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Sunday
Nov152009

Failure to Progress: A New ICAN Video Project

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The first hit in a Google Search for the term “Failure to Progress” is an article of the same name posted at Pregnancy.org, which notes that the diagnosis of labor dystocia is fairly arbitrary and varies highly from hospital to hospital, as “some doctors and patients can be too quick to abandon plans for a vaginal delivery.” For reasons detailed in the excerpt below, many consider “Failure to Progress” to be a failure of the doctor to wait.

Maybe the problem lies not with the women diagnosed with dystocia but with how doctors define the term. 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.

One of the results of this mass over-diagnosis of labor dystocia is that many women are left feeling inadequate about their bodies, telling friends “I’m just not good at birth” or “My babies just don’t descend on their own” or “My labors just don’t keep going on their own without Pitocin.” While it may be true in some cases and I refrain from passing judgment about individual situations, I remain highly skeptical that labor dystocia is the epidemic that obstetricians are making it out to be by operating so frequently.

 

The International Cesarean Awareness Network must be skeptical, too.

 

ICAN’s next education project is the production of a video about women who overcame a diagnosis of “Failure to Progress”. They are looking for women who were diagnosed with “Failure to Progress” (FTP) as a reason for your cesarean, and who subsequently had:

  • a fast birth, contrary to a care provider saying something akin to “your body just will NEVER dilate past X cm”
  • OR had another long labor, going past the time or dilation “stall” of the previous “FTP” but then kept going and had your VBAC, showing that all that was needed was patience for a body that liked to go slow

If you have a story that falls into the above categories, please email to youtube@ican-online.org the following things:

  1. a very short summary of the two births, including any pertinent quotes like “doc said my body just wouldn’t dilate past a 4…” or “I gave up because after 24 hours at 5 cm I was told I’d never progress…” and then the next birth “another 24 hours at 5 cm but then I went from 5 cm to 10 in 20 minutes!” or similar stories.  If you did anything DIFFERENT (changed care provider, didn’t have dilation checked, hired a doula, read X book, or anything else relevant, etc.), please include that information, too.
  2. TWO pictures from each birth.  They would like to have one “labor” and one “birth” picture from each.
  3. Your name, contact phone number or email.  They will send you a release form to sign once they receive your submission and might follow up with questions about your story. Please remember to use the email address youtube@ican-online.org

 

Personally, I would like to hear from all of the women (or witnessing birth workers) who have ever had to beg for more time in labor, imploring their doctor to just give them just thirty more minutes or one more hour to push out their baby. In the absence of any fetal distress or risk to the mother, recommending unnecessary surgery is an inhumane practice and women and their partners should not be begging for permission to allow a physiological process to continue on its own to completion.

 

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Reader Comments (6)

There can be valid reasons for FTP (which name I find blech) and the basic ones like a mal-position that doesn't resolve with active re-positioning techniques notwithstanding; we all know about those.

But, there can be biochemical reasons for FTP, too. I've heard nurses talk about women with FTP for years and this study says what many of the anecdotal stories include: http://informahealthcare.com/doi/abs/10.1080/jmf.11.6.409.413 . I have found several women with PCOS also seem to have laboring issues, possibly a hormonal issue.

Vitamin D deficiency is also implicated in FTP (http://www.medpagetoday.com/OBGYN/Pregnancy/12260) - " ... researchers said that vitamin D deficiency has been associated with proximal muscle weakness, as well as with suboptimal muscle performance and strength." This is one reason I am on the serious bandwagon to have women supplement with 6000-8000 IUs of Vitamin D a day throughout their pregnancy and nursing (although many experts believe it should be for always). Prenatal Vitamins have a measly 400 IUs a day. In my own practice, I have not had a labor longer than 8 hours since beginning the Vit D supplementation (quite anecdotally, of course) and the women seem to be in much less pain than those that didn't supplement previously. I look forward to future labors to continue testing the theory that Vit D does assist the uterus in labor and postpartum. I believe the supplementation would even help the higher-risk-for-FTP women. (Of course, ask your provider. Gotta say that.)

