Does failure to progress really exist?

(44 Posts)
Again Tue 23-Nov-10 12:27:23

I am 40 + 5 and don't feel like birth imminent. Head not engaged and no plug released. Don't feel pregnant most of the time because have no aches. Have been asked to bring in bag when go for check up tomorrow which I'm not going to do, but I do wonder whether I will actually go into labour at all. Are there some women for whom it judt doesn't happen. If I was left another 4 weeks would it happen? I'm not convinced it would anymore. Last time I didn't dilate even on synt drip and they did an ecs after 9 hours when baby was in distress (he had cord wrapped around neck).

Mumcah Tue 23-Nov-10 13:10:22

Yes everyone would go into labour eventually but the risk of stillborn baby is higher which is why some people are induced.
I have had two Emcs and both times for FTP,I didn't dilate past 4cm both times despite going into spontaneous labour myself and hours of synto drip during the first labour.
My first baby was in the wrong position so the midwives thought that was the problem which is why I went for a Vbac the 2nd time.However my 2nd baby was engaged and in the correct position so I guess my cervix just doesn't work!
The 2nd section was way better and I'm glad I tried,it also made me see that an elective would be a fantastic experience.
Good luck and keep us updated.

carlyvita Tue 23-Nov-10 13:36:38

Ditto. All babies come out naturally eventually when they're ready. Oh and I read somewhere that there's no history of a woman going past 44 weeks, even in countries with no healthcare services to provide accelleration/ induction. Though can't reference it, so may be poppycock!

Very sceptical about what Failure to Progress really means to be honest. Failure to progress on whose terms? I had a break in my labor at about 5cm for a good couple of hours, but quickly cracked onto 8 after that much welcomed break.

The consultant then told me that baby was distressed and ECS was the absolute only way forward. Gutted. Especially when I read the notes a couple of weeks ago and found that the reason for my ECS was listed in the notes as Failure To Progress. It was surgery that I cretainly didn't sign up for. Strop!

BalloonSlayer Tue 23-Nov-10 13:54:54

I always thought that Failure to Progress meant (certainly in my case when I had an EMCS) that baby was showing signs of mild distress and that given that syntocinon (sp? induction drip) was already turned up quite high, it didn't look as if the baby was going to come out by itself anytime soon, and signs were that it needed to be out within the next couple of hours.

I dare say that if DS1 hadn't shown the very mild distress signs he did, I would have eventually have progressed to 10cm. I was at 3cm after having had contractions for 23 hours after waters breaking, and 10 hours of those having been on drip.

AlpinePony Tue 23-Nov-10 13:55:48

I'm pretty sure it does exist - and for those of us with a non-working cervix, I assume without medical intervention the baby would die and likely us too - whether through shock at the time or infection later. If it didn't exist, how would we explain "stone" babies? (Calcified corpses found in uterii sometimes decades after any pregnancy would have been possible.)

Not sure what you were told, but a mw told me afterwards that I fell in to the category of "ones we used to lose".

Thank GOD for c-sections!

Mumcah Tue 23-Nov-10 14:19:19

Forgot to say that neither of my babies were distressed,but with DD I had been labouring for two and a half days so I guess she would have done at some point.

Sparklies Tue 23-Nov-10 15:12:55

I did have genuine failure to progress. My cervix was scarred badly after tearing through a cervical stitch. Despite having the drip up to maximum for 10 hours, I never got past 4x6cm. Not an exactly natural shape for a cervix! The scar tissue was stopping me dilating so a c-section it was.

Again Tue 23-Nov-10 19:18:22

I wasn't really told anything except that he was in distress. After 5 hours I had only dilated 1/2 a cent, 48 hours after my waters broke, but that was two weeks early. They won't induce me because of previous section. Obviously I don't want any risks to baby's health and I don't feel that the emerg section last time was a very negative experience, but a natural birth is the preference. I think it's a better way to come into the world.

