As a midwife, the labour plateau is a phenomenon with which I am very familiar. I have attended mostly physiological births, and it is common to see labour slowing, pausing or even stalling. 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.
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 latent phases, 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: 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.
Labour plateaus in life and literature
But these are concepts that get discussed frequently in midwifery study days, workshops and online courses, and not so much in the literature. The authors of a recent scoping review suggest a reason for this. They think it may be 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.
Researching the labour plateau
Weckend et al (2021) set out to, “provide a point of orientation, mapping contemporary concepts, and terminologies of physiological plateaus during normal labor and birth.”
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 has been 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.
Why we need to pay more attention to labour plateaus
As the authors explain, 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 the paper discusses.
“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 am so reassured that people like Elizabeth Davis are talking and writing about this:
“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).
I also think we can take some comfort from studies like the one by Weckend et al (2022). 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.
Weckend, M, Davison, C, Bayes, S (2022). Physiological plateaus during normal labor and birth: A scoping review of contemporary concepts and definitions. Birth. 2022; 00: 1– 19. doi:10.1111/birt.12607
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