It's likely you have met at least one mother who had a long labour that resulted in a c-section.
Maybe you've even experienced this yourself.
With c-sections at an all-time high (around one in three births in the US and Australia), failure to progress (FTP) has almost become a household term.
When medically necessary, a c-section is a wonderful obstetric procedure used to save lives. When performed unnecessarily, it carries risks that do not outweigh the benefits.
Failure to progress is a leading reason for c-section births being prescribed by caregivers.
While used as a medical term, failure to progress is widely used as a ‘catch all’ term for labour not happening in a care provider's expected time frame.
This is why and how informed consent becomes vitally important with regards to c-section birth.
What Is Failure to Progress?
Failure to progress is a term generally used to describe a labour that has continued beyond 20 hours for first time mothers or beyond 14 hours for a mother that has given birth before.
It's also used when a labouring mother is dilating less than 1-2 cms per hour (during active labour, which is 3-7cms of dilation).
Where Did These Time Frames Come From?
These ‘average' labour times have come from the Friedman's curve. Dr. Friedman developed the curve after studying 500 first time, full term mothers in 1954.
He found that the average time for first time mothers to go from 0-4 cms dilated was 8.6 hours. He found that once women hit active labour, defined at the time as 4 cms, their labours sped up to dilate an average of 1-3 cms per hour. Of these women, the average pushing phase (the second stage of labour) was 1 hour.
Why Is The Friedman's Curve Not Applicable To Modern Birth?
While the Friedman's curve was an innovative and important study, it didn't measure normal physiological birth. Our birth practices have also changed dramatically since 1954:
- Twilight Birth was common place in 1954, where 96% of the mothers involved in the study had some level of sedation. Of these women, 23% were lightly sedated, 42% were moderately sedated and 31% were deeply sedated
- 55% of the women gave birth with the assistance of forceps, which would impact the average length of the pushing phase
- 13.8% of the women received synthetic oxytocin (used for induction or augmentation of labour)
Women are no longer sedated during birth. The use of forceps is much lower today. More women are given Pitocin (Syntocinon in Australia). Epidurals are more common. All these differences can lengthen or shorten labour times.
If Failure To Progress Isn't A Real Problem, Why Are So Many C-Sections Performed?
A labour taking longer than expected isn't an indication for a c-section. Fetal distress (which can happen due to an induction or augmentation of labour), maternal exhaustion, blood pressure concerns and rare true cases of cephalopelvic disproportion (baby not fitting through the pelvis) can be indications for c-section.
However, a labour taking longer than expected is not an indication for surgery. If mother and baby have healthy vital signs, there isn't a reason to opt for a c-section, simply because the clock is ticking faster than she is dilating.
Why Are So Many Women Having Their Labours Labeled As Failure To Progress?
The way we give birth, the choices we make and the interventions used can impact the length of labour.
Here a 6 things that can lead to a longer or prolonged labour:
#1: Inducing Labour
Our uterus does an amazing job of creating a safe space for baby to grow, as well as keeping baby put until they're ready to be born. When we induce labour, we are trying to make the uterus work before it's ready and primed for labour. We are trying to get baby to come out before he or she is ready to participate in the process.
Our body naturally ripens the cervix and then releases oxytocin to trigger uterine contractions. These effective contractions cause the cervix to continue to ripen and dilate, and eventually help baby descend through the birth canal.
Using synthetic prostaglandins to ripen the cervix, it takes 12-24 hours or more, and they still might not effectively ripen the cervix.
Synthetic oxytocin, which is used to trigger uterine contractions, can cause very strong and painful contractions. Despite their intensity, in many cases they aren't as effective as normal physiological labour contractions. The way our body responds to synthetic oxytocin can vary greatly to have an impact on the length of labour. If an induction is medically indicated, patience is key.
#2: Using Interventions During Birth
Every intervention, even the seemingly small ones, can impact the length of labour. Birth is a complex hormonal process — all the hormones need to dance together for the process to work beautifully. When interventions impact or interrupt those hormones, labour can be prolonged. Many interventions also restrict movement, which can also prolong labour.
