Wednesday, November 12, 2008


Failure To Progress or Failure To Be Patient?

The diagnosis of FTP ("failure to progress") in labor is a hotly contested term. What does progress mean? By whose definition? Should labor always be expected to progress? What if it stops and starts, or even goes "backwards" at points (as measured by cervical dilation)? If a woman's labor falls outside statistical norms, is that an automatic indication to intervene?

One of the dangers of making clinical judgments based solely or primarily on how long a certain stage of labor is taking is that time can often be irrelevant, and taking action based on arbitrary time limits might lead to undesirable consequences. For example, just yesterday a story came out about a baby who died of a brain hemorrhage after a vacuum extraction (a rare but known risk of this procedure). The reason for the vaccuum delivery? According to the doctor, the woman's baby was not crowning after over an hour of pushing. The doctor remarked:
Mrs Kaymak had been pushing for over an hour but had still not crowned. She seemed motivated and able to complete a successful vaginal delivery so it was decided to take her to theatre to perform an assisted vaginal delivery with the option of an emergency caesarean if necessary.
Of course, we do not have the complete details of the situation, as is often the case with reports about infant deaths. However, the doctor never mentioned the baby being in danger. The woman's time limit had simply expired. And it was a short one at that--just over an hour! This was the mother's first baby, so that time limit seems especially out of place. It is not at all uncommon for a first-time mom to take 2+ hours to push her baby out.

The most dramatic real-life story of taking the whole picture into consideration, rather than making decisions based on arbitrary time limits, happened to my doula trainer during her fifth birth. She had given birth to four babies without pain medications, so she was surprised when her fifth birth proved especially challenging. She pushed and pushed and pushed with no sign of the baby coming out. After three hours of pushing, she finally asked for an epidural--the first time ever. She pushed for eight more hours with the encouragement of her obstetrician. She and the baby were both doing fine and showing no signs of distress; it was just an agonizingly slow process. Finally, the baby was born after eleven hours of pushing. They finally discovered the reason for the slow pushing stage: the baby had a compound presentation, which is when one or both of the baby's arms are up along its head. She remarked that she had an extraordinary physician; most doctors would have taken her in for a cesarean after only a few hours of pushing.

Please share your stories of FTPs (or SBPs= successfully being patient)!


  1. This is incredibly sad. I agree, these types of interventions should never be used for FTP when mother and baby are in good shape.

    I have a unique position, however, because vacuum extraction likely saved my son's life (and certainly saved me from a crash cesarean). I told my midwife that I was adamantly against vacuum/forceps extraction, however, when my son's heart literally stopped beating after only 5 minutes of pushing I was extremely grateful that I had these interventions available to me. The neonatologist said if we'd waited much longer, or if I'd had to have the cesarean, that my son would likely have suffered extensive brain damage.

    I had planned an all natural, low intervention birth and it obviously didn't go as planned, but I've come to terms with it now and am eternally grateful to my midwife and the fast-acting OB who took such wonderful care of my son and me.

  2. My SBP doesn't turn out the way I had hoped, but I can tell you that Monkey #2's birth was incredibly healing. With #1 I was 41w 5d, and I didn't know I could say no to an induction (even though I was already in labor). My midwife got tired, kicked me out the door at 2am and told me to show up to the hospital at 7 for my induction. WTF, right??

    Well, this last time, I went into labor on a Monday and she was born Thursday morning after 6 hours of pushing. Six hours of pushing that didn't get her past 0 station, with shooting pains down my legs and incredible electricity-like pain in my pelvis. Not one single time did my midwife say anything besides encouraging words. Even when we made the decision to transfer, it was just *different*. We made the call after her heart rate was dropping during contractions even after position changes, O2, electrolytes, food, and water.

    We think that the baby had her hands up by her head and that was what caused it all to go down the way it did.

    There was never any discussion of time, hours, limits--nothing. We were left to labor and push as long as we both were tolerating it. When one of us didn't, we started low tech, then moved to high.

    Next time...I have to believe that next time will be different.

  3. For my first birth, I pushed for 5 hours. He came out...slowly, just like everything else about the pregnancy and birth. Even his demeanor is very relaxed and at his own place :)

    Right when my midwife started to get more concerned about how we were doing, he crowned. Nice timing!

  4. Amy--yours is an example of when an intervention was very much needed. I think what is most important is taking clues from each individual labor, not from the clock.

    Had I been with that physician in the article, I might very well have been offered a vacuum extraction because my pushing stage was around 2 hours and most of the progress happened at the end of those two hours. The baby was certainly nowhere near crowning after an hour!

