By Janelle Durham, Kim James, Tracy McPhillips, Audrey Miles Cherney, Sharon Muza, Katie Rohs, Penny Simkin and Katherine Steen (Revision by Mindy Cockeram, IBCLC, LCCE)

It has been over ten years since the American College of Obstetricians and Gynecologists (ACOG) changed the definition of the start of active labor from 4 cm to 6 cm of dilation (Caughey, 2014).  While most Educators updated their teaching curriculum to account for the change, some may still need to adapt the emotions and expectations of the previous definition of early labor.  The definition of active labor beginning at 6 cms requires different thinking about the phases of labor and how we teach parents to recognize and cope with each phase.  If we do not explore the changes from cm 4 to 6 with future parents, we are not adequately preparing them for the skills and techniques needed to avoid going in too soon.  

For most laboring parents, their experience of intense contraction pain and the need for comfort measures and emotional support starts well before 6 cm of dilation.

Katie Rohs CD(DONA), LCCE teaches a 4^th phase in early labor: "In addition to the traditional "early", "active", and "transition" phases of the first stage, I teach a 4th 'phase' of labor called 'Early Getting Into Active' which is approximately 3 or 4 to 6 cm. There are such clear emotional & physical changes that happen in this phase that I find it to be critical to teaching realistic expectations."

Janelle Durham LCCE reiterates the work needed from centimeters 4 to 6 : "The important message is that laboring parents have to do really hard work to get from 4 - 6 cm, and they shouldn't be discouraged if that phase is really challenging and it takes a while - that's normal. I think it's almost as if we're adding a fourth phase to 1st stage: early labor is the warmup - then there's the intense-but-slow-progress of "getting into active" - the intense-but-at-least-there's progress of active labor - and then transition."

Here are a few tips for teaching about the laboring woman’s needs from cm 4 to 6:

Use AV aids that realistically show what parents experience in each phase of labor.  One of the best teaching graphics may still be Penny Simkin's Road Map of Labor depicting parents' coping at all phases of labor. (Please note, the Road Map of Labor also appears on page 498 of the latest edition of Pregnancy, Childbirth and the Newborn, 2024.)

Teach parents that the ability to cope is independent of cervical dilation.  Ability to cope varies depending on numerous factors, including pain intensity, speed of labor progress, knowledge of comfort measures, understanding what is going on with the baby and cervix, having good support and patient caregivers and companions.

Teach realistic expectations about when to arrive at the birth location.  Most hospitals prefer admitting laboring parents at 4 cms dilation or beyond and parents need to understand reaching the active labor threshold for most first-time parents will take between 15 - 24 hours. The greatest areas of influence childbirth educators have is teaching parents to cope confidently with a long early labor, recognize the signs of labor progress, and understand the signs and signals of when to appropriately leave for the birth place. Many hospitals recommend that laboring parents arrive at the hospital when contractions are 3 minutes apart or if the bag of waters breaks. Additionally, hospitals may recommends discharge home if:

• Cervix 4-5 cm without change x 2 - 4 hours
• Less than 80% effacement
• Membranes intact
• Reactive NST/FHR category I (if uterine contractions present)
• Contractions less than 3 in 10 minutes

Tracy McPhillips PCD(DONA), LCCE: "The instructor is key to helping parents understand what it's like to progress from early labor into active and when it's time to leave for the birth place or call the midwives to come. Ideally, class members develop patience for how labor unfolds and appreciate the need to learn and use skills to cope with a longer early phase of labor.

Focus on teaching coping skills and comfort techniques to increase parents' ability to confidently cope with labor pain intensity, regardless of the phase of labor.  Instead of creating false expectations that the latent phase of labor will be the easiest phase of labor and last until 6 cm, childbirth educators must prepare parents to confidently cope with whatever intensity they feel whenever they feel it.

Penny Simkin – known as the  ‘Mother of the Doula Movement’ once said:

"If we don't prepare people to cope with early-to-active labor, we are not doing our job."  She further recommended that "We should go into detail about the emotional and physical challenges that come with getting into active labor, and tie them in with cervical changes and the 6 Ways to Progress, which we have already covered in class. (i.e. the contractions intensify before the cervix responds with dilation, as it continues thinning, moving forward, and ripening). The cervix tends to resist dilation until it becomes very thin. This causes an emotional struggle for the laboring person, who may feel overwhelmed and anxious, especially if they think the contractions are very intense and doing nothing”.

They struggle with "control," and may decide it's too hard and request an epidural, or they may release control ("I can't do this. It's too hard. My body will have to do it!"). (I've wondered if the well supported laboring person releases control about the same time that the cervix lets go -- just a thought!) When she does release control, she often becomes more instinctual and discovers her own spontaneous ritual.