Cleofartra Wed 24-Nov-10 18:05:10

I had 'failure to progress' with my third labour - was 5cm at 10am Tuesday morning, 8cm by midnight Tuesday, and eventually gave birth (after a few hours of synto) at 4pm on Wednesday. However, because I was at home with an independent midwife checking my progress from Tuesday morning to Wednesday lunchtime (when I transferred into hospital) I was allowed to labour at my own pace and not the hospitals. Personally I think that I'm one of the lucky mums who dodged a c/s by booking a homebirth - we know that women who do this have lower rates of c/s than women who book for a hospital birth.

Some women have longer pregnancies than others - one reason why 'term' covers a period of a month. I certainly would never have even considered induction before 40+7 (which is when two of my three were born). Even then i would have insisted on a scan and monitoring beforehand, to try and judge whether there was any risk in letting the pregnancy continue.

I have heard that, if induction does not start labour, or starts a slow and inefficient labour, it could well be because the woman's body was not ready for labour and she was one of those who would naturally have longer pregnancies.

As for FTP once in established labour, I'm sure it is a real condition, but one that is far less common than its actual occurrence. I'm certain that, in many cases, FTP is created by the medical environment. FTP is rare in homebirths, and is far likelier to occur in highly managed births and where the woman is a passive recipient of instructions.

WidowWadman Wed 24-Nov-10 21:04:05

carlyvita obviously they all come out eventually. Buit not neccessarily alive - there is plenty of evidence pointing that going long overdue does indeed increase the incidence of stillbirth.

I never go into labour spontaneously. Have always been induced at 42 weeks. Heavy use of synth helped me avoid sections.

Alibabaandthe40nappies Wed 24-Nov-10 21:13:45

I had FTP with DS. I was induced at 11 days overdue and went into labour immediately - really strong contractions with no breaks between them at all. That lasted for 5 hours, at the end of which I was 2 cms. Everything ground to a halt, synto drip turned right up and 12 hours later I was only 3cms.
By that point DS was banging his head against my cervix trying to get out, which was making it swell so it wouldn't dilate any further.
He was getting distressed, heartrate dropping and dropping.

Thank god for c-sections

mnistooaddictive Wed 24-Nov-10 21:14:03

I was 3cm dilated for 12 hours before emcs. She was in a weird positio apparently and her head was stopping her move down. Would she have come out eventually? I doubt it. I personally believe that 60 years ago we would both have died.

Cleofartra Wed 24-Nov-10 23:15:59

"there is plenty of evidence pointing that going long overdue does indeed increase the incidence of stillbirth".

Interesting article:

Induction of Labour

This article was published in THE PRACTICING MIDWIFE (2004 Jul-Aug;7(7):45-6)

"Thousands of women in this country with normal pregnancies and healthy babies are being put at risk every day in maternity units across the country. Yet like lambs to the slaughter they pack up their bags and head for the hospital in the belief that the doctors, who instigate the barbaric treatment they are about to undergo, are saving their babies lives.

Many of them then spend the next few days in excruciating pain over and above that what is experienced in normal labour in an effort to drag their unready and unwilling bodies into labour. Their bodies are filled with drugs that may compromise their long-term health so they begin the spiralling cascade of interventions that all too often culminates with entry through the theatre doors.

The women and their families thank the doctors and hospital guidelines for saving them from the problems they had, problems that are often itrogenic in origin. And so the myth, that their bodies are failing them in the one thing women are best at, procuring a future generation, is perpetuated.

To add insult to injury my colleagues, midwives, who by definition of their title should be the protectors of women and babies, help daily to continue this unnecessary practice. Induction of labour for no medical reason has become a socially acceptable procedure.

The N.I.C.E. (National Institute for Clinical Excellence 2001) Guidelines are the gold seal that have been adopted with open arms and are now governing practice in maternity units throughout the country. The Induction of Labour (IOL) is one such guideline and one that recently instigated a rather heated conversation between a hospital antenatal clinic midwife and myself. Her role as head of the clinic involved speaking to many women who were booked for induction and therefore she was in a very responsible position to give true and unbiased information about IOL to large numbers of woman.

