Proactive Support of Labor

2nd edition out now

2nd edition cover 

Striking a new balance between natural birth and intervention, and invariably enhancing women's satisfaction with the childbirth experience, the fully updated revision of this groundbreaking work will be essential reading for obstetricians, midwives, gynecologists and the like.

Paul Reuwer

Paul Reuwer

Consultant Obstetrician-Gynecologist

Dr. PJHM Reuwer MD, PhD
Former Director of the residency program in obstetrics and gynecology and Master of the Labor and delivery Unit at St. Elisabeth Hospital, Tilburg, the Netherlands. Initiator of the integrated midwifery-obstetrical birth-center “Livive”

Hein Bruijnse

Hein Bruijnse

Professor Emeritus of Obstetrics at the University Medical Center Utrecht, the Netherlands.

Dr. HW Bruinse MD, PhD
Initiator and former Chairman of the Guideline Committee of the Dutch Society of Obstetrics & Gynecology. Former Chairman of the Dutch National Perinatal Audit Foundation.


Arie Franx

Arie Franx

Professor of Obstetrics and Chair of Division Woman & Baby, University Medical Center Utrecht, the Netherlands.

Dr. A Franx MD, PhD
Director of the specialty training program in Obstetrics & Gynecology in a collaboration of seven teaching hospitals.


The right for every woman to have a 'natural' birth has been recognized for many years, yet surgical interventions continue to rise and, paradoxically, complaints and the degree of litigation for disappointing labor outcomes escalate.

Proactive Support of Labor enhances professional skills by providing the expertise for preventing long labors - the root-cause of traumatic birth experiences and the cesarean pandemic. Step-by-step, evidence-based guidance on expert care and support during labor is given. Emphasis is placed on pre-labor education, personal attention, and well-defined birth planning – including strict diagnoses and timely corrective measures in abnormal labor – and constant audit of all procedures and outcomes. Striking a new balance between natural birth and intervention, and invariably enhancing women's satisfaction with the childbirth experience, the fully updated revision of this groundbreaking work will be essential reading for obstetricians, midwives, nurses, and trainees.

Check the rest of the book at Google Books »

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The book has been released in the USA in 2010.

Cited in:

  • Gross MM, Petersen A, Hille U, Hillemanns P.
    Association between women's self-diagnosis of labor and labor duration after admission. J Perinat Med. 2010;38(1):33-8. doi: 10.1515/JPM.2010.005.
  • Jukelevics N. Understanding the Dangers of Cesarean Birth: Making informed decisions.
    2009, Praeger Publishers.
  • Manders K, Wentink-Lander D, Roumen F. Van thuisbevalling naar ziekenhuis. Medisch Contact 2009;64:1674-75
  • Gaudernack L.C. Langsom framgang hos førstegangsfødende - fødselshjelpens største utfordring? Har vi noe å lære? Den norske jordmorforening. 
  • Stuurgroep Zwangerschap en Geboorte. "Een goed begin". Advies van de stuurgroep aan de minister. januari 2010
  • Guideline ïndication for Cesarean delivery of the Dutch Society of Obstetrics and Gynecology, 2010. In Dutch: NVOG Richtlijn Indicatiestelling Sectio Caesarea. 2010
  • Reitsma W, Lammerink E, Zeeman G. De diagnose van het baringsbegin: mee dan een definitiekwestie. Ned Tijdschr Geneeskd 2011;155:A2273
  • van Runnard Heimel PJ, de Heus R. De verloskunde in Nederland en de opleiding tot gynaecoloog. NTOG 2011;124:298-300
  • Manders, D Wentink-Lander, F Roumen. Van thuisbevalling naar ziekenhuis  (From home birth to hospital). - 2009 KC
  • S Bernitz, P Øian, R Rolland, L Sandvik, E Blix Oxytocin and dystocia as risk factors for adverse birth outcomes: A cohort of low-risk nulliparous women. - Midwifery, 2 Volume 30, Issue 3, March 2014, Pages 364–370 
  • R Mander, J Murphy-Lawless. The politics of maternity. Routledge publishers, 2013
  • Pieters A, Oirschot van C, Akkermans H. No cure for all evils: Dutch obstetric care and limits to the applicability of the focused factory concept in health care. International Journal of Operations & Production Management 10/2010; 30(11):1112-1139.
    DOI: 10.1108/01443571011087350
  • Gross M, Petersen A, Hille U. Association between women's self-diagnosis of labor and labor duration after admission. Journal of Perinatal Medicine 12/2009; 38(1):33-8
  • Franx A. 2011 -
  • Offerhaus PM, Otten W, et al. Variation in intrapartum referral rates in primary midwifery care in the Netherlands: A discrete choice experiment. Midwifery, 2015, Volume 31, Issue 4, Pages e69–e78
  • Offerhaus PM, de Jonge A, et al. Change in primary midwife-led care in the Netherlands in 2000-2008: a descriptive study of caesarean sections and other interventions among 789,795 low risk births. Midwifery. 2014 May;30(5):560-6. doi: 10.1016/j.midw.2013.06.013. Epub 2013 Jul 25.
  • Pieters A, Akkermans H, Franx A. E pluribus unum: using group model building with many interdependent organizations to create integrated health-care networks. Adv Health Care Manag. 2011;10:321-44.
  • Sanders A. Functional discomfort and a shift in midwifery paradigm. Women and Birth Volume 28, Issue 3, September 2015, Pages e87–e91
  • Gaudernack LC, Egeland T, Voldner N. Knowing the midwife before delivery reduces the prevalence of caesarean section on demand in a group of second time mothers with a complicated first delivery. Nordic Journal of Nursing Research. Published online before print October 16, 2015
  • Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study. Offerhaus PM, Geerts C, et al - BMC pregnancy and Childbirth. 2/2015; 15(1)
  • Smith J. The 'natural caesarean' technique as inspiration for normalising practice for all types of birth. In: Promoting Normal Birth: Research, Reflections & guidelines. Donna S (ed) Fresh and Heart Publishing 2011 
  • Offerhaus PM, Otten W, et al. Variation in intrapartum referral rates in primary midwifery care in the Netherlands: A discrete choice experiment. Midwifery 2015 Volume 31, Issue 4, Pages e69–e78
  • Nolan M. Creating family wellbeing: pregnancy to early parenthood. British Journal of Wellbeing, 2010, Vol. 1 Issue 9, p27
  • Eggebø TM, Rossen J, et al. Stimulering av rier. Den Norske legeforening 2014
  • Schrijvers G. Zorginnovatie volgens het cappucinomodel. Voor hetzelfde geld een betere gezondheidszorg. Thoeris, Uitgeverij 2014

