A labour plateau is a phrase used to describe a pause or slowdown in labour.
The labour plateau is a phenomenon with which I am very familiar. As a midwife, I attended mostly physiological births, where it is common to see labour slowing, or pausing for a while.
There are – to put it in simple terms – times when such changes seem to be a positive physiological response to a woman’s or baby’s need for a bit more time, rest or nourishment. And that’s what midwives mean when they talk about a labour plateau. It’s a temporary stop in the labour, to rest, regroup, sleep, breathe, or perhaps take some nourishment.
A labour plateau might look like the woman having an hour’s break from contractions as she dozes in her lover’s arms in the birth pool. I’ve also seen labour slow while a family eat a long-awaited meal.
I’ve experienced many labour pauses, as a baby takes her time to navigate the birth canal. Sometimes a midwife will have detected that the baby isn’t in an optimal position or, after the birth, will spot that the cord was short. Such signs are often pondered over among colleagues. Is that why they needed things to slow? Was that the reason for a labour plateau?
And as a midwife who has also seen women transfer to hospital, or choose hospital birth, I’ve seen situations where labour stalls almost as soon as the woman arrives on a labour ward. Her cervix may even regress or, as some people prefer, recoil. The latter term is felt by some to more accurately describe a bodily response to feeling unsafe. I’ve written more on that here, and also in In Your Own Time.
So-called ‘failure to progress’
But anyone who has been involved with birth for any length of time will be aware that labour plateaus are not recognised as a physiological and potentially helpful phenomenon within the dominant, medical approach to birth. Instead, so-called ‘failure to progress’ is one of the most common reasons for recommending intervention.
More often than not, humanistic birth practitioners will have a sense that, actually, the real failure is in a system that doesn’t allow for individual variation in how we labour and birth.
Worse, failure to progress is often defined (or at least interpreted) in an arbitrary manner. But it is also the case, as I have been writing about for several years now, that we are ignoring evidence showing that it can be totally normal and physiological for labour to slow, stall, and vary in speed.
For physiological labour plateaus to be a very real and potentially helpful phenomenon.
Midwifery conversation and experience
I want to acknowledge that I heard physiological labour plateaus being discussed by midwives long before they appeared in the literature. And I know from older colleagues that they were being discussed long before my direct experience of these conversations.
Some of my earliest midwifery mentors would mention phrases which I later realised were their way of interpreting plateaus in labour. Many people will have heard the transition between what the medical model defines as the first and second stages of labour described as the ‘rest and be thankful’ phase. You may or may not have heard of phrases such as ‘physiological rest,’ ‘safety labour,’ or ‘normal resting phase,’ but I have heard all of these and more from the midwives who taught me, and with whom I worked in the early years of my midwifery career.
The first open conversation that I recall hearing on this topic was led by Elizabeth Davis. Many years later, she wrote about this phenomenon (Davis 2018), but she had been talking about this for at least two decades by then. She sees plateaus as a normal phenomenon not only in labour and birth, but in other areas of women’s lives, including sexuality, and she uses this example to explain how unacceptance of the normalcy of this physiological phenomenon can actually cause prolonged stalling.
“I suggest we reframe plateaus as being both physically and psychologically purposeful, rather than worrisome or in need of a remedy. Returning to the subject of plateaus during sexual activity, I’ve spoken to many women who said they felt judged or pushed by partners who did not understand what they were doing in these integrative moments; in fact I once had a partner who said outright (and in the middle of the act), “You’re not progressing!” Needless to say, that stopped the action – just as it does in labour, when women are pushed with repeated exams and threats of interventions unless they dilate according to the Friedman Curve.” (Davis 2018).
Labour plateaus in life and literature
For years, the concept of plateaus being a normal aspect of birth were discussed frequently in midwifery study days, workshops and online courses, but not so much in the literature.
One team of researchers suggested that this was because, “heterogeneous conceptualizations and terminology have impeded effective communication and research in this area, raising concern as to whether some physiological plateaus might be misinterpreted as dystocia.” (Weckend et al 2021).
In other words, we don’t have really clear language to discuss this. It’s also hard to discuss it in situations where the prevailing viewpoint is a biomedical one. The medical perspective tends to demand that things are defined, plotted and made tangible. In a world focused on the physical, it’s far easier to describe linear progress, distance, rate or speed than it is to discuss the curves, spaces, pauses and ‘in between’ that are just as important a part of any journey.
But discussion in the literature did occur. The earliest paper on this topic that I know of was published in 1998, when Betty-Ann Daviss and Ken Johnson analysed data from MANA midwives and found evidence of cervical regression and plateaus in physiological labour and birth. Their data showed that, in some cases, labour could pause up to four times and still result in the physiological birth of a healthy baby to a healthy mother with no adverse consequences. (This isn’t to say that labour stopping is always normal; just that it can be. More on that in a bit.)
