When a pregnant woman is admitted to the hospital before active labor starts (6cm is the benchmark for active labor as established by the American College of Obstetricians and Gynecologists in 2014), her risk of having a C-section goes up [1][2][3]. This is a result of multiple factors, among them a slowdown of the hormones that drive labor forward, due to being in an unfamiliar, not-homelike environment.
When her labor slows while she’s at the hospital, she is more likely to be put on an artificially time-crunched conveyor belt of sorts, offered multiple interventions to speed things up as opposed to respecting, allowing, and facilitating her body’s timing and need for warmth, security, and support [4]. But, as a 2017 committee opinion of the American College of Obstetricians and Gynecologists acknowledges, “Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor” [5]. The end result can be a medically unnecessary C-section, with its attendant risks.
Unfortunately, once a woman has had one C-section, she may be encouraged to have another if she conceives again. Not all medical practitioners are on board with and comfortable in recommending vaginal birth after Cesarean (VBAC). What’s more, the risk of rare but serious complications such as uterine rupture naturally ticks up with each additional C-section, potentially limiting a family’s size out of an abundance of caution for the mother’s health.
But what if an early labor lounge (ELL) could disrupt the cascade of interventions and change a family’s whole future, by keeping the mother off the conveyor belt in the first place? What if broader incorporation of ELLs could help bring the U.S. C-section rate of 33% of births in line with the World Health Organization’s target of 10-15% of births?
But what if an early labor lounge (ELL) could disrupt the cascade of interventions and change a family’s whole future, by keeping the mother off the conveyor belt in the first place?
Who can use an early labor lounge?
The existing research on early labor lounges centers on a community hospital in Massachusetts that welcomes 3,500 babies per year, and 25% of births are attended by midwives. According to the hospital’s website, ELLs may be particularly important for first-time moms, who are more likely to have longer early labor than moms who have had at least one child. Any low-risk laboring woman who is not yet in active labor (6cm dilated or beyond) and is not receiving IV pain medication or anesthesia (since these would require hospital admission for fetal monitoring) could be a candidate.
The Massachusetts hospital’s website even mentions the possibility of early labor lounge use for low-risk laboring women who are being induced, though presumably this would reference non-medication induction, since any woman receiving Pitocin would need to have fetal monitoring.
What’s in an early labor lounge?
The core concept of an early labor lounge is having a physical place where pregnant women in the early stages of labor can be close to the Labor & Delivery unit (in case something changes quickly), but not formally admitted. The goal is to remove any pressure to progress at a certain pace. What this looks like in practicality can vary.
The core concept of an early labor lounge is having a physical place where pregnant women in the early stages of labor can be close to the Labor & Delivery unit (in case something changes quickly), but not formally admitted. The goal is to remove any pressure to progress at a certain pace.
The website for the Massachusetts hospital mentioned above lays out the details of what an ELL could look like. “It is a home-like, relaxing space with low-lighting, soothing music, yoga mats, birthing balls, comfortable chairs and rebozos. Additionally, there are heating packs, tennis balls and rolling pins for massage and tools for acupressure.” Many Natural Womanhood readers who have worked with a doula will recognize the value of these different tools and tweaks to the environment. Early labor lounges offer these benefits to laboring women with or without a doula (though a doula would still arguably be helpful to emotionally and/or physically coach a mother and her support person on their use) [6].
This 2019 research article about the Massachusetts hospital (and a study of the clinicians who staffed and encouraged women to use it) had a main lounge area and then several “walking stations” throughout the hospital. The 20 by 12 foot lounge area has yoga mats, hot packs, a shower, acupressure, and a “well-stocked nutrition area,” along with instructions for each tool or area [7]. We’ve touched before on the value of eating and drinking during labor (especially early labor, which may last hours or more than a day), though many hospitals retain outdated policies or order sets (orders automatically placed when a laboring woman is admitted to the hospital) about not eating or only consuming “clear liquids” during labor.
This 2017 poster presentation about the same community hospital mentioned in the 2019 study additionally references being “designed for activities that promote labor progress, including yoga, birthing balls, meditation, and rebozos.”
Kaiser Permanente healthcare system in California, whose locations welcome 40,000 babies each year, has instituted a ‘guided walking and movement tour,’ through their halls for women who are in early labor or women in any stage of labor who are trying to get baby into optimal position. The walk prompts women to move through various positions, including lunges, squats, hip circles, and more.
What are the benefits of an early labor lounge?
2021 research found that low-risk women without an epidural were less likely to end up with a C-section if they were in upright positions during early labor (think walking, movement, position changes). Early labor lounges support these very things [8]. Preliminary data, like this small 2021 trial, suggests that, when paired with other initiatives, early labor lounges can help prevent early labor admissions and ensure that evidence-based guidelines are being followed [9]. In the 2019 community hospital study, 67 women utilized the early labor lounge, and just 7% went on to have Cesarean sections [2].
Importantly, ELLs normalize the possibility that a woman ends up going home and returning another time. One nurse interviewed about the community hospital ELL observed, “I think the midwives have helped support the decision that it’s okay to go home after using the lounge. These were the words of one of the midwives the other day. ‘You might end up driving home and pulling in your driveway and deciding you have to turn around and come back. That’s okay. At this point we could say, after two exams, two hours apart, that you are not in active labor.’”
Why doesn’t every hospital have an early labor lounge?
There are multiple potential roadblocks for hospitals considering implementing an early labor lounge. Among them are the establishment of protocols on when to refer laboring women to an ELL, and the education of all staff and referring practitioners (think midwives and OB/GYN practices who have privileges at the hospital) on how to refer.
There are also questions about how to bill for ELL use when women have not yet been admitted to the hospital, ensuring that adequate staff are available (even as maternity care deserts are on the rise across the country and many hospitals are dealing with critical nurse shortages), and concerns that ELLs will be underutilized [10]. Similar to billing questions, there are unknowns around who assumes liability in case “something should happen” during the time a woman is using an ELL.
Can’t women do ELL activities at home?
But the core question is whether women couldn’t just do most of the same things at home? For that, the answer is “it depends.” A woman who has adequate physical and emotional support, especially if she has had children before and/or has the help of a doula, could very probably labor at home until she is in active labor.
However, early labor lounges promote evidence-based best practices that are, at least theoretically, available to every low-risk woman, whether or not she has the financial means or access to a doula. What’s more, the presence of an early labor lounge within a hospital’s campus says something important about their commitment to driving down C-section rates, which is universally a good sign.
Certainly, more research is needed to demonstrate on paper just how effective ELLs are in reducing early labor admissions and secondarily in reducing C-sections. Even if a woman plans to labor at home as long as possible, the existence of an ELL in her local area may help guide her decision on which hospital will be most likely to facilitate a vaginal birth.
Besides early labor lounges, how else can we drive down C-section rates?
Fortunately, even if a local hospital doesn’t have an ELL, there are other options to help prevent unnecessary C-sections. Doulas are proven to improve vaginal birth rates, as is a midwifery model of care. Ensuring that only medically necessary inductions are done is another way to help prevent down-the-line interventions that could lead to C-sections. Birth centers can be another great option for low-risk mothers. An increasing number of women are also choosing homebirth.
At the end of the day, the vast majority of women continue to give birth in a hospital setting. When it comes to ensuring the broadest possible access to care that facilitates vaginal births, ELLs appear to be a step in the right direction.