  5. I was just one big failure, from a traditional obstetric point of view: I failed to get started on time in the first place (and somehow it's hard to imagine a hospital 'letting' me start labor on my own and give birth 18 days after my 'due date' ...), and then I failed to progress according to the standard curve in early labor, and then I capped off my 50+ hours of active labor by spending eight hours 'stuck' in transition. While that part did suck, the whole long labor before it was romantic and wonderful, and pushing my baby out was flat-out AMAZING. (That part, actually, took a more 'normal' amount of time. It had just taken the fetus a long time to turn from sideways-stuck-head to a better position and get ready to emerge. In my opinion, no amount of pitocin would have fixed that problem.)

    I gave birth in a freestanding birth center with midwives who didn't toss around the word "failure," and I certainly didn't feel like one--I am so fortunate not to have been in an institution where this experience would have been taken from me. Definitely a case of SBP, but I think a lot of OBs would consider it a Failure to Induce (or Failure to Section) more than anything else ...

  6. Had I been with a OB or midwife, my 44 hour long labor would have probably been labeled as FTP. My pushing stage was only half an hour at the end, but those first 43 hours showed little in the way of progress. I really think that there are harmful expectations of what a normal labor looks like. Sometimes a woman's body wants to ease itself into labor and take its time dilating.

  7. With my first's birth, my water broke at home, so of course I was immediately on my doctors "must deliver in 24 hours clock." I was very insistent on no epidural, and no pitocin. After about 18 hours of labor, I was still not dilating past a 4, I believe. My doctor was getting anxious, but my nurse (a midwife in training) was fabulous. She knew what I wanted and staved off the doctor (who was again worried about the clock) while sneaking me juice, and letting me take long hot showers instead of being monitored every hour.

    In the end it worked great. The showers helped me relax and dilate, and after 21 hours of labor and 15 minutes of pushing, out came my beautiful little boy!

  8. I'm a FTP mama as well - no problems with the laboring itself - I was able to avoid induction (though it was threatened), and labored fine until it came to pushing him out - I pushed for 4+ hours (I'm not sure how long exactly, the hospital had it down as more than 4, and my husband agrees) - in the tub, in every position imaginable, until I was beyond exhausted (and frankly, I had been pretty tired when labor began...). Anyhoo, the midwife suggested an ultrasound to see how he was lined up, and he was posterior - my choices were an epidural and more pushing, an attempt with a vacuum (the OB even said it was a bad idea), or a c-section. I chose the last one. I don't know if it would have ended differently if I had been at home, or at a birth center, or if I had been able to even labor at home longer...I know of women who've had successful vaginal posterior births and pretty horrific vaginal posterior births. I think what burns the most is that NO one ever checked to see how he was lined up before I started pushing (and I know of various women who had OBs who were able do determine it...). So yeah, that FTP on my medical records...who knows if it was true.

  9. Well, two of the three home births I have attended as a midwifery apprentice most likely would have ended as C/Ss in the hospital (and the third had heavy mec staining, and would have been highly interventive as well).

    The first was a primip at 38+4. At 5 a.m. she was completely dilated and started pushing...and kept pushing for the next 3.5 hours! This primip birthed her 6 lb 14 oz baby boy in a posterior, acynclitic presentation!

    The second was just yesterday - a G2P1 at 39+1 who started having contractions around 2p.m. on Wednesday. We first went to their house around 5 p.m. She was at about 3 cm but hard to measure, thanks to a thick anterior cervix...she stayed there for a long time...we went home, came back, went home again (no change) and then went to stay at 6 a.m. on Thursday. She was at about 5 cm, still thick anterior cervix, though 100% effaced. By about 10 a.m. she was closer to 8 cm but no other changes, and that cervix just wouldn't budge from pinching between head and pubic bone. She stayed there until about 12:30, at which point her water broke and four minutes later healthy baby was born. No other complications, "normal" presentation, but a very sticky cervix that would likely have been a C/S...especially staying at 6 cm for so long, and then at 8 cm for a couple hours, and being a multip. :(

    It will never cease to amaze me how a simple choice of provider or birth place can mean the difference between major surgery and simple vaginal birth.

  10. Wow Jen, that was a lot of numbers! Did you just type that off the top of your head? :) Congrats on your third birth. You sound very inspired!

    It seems like most birth stories have a definite starting point from which the mother, or her care provider, times a particular stage of labor. A point when the narrative becomes about 'x hrs of y'.

