Failure to Progress: Tips to Fix or Prevent a Stalled Labour

Labour Dystocia, also known as stalled labour, or “Failure to Progress” is one of the most common reasons for unplanned Caesarean births. Many, many people experience a cascade of medical interventions when their labour slows or stalls at some point along the way. Some people reach a dilation number that doesn’t seem to budge no matter how many subsequent contractions occur, and some people’s contractions fizzle out and taper off causing a slow-down or even a regression in their dilation progress. Depending on the circumstances of the FTP (Failure to Progress) diagnosis, medical interventions might include an IV of synthetic Oxytocin, a Forceps or Vacuum assist, a Caesarean birth, or all of the above.

This is a very well-known story. Labour starts off slowly and erratically and never really gets traction, or labour seems to be going well but eventually sputters and levels off. Given how common this is, it can be handy to understand some of the reasons why a labour might stall. We can then take proactive steps to minimize the likelihood, or know what to try if it happens anyway. Depending on the reason for the stall, there are a number of things we can do to attempt to get labour back on track. 

Whenever I’m attending a labour that stalls, or slows down and appears to lose steam, I go through a mental checklist, in roughly the following order. But first, it is important that the only issue is the stalled labour. If there is also foetal or maternal distress, or any kind of medical concern, the following list might not apply. Sometimes a situation requires immediate medical attention, which would trump all the ideas below. But if the only concern is the stalled labour itself, it might help to walk through these considerations.

1.The Diagnosis

Is it true? “Failure to Progress” is not a universally agreed-upon diagnosis. Many medical caregivers want or expect labour to progress along a specific timeline, at a certain steady pace, and measurable only by one singular criterion: cervical dilation. Anyone failing to meet this narrow definition of ‘progress’ is labeled as having stalled, with medical interventions recommended accordingly. 

Too many practitioners still chart according to the outdated “Friedman’s Curve” or “partogram”, clinging to the misguided notion that everyone will dilate at the exact same unrealistic rate. They label any outliers as dystocic, which would encompass a majority of labourers. Some practitioners only take cervical dilation into account, and ignore other signs of progress such as cervical ripening or effacement, baby’s descent, repositioning, or engagement, or changes in the mother such as pupil dilation or the altered labour state. This narrow focus would also fail to include relevant labour progress in sweeping numbers of people.

There are many normal and healthy things that may make labour take longer. Sometimes more time is needed to adequately stretch the pelvis or compress the baby’s head. It takes a long while for hormones to suffuse each bony structure to achieve the necessary softening and yielding; to allow a big head through a narrow pelvis. Generally speaking, any baby can fit through any pelvis, but it takes many hours and lots of patience for the gentle stretching to occur, and it takes trust and experience to understand labour progress that is not medically measurable.

Sometimes we need longer to allow the baby to rotate, to move a nuchal hand or correct an asynclitic head, to softly shift the baby into the optimal position for descent and birth. Sometimes dilation appears to stall because the labour is focused on correcting the baby’s position, lining everything up just so, to ensure a perfectly choreographed journey down and out. Again, this can all happen in the absence of cervical dilation.

Sometimes the solution to apparent labour dystocia is simply patience. Maybe the contractions are working to soften the cervix, to build oxytocin, to prepare the baby for life outside the womb, or to accomplish any number of things that may eventually lead to cervical dilation if given enough time. But we are quick to pull the plug on slow labours, branding them as pathological rather than a variation of normal. We are quick to find the woman’s body faulty, rather than trusting the process.

So sometimes the problem is actually just the diagnosis itself. In these cases, the solution is simple: wait. As long as the birther and the baby are healthy, and both coping well, there is no rush. In these cases the only true problem is our expectations. Ina May Gaskin, famed American midwife, is well known for saying there’s no such thing as failure to progress, only failure to wait. 

2. Mechanics

Sometimes dilation stalls for a mechanical reason, which could be the baby’s position, or an easily corrected obstruction. Often, it’s simply because the baby is not low enough in the pelvis. Sometimes it’s because the baby is not yet in the optimal position for birth, and needs more time to get positioned in the pelvis. The baby might be posterior, or partially rotated, or have a tilted head, or have an errant hand or foot in the way. In any of these cases, the solution is usually movement.

The birthing person can try the following movements to help correct the baby’s position and encourage the baby’s descent.