I had telephoned the clinic to arrange an ultrasound scan for a client who was 42 weeks pregnant with her second baby. The pregnancy was normal. The client was very well informed and despite knowing there was no evidence to support fetal surveillance had decided on a scan to check the well being of her baby. Social pressure had made her feel that she needed to "do something" and this course of action, she felt, at least appeased her family, friends and neighbours. What she did emphasise to me was that she did not want to be put under any pressure by anyone to be induced and this I clearly explained to the midwife I conversed with. I asked her to pass that information on to the midwife in charge; an appointment was made for 2 days hence. The following morning I received a letter from the midwife in charge. The letter informed me that a review of the hospital notes made the clients dates "wrong" and stated "in accordance with N.I.C.E Guidelines on post maturity, no woman should go over 42 weeks".

After reading the letter my client, feeling that was this was just the pressure she did not want to subject herself to, lost all faith in the maternity unit. She understandably felt that she would not be given the respect to make her own decisions especially as, without meeting her, judgment had been passed on her by the professions from which she had requested help. Also she must be a stupid woman after all if she knew when she got pregnant! She cancelled the appointment.

The guidelines of course do not say what the midwife had stated. The letter left me in no doubt that this head of antenatal clinic not only had not read the guidelines but also more worryingly had put her own interpretation on them. If this is but one example of how they are being used to manipulate and lie to women what hope do women and society have of knowing the truth and making an informed choice?

Following the publication, in Canada, (Hannah 1992) of the largest Randomised Controlled Trial (RCT) to date concerning induction of labour and further meta-analysis of other RCT The Royal College of Obstetricians and Gynaecologists (RCOG) adopted of the policy of offering induction at 41 weeks. This is now the recommendation of what is regarded as gold standard, The National Institute for Clinical Excellence (N.I.C.E) Guidelines.

However what is not widely known by obstetricians and midwives alike is that all the studies used to govern today’s practice was and is based on 8 babies! In the case of induction of labour, the number of babies that died following their mothers being induced versus the numbers of babies that died following their mothers left to proceed with pregnancy beyond 41 weeks. There were approximately 3000 women in the IOL group and 3000 in the expectant management group.

One baby died in the IOL group and 7 died in the expectant management group.

Hey presto it is obvious then many babies’ lives will be saved if we offer to induce every woman over 41 weeks.

Does anyone care about looking at the wider picture?

I was taught as a student nurse on diploma courses at the very beginning of my education not to use research that is more than 10 years out of date to underpin my practice. Yet to govern and recommend practice affecting thousands of women and babies, many of the RCT in the Meta analysis used to compile the N.I.C.E Guidelines are more than 20 years out of date, some of the studies even 40 years old. Whilst the way women grow and birth babies has not changed in millions of years, the ways our health as a nation and the ways in which maternity care is delivered and received certainly has. Never more so than in the last 40 years. We now have testing and screening so that abnormalities can be detected earlier fetal surveillance is available for at risk babies and the appropriate care free and accessible to all women.

If we do indeed look at the wider picture we see a whole new one emerging. Of the seven babies that died, two occurred in the 1960’s, one of which had a suspected diabetic mother. Hardly a good inclusion criteria in a controlled trial by today’s standards. One baby had pneumonia that is irrelevant to induction of labour. One from a Chinese study that the baby had Meconium aspiration following refusal of induction of labour by its mother after a positive amnioscopy. Another from Meconium aspiration at 43+3 weeks, which would not have any bearing of induction at 41 weeks. One was from a placental abruption, which could occur at anytime. One was a baby of 2.6 grams and clearly growth retarded and the mother had received no antenatal care, (Menticoglou and Hall 2002).

Based on these finding where is the evidence that there is an increased risk of unexplained still birth at 41 weeks? How are the benefits to the 20-25% of women and babies that are being daily induced being demonstrated?