Women who have had several babies or previous large babies are also at risk for FTP because the stomach muscles are more pendulus and the baby isn't able to put enough pressure on the cervix to open it as efficiently. A rebozo tied around her belly, pulling it up and in, can make a world of difference.

Blessedly, I have not had to beg a doctor to wait, but my homebirth would totally have been a cesarean if I had been in the hospital. Meghann was a 39 hour labor. I was fat, certainly had PCOS, she was 10 lbs. 6 oz. and I had no stomach muscles as well as my abdominal rectii muscles were split. I needed a rebozo, but didn't know about them back then.

I hope some of this information helps.

November 16, 2009 | Unregistered CommenterNavelgazing Midwife

thank you for sharing this article. i work as a doula. recently i had a client who "failed to progress". she labored long and hard and stuck to her beliefs as best she could. her determination was the sole reason she avoided a c-section. she did have a few interventions. after the birth, she had some remorse and a lot of "what if's".
i was surprised that her midwife was in favor of leaving the birth center for the hospital and of pitocin.
i discussed options with the mother but let her make all her own decisions as i was trained a doula should do.
what i'm looking for now is both options in how i can support the mother to feel her grief over the turn her birth took, as well as support her and ease her mind, as well as suggestions in how i might have handled the birth scenario in alternative ways?

November 16, 2009 | Unregistered Commentersometimeslacey

During my second birth I was diagnosed as FTP. I'd had a previous c-section (for CPD, BS), and this was my first VBAC. I was told that I was "just not going to be able to do it" and that it was time to give up. Then the nurses (I don't know why, but that entire labor I don't recall ever seeing a doctor until my son was actually crowning), said they were going for a dinner break and to get an OR for my c-section. (Obviously a big hurry, right?) A new nurse came in, I changed positions, and my son was born within minutes.

My first birth was 24 hours, and then a c-section. My second birth, the VBAC I just described, was about 8 hours. My third birth (UBAC) was 45 minutes. My fourth (hospital VBAC) was 12 hours. And my fifth was about 12 hours before we opted for a c-section that was actually *medically indicated*! (Not for FTP or CPD, by the way. My son was in distress -- the real kind, not the made up/blown out of proportion kind -- and nothing helped.)

November 16, 2009 | Unregistered CommenterMichelle Potter

I had a very unneccesary c section about 7.5 months ago. I was induced (at 36weeks) for what I was told was pre-eclampsia, I later found out I didn't have it at all, and that the dr. for whatever reason, just decided to induce me... and without ever checking position, lung maturity or anything!

I was induced about 11pm with pitocin, at that time I was not dialated. at 730am the dr came in and i was at a 1 and he broke my water, and suggested the epi. I had planned to get it, but not that soon, but i did anyway. about 10am i was a very loose 1. he then said 'its time to throw in the towel'. He first said that my baby's heartbeat was not good. which i was confused abotu since i was watching the monitors like a hawk! weeks later after finding out he'd been fired, i got my records. turns out he documented FTP as the reason for the c section, and not a word about baby's heartbeat.

I was a first time nervous mom, and therefore did as i was told. I now am furious over this, and feel helpless all at the same time. My city doesn't allow VBAC and if I wanted one, I'd be required to drive at least an hour away for all appts and to give birth.

June 11, 2010 | Unregistered CommenterStephanie

Hi Stephanie,

I'm so sorry. You're definitely not alone. There is still hope for you to VBAC if that's what you would prefer to do. Check into your local ICAN chapter and track me down on the Unnecesarean Facebook page if you want any help finding someone to talk to.

http://www.facebook.com/theunnecesarean

Hang in there.

Jill

June 11, 2010 | Registered CommenterJill

That's good to know and I did notice nowaday alot of c-section are being performed.

June 15, 2010 | Unregistered Commenterdoula los angeles
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