Obstetric Lie #100- Failure To Progress

(Do you think I will be able to come up with 100 lies in obstetrics? I do.)

Failure to progress. Oft named as a reason for cesarean. Oft mentioned to the supine mom in the hospital as she is encouraged to get her epidural and "relax". By the naysayers in the natural birth community, it is often renamed, Failure to be Patient or just, Doc must leave to make his golf game.

Whatever it means to you, the term failure to progress is both powerful, disturbing, and strongly indicates not just lack of ability but complete and utter physical failure on the part of the mother. Personally, I would love to see this phrase just disappear from our culture all together.

And so, in an effort to trash this phrase for once and for all, lets take a closer look at it.

The Vaginal Exam

Ahh yes, you can not actually talk about the term "failure to progress" without first discussing the vaginal exam. Though the VE can give you plenty of useful information, it can not in fact tell you when you are going to actually HAVE YOUR BABY.

If you learn nothing today, learn this: Nobody will know how you are progressing, if nobody puts their hands in your vagina. If you don't want to be diagnosed as a failure, simply remove the test that does the diagnosing.

You do not need a vaginal exam to have a baby. I am serious. They will still come out.

So, one first step to eliminating the term, "failure to progress" is to eliminate the routine vaginal exam. The truth is, a woman can be dilated to a five for a month and have her baby at 40 weeks. A woman can also be dilated to a five and have her baby 10 minutes later. The body does not listen to textbooks. Especially textbooks that say you must dilate one centimeter an hour once you hit active labor. Like a baby, your body has no idea how it should act in order to ensure a textbook medical labor. Leave it alone.

Understanding Birth

The truth is this- science can not totally understand, quantify or write books about birth. You can take all measurable things and put them together and still not KNOW when a woman should have her baby.

Can we understand birth? On an instinctual and female level, yes. On a scientific level, no. Birth is not science. It involves head, emotions, body, place, fear, expectation, and much more.

Now lets assume you are getting vaginal exams and your body does "stick" or "fail" at a certain point of dilation.

What Happens During Birth?

As a birthing woman I believe there is much more going on here than simple measurements. A woman who is stuck at a six for hours on end is not a failure. Is the baby healthy? Is mother healthy? If the answer is yes to these questions then plenty could be happening that we can't see or feel.

You are taking a huge step into an unknown realm. I think this is part of the reason why the first labor is often the longest. It is not just the first time our body is doing this, it is the first time our brain and our spirit are doing this too. (Even if it not your first child, it is still the first time you are birthing THIS child.)

Maybe you fear something. Maybe you have to let go of something. Maybe you have to say goodbye to something. What could this "something" be? Closing a chapter and opening a new one on your relationship with your lover. Letting go of fears about becoming a mother. Letting go of fear and hurt and abuse and worry. Letting go of or working through past birth trauma. You are not failing, you are learning.

But birth is not just emotional either. It is also physical. Things can be happening in the body that we can't see either. Bones and ligaments are moving and stretching. The baby is being massaged as he comes down the birth canal. Your body is preparing colostrum for that first feeding. The baby is turning and finding his best way out. Your body should be moving with him and helping him. Being strapped down and getting medicated or cut open is not necessarily the answer. You are not failing, you are preparing.

Patience, Young Skywalker

If it takes time to become a Jedi, then I think it is safe to say that it takes time to become a mother. Why don't most babies just fly out? Your body births with all the accompanying signs and feelings and sensations in order to prepare you for motherhood. Motherhood is a big deal. It takes time to prepare for it. Let it take its time.

Stay where you feel comfortable laboring as long as you need too. If you get to your birth place and you are not very dilated and not showing signs of very active labor, go home. Don't feel like a failure about it. It is OK. You are excited to be on the journey.

Studies have shown that c-section rates are high in part to simple lack of patience. Talk to your care provider. Ask questions. "How long can I be in active labor before you start to worry?" "Can I avoid vaginal exams?" "If mom and baby are fine, can I labor as long as I would like?"

So how do you avoid failure to progress?

First, don't assume that the vaginal exam will tell you if you are progressing. If that is how we measure the pass/fail in childbirth, then I for one am scared to take that test. (It is always a bad sign when the person handing out the grades puts on a glove and asks you to spread your legs.)