How are we as professionals informing women of the risks of induction of labour versus continuing the pregnancy? Are women given the information in a true and unbiased manner? I doubt it. Just as women are only told the "risks" around birth when they are planning a home birth but conveniently not told the many more risks associated with going into hospital. A woman screened for having a Downs Syndrome baby is informed that if she has a risk factor of less that 1:250 she is a low risk and further action not recommended and yet at 41 weeks gestation she is offered (if indeed it is an offer) IOL because the (very dubious) risk of increased stillbirth is 1:1000.

In a detailed review of the literature Menticoglou (2002) also highlighted details of a women who died in a hospital awaiting treatment for what appeared to be fulminating eclampsia. She was waiting because the wards were full and busy. As many midwives know the wards are often full to capacity and often due to the amount of routine induction of labours that are on going at any one time. Where do women and babies such as these two who died feature in the calculation of risk?

Other than the Hannah trial no further studies were looked at in depth for taking into account when devising the N.I.C.E guidelines. There are other good retrospective studies looking at this subject. Many that shows a substantial increase in the caesarean section rate for routine induction of labour and no significant difference in neonatal outcomes for women and babies that are left alone to continue with healthy pregnancies. The cost to the maternity services must be phenomenal. A cost that could be put to far better use. Money that could spent on improving services so that midwives come back to the profession. Then women and babies who ARE at risk from on going pregnancies may well be highlighted appropriately through good antenatal care instead of a hurried 10 minutes at each antenatal visit and routine induction for all!

We also must not forget the baby in the whole process because it too plays its part in the instigation of labour. The baby is not a passive receiver of the labour process and induced earlier may not have the readiness for labour itself. The biggest reason of all (22%) given in the National Sentinel Caesarean Section Audit (RCOG 2001) was fetal distress. Even given the many wrong diagnosis of fetal distress that exist how many of these babies were induced before they were ready to be born.

Routine induction of labour has become a socially acceptable norm. It is time we professionals, we who are the instigators of what over time becomes "normal" in women and societies eyes, stop this barbaric treatment and give back to women the respect that they and natures deserve.

duchesse Wed 24-Nov-10 23:34:50

I was tickled to see "failure to progress" on my notes as a reason for my crash c section last year. It covers a multitude of sins apparently, even cord entanglement that leads to labour not starting that leads to failed induction and crashing foetal stats. Basically the baby was never to come out the usual route, I never went into labour despite hours on syntocinon, and her only way out was through the sun roof. She was born at 41+10. If she'd been induced at 40 weeks the result would have been the same as she was already entangled by then, unbeknown to everyone.

I do wonder how many babies go overdue because they can't get out rather than because they aren't ready. This would somewhat muddy the figures for poor outcome.

Having said that all my other babies were at 41++ (up to 40+13), so there was no reason to suspect this one wouldn't. They all seemed not to have any inclination to come out and then did anyway. The third one went from 0-birth in 4.5 hours. My sister has 44 week pregnancies naturally. Her babies are induced at 42 weeks and emerge covered in vernix. I think she may be a rhino.

thecaptaincrocfamily Wed 24-Nov-10 23:40:51

FTP is usually due to a cause, the baby for some reason fails to descend (cord tangled, back to back so not dilating the cervix etc)Its the head pressing on the cervix that aids dilation and if that isn't happening then things fail to progress.

kikibo Thu 25-Nov-10 16:47:09

I was an entangled baby, in the 80s, so no scans for my mum. She went into labour naturally and they only noticed when my head was out and my mum had to stop pushing while dr was cutting or disentangling my cord... They did have a scare that I didn't start breathing, but I did anyway. I like to keep the tension grin.

No, I mean, entanglement of the cord has nothing to do with not going into labour naturally at all. If the cord gets so entagnled that the baby's food supply gets broken off, but then it dies, so induction won't do the trick at any rate.

It's really pretty scary that practices are based on such shoddy research. I had already noticed that there is such an amazing amount of indocutions and emergency sections on here... Seems to me that you have to be a doctor yourself in order not to become insecure.