From my experience, I've learned that when in this instinctual state, "coping" seems to consist of spontaneous behavior, which includes the "Three Rs:" 1) Relaxation between contractions (if not during contractions); 2) Rhythmic behavior (breathing, vocalizing, moving; or rhythmic mental activity, such as counting, a mantra, a song); and 3) Ritual, which is the repetition of these rhythmic behaviors for many contractions in a row. After that, labor becomes more manageable, not because the contractions are less intense, but because the laboring person has discovered how to work with the contractions. A key point is that in order to get through this challenge, the laboring person really benefits from freedom to move around to seek comfort, and "emotional safety," which I define as unconditional acceptance by others of the way they discover to cope -- sounds, movements, etc.

The laboring person shouldn't be criticized (even though the intention of the criticism to be helpful: "You're breathing too fast" "Try to stay still during your contractions or you'll exhaust yourself" "Those high-pitched sounds aren't doing any good. Try to lower your pitch." This translates to the laboring person as, "I'm doing it wrong. They disapprove." The laboring person is likely to remember, "I was awful in labor. I did it all wrong," rather than, "I found a way to cope!" We should teach that these 3 Rs (Relaxation, Rhythm, and Ritual) indicate that the laboring person is coping, and teach the partners to match the laboring person's rhythm in some way (head or hand movements; stroking the laboring person's arm or back, vocalizing with them, etc.)"

‘PAIN’ and The Other 3 R’s

In addition to Penny Simkin's 3 R's, Audrey Miles Cherney, Great Starts Program Manager and Childbirth Educator, talks about "labor P.A.I.N." and really emphasizes the need to relax during the contractions, releasing any muscles not needed to support oneself during a labor contraction, as well as the "other 3 R's" that are important during the "resting time" between contractions.

Audrey explains, "As many educators do, I teach families about the acronym for labor P.A.I.N. as a way to transform a word with which we otherwise have negative associations. "Pain" is a word that is often assumed as meaning "suffering" or that something is wrong that has to be put right and healed, but there are many ways to experience pain and the sensations of labor without suffering and to work with it, instead of fighting or resisting it. When I explain the acronym, I talk specifically about how labor is "Powerful" as well as "Purposeful". It is the laboring person's inner power and strength at work signaling what we need and when we need it when birthing the baby. In one such way, it is a signal to be in their "safe place" and to be surrounded by the people who make them feel safe, if not also loved and respected, and help them be comfortable during this process. Early on, their safe place may be in their neighborhood going for a stroll, then a little later at home actively coping with partner and/or doula. And then even later still, either at the hospital with their medical team, or at the birth center or at home with their midwife. And while we can "Anticipate" what will work for coping, such as with Penny Simkin's "3 R's", we can also anticipate that the strong sensations of labor are "Intermittent"--that there will be a peak with each powerful surge and then it subsides and allows time for the "other 3 R's" to happen: Rest, Rehydration/Refuel, and Reconnect as a couple (or Regroup as a team, and ask questions, or Re-strategize if something is not working).

These elements between contractions work in compliment to what is happening during contractions since the resting time is at least as important to the support happening during the contractions when it comes to maintaining one's ability to reasonably cope and achieve better outcomes overall. And, of course, barring any medical complications, the sensations of pure labor are "Normal." Our bodies are designed to give birth, just as it is designed to breathe and digest food. We certainly do not give birth every day, but it is still a normal physiological process we are designed to do. According to WHO estimates, every second there are 4-5 babies born, so literally, there are hundreds of people worldwide giving birth to babies any given minute. As has been noted by many others before, the human race would not have survived this long, or been so successful breeding if our ability to birth was inherently flawed."

Building parents' confidence in their ability to cope takes time. There is no way around it: Mastering self-comfort coping skills is reached through repetition and practice. Educators should aim for 35% - 50% of their class time teaching and practicing physical and emotional/mental coping skills for labor and self-advocacy skills for shared medical decision-making.

Conclusion

The new guidelines, "6 is the New 4" will lower cesarean rates for failure to progress, but they require laboring persons to be able to endure longer labors, and potentially more emotional distress if they have not found ways to cope. Even those with an epidural find the longer duration of labor until they are eligible to receive and epidural to be stressful. Labor is as much an emotional experience as a physical one for the laboring person and their team. Our job as childbirth educators is to present them with accurate information, help them develop realistic expectations and practice the skills they will need to cope successfully with this challenge.

References

Caughey, A. B., Cahill, A. G., Guise, J. M., Rouse, D. J., & American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.

Simpkin P, Whalley J, Keppler A, Durham J & Bolding A. (2024). Pregnancy, Childbirth and the Newborn: The Complete Guide.

Wagner, C., Zabari, M., Handel, S., & Director, I. C. (2015). Best Practice Recommendations for Labor and Delivery Care.

Originally Published 06/14/2016
Revised 06/17/2027

Published: June 17, 2026

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