Second, don't assume that staying in a certain spot dilation wise indicates failure. There is a lot we don't understand about birth. And there is a lot more to birth than what we can measure.

Then, be patient yourself. It isn't just up to your doctor to trust birth. It is up to YOU. Let your baby come when it is ready. An induced, undercooked baby may simply not want to come out yet. They can get it out. But not the way it normally comes. Let your labor start on its own, and then let it proceed on its own.

Stay mobile. Your body wants to move that baby down and out. Be logical. What positions assist that and what positions work against that?

Lastly, be aware of your own emotions and fears. What are they? What can you do about them? Could they effect your labor? Are you willing to face them and deal with them?

Oh wait- I forgot one! Don't get an epidural! Sometimes they cause no problem. But many a woman has had trouble with failure only AFTER the administration of drug that numbs half your body. Who would have thought?

Do some women have to have their babies via c-section? Of course. But your body is not a failure and it is not broken. It works. I am willing to bet that not only is your body perfectly capable of opening and having a baby, it is more capable of doing that than 100% of the male Ob's out there.

(Because of course, they don't even have vagina's.)


Krista Eger said…
I was the one dilating from a 5 to pushing in 10 minutes. If my labor followed textbooks, my midwife would have been there for the birth instead of just the student (who was my close friend). I worked at the hospital as a nursing assistant in postpartum for several years and saw failure to progress nearly every day!!!!! It is SOOOOOO.common!! Especially on first time moms. To ruin birth is EVIL in my eyes. It's like crashing someones wedding! You don't want to ruin some girls big day and traumatize them forever would you? Well this is like that multiplied by a hundred!
Unknown said…
Like Krista, I dilate quickly once I get going. With my first, I went from 3-pushing in about an hour. With my second, I didn't have internal exams. I was nearly in transition by the time the midwives arrived, and that lasted for 2 contractions before I started pushing.
Unknown said…
i'd like to see a study on what time of day failure to progress is often diagnosed. i saw it a week ago for a relative and it happened at about 4pm...how convenient. the c-section was shortly after 5pm, right in time for dinner...
Mama Birth said…
Word is (I should find a study) more c-sections are done at 4 pm and 10 pm- in time for dinner, or in time to get home before it is too late.
This comment has been removed by the author.
I am also one who gets to 5cm and then is pushing within 15-20 minutes. This happened with all of my kids.

It's maddening how they label everyone with failure to progress. It's just as maddening when you are telling them something and they think you are crazy or lying because they know more than you.

With my first, I was 5cm dilated at 3:25am. I started pushing at 3:50am and the nurses kept telling me not to and I kept telling them, I'm going to have my baby...and they laughed and said, "That's impossible...you were only 5cm about 30 minutes ago..." My husband said, "Then check her!" and they got a resident who came in, pulled up the covers and said, "Here comes the baby! Go get the doctor!"

The thing I liked about my midwife is that she would listen to me. Listen to what I was saying, how I was saying it and how I was acting and make decisions from there. I also liked that she can tell about how dilated you are by the feel of the belly...no internals needed (of course, she didn't use that to label failure to progress, just to get a better idea of where you at).

Modern medicine was the worst thing to happen to healthy, normal, uncomplicated births. They are great for the people who really need them (high risk, etc) but a nightmare for others.
Sara said…
My friend at work was labeled FTP after only 8 hours of induced labor and given a c-section at 4:30 :( It made me want to cry when she called me and told me.

I never had any vaginal exams during my labor (or before it), but went from mild contractions 10 minutes apart to baby-in-arms in 5 hours, almost all of it in the safety of my home. I wish that more women could be confident enough with their bodies to stay at home and labor as long as possible so that they might avoid this bogus "diagnosis".
Anonymous said…
Call me crazy, but I think the best thing you can do to prevent FTP is get an OB (If you're not going the midwife route) who you trust and is on the same page as you are about how you view labor. I was lucky enough to have my OB be someone I had the privilege of interning with years ago, so I know her well and trust her completely. Even so, the first visit I had with her when I was pregnant, I discussed with her my concerns about what I'm seeing happening in labor and delivery wings and what her views are on it. She agrees that there are too many unnecessary C-Sections, and that as long as I was comfortable and the baby wasn't in distress I could labor as long as needed. As a result of this, I labored for 29 hours and my awesome OB had do drive across town to help me deliver my son at almost midnight.

