arrest of descent

Failure to progress

Contractions begin in earnest and you drive to the hospital in anticipation. Today is the big day when you get to meet your baby! You get checked in, you change into the hospital gown, your baby is on the monitor, and now you wait. The contractions continue coming every few minutes, but then, for seemingly no reason, they just stop.

Now what? You may be surprised to know, this scenario is actually very common. In fact, the American Congress of Obstetricians and Gynecologists estimates that 60% of all cesareans are due to a complication called labor dystocia. If you find yourself in this situation your doctor may use such terms as failure to progress, cephalo-pelvic disproportion (or CPD), uterine inertia, dysfunctional or arrest of labor or descent, or labor dystocia, but whatever the name, it all means the same thing: no baby.

You should first know there is a wide variation in the normal length of labor. Just because you may not dilate a centimeter per hour doesn’t mean your baby is stuck or your body is broken. To the contrary, the average first time mom can be in active labor (4-10cm) for as much as 20 hours and still have good outcomes. And that’s on top of the hours, or even days, of early labor!

But what happens if you have been having contractions close together for a while (less than five minutes apart and at least 45 minutes long) and they either fade out or they aren’t resulting in labor progress?

The Labor Progress Handbook by Penny Simpkin and Ruth Ancheta identified six causes of dysfunctional labor. Some of the potential causes are identifiable in individual women prior to labor, and some of them are correctable, thus it is important for care providers and women to be on the lookout for these indications for dystocia. These potential causes are not indication for an immediate cesarean, but early recognition of them provides opportunity to correct them before they lead to labor dystocia.

The potential causes are:

  1. Cervical dystocia – posterior unripe cervix at labor onset, scarred, fibrous cervix or ‘rigid os’
  2. Emotional dystocia – maternal distress, exhaustion, severe pain
  3. Fetal dystocia – malposition, asynclitism, large or deflexed head, lack of engagement
  4. Iatrogenic dystocia – misdiagnosis of labor or 2nd stage, inappropriate oxytocin use, maternal immobility, drugs, dehydration, disturbance
  5. Pelvic dystocia – malformation, pelvic shape other than gynecoid, small dimensions
  6. Uterine dystocia – inadequate, or inefficient contractions

To prevent labor dystocia, you should take a close look at each of these potential causes to see if any apply to you, prior to birth. If you are not sure, ask your care provider if they have any particular concerns related to labor dystocia in your case. Remember that with the right care, many women who might be considered “high risk” for failure to progress do have normal births.

Now that you understand the causes, I’ll give you my recommendations as a birth doula and student midwife on how you can prevent the most common causes of failure to progress.

  • With your care provider’s help, use the belly mapping technique described at www.spinningbabies.com to ensure your baby is in an ideal position for birth after 34 weeks of pregnancy. If not, use these tips for turning your baby before or during labor.
  • Make sure you feel comfortable with your birthing environment and birth team. Shop around until you feel you have found a place and support team that are conducive to normal birth and your desires for your birthing experience.
  • Do not go to the hospital until active labor is established. This will ensure you don’t go to the hospital when you are only having prelabor, and will help you to get a rythm for coping with contractions in your own safe and comfortable environment. A labor project that offers distraction such as reading, bathing, movies, puzzles, or dinner with friends will help you to relax and pass the time.
  • Do not accept interventions unless they are truly medically indicated. Inductions on an unripe cervix have at least a 40% failure rate and end with a cesarean. This includes having your water broken. Pain medications are also associated with more posterior labors, slower labors, more painful labors, and cesareans.
  • Eat and drink! If you don’t, your uterus will get tired and not work as efficiently or painlessly as it could.
  • Sleep! Rest in early labor to maintain your energy level and strength when labor gets tough – take care of your uterus!
  • Get emotional support from a bith doula. Extreme fear, anxiety, loneliness, stress, or anger can easily result in a slowdown of labor. This is of course not good for getting baby out, but it can also result in birth being an unecessarily emotionally traumatic experience.
  • Stay mobile. Using forward-leaning positions in labor makes birth more comfortable, increases transfer of oxygen to your baby, and makes contractions more efficient because the uterus doesn’t have to work as hard. Pushing in gravity-friendly or gravity-neutral positions (specifically, not on your back) reduces the work it takes to push your baby out as well.
  • Be patient. Birth is hard work, and it takes time. Remember that as long as the baby is not distressed, you don’t have any health problems, and you are tolerating the contractions, there is no medical reason to rush birth. It is designed to be a gradual process so it will be easier on both of you, and with patience, progress will occur almost always without intervention, even if you have already had a cesarean or difficult vaginal birth because of labor dystocia.

Failure to progress can be a scary situation for moms who don’t know what to expect, are tired of the pain, and just want to meet their baby. But a cesarean is not the easy way out that we are led to believe it is. The simple, non-invasive, preventative or corrective measures listed above really do work! And they can mean the difference between a difficult, more painful labor, and a straight-forward, “textbook” birth.

If you have had a personal experience with labor dystocia, please share your story with us!