    I'll be bold and hope not to offend anyone when I say that 'x hours of y' talk is gobbledygook. We all participate in this kind of discourse, I do too, but it's nonsense. There is no meaningful, discrete, non-arbitrary starting point from which to measure x. We are (literally, yikes!) groping around for something that we should not be able to put a finger on. Onset of labor? Full dilation? Descent? Why bother charting all this? Other knowledge, such as positioning, fetal heart rate, maternal energy/spirits are all more informative. It is gathering too much irrelevant information that enables FTP. Could vaginal exams be the most frequent potentially harmful routine intervention?

    How do y'all feel about this?

    I birthed my second baby without a single vaginal exam. All those times I fondly think back to that labor, I've never once wondered how many centimeters my cervical opening might have measured at which hour of the night... Or whether my regular ctx were some intense prodromal labor, or early labor, or a slow progressing active labor all day long? Who cares! Did it ever occur to me to ponder whether I started pushing as soon as I got to 10 cm? Never before. Depending on how I count, I could say I 'labored' for anywhere between 30+ to 8 hours. I honestly don't know, but I bet most other labors are similarly tricky to quantify, in theory as well as in practice?

  11. Judit, I heartily agree. I think the combination of vaginal exams + a clock is a dangerous mixture for a laboring woman. Not to say that vaginal exams don't have a place, but I wish they'd be used with discretion and kept to an absolute minimum--which in an ideal world could mean that many laboring women don't receive any at all!

  12. 11 HOURS. Holy smokes. Hats off to her!

    I pushed for 2 hours and baby wasn't crowning until about 1 hour 40 minutes into it. Sure glad I didn't have that OB!

    -Jill (nsi)

  13. failure to be patient.. that makes me think of my OB. it seems like my cesarean had something to do with him not wanting to work late. the whole experience was horrible. even after my cutie arrived one of the nurses had me in tears because i was breastfeeding and she said i was starving my baby. i can't even think about his birth without wanting to cry and it was more than a year ago...

    sorry about the pity party.. anyway.. i'm really glad i found your blog! i'm a breastfeeding pc in ms and i was looking for breastfeeding images and stumbled upon it. i usually read art/craft/design/fashion type blogs, but i'll definately throw yours into the mix..

  14. I'm pretty sure I was "officially" c-section due to FTP. (I'm still waiting for my record to be sent to me.)
    I was planning a home birth, but ended up in the hospital because of a wicked UTI. I had PROM (not sure for how long, may have been days), low amniotic fluid, and was at 43 weeks, so they induced.
    After 14 hours still "only" at 9 cm, and with baby's heart rate dropping at random (which BTW nobody told me was a side effect of the Pitocin, had I not known that from my Bradley classes, it would have been super-scary), I agreed to the c-section. I don't regret it, but I would call the FTP a failure to position. I spent the whole time flat on my back, which is why I believe I dilated to realtively slowly and why I had a lip of cervix at 9cm.

  15. I wrote my son's birth story on June 3 2008 at . I had no urge to push once I was fully dialated. After having been somewhat supportive of being drug free, the doctor said I needed an epidural and left the hospital for dinner. Ten minutes later the urge came, but the nurses insisted I wait for the epidural. It took over three hours for that doctor to come, and 45 minutes to get the epidural in. My son could have easily been born in that time. I had an hour of rest then his heart rate dropped to about 80, all hell broke out, and eventually, he sliced me, put his fingers up in my son's ears, and pulled. My son had had his head sideways, the cord around his neck, and a true knot. He was lucky to have an extemely long cord. I was upset with the doctor for letting it become an emergancy, and for allowing me to go three hours of trying to not push. That was over 8 years ago. Recently, I found out that the doctor (he was on call) had been the specialist in difficult births before OBs came to the hospital. I still think a midwife would have known what to do to get him in a good position and to help me work with it instead of resort to drugs.
    My next two were with an OB and I was worried about too much interventions, but he was great. With my third, I did stall at 4-5cm but was coping fine. I agreed though to having my water broken, and she was born 45 minutes later. Intense, LOL.

  16. I am SURE that if I had labored in the hospital with my daughter, I would have been labeled "FTP" and been given a c-section. I pushed for about 6 hours. During that time, my wonderful homebirth midwife assessed the situation: my contractions were regular and strong, and the baby's heartbeat was strong, so we stayed at home. When my daughter was finally born, she was asyncletic, with a fist crossed under her chin and up near the opposite cheek.

    With my second child, I pushed for almost two hours, a *relatively* long time for a second time mom. And when my son was born, low and behold, he had a hand up by his head.


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