My point is, there isn't going to be much that you personally can do about the way things are trending in hospitals right now. What you CAN do is be choosy about your provider and make your wishes known in advance. Patients need to start taking more ownership over their care. If women stop going to doctors who urge them into C-Sections, those Dr's won't have any more patients.
Anonymous said…
A fantastic post! Thanks so much, Christy @ pureMotherhood
Unknown said…
I was the one who got to an eight and was there for many, many hours (like 7). Thank god I had a midwife! I finally got some sleep and went from that 8 to pushing within an hour of falling asleep. It was hard, but I was so happy I wasn't in a hospital. Then again I was so happy because my second stage was nearly 4 hours as well.

The time of day has something to do with the c-sections but so does the length of time in the hospital. 3 of the last births I have seen, the c-section came up almost exactly 12 hours from check in. I tell all of my students to stay away as long as possible to stay off of that clock!
Momofthesouth said…
I am SO glad I had a plan for a natural birth and knew what to expect and was able to let my labor progress...Both my children were born at 38 weeks, healthy full term. I started dilating way early with them like 35 weeks or so I imagine. with my son I had the standard (horrible) Obstetrician who tells you all of the nonsense and is condescending and tells you that you WILL have an epidural and you WILL give birth at 41 weeks exactly because they WILL induce you. I promptly said, we'll see about that (of course in the end I got the birth I CHOSE, she wasn't even there and my nurse caught my son, thank goodness because I would have kicked this lady. Back to the point, I started "labor" at 8:00am on 4/10 (this was being already dilated for 3 weeks) and it still took until 6:45am on 4/11 before I had my son, I did have my water broken at around 9pm which nurse said I was 9cm but the OB came in broke me THEN said I was only 8cm O_o

2nd time around, same thing, 38 weeks on the dot, was feeling laborish that morning as well but still wasn't "sure" (MW put EPO on cervix) finally picked up by the evening just like DS's birth, but with DD I had a CNM (who thought it was hilarious that I was so giddy and walking around at 7cm LOL! still though took me till 10pm to have her. So you think, ok w/ ds it took me 24 hours to fully dilate and about 40 min pushing, and that was with dilating for 3 weeks in advanced.

So that is why the whole failure to progress BAFFLES ME!!!!

It took me WEEKS to progress if you really want to think about it and even in active labor I only had to go HALF the distance and it STILL took me 24hrs the first time and I dunno 12 or 13 for the 2nd.

C-sections based on failure to progress should be called, C-sec due to impatient doctor who has better things to do than wait on a PATIENT. :/ Ironic, that we are called PATIENTS? who came up with that title considering doctors are the most IMPATIENT of people?!
Birthkeeper said…
CPD=Close Proximity to Dinner
ArtsyAndi said…
I respect the sentiment in this post and believe that "failure to progress" is an often overused term. However, I would love to see more written about when it TRULY is necessary to have a C-Section.

With my son, I labored for 21 hours... the last SIX of which I was "stuck" at a 9.5

When my OB told me I needed a C-Section I felt like a failure. I felt like my birth was robbed from me. However, it was a good thing that I listened to my doctor. Once they got my son out, they found that he weighed 10lb 2oz and he only had an Apgar of a 3. Had I continued laboring I was told that either he would have died or they would have had to break my pelvis to get him out... without meds.

