may create a backlash among some clinicians. In a field where time limits and fear of litigation too often rule, all the players, including physicians, hospital administrators, nursing staff, third party payers, and risk managers, will have to make adjustments. As exciting and promising as these recommendations are, implementation will not only require buy-in from providers, but also from the childbearing public. Expectant parents will need quality education and support to address their fears and enhance their willingness to embrace longer labors. Ironically, as obstetricians steadily increased their use of cesarean delivery over the past two generations, women at first resisted (4, 5). They had to be convinced that this surgery was beneficial and safe. In an effort to reassure or convince women that a cesarean made sense, obstetric care providers emphasized the risks associated with labor and vaginal birth to both baby and mother. This emphasis is sometimes cynically referred to as “playing the dead baby card.” Even when those risks were not supported by scientific evidence or best practice models, the suggestions of harm were very powerful, especially when coming from the expert. But now all that is changing! Updated “best practice” models call for a reversal of management to include practices that were previously thought to be dangerous. Clinicians and expectant parents must now be persuaded that widespread use of cesareans or measures to speed early labor are no longer believed to be