Cleofartra Thu 25-Nov-10 17:46:23

"FTP is usually due to a cause, the baby for some reason fails to descend"

But 'mechanical' issues aren't always at the root of FTP. You're much more likely to experience FTP if you have your baby in hospital than if you have your baby at home. Also more likely to experience it if you don't have one to one care in labour. To me that says that disruption of the normal hormonal cascade of labour is to blame for many cases.

"Seems to me that you have to be a doctor yourself in order not to become insecure"

I suspect doctors are the most insecure birthing mothers of all. Probably the least insecure are teenage mums who've not spent more than 5 minutes reading about what happens in labour and who haven't been exposed to too many horror stories! Ignorance is bliss!

mosschops30 Thu 25-Nov-10 17:53:02

'all babies come out naturally when theyre ready' ...what a load of bollocks, no evidence for this as its simply not true.

I had FTP in my third labour, as in just wouldnt dilate, despite them trying for 4 days. Didnt get any further than 5cm.
Having been back through my notes its clear that ds2 would never have come out naturally, labour would never have started naturally either.

I have been induced with 2 out of 3 births. Im not sure the two inductions would have ever come out without intervention and ds2 certainly wouldnt

duchesse Thu 25-Nov-10 17:59:42

kikibo- my baby was so tangled in her cord that she had basically used up all the available length. Her placenta was at the top of my womb, and she had wound the cord all the way around her body once and round her upper thighs five times, leaving her about 4 inches of spare cord. Nuchal cord entanglement hasn't anything on this, trust me. Nuchal cord is a doddle compared to attempting to kick start the labour of a baby who can't even touch the cervix with her head, let alone exit through it. Her entanglement was one of those rare situations where she would have died or been severely damaged had they not stepped in with the scalpels pretty sharpish. Mercifully she appears utterly unharmed now.

Showaddywaddy Thu 25-Nov-10 18:02:14

'all babies come out naturally when they're ready'. Definitely not true.

I was planning a homebirth and I did stay at home. I had an 8hr second stage (6hrs of active pushing before it became necessary to transfer). It wasn't until I had a cs that it became apparent what was wrong. DD couldn't come out as she was ot and asynclitic. If cs didn't exist, we'd both be dead.

So I made it to 10cm but still had a ftp as dd was unbirthable.

Poppet45 Thu 25-Nov-10 18:30:51

Ditto 10cm, pushing for almost two hours, c section after 19 hours of labour for FTP. DS was OT and a whopper. I firmly believe I'd have never got him out on my own. Sigh.

kikibo Thu 25-Nov-10 19:12:08

@Duchesse: I realise that there are some babies who genuinely do not get down there quickly enough and indeed those mothers would be totally lost if there wasn't anything else but natural, but in most cases FTP is just a way of passing people through who are clogging up beds, and inducing is a way of predicting when someone is going to give birth. More convenient than natural if you have only one midwife in attentdance (and that is fact). Why not offer a cesarian straight away? Then you do cut out the rest in the meantime, as most of those inductions end up with cesarian anyway.

That said, though, wrapping the cord round your neck, does not mean you will never induce natural labour at any point in time. That baby will probably get ready at some point to be born and mother will also get ready and then it starts. And then... it does not advance. But that is no dilation at all. I do not call a break in labour FTP. As people have stated here, it doesn't all go smoothly. But that is no reason to suppose that babies should be born after x amount of hours because that's the average baby's length, or even worse, it is a target.

Showaddywaddy Thu 25-Nov-10 19:17:44

kikibo, while you speak some sense and obviously there are questions about and a discussion surrounding why a hospital intervenes and how it intervenes, you need to be very careful about how you word things. Because "in most cases FTP is just a way of passing people through who are clogging up beds" is a very sweeping and dismissive statement. And there is some little hidden gem in there that implies that those women who were unfortunate enough to have a ftp during labour, could have had it another way 'if only' they'd stayed at home/refused intervention/read up more.

I know this is not what you meant but 'most cases' refers to a lot of real women on here and their very real experiences.

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