Just want to point out the other side of things. As a "natural birth" proponent it was hard for me to get rid of the guilt I went through. If Cesareans weren't so overdiagnosed it would have made it a little easier to accept the doctor's recommendations to me in the hospital. I feel for all the hopeful moms that go through similar experiences.
Anonymous said…
As ArtsyAndi pointed out, because there is no hard and fast rule, it is difficult to say when a C-section is really necessary and when a doctor is simply angling for the convenience and has decided to scare the mom into compliance. Having faith in your care provider is key. I am so grateful that I decided to have a homebirth with a CPM instead of a hospital birth even with a CNM with my third baby. She was large enough and I am small enough that there were a limited number of birthing positions that would have worked. I was blessed that my midwife knew what she was about, took charge and got me into a position that torques the pelvis so there was enough room for my little girl. I was labeled FTP because I got to a 7 with my second and my contractions stopped. My CNM decided to break my water rather than wait and see and the result was much more painful than it had to be. I still got my natural birth but at a very high cost and my middle kid was brought into the world in a noisy and painful way, rather than the relaxed and quiet way her younger (and bigger) sister was. Confidence in your care provider, whomever they may be, is key. And making sure they agree with your views about all of it.
Anonymous said…
I too was a FTP and whilst I agree with the message you are trying to impart here, your tone in delivery is like pouring salt on a wound.

I was in active labour for 13 hours before I let them examine me. I was only 2cm. Another 3 hours and I allowed another and I'd only progressed 2cm. After 20 hours of active labour, I finally asked for pain relief. After almost 26 hours of labour, my baby was born via emergency caesarean and a general anaesthetic when she was showing signs of distress.

I had it so stuck in my mind that i wanted a natural drug free birth that I effectively wasn't present at the birth because there wasn't time to give me an epidural when they did intervene. For the record, my baby was born at 5am, not dinner time.

Yes, more people could have a natural birth and more belief in themselves but please be careful with your message and delivery because it's this steadfast belief that I could do it that ultimately lead to me missing my daughters first 2 hours of life. It took me months before I could think of what I missed and not cry.

This story needs more balance.
Anonymous said…
An insightful post on something I've been considering recently for and essay for Uni. I'm looking at removing the "routine VE" from "normal" labour, and I hadn't got to the point where I'd considered the impact on FTP etc - I would have got there, but this just brought it to the fore! Thank you!

There are good OB's out there, but I agree too many of them rush in and upset normal birth.
Anonymous said…
Re: Story needing more balance.

I disagree. I think this story tells the truth of the matter- that far too many women are being to made to feel as though they are failures as birthing mothers, that childbirth has become yet one more item in the list of convenience activities that our society engages in, and that in far too many cases, women are being subjected to unnecessary major surgery. Because of this, those women who actually do need this surgery do not get the support they need at the time they need it most. Why not? Because it is routine. Mundane. Ho-hum. C-sections have gone from the realm of the extraordinary, resulting in additional care for the mother, to the realm of the ordinary, where no one really cares. It's not right.

As late as last September I used to believe that whether one had a C-section or not should be left up to each mother. I had not realized just how far out of whack society's views on childbirth had become until I was at church on October 10th last year. I was sitting in the women's meeting, after the service and Sunday School, and one of the women stood up to announce that she was going to be an auntie that day. Congratulations were offered all around. One women stated, "Oh, how wonderful! Your sister is in labour!" To which came the reply, "Oh, she's not in labour. She's having a C-section at 10:10 this morning so her baby can be born at the tenth minute of the tenth hour of the tenth day of the tenth month of the tenth year of the new millenium. It's supposed to be good luck."

I was dumbfounded. I had never heard of such a thing. And after much research and reading, my stand on current birthing practices has changed.

For those women out there who really do need to have c-sections, my heart goes out to you.
cathicog said…
As a young midwife, I am learning to assess a labor by how the mom is behaving, rather than what her cervix is or isn't doing. I don't like doing unecessary VE's, and can usually get a mom thru labor without one. Keeping mom upright, letting her choose position, resting, eating/drinking to satisfaction, and going potty often, so far has brought the best results, whether the mom was at home, or hospital (I was doula). If hospital, staying home til mom was approx 6-7 cm, has brought good results(this is without VE, just going by how close ctx are, mom's behavior, other signs.
Michelle said…
Love it. Took me almost 2 days to birth my 5 year old and I most assuredly would have ended up failure to progress if I had been in the hospital. My body just hadn't given birth in a really, really long time. And she wasn't positioned perfectly.

