Active Labor’s Move from 4 to 6: Benefits & Signposts

Doulas are unique, talented and knowledgeable; holding space for families and walking with them as they meet their babies. What an incredible honor! Doulas also have the opportunity to be the perfect guide as providers begin to adjust to the new recommendations from ACOG. But just how do we get there?

The American College of Obstetricians and Gynecologists, in their Committee Opinion Number 687 from February 2017 suggests that when women are admitted to the hospital in the active phase of labor, now defined as 6 cm, “women had lower rates of epidural use and augmentation of labor, had greater satisfaction, and spent less time in the labor and delivery unit.”

Such great, welcome news! Yet also a challenge – how can a family and their doula know when they have slid past 4 cm, hung out at 5 for a bit, and are now headed to 6, thus optimizing the chance of a fewer interventions once they are at the hospital?

Bridging is the term I use in my practice and draw from the work of Dr. Sarah Buckley and Childbirth Connection in the free download Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. (If you haven’t read this work, please grab it!)

When meeting clients for the first time, we cover the chemical changes that occur in babies and mothers to initiate labor, and then how to optimize each phase. When should the doula join them? We often use 4-1-1 (contractions 4 minutes apart, lasting 60 seconds, for an hour) as a guide, and clarify that those are just numbers, not by any means a set rule, and may be incredibly different for each family. Yet often this is around the time in which women are powerfully working, and the support and tools of a doula can create calm and confidence to help families stay home a bit longer.

Where does a bridge come into the conversation? By drawing a big hill on a white board, we imagine a train working to leave the station. It takes so much energy to start the train wheels turning, and then moving forward powerfully. Yet the train has to make it up and over a mountain, and just on the other side of the peak (6 cm) the train can easily go downhill and return to a lovely plateau….and meet the baby! As the train is going up the hill, not yet at the peak, is where the early-active labor begins, and doula support is helpful to “bridge” the 4-6 cm intensity of labor.

Doulas supporting families at home to help the “train” of labor, which is carrying oxytocin, beta-endorphins, and epinephrine-norepinephrine in the perfect combinations, get up and over that mountain, cross the bridge, and get just to the other side of the peak. Were we laboring at the hospital already, the providers would likely find the cervix to be going from 3-4 cm to 5, and then 6 cm.

However, the process of getting in the car, driving to the hospital, and then triage, intake, moving to labor and delivery—all of this—can increase the epinephrine-norepinephrine levels and other stress hormones creating a pause in contractions.

What researchers are finding is that if women are admitted closer to 6 cm, the amazing, intricate, perfect balance of hormones are less impacted by the process itself, and birth continues safely.

Great! Yet, how do we know we’re there? What are the signposts to help families optimize their time to go to the hospital?

Women have an internal knowing that we always respect and honor. If she feels going to the hospital is near, then we support and follow. We also have her provider as a resource. Solution focused conversation, sharing her goals, and gathering information from the provider can be an excellent tool.

Some of the “soft signs” that doulas know all so well are some of our best tools in this moment.

  • Bloody show (may not be present in some labors at all)
  • Nausea
  • Vomiting
  • Shaking
  • Hot/Cold shifts
  • Contractions that are more likely to be 3-1-2 (3 minutes apart, lasting 60+ seconds, for 2 hours)
  • Perhaps the purple line? (In this study from BMC, 76% of women had a purple line, which did correlate with dilation.) (Source)

I live in Chicago, and 312 is the primary area code here, so our clients have an easy time relating to this concept.

Are there times in which families should consider going earlier?

  • A sense of pressure
  • Water releasing with color / odor / GBS +
  • Frequent bloody show
  • Frequent vomiting
  • Mother’s intuition

Our CAPPA Doula Training and experiences have shown us these general patterns, and birth is often a variation on a theme (from which we learn something new each and every time). Perhaps the idea of bridging is a tool you can share with your clients and help illustrate the importance of having a doula.


  1. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Dr. Sarah Buckley 2015
  2. The purple line as a measure of labour progress: a longitudinal study BMC Pregnancy Childbirth. 2010; 10: 54.
  3. Oxytocin: The Biological Guide to Motherhood, Kerstin Uvnas-Moberg, 2014
  4. Safe Prevention of the Primary Cesarean Delivery, ACOG Obstetric Care Consensus Number 1, March 2014, reaffirmed 2016

Heather McCullough


Heather McCullough, CPM is a midwife, Certified Labor Doula (CAPPA), Certified Postpartum Doula (CAPPA), Certified Lactation Educator (CAPPA), Certified Hypnobabies Instructor, Birthing From Within Mentor, as well as an Evidence Based Birth® Instructor and Professional Member. Heather is also a student of Acupuncture and Traditional Chinese Medicine, and certified in Acupressure for Pregnancy, Birth and Postpartum. As an educator and midwife for nearly 25 years, she regularly presents to both expecting parents and professionals on current childbirth research. A passionate, experienced, and innovative birth provider and doula for over 1,000 families, Heather began this work when she was 19. Initially going to pre-med to become an OB-Gyn, she was re-directed to Midwifery and became a Certified Professional Midwife. Heather practiced midwifery in Portland, Oregon serving at home births and birth center births. After moving back to the midwest, Heather settled in Chicago, Illinois. As of this writing, Illinois does not offer a license for CPMs. She therefore works as a Doula, Monitrice, and Childbirth Educator. As owner of 312Doulas & HMBirth, she has a thriving labor support business Chicagoland, while teaching classes and in-services for families, doulas, midwives, nurses and educators.

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