Monday, November 29, 2010

Failure to Wait

New research is showing what many critics have been saying for years ─ that too many cesareans performed for "failure to progress" in labor are actually cesareans for "failure to wait." 

In other words, some doctors don't wait long enough for labor to progress on its own before declaring that a cesarean is needed. 

The problem of "failure to wait" cesareans is often particularly prevalent in women of size and may be one reason for a higher rate of cesareans in "obese" women.

A Lack of Patience for Women of Size

Since "failure to wait" is especially common in induced labors (recent research shows that "half of cesarean[s] for dystocia in induced labor were performed before 6 cm of cervical dilation"), and since women of size are induced at far higher rates than other women, discussions about "failure to wait" cesareans in this group are very important.   

Adding into this is the fact that labors tend to be longer in women of size, perhaps reflecting more malpositioned babies or induction for longer gestations (i.e., bodies not quite ready for labor yet).

If labor tends to be longer in women of size and caregivers do not allow for that, more "failure to wait" cesareans are going to occur.

For example, Pevzner 2009 found that induced labors took longer and required more induction drugs in "obese" women. Even when controlled for induction, Nuthalapaty 2004, and Hamon 2005 showed that "obese" women had longer labors, especially in the first stage. 

In addition, Vahratian 2004 showed that the slower duration was concentrated around 4-6 cm of dilation, exactly when most "failure to wait" cesareans are performed. They concluded:
Labor progression in overweight and obese women was significantly slower than that of normal-weight women before 6 cm of cervical dilation. Given that nearly one half of women of childbearing age are either overweight or obese, it is critical to consider differences in labor progression by maternal prepregnancy BMI before additional interventions are performed.
In other words, doctors need to wait a little longer in women of size to give labor every chance to progress further before performing a cesarean.

Another classic example of "failure to wait" is found in the first VBAC study on "obese" women, which is often cited as a reason not to let very fat women try to VBAC.  The study found only a 13% success rate in this group, and so it was widely concluded by many authors that very fat women were not appropriate candidates for VBAC.  (Don't worry; later studies have found much higher success rates.)

A closer look at the study reveals that there were only 30 women in the trial of labor (TOL) group, certainly not a large enough sample size on which to make sweeping policy decisions for a whole demographic group. The study also showed that, of these women, 57% had their labors induced, which research clearly shows lowers the rate of VBAC success.  (In the 13% VBAC study, none of the women who had their labors induced had a VBAC; all the VBACs went into labor spontaneously.)

Most tellingly, the average dilation at the time of the decision for repeat cesarean during labor was 4.5 cm.  This shows that these women of size were not really given an adequate chance at labor, and were sectioned far too early, as is so common in the labor management of "obese" women.

Is it any wonder that the women in this study only had a 13% VBAC success rate?  Their doctors clearly did not believe that very fat women could give birth vaginally on their own, and so induced more than half of them, despite all the evidence showing induction lowers VBAC success rates.  Furthermore, they gave up on the trial of labor very early, before the women had really even reached the active stage of labor

Although I'm sure the physicians justified intervening earlier in order to avoid difficult and risky emergency surgery later on, it shows a troubling pattern in not letting fat women even have an adequate trial of labor before jumping to a surgical conclusion. 


Yes, surgery in very fat women is harder and takes longer, so it is understandable that doctors don't want to wait until there is an emergent situation before intervening.  But more and more, they are moving towards only giving "obese" women a token trial of labor (if they let them labor at all), and moving prematurely to a surgical solution if the baby doesn't practically fall out.  This is not a reasonable alternative.

Given the increased risks of surgery in women of size and the long-term implications of surgical births, I would argue that the better solution is not to section fat women prematurely, but instead to give fat women every chance to deliver vaginally by awaiting spontaneous labor whenever possible, and to apply a tincture of patience, knowing that labor may simply take a little longer in women of size. 

As long as mother and baby are doing well, a tincture of patience is the best option for long labors in many women, and may be particularly appropriate in women of size.