I had an amazing homebirth.
madasaspoon said…
//To ruin birth is EVIL in my eyes. It's like crashing someones wedding! You don't want to ruin some girls big day and traumatize them forever would you? Well this is like that multiplied by a hundred! // - - I could weep for the truth of this comment!!!! I have said before, that lots of women spend months of YEARS planning their wedding day... those same women don't plan for their Birth Day at ALL.... :-/
Gombojav Tribe said…
How much do I love this post?! I'm going to link to it in my blog tomorrow! :-)
C S said…
First 24 hours of labour: sent home even though my contactions were 1 minute apart
Day 2: fine,fine, still 1 minute contractions, made cupcakes, went to hospital, dialated 4cm. My daughter's heartrate was dropping. No drugs administered. 8 hours later, no further dilation, given Stadol which just made me hallucinate between the pain. Asked for epidural, the Hospital put it off. 15 hours later, still in excruciating pain, dilation still at 4cm. Epidural, passed out. 3 hours later, pitocin. Still no prOgress, my daughter was still trying to get out, my body remained at 4cm dilated. Fear for my daughter's life, as she was stressed, and we had an emergency Caesarian.

I was prepared for a happy, easy, natural childbirth. I had an easy pregnancy. Labour started at 41 weeks--no induction. I took yoga through 40 weeks. I wanted an epidural late during day 2, but the hospital kept putting it off. So yes, some of us do FAIL TO PROGRESS and it sucks. Then you get shame from all of the natural moms whose bodies were so much better than yours, la Leche league, and childless nutrition gurus who tell you that no doctors are ever needed for childbirth (omitting infant and maternal mortality). Thanks a lot for your support when things go wrong. I'm having my second in 2 months, would like a VBAC, but the natural maternal/child rearing groups are not supportive and pretend that I have done something wrong and that is why I had a Caesarian. Sorry, but no. I did nothing wrong. My doctor did nothing wrong. My husband was furious that we couldn't make my daughter's birth happy, but we are all glad she is alive and happy and wonderful--had I tried for a home birth, the likelihood is that she would have died & I would have had an even worse experience.
C S said…
So no, I heartily disagree with your message that failure to progress is really failure to be patient. I was patient. I did go into labour naturally. My daughter, hospital, and I tried our damnedest for a natural birth, but it didn't happen.

Where is the support for the women whose bodies didn't progress? Or that's considered so rare that we can be tossed to the side?

It's like nursing--not everyone can do it, and everyone I know tried and worked hard at it (except me--my daughter had no problem with it while my friends had plugged ducts, mastitis, poor supply--yes, that too is real when your child hasn't even gained 1 lb in 2 months but you insist on exclusively nursing--tongue tied, poor latch, lazy eating...and we are in a very pro-nursing community with free lactation consulting nearly every day of the week for new Mothers).