• Hip circles (like belly dancing): first in one direction, than the other, then figure eights

• Swaying hips: rock hips/pelvis side to side, back and forth

• Lunges: lean towards one bent knee with a foot on a chair for several contractions, then switch legs. This opens the pelvis at a diagonal angle

• Kneeling lunges: lunge on floor or bed with one knee raised

• Squat: squat during several contractions, with assistance or support

• Sifting: using a scarf or rebozo, jiggle or sway the belly while leaning forwards, either on hands & knees or leaning on a chair

• Pelvic rocking: on hands & knees, rock pelvis side to side, forwards and backwards

• Walking: walk up stairs two at a time, or walk slowly on floor taking extra long strides

• Curb walking: Walk along street with one foot up on curb and one on road

Another mechanical issue that can sometimes stall labour is an obstruction, and a particularly common obstruction is a full bladder. The solution to this one is simple: empty the bladder. When full, your bladder blocks the baby’s exit route and adds unnecessary discomfort to your contractions. Anyone in labour should try to go pee at regular intervals whether you feel the need or not. Partners and support people can help with a gentle reminder every few hours.

3. Fatigue

Sometimes labour can stall due to fatigue. Labour is hard work. Our muscles, stamina, and energy can succumb to tiredness. It is quite common for long labours to fizzle out, especially when they last several days/nights, and exhaustion becomes overwhelming. There are several things we can try when this happens.

One solution to exhaustion is rest. Labouring people can try to get some sleep. Barring any medical complications (check with your caregiver) it is usually safe to take a gravol and a tylenol and try to sleep for a bit. A useful sleeping position during labour is a modified ‘child’s pose’ (the yoga position) in which you kneel with knees far apart, and lean forwards with your upper body on a stack of pillows. For other people, relaxing in a warm bathtub or birthing pool provides the needed rest. Sometimes labour will appear to stop completely while rest is sought, and then resume after a needed break.

Another fatigue factor is hunger. Your body needs fuel to function, especially during such an intense physical feat as labour. In the midst of challenging exertion we don’t usually feel our normal hunger cues when our reserves run low, but rather a depletion of energy. We feel tired out, weak, drained. This ‘spent’ feeling is common in labour when fuel stores are depleted. The solution? Food. The person in labour needs to eat.

There are no evidence-based limits on what you can or can’t eat during labour, but most people have similar preferences. Because we are very smell-sensitive in labour, foods with strong odours are usually unwelcome (hummus, sardines, onions…), and because we are so focused and selective in our use of energy, foods that require work or attention are likewise unwelcome (steaks or salads that need cutlery, sandwiches that require two hands, foods that are sticky or drippy…). Favourite foods include yogurt, apple sauce, bananas, smoothies, raw nuts, honey, and dates. A spoonful of honey is well known to boost a stalled labour, and dates are often considered the ultimate labour pick-me-up because their particular mix of sugars and carbohydrates provides lasting energy.

But perhaps the most common culprit for labour fatigue is simple dehydration. The uterine muscle can’t keep working unless lubricated. Like all muscles, it gets cramped, painful, and weakened when dry. So it’s essential that we hydrate continuously throughout labour, as otherwise effective contractions can become more painful, even while losing power and chugging to a halt. Good beverages include water, obviously, but also clear juices, coconut water, and “labourade”. The minimum is one sip after every contraction, beginning in early labour and continuing right through until the baby is born. Don’t forget during second stage! Pushing is especially thirsty work.

Partners and support people can keep an eye out for fatigue. If labour slows down or stalls, helping with rest, refuelling, and hydration can be all it takes to get labour going again. But we can also aim for prevention by ensuring that these needs are met before they become an issue or a cause of concern. 

4. Hormones

I think the very most common culprit of labour dystocia is something a bit harder to verify. Often, people are labouring fine at home, but stall shortly after being admitted to the hospital. Or, things are going fine in either setting until a shift change results in a new care-provider joining the scene. Or, things are going fine until someone mentions how long it’s been, or how dilated the cervix is, or talks about the election or the traffic during a contraction, or even asks the birthing person “how are you doing?” Any of these things can cause a shift in the brain that constricts the flow of oxytocin. 

Oxytocin is the hormone we produce that causes the dreamy mental landscape of labour, allowing us to inhabit only the present moment with no sense of time, and little sense of anything except inner focus. Simultaneously, oxytocin causes the uterine contractions, which get increasingly more powerful to move the baby down and out. Oxytocin is the animating power of labour. It saturates our brain with foggy mist to bring us deep into an awareness of our body--how we need to move, how we need to breathe, how we need to push--and it causes the very powers that propel labour forward. 