Placing an IV or performing a vaginal exam can interrupt hormonal flow. The medications in an epidural can block the release of your body's natural oxytocin. It's important to weigh up the benefits and risks of each intervention, before choosing to use them. If intervention becomes medically indicated, just like with inductions, patience is important.
#3 Less Than Optimal Prenatal Nutrition
Gestational diabetes has become an epidemic in western cultures. Many families routinely eat processed foods full of carbohydrates and processed sugars (and it's very easy to do when we're tricked into believing that something is healthy when it's not). These foods can increase the risk of gestational diabetes.
Naturally large babies sometimes happen, and it doesn't necessarily lead to prolonged labour. Your body is designed to make a baby that fits through your pelvis and birth canal. In cases of uncontrolled gestational diabetes, your uncontrolled sugars can lead to your body growing a baby larger than nature intended. While baby is still likely to fit, a large baby due to gestational diabetes can create complications, prolong labour and increase the risk of a c-section.
If you are diagnosed with gestational diabetes, be sure to follow the advice given by your nutritionist. A healthy diet and physical activity can help keep blood sugars under control.
If you haven't seen it yet, make an effort to watch the eye opening documentary, That Sugar Film.
#4: Restricting Movement During Labour
Getting to the hospital, heading right to the bed, and getting hooked up onto an IV and monitor can greatly restrict movement.
Being mobile during labour helps to keep our pelvis moving and asymmetrical. This will help your baby to navigate the descent through the pelvis. If labour isn't progressing, sometimes walking, swaying, squatting or other activities can help get things going again.
During the pushing stage, lack of movement or lying on your back can prolong the process. Being in an upright position allows for the use of gravity and more pelvic space. It's also less painful this way. Find out more benefits of giving birth upright in BellyBelly's article, 9 huge benefits of giving birth upright.
#5: Uncomfortable Labouring Environment
Birth is a complex physiological process that we are only beginning to really understand. The many hormones involved mean nearly everything can impact the length of labour. Oxytocin, melatonin, adrenaline and endorphins are just some of the hormones involved in childbirth.
When a mother feels watched or uncomfortable, her body releases adrenaline, which can reduce the flow of oxytocin. A slowed or ceased flow of oxytocin can lead to a stall during labour.
When there are bright lights and noise, the release of melatonin is less. Melatonin encourages the release of oxytocin. Less melatonin, equals less oxytocin which can equal a longer labour.
Endorphins are our body's natural pain relief. They help mamas cope with labour contractions. Endorphins are released in response to oxytocin. When we interrupt the natural flow of hormones, we also interrupt a mama’s ability to cope with her contractions.
We don't need to understand the exact way each hormone works, but we do need to be aware of how external things can impact labour.
#6: Lack Of Food And Hydration During Labour
You're preparing to run your first 5k, so naturally you skip breakfast, right? Probably not. You know your body needs fuel to tackle the physical and emotional challenges of a long race.
Labour is no different. Your body needs energy to tackle the physical challenge of labour.
While many women don't have a big appetite during active labour, eating to hunger in early labour is a good idea. High protein and high healthy fat foods (avocado, eggs, fish etc) offer the slow burning energy your body can use to get through labour.
Nausea and vomiting can occur during labour, but this isn't a reason to completely avoid food — you can still throw up without food in your stomach — and sometimes it can be even more nasty! Staying hydrated and alternating between water and electrolyte beverages can help your energy levels up, even if your appetite is gone.
It's wonderful that we have access to modern obstetrical care to save lives. Unfortunately, modern obstetric care can make birth more complicated, longer and riskier than it needs to be.
Choose a care provider that is supportive, up-to-date with evidenced based practice and understands the limits of following the Friedman's curve. If you choose intervention or if it becomes necessary, be sure you have a provider that understands the nature of birth, isn’t working to a time schedule that your birth needs to fit into, and is genuinely caring and patient.
Making informed decisions can help you avoid the confusing term ‘failure to progress.'