Failure to Progress, Failure to Wait caesareans are an epidemic. They account for a huge number of totally unnecessary caesareans. There’s no excuse for the surgical birth rate to be 1 in 3 births or higher as it is in many places. Outrage at this is growing and rightly so, awareness is growing about obstetric myths, but there’s another side to Failure to Progress that we need to be mindful of. Sometimes mothers really can’t go on anymore. Sometimes a caesarean given for emotional and physical exhaustion is humane. We should stop referring to those caesareans as Failure to Wait.
There’s a saying in the obstetric world which I will paraphrase “never let the sun set twice on a labouring mother”. A woman in hard labour for an extended period will most likely be beyond exhausted. It’s not uncommon for babies to show distress under these circumstances either. Where a baby shows distress there is a clear medical need for a caesarean, but those of us who are keen to lower the caesarean rate, can overlook the mother’s emotional and physical exhaustion when the labour isn’t intense, when it is slow going, stilted, and contractions aren’t terribly strong.
To have this discussion, it seems important to first narrow down the terms of necessary Failure to Progress caesareans, versus iatrogenic Failure to Progress, and genuine Failure to Wait caesareans. Many hospital births that end in Failure to Progress are the result of the full cascade of interventions.
An induction, further augmentation, pain relief from an epidural, the woman having multiple vaginal exams, bright lights, no privacy ….. Failure to Progress. That’s nature at its finest clashing with obstetrics at its worst.
Induction is as commonly overused as the Failure to Progress caesarean, and they go hand in hand. Our bodies work exceptionally well to fight off premature birth and induction, unless they are absolutely ready for birth (in which case why not just wait anyway?). Unless there is a very clear medical need for the cessation of a pregnancy, no inductions should occur. This would very easily cut the number of Failure to Wait caesareans dramatically.
With medical indications for induction the Failure to Progress caesarean is still a very real risk, however if the benefits of bringing the pregnancy to a conclusion outweigh the risks of remaining pregnant, then this is a reasonable decision for women to make. It’s important that women understand the heightened risks of Failure to Progress, during an induction though. It’s clear that many women have no idea about it when they consent to induction. Couple that with the high number of inductions that are undertaken for poor reasons and we understand why the caesarean rate is out of control.
If the onset of labour is natural and yet labour slows, this is referred to medically as stalled labour, or often stop / start labour by non medical people. It isn’t uncommon in births that are planned outside of the hospital and with good support it is rarely a problem. Labour starts up again and a baby is born. Stalled labour can Stop and Start more than once, and if the woman uses the Stop period to replenish her resources (emotional and physical) and she and her baby remain in good health then there is no reason to take any action.
Problems arise when a woman believes her labour has begun, and she leaves her home heading for the hospital and then her labour stops, this is often viewed as a reason to augment within a clinical setting. Augmenting labour results in no further dilation because her body is not ready, and Hello Failure to Wait. Augmentation results in an exhausted mother. The caesarean is humane but it is also iatrogenic. Send this woman home with instructions to be nurtured, restful, healthy, and the odds are good that she will give birth vaginally without medical interventions.
If labour stops the woman should be encouraged to eat, drink, rest when it is dark, stay relatively active in the daytime, and just wait. She should be in an environment that is private, comfortable, and free of interfering strangers – this includes hospital staff as well meaning busybody family and friends. No one should do any vaginal exams. When a woman and a baby are both showing no sign of distress the dilation of the cervix is of no significance. None. This must be explained very clearly to women. Often performing vaginal exams on a healthy woman with a health baby, steals her confidence, if she doesn’t hear a number that makes her feel like the moment of birth is inching closer. We need to bring the focus onto health and not the progress of cervical dilation. Health and not time. Which brings us to the crux of the issue. Health.
Health is a multi faceted issue. Physical health is an obvious priority, but emotional health is equally important and clinical birth consistently ignores it. Birth is an issue that transcends all fronts of healthy womanhood, physical, emotional, and spiritual, and that is where we run into trouble with the Failure to Wait / Failure to Progress caesarean.
When a woman has undergone an unnecessary induction, and the typical cascade of interventions, her emotional recovery from a caesarean can be a complicated process. Join a birth trauma group if you’re in any doubt. The risks to her future pregnancies are not worthwhile The emotional toll of a prolonged cascade of interventions is quite literally tortuous. Women who are induced deserve to know this. In fact, without this knowledge, they are unable to give informed consent, and medical practitioners require informed consent before so much as laying a hand on a patient, let alone before injecting synthetic hormones into them.
Please do not be mislead though, hospitals are not the only setting for Failure to Progress. Although they are most commonly the setting for Failure to Wait, Failure to Progress caesareans can occur after unhindered homebirths as well. When labour begins spontaneously in a private setting and continues. Where the mother has access to nutrition and hydration, where she can move freely and has access to natural pain relief methods (water, emotional support, free movement etc) and yet after a prolonged period no birth has occurred, a vaginal exam can provide useful information.
Slow dilation in a mother who has exhausted her physical and emotional capacity, with a good support team in an unhindered environment, can suggest that a caesarean section is a humane option. However before surgery commences it is crucial to ascertain the mother’s understanding of the situation, and also to be certain that her request is not the result of the transition stage of labour.
It is time to lower the caesarean rate, there is no doubt about it. Women and babies are facing huge risks as a result of our current caesarean rate. We still do not fully understand all the ramifications of caesarean surgery for women and their babies, but we do have some inkling of the problem. We know that women struggle to recover both physically and emotionally in many instances. We know that babies struggle to begin life after the sudden beginning that a caesarean gives them. We know that the risks of uterine rupture, placenta accreta, and placenta previa increase with each caesarean, and that after one caesarean a woman is more likely to undergo a subsequent one, or more.
We know that women suffer great physical and emotional trauma from the cascade of interventions and the resulting caesarean. However we don’t often examine the result of caesareans that occur after optimal labouring with excellent support teams. The second group of mothers can come to question their surgery more so than the first. Often they question the necessity of surgery when faced with the emotional healing and the potential complications in future pregnancies. Their questions have no easy answers, and can leave them feeling very uncertain.
These questions need to be addressed before the Failure to Progress caesarean takes place. Is the woman aware of the risks that this major surgery poses to her and her baby now? Is she aware of the risks that it poses to future pregnancy? Is she aware of the difficulties in both physical and emotional healing? Has she had access to all the conditions that promote optimal hormone release and optimal conditions for birth? And most importantly is she aware that labour can simply continue at this point? No medical reason for surgery exists, she can opt to labour more at home, in water, she can eat and drink, she can be in a darkened place where she moves freely, she can opt for an epidural (after being fully informed of the risks epidurals pose) OR she can opt for surgery.
Sometimes Failure to Progress caesareans are humane, although waiting wouldn’t have any adverse physical effects we have to be more aware of the emotional and psychological presentation in individual women. Sometimes the medical presentation that requires a caesarean is emotional and physical exhaustion. Referring to those caesareans as Failure to Wait dismisses the woman’s capacity to manage this situation for herself. At the end of the day the emotional trauma suffered because of caesareans could be dramatically reduced by simply trusting women more, and supporting them where they are at rather than applying a conveyer belt approach to their births.
It’s time for obstetrics to humanise its practices. With greater humanity obstetrics can be trusted to provide a way out when a woman really can’t go on. The Failure to Wait label is a cynical assessment of obstetric practices, and as such is a very apt description. It can be useful in describing the overuse of obstetrics where a caesarean is the final result, but when applied to the humane utilisation of a caesarean for a woman who has truly given and exhausted her all, it can be detrimental to a woman’s emotional healing.