Don't literally throw out the baby with the bathwater simply because it doesn't fit in nicely with your agenda & dogma.
Anonymous said…
I dont know if i agree with this or not. I had an emergency c-section as my baby was stuck after pushing for 2 and a bit hours and i hadnt progressed, after trying to get her out with forceps i had the csection (my labour was very long)and they were really pulling to get her out.
The point is I never felt a failure for having a csection ever! (i have had a VBAC since) I just wanted me and my baby to be born safe, i never cared how she came out!! I am a nurse who works in an intensive care unit and i have seen many things go wrong with childbirth! I also know many doctors who do not do csections to get home for tea! They work very hard and they try to leave most of it to the midwives and only intervene when needed. I agree their are probley some who dont, but dont put all doctors in the same box.
MKivig said…
This comment has been removed by the author.
MKivig said…
I would have been considered as "failure to progress" had I given birth in the US instead of Denmark. I labored for 103 hours-or the better part of 5 days. I just wasn't dilating! After laboring for 2 1/2 days,I was only dilated 2 centimeters! After giving me something to help me sleep on the 3rd day,I rested and then was sent home. The 4th day,I came back and they offered me acupuncture and then finally sometime again to help me sleep after the acupuncture effects wore off. I was able to sleep for 10 hours and then,after waking,was able to labor enough to be allowed into the birthing room.
After being in the birthing room most of the day where I tried to have my dream birth-in a tub,I was offered so many other more natural things to help with the pain or progression. Finally,I did ask for an epidural,but after something like 90 hours of laboring did I ask for this and that was only because I hadn't the strength to go on any longer. I had to specifically ask for it by name.
In the US,I would have been cut open long before the 103 hour mark,that I know. I would have probably also had the epidural pushed onto me. I did end up having my water broken and finally induced,but that was all only to keep me from having to end up in surgery. By that point,they were truly worrying about me and my baby so they wanted to help me to deliver soon so I didn't end up on the operating table. I was greatly relieved and very grateful for the way things turned out.
So,this is one "failure to thrive" women who got to have the closest thing to her dream birth as was possible and I was only able to do this with the help of many patient midwives. There wasn't an impatient doctor in sight! Only loving women who helped me the best way possible.
Kat F said…
The hosptial tried to send me home when I was in labor with my 4th baby because I wasn't progressing. But I really, honestly felt like I KNEW he was gonna come out soon and it was gonna be a quick labor. Sure enough, just before we left the hospitl - BAM! I had one huge contraction and went from 0 to 7 centimeters. And 30 minutes later, he was born. The OB didn't even make into my room in time, so the nurse had to deliver him. Thank goodness we didn't leave or my husband would have been delive
rin him in the car!!!
kblphotography said…
I was a FTP and thank GOD for my c-section! My water broke at 3am on Wednesday (8 days after my due date) and the doctor waited 24 full hours only to find that I was still 1CM dilated and not fully effaced. I was contracting every 45 seconds for HOURS without pain medication, in an effort to do things completely naturally. Finally, after laboring for over a day, in transition for over 6 hours, NO PROGRESS, I came down with a fever and my baby's heart rate was dropping - they called the C-section and it was such a relief. THAT is failure to progress. No dilation, fever, baby in distress. So, there ARE circumstances in which a section are needed.

I do believe C-sections are WAY over used and I did everything in my power to avoid it before falling ill in my labor. However, I am so glad the option of a section was available.
maggie said…
What is wrong with these people? They need to reread the post. No one is saying that sometimes baby can't come out. Especially if baby is in poor position. But the truth is that most times its more like FTW rather than failure to progress. Labor can take days, especially when baby is trying to get into a good position.
MH said…
I think the women who have experienced failure to progress and who are upset that they seem to have no support from those who made it through in a different way are just expressing a very natural frustration and hurt. To address some of the things that they labeled in their descriptions, namely he size of the baby relative to the mother's size, my aunt gave birth to a 13 lb baby at home with no help -- not on purpose, but it definitely happened. I'm not saying true failure to progress doesn't happen, but I agree that it does seem rarer than the actual statistics would have us believe. Reading Ina May Gaskin's Guide to Childbirth put in perspective for me why failure to progress would happen for those women who did everything they could for natural childbirth. I believe that the crucial thing missed in those births is the mind-body connection and the knowledge level of the birth attendant. A big baby (10-13lbs), a bad position, a cervix that refuses to dilate, the emotional state of the woman, all of those are still doable, but I think often times an attendant of unusual skill and experience is needed to make these cases work out without surgery. All that to say, unless you have such a person with you who is experienced in how to handle those extremes without surgery, probably the safest thing those of you who "failed" to progress could have done was to do exactly what you did. You shouldn't feel any shame for that.
Unknown said…
The original post is irresponsible and insensitive. The internet has brought many wondeful benefits, but also those who crave attention using it to satisfy their needs.
How can you possibly think that it is wise to give this advice....each birth is unique and must be evaluated by the mother and medical proffesionals present. No doubt there are c sections performed that are not necessary....some women even request them, but some are performed to save the life of the baby. Shame on you.
Vaccinesrgood said…
It's called failure to progress not failure to give birth. It's not meant to make women feel like a failure or defeated but I understand how it can make some feel that way. The author needs to recognize that while there are multiple problems with modern medicine/obstetrics, it has contributed to a marked decrease in maternal & infant mortality. I am right with you on the woman can give birth naturally thing because they have done so for millions of years without modern obstetrics, but you must also accept that a lot of women and their infants died during childbirth in those times. If that is a risk these readers can accept then by all means disregard the advice of medical professionals and scoff at their silly opinions. While your at it don't vaccinate your children as well but please move to your own colony far away from me. Thanks!