1. General introduction

Section 1: A Wake-Up Call

2. Medical excess in normal childbirth

3. Avoidable causes of failed labors

4. Harmful birth care practices

5. Destructive territorial disputes

6. Self-sustaining mechanisms


Section 2: Back to Basics

7. Forgotten lessons from nature

8. Elementary biophysics of birth

9. Definitions and verbal precision

10. First-stage labor revisited

11. Second-stage labor redefined


Section 3: Proactive Support of Labor

12. Leading principles

13. Nulliparous versus parous labor

14. Diagnosis of labor

15. Prevention of long labor

16. Personal attention and support

17. Amniotomy and oxytocin

18. Pre-labor preparation

19. Affective dimensions of labor pain

20. Pain relief re-examined

21. Dynamic dystocia unraveled

22. Obstructed labor

23. Curtailed use of induction

24. Safe care of the fetus

25. Organizational reforms

26. Implementation and ongoing audit cycle

27. External audit of procedures and outcomes


Preface 2nd edition

The central message remains unchanged in the updated Second Edition of this book and continues to emphasize the need for fundamental reforms in the world of obstetrics and midwifery. The policy proposals – aimed at enhancement of women’s satisfaction with the childbirth experience and a safe reduction of the cesarean birth rate – stay the same.

New is the deeply researched treatise on the worrying misapplication of Evidence Based Medicine, leading to false evidence claiming a tempering effect of labor inductions on cesarean rates. Many other prevalent misinterpretations of the literature are exhibited, and several new examples of disturbing misguidance from official guidelines are exposed.   

The chapters on audit and quality control have been rewritten. The clinical procedures and outcomes are now analyzed according to the Robson ten-group classification system, providing the best evidence of the effectiveness and safety of the combined policies and the overall strategy of proactive support of labor.

Check the rest of the book at Google Books »

Proactive Support of Labor - 2nd edition

Proactive Support of Labor is a carefully orchestrated and audited team approach involving the laboring woman, nurse, midwife, and obstetrician committed to a safe and normal delivery. Its disciplined, evidence-based policies provide the expertise for adequate labor support, both emotionally and technically, effectively preventing protracted labors and traumatic deliveries. Unnecessarily long and insufficiently supported labor is the root-cause of avoidable operative delivery and a womans dissatisfaction with the childbirth experience.