What Is Failure to Progress?

Failure to progress is a situation in which labor is not advancing enough for a safe labor and delivery. The situation increases the risk to the fetus and to the mother, and it’s more likely to occur in women who are giving birth for the first time compared with those who have previously given birth.

The first stage of labor has three phases. The first phase is when the cervix dilates (opens) up to 3 centimeters, which should happen at a rate of 0.5 cm per hour. The next phase, called the active phase, is the period when the cervix dilates from 3 cm up to 7 cm. This should happen at a rate of approximately 1 cm per hour and there should be regular contractions of the uterus. In the next phase, called the transition phase, the dilation of the cervix increases from 7 cm to 10 cm, also at around 1 cm per hour, and there should be regular, strong contractions of the uterus while the cervix is dilating.

Your doctors will consider the first phase delayed, if the progression of dilation of the cervix is not more than 2 cm over four hours, or, if you have already given birth multiple times, when an already progressing labor slows down.

Doctors use what they call a partogram to monitor labor through the first stage and beyond. Information recorded on the partogram include cervical dilation, the descent of the head of the fetus in relation to the mother’s pelvis, the mother’s heart rate, blood pressure, and temperature, the heart rate of the fetus, the frequency of uterine contractions. The status of the membranes surrounding the fetus and amniotic fluid (the chorion and the amnion), the presence of amniotic fluid stained with meconium (the fetal and newborn precursor to feces), and the drugs and fluids that doctors have given to patient.

On the partogram, uterine contraction activity is measured in the number of contractions per ten minutes. Progress of cervical dilation is plotted against the amount of time that has gone by since labor began there are alert lines, which are positioned in relation to the information, so that doctors, nurses, and midwives can react when progression through labor is not normal.

When the progress through labor takes too long, the alert will be triggered. If this happens to you, doctors will need to rupture of the membranes artificially which means that they will “break the water” with an instrument.

Once the cervix is dilated 10 cm, it is big enough for a normal newborn head to pass though. This is the beginning of the second stage of labor which lasts until the baby itself is delivered through the vagina. The success of this stage depends on what obstetricians and midwives often call the three Ps:

Power: This refers to the uterine contractions

Passenger: This refers to the size, position and presentation of the baby

Passage: This refers to the shape and size of the pelvis and soft tissues

To the 3 Ps, some people like to add a fourth P, Psyche, which means the social and psychological support of the woman in labor.

Doctors consider the second stage delayed when a nulliparous woman (a woman who has not given birth previously) is pushing for more than two hours. For a multiparous woman (a woman who has given birth multiple times), the second stage is considered delayed if the pushing lasts more than one hour. When the uterine contractions and pushing are not strong enough to advance through the stage quickly enough, doctors can give oxytocin, a hormone that stimulates uterine contractions. The evaluation of the quality of labor and its chances of succeeding also includes assessment of the size of the baby and the baby’s lie, meaning the orientation of the fetal body with respect to the womb and the birth canal.

The situation of the baby being extremely large called macrosomia, is something that can happen, particularly when the mother suffers from diabetes. This includes gestational diabetes, meaning diabetes that emerged during pregnancy itself, rather than preexisting (pregestational diabetes). In a vaginal delivery, macrosomia can lead to shoulder dystocia, meaning that the baby’s shoulder is injured in a way that harms a nerve plexus.

When the positioning of the baby, the size, and other things are not right, doctors will move either toward an instrumented delivery, meaning that forceps or a vacuum will be employed to pull the baby out, or they will stop the vaginal delivery and proceed with a cesarean section.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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