8.23.2011

Failure to Progress... part one



Failure to Progress... a blanket diagnosis used in obstetrics to declare a woman unfit to deliver without a cesarean. Medically, the definition is:
"no fetal descent or cervical change (with adequate contractions) for more than 2 hours."

eh? (insert quizzical expression). Any person who has spent any amount of time with women experiencing normal, physiological labor can attest to the fact that women can take anywhere from 4 hours of labor, to many days of labor (I'm talking, like 56 hours or more), and still achieve safe, healthy, vaginal birth without complications or interventions. In fact, the average first time mom will experience 18 hours of labor. This means that any number of hours on either side can be seen as normal and natural.


I hate that term. I can say hate, can't I? Talk about putting all the blame on the woman's shoulders (or cervix and uterus)! The part that irks me most about this is that the label of FTP rarely is truly the uterus, cervix, or babies 'failure'.

There are a large number of reasons, other than failure to progress, as to why a woman might not dilate by the book.

One of the biggest reasons for a woman's inability to dilate or move baby down further within the allotted time could simply be because she didn't read the book, and thus her body didn't know the 'rules'. Another way of saying this is to consider that our bodies don't follow Friedman's Curve because we are not medical textbooks, but organic beings that, because of variations in babies and bodies, we might need different amounts of time to accomplish the work of labor.
"Women today are held to a half-century-old labor standard called the Friedman curve, one of the first things obstetrics students learn in their training.


Emanuel Friedman wasn't yet 30 when he plotted the eponymous scale in 1953, during his residency training in obstetrics and gynecology in New York. Friedman found that, on average, it took 2½ hours for the cervix to dilate from 4 to 10 centimeters.

"In the last 50 years, the Friedman curve pretty much dictated obstetric practice, at least in the United States," says Jun Zhang, an epidemiologist at the National Institute for Child Health and Human Development.

Several reports suggest that many cesareans performed for dystocia might be unnecessary. When labor appears to be stalled, doctors -- as well as patients -- often give up too quickly and move on to a C-section.

For example, a study of deliveries at 30 Los Angeles and Iowa hospitals found that about one-quarter of women who had cesareans for lack of progress were only in the very first phase of labor, called the latent phase, when the procedure was performed. Some hadn't begun to dilate.

That doesn't square with the American College of Obstetricians and Gynecologists' definition of dystocia: no dilation of the cervix and no descent of the baby for at least two hours during active labor.

Maybe, the Los Angeles and Iowa researchers suggest, doctors have become so comfortable performing C-sections that they've relaxed their definition of lack of progress in labor." - FTP

In other words, we should be more patient.

Variations that can influence a woman's dilation and babies descent beyond simple patience include:
  • mom's energy level - if she has not been eating or drinking, she may be dehydrated and have no energy to work the uterine muscle. If mom eats a high energy snack, drinks some fluids, and rests, she might start dilating and bringing baby down after she recoups her energy.
  • babies/mom's position - a baby in a posterior, asynclitic, or breech position might take longer to dilate mom's cervix and move down. This is exacerbated by mom's position. If she is mostly laboring lying down or, heaven forbid, on her back, a baby cannot wiggle and move into the best position as easily as (s)he could if mom was upright and 'showing' baby the exit route and shape through movement and gravity.
  • mom's physical make-up - a woman who is less physically fit might need more time to allow her body to dilate as her body might not be as physically efficient at muscular contractions and endurance as someone more physically fit. Additionally, women all have different pelvic shapes. Some shapes might require more time for baby to move through. If there are ligament or muscular torsions, or spinal subluxations, again, her body might need more time to fully open and move baby down.
  • mom's emotional state - if a woman is fearful or anxious, she might simply be holding her baby in because of the presence of adrenaline. This is common when a woman moves from her home (laboring) to her place of birth (hospital or birth center) because she needs time and privacy to get re-acclimated to the work of labor and birth. Labor also has a way of bringing up other issues and concerns... so it might mean mom needs to talk about any fears vs faith that she has running through her heart and mind. Additionally, this is another reason why choosing your birth team wisely is so important.
  • induction - when a woman's body or baby is not ready for labor but is being forced into the event, it might take longer for her body and baby to make the journey. This preemptive decision may, truly lead to failure to progress (and cesarean) if the mother and baby are truly not ready to birth. This is why it is so important to truly weigh the benefits and risks before agreeing to a routine induction based on 'post-dates'.
  • Other - I liken this to the very strong prevalence of iatrogenic complications indicating failure to progress. This can include induction (see above), hospital policy requiring mom to stay immobile on the bed during routine monitoring, medications used during birth which require mom to stay in bed, AROM, and others.
All in all, there are very few times in which a woman truly 'fails' to progress. All of the above can be remedied by patience and knowledge of the human body and personal needs of the laboring woman and baby. Autonomy and patience. Seems simple, right?