But oxytocin is extremely vulnerable to interruption. To produce high enough quantities to power labour, we need to inhabit the limbic system of our brain. If we feel at all unsafe, we switch to the brainstem which deals with survival. Like a person hiding might freeze at every little creak or twig snapping, our labouring brain is highly alert to perceived dangers, and startles at anything unfamiliar, including sounds, smells, technologies, environments, and strangers. Something as benign as an unfamiliar nurse entering the room, or a machine beeping, is enough to alert our lizard brain to freeze oxytocin production because something is strange. Our thinking brain might know the hospital is safe or the new doctor is friendly, but our survival brain will react by pausing labour until it feels sure.

Equally disruptive to oxytocin is the thinking part of the brain: the prefrontal cortex. If we try to move into the part of our brain that tracks time, that measures things, that uses language, we also risk losing our trance-like oxytocin state. Fear, stress, and tension are antidotes to oxytocin, but so are thinking, analyzing, counting, and explaining. So some of the very protocols aimed to keep labour on track, such as measuring cervical dilation or tracking time, can accidentally interfere with the body’s progress. When we drag the labouring brain out of its trance and into the arena of numbers and words, we also drag the brain out of the oxytocin zone.

If everything feels safe and supportive with no need to worry or think, if the birthing person can float in the altered oxytocin state without any distracting cares or concerns, if the support team is keeping her comfortable, hydrated, and feeling safe, then the oxytocin levels can build to the elevated heights necessary for birth. But it’s like building with cards or pebbles. It takes a lot of stillness and patience to gain any height, but only one ill-chosen word or loud noise to bring the miracle tumbling down. The oxytocin trance has to be protected for birth to progress.

To encourage and protect the oxytocin trance, partners and support people can try to make her environment as cozy and comfortable and peaceful as possible, emphasizing dim lighting, quiet or soft music, few attendants that don’t change unless necessary, familiar comfort objects, comfortable clothing (consider forgoing the hospital gown in favour of comfy pyjamas or sarong), pleasant smells, and calm surroundings. Keep conversation and questions away from her if possible. Try to create a sense of privacy in which she can feel uninhibited, unobserved, free to cope in whatever ways her body needs. Help her feel loved and supported, unhurried, and un-distracted.

5. Prevention

Of course, even though all these steps can be used to kickstart a stalled labour, there’s no reason not to use them proactively; to prevent rather than correct. Using active labour positions such as hip circles, lunges, forward leaning and squatting, emptying the bladder regularly, eating & drinking, resting, and protecting the sacred oxytocin space are all equally effective at keeping labour moving so that dystocia is avoided. A lot of labour comfort measures are not just to facilitate coping, but work to keep labour progressing as well. If an ounce of prevention is worth a pound of cure, then preemptively keeping labour on track is much easier than getting it back on track if it gets derailed. Better to prevent the derailment in the first place. 

Partners and support people can quietly and surreptitiously cycle through all these measures during the labour, ensuring that upright movement happens, that refuelling and rehydrating is constant, and that the comfy/cozy sanctity of the oxytocin space is upheld. Protecting the birth space and supporting the birthing person can pave the way to an efficient and seamless labour experience.

6. Medical reason

However, sometimes a medical situation will cause labour to stall no matter what we do. Sometimes the baby or the birthing person requires medical assistance for the birth to happen safely, and no amount of prevention or remedial attention will help. Sometimes people can only have a positive or restful birth experience with help from an epidural or narcotics, and sometimes babies can only be born safely with the help of medical interventions such as forceps or caesarean. No matter how many lunges we do, or how many dates we eat, sometimes there is no alternative to medical support, either for the birther or the baby.

If labour stalls for a medical reason, an IV of synthetic Oxytocin is often the best route forwards. Sometimes this will help labour to progress until its conclusion, and sometimes this will lead down the pathway to a necessary Caesarean birth. It must be emphasized that if trials of active positions, refuelling/re-hydrating, and tending to oxytocin encouragement don’t work, there might well be an underlying medical cause for the stalled labour, and medical assistance might be the only path forwards. It is wise to be open to this possibility, even if it’s not our first thought or approach.

In birth, it is always important to be flexible: to listen to the body, to embrace the unexpected, and to be willing to try stuff to support the physiology of labour, but also to yield to medical support when it’s beneficial, whether for strictly medical reasons, or for equally important personal or experiential reasons. Every birth is different. And every person giving birth needs to be well informed enough to make their own, personal best decisions, especially for very common situations such as Failure to Progress.

Stephanie Ondrack has been with The Childbearing Society since 2003. She lives in East Van with one partner, four kids, four chickens, and five cats. You can read more of her rants on birth, parenting, and learning at www.thesmallsteph.com