Researching the labour plateau
In more recent times, a team of researchers have published two useful papers on this topic.
In the first, they set out to, “provide a point of orientation, mapping contemporary concepts, and terminologies of physiological plateaus during normal labor and birth.” (Weckend et al 2021).
They did this by searching the literature and one very important aspect of the method they used is that they didn’t stop at formal literature. They also searched the so-called grey literature, which includes papers, articles, blog posts and other pieces of writing that might not normally be discoverable by a formal search of published literature.
The authors discovered 43 reports from eleven countries, and not that I think there’s a conflict of interest here, but I will add for the sake of transparency that some of my work was used in this review.
What did they find?
The results are fascinating:
“Conceptualizations of physiological plateaus are heterogeneous and can be allocated to six conceptual groups: cervical reversal or recoil, plateaus, lulls during transition, “rest and be thankful” stage, deceleration phase, and latent phases. Across included material, we identified over 60 different terms referring to physiological plateaus. Overall, physiological plateaus are reported across the entire continuum of normal labor and birth.” (Weckend et al 2021).
This really resonated with me, and not just because the findings included an article of mine or are consistent with my own experience of attending physiological labours and births. What I find even more pertinent is that, as someone who has led tens of workshops on the topic of labour progress around the world, I can say that the findings are consistent with the topics and themes that get discussed when I’ve invited many other midwives and birth workers to share their experiences. I found it fascinating to read the paper in full and to see what we know on this topic brought together in one paper.
In their second paper, Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth, Weckend et al (2023) interviewed 20 Australian midwives in order to further our knowledge in this area.
As the researchers explain, “This article illustrates the difference between failure to progress and physiological plateaus, explaining why slowing, stalling and pausing labour patterns are interpreted differently, and which impact this can have on labour trajectories and birth outcomes.” (Weckend et al 2023).
The researchers show how people who take different perspectives towards birth will assess, interpret and respond differently in the same situation. If you have read my work, or that of many others, you will already be aware of these perspectives, and how proponents of a very medicalised approach to birth are likely to interpret things in a way that contrasts starkly with how someone with a holistic midwifery mindset might interpret them. Weckend et al (2023) show how that happens in relation to plateaus in labour, and also details how holistic midwives analyse possible causes of plateaus. But the midwives they interviewed also discuss red flags, and some things that they see as possible warning signs. I was particularly fascinated by this part, because I saw a similar progression of discussion in my research asking holistic midwives about post-term pregnancy.
The existence of different approaches inevitably leads to tensions, especially as the medical paradigm is currently the dominant one, and the paper also discusses this, and many other aspects of this area.
Why we need to pay more attention to labour plateaus
There is an important need for this sort of work, and more like it.
“Physiological plateaus are reported across the entire continuum of healthy labor and birth and may reflect a healthy mechanism of self-regulation of the mother-infant dyad. Although the notion of physiological plateaus contradicts a prevalent paradigm of continuous and linear labor progress, existing evidence is compelling and warrants further investigation. Of particular concern is a risk that some physiological plateaus may be misinterpreted as dystocia. Research on physiological labor patterns, including plateaus, is a matter of some urgency as it is a necessary precursor to efforts aimed at reducing unnecessary and harmful interventions.” (Weckend et al 2021).
I couldn’t agree more. Labour and birth is not a race, nor a time trial. I’ve never seen any evidence showing that faster is optimal. In fact, too fast a labour can lead to problems, just as too slow a labour can. That may be the very reason why there are physiological mechanisms to adjust things, which these papers discuss.
“The bit in the middle”
The medical, obstetric viewpoint does of course recognise the crude concepts of “too fast” and “too slow”. It’s the huge, varied and complex bit in the middle that the medical viewpoint seems to have trouble incorporating in the assumptions, charts and guidelines that are being used to dictate when intervention is offered. The timespan of labour, as this latest research continues to attest, is individual, non-linear and essentially unpredictable. The discomfort that some people have with these notions, however, should not mean that a particular labour pattern is deemed pathological just because it doesn’t fit a curve that wasn’t evidence-based in the first place and that doesn’t account for individuality.
I also think we can take some comfort from the studies that I have discussed here. Because, while it its true that women, families, midwives, and birth workers are facing dreadful situations right now, it’s also clear that there is still an undercurrent of people working towards finding better ways of thinking about and understanding labour, birth and the female body. Long may this kind of research continue.
Daviss BA and Johnson K (1998) Statistics and Research Committee [statistics on cervical ripening] MANA Newsletter, 16(2): 16-17.
Weckend, M, Davison, C, Bayes, S (2021). Physiological plateaus during normal labor and birth: A scoping review of contemporary concepts and definitions. Birth. 2021 00: 1– 19. doi:10.1111/birt.12607
Weckend M, McCullough K, Duffield C et al (2023). Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth. Women and Birth https://doi.org/10.1016/j.wombi.2023.10.003
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