If she goes into spontaneous labor, remains upright and mobile, hydrated and nourished, has a supportive and loving birth team protecting her emotional and physical self, and she is educated and confident in the process of labor and birth, her odds of 'failing' to progress are greatly diminished.

Up next in part two is a totally different twist on the term "Failure to Progress"...

Some Related Additional Reading:
A nifty pdf about FTP
Risk Factors, a medical paper

7 comments:

Michelle said...

This post really irritated me because this is EXACTLY what happened to me. It frustrates me simply because I feel like I should've fought harder to wait. There was no risk of infection, my daughter's heartrate and health were strong. It was late at night and I was exhausted. I had been induced only 4 days after my due date and my girl just wasn't ready to come out (didn't help that they lowered the pitocin dose partway through labor just to try to make it more "natural" basically put my body back to square one). I requested food but both my husband and the nurse argued against it. I complained until the nurse finally got me a popsicle (TOTALLY helped, but just wasn't enough). My biggest complaint is "why does no one listen to the opinion of the woman in labor?" I had an epidural as well (no, I don't think that was a factor, that's the only reason I lasted so long actually. During the pushing stage I even had them take the epidural dose down to a really low level so that I could feel and move around to different positions). Sorry, I'm done with my rant now, thanks for reading :)

Afterward: my daughter is very healthy and is almost 2, I'm FINALLY recovered and have a lot more knowledge going forward with my next child (not yet expecting but hopefully will be soon) and I now know how to stand up better to people (2nd yr med student husband included) with knowledge and information to back me up. Thanks so much to this blog for helping inform me!

Michelle said...

This post really irritated me because this is EXACTLY what happened to me. It frustrates me simply because I feel like I should've fought harder to wait. There was no risk of infection, my daughter's heartrate and health were strong. It was late at night and I was exhausted. I had been induced only 4 days after my due date and my girl just wasn't ready to come out (didn't help that they lowered the pitocin dose partway through labor just to try to make it more "natural" basically put my body back to square one). I requested food but both my husband and the nurse argued against it. I complained until the nurse finally got me a popsicle (TOTALLY helped, but just wasn't enough). My biggest complaint is "why does no one listen to the opinion of the woman in labor?" I had an epidural as well (no, I don't think that was a factor, that's the only reason I lasted so long actually. During the pushing stage I even had them take the epidural dose down to a really low level so that I could feel and move around to different positions). Sorry, I'm done with my rant now, thanks for reading :)

Afterward: my daughter is very healthy and is almost 2, I'm FINALLY recovered and have a lot more knowledge going forward with my next child (not yet expecting but hopefully will be soon) and I now know how to stand up better to people (2nd yr med student husband included) with knowledge and information to back me up. Thanks so much to this blog for helping inform me!

mamapoekie said...

thank you, will be sharing on FB and Sunday Surf. Love your work. As always :)

Arual said...

I love that you touched on the Sphincter Law, even though you didn't mention it specifically. Fear, anxiety and embarrassment go a long way in keeping a woman's cervix closed, even going so far as to lose some of its progress in the interest of finding a safer place and/or time to birth.

Karen Joy said...

I've had 5 all-natural, no-med, no-intervention, no-med hospital births. If I have a sixth (my hubby is not convinced!), I will very likely have the baby at home. However, choosing the right OB or CNM goes a long, long, long way to having a natural hospital birth.

With my fifth, I was "stuck" at 7 cm for nearly 7 hrs. I had none of the risks you posted: I was not dehydrated, had great energy, baby was in optimal position, I am physically fit, I was in a fabulous emotional state, I had not been induced, had no AROM, was TOTALLY mobile the whole time (except for a 15 minute strip of EFM each hour) -- on my feet virtually the whole time...

But, thankfully, my OB trusted me to birth the baby. He believed me when I told him I was doing great, and I wanted everyone to just be patient. The nurse was the only problematic person in the room.

Eventually, I went into transition, dilated from 7-10 and pushed out the baby, all within 12 minutes, and had my 8 lb 13 oz baby with absolutely no problem. :)

Everyone I tell the story to can't believe how patient the OB was. Unfortunately, he just took a medical retirement, and I can no longer recommend him. :(

If anyone is interested, the birth story is here: http://wp.me/p1wkS-cm

Maureen said...

Great post!

Rachael said...

This is a great post. I wish that more women knew about the different reasons things can slow or speed up - especially how much emotional state can affect or even slow labor to a stop.

Related Posts Plugin for WordPress, Blogger...

Total Pageviews