"Failure To Progress" cesareans are far too often "Failure To Wait" cesareans, and especially so in women of size.

Here's the abstract of that new study:

Zhang J et al. The Consortium on Safe Labor. Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes. Obstet Gynecol. 2010 Dec;116(6):1281-1287.

OBJECTIVE: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States.

METHODS: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter.

RESULTS: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95 percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed.

CONCLUSION: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States.

PMID: 21099592


Regina T said...

Failure to wait is the exact terminiology I would use. My own experience included a doctor who, on the day of my induction, had chest pains and ended up in the ER. When he finally was cleared from the ER, he came up to see how I had progressed. After six hours of induction, I was close to fully dilated, but he was prepping for a C-section anyway because I had so much amniotic fluid. He didn't want to break my water for fear of the cord becoming pinched in the rush of water from my uterus. I told him I didn't want a c-section if at all fact, I strongly urged him to reconsider since the baby wasn't in any distress. He called in an OB specialist to break the amniotic sac while he scrubbed. Magically (eye roll), the cord did not become cinched and I was able to deliver within a few short hours. I'm proud of myself that I didn't get caught up in the fear speak coming from my doctor and was able to advocate for myself and my baby even while in the throes of pitocin induced labor. The best part for me was when my baby girl decided to pee on the doctor at delivery. My sentiments exactly. Failure to wait, even when there are no signs of fetal or maternal distress, just doesn't make sense.

Anonymous said...

I had one client--certainly not a study! She had so many issues associated with her obesity it was hard to pull her weight out of the other issues and isolate it. I do agree with everything you say and hope that there is a way to impact the medical/midwifery community with this information. Every cesarean I have been a doula for seemed premature so "waiting" would be my hope as well.

S said...

I guess I need the study explained more. How can they tell from a birth that resulted in a section that it was due to "failure to wait"? Is the idea just that nulliparous obese women are statistically likely to have a "stall" but not a "stop" around 4-6 cm dilation? I am particularly interested because with my first (and so far only) child, I had a failure to progress section at 5cm, which at the time and since I felt was very justified. I was a very educated preggo and did a lot to avoid a c-section: chose midwifery care, tried to keep mobile throughout labor, declined induction as long as possible (though I did end up with an induction at 42 weeks).

Anonymous said...

I don't have any children yet, and this is one of my biggest fears about becoming pregnant. As a doula, I have plenty of witness/vicarious experience of what an induced labor and other interventions are like, and I do NOT NOT NOT want any. I trust my body. I may be fat, but I am HEALTHY, with perfect blood pressure, perfect blood draws - yet I know beyond a shadow of a doubt because I know the care providers in my area and the way the practice rules work in my state that I'll be treated as high risk. It's such bull$#!+. I've even considered going unassisted to avoid interventions, but I'm not comfortable doing UC for my first pregnancy, so I know it's going to be a battle to get what I want. I've even started a savings fund to I can birth elsewhere (maybe at The Farm) if I have to travel to find the best care provider and care situation.

Karen said...

Thank you for this post :) I am 32 weeks pregnant and was told a few weeks ago that they suggest an early epidural for me (to save time later or something) and that they wont "let" me go over 40 weeks. This scared me beyond imagine. This is my first pregnancy but I am pretty certain of the things that I don't want to happen unless absolutely necessary - such as drugs, caesarean and induction. I felt powerless and beaten down. Today I met with the pre-operative service and the doctor I met was fantastic. She was surprised that I had been told what I had by the Obstetrician. I feel better that it's not a set policy within the hospital and most probably just one doctors opinion. This post also helped reaffirm my want and need to trust my body in labour :) Thank you

Elena said...

It is no easy to be overweight,but I think you can be treated correctly.

Cassandra said...

I have a great suggestion for dealing with this problem! Don't check the cervix!! They can't tell you that you're not progressing if they have no idea how far along you are :D

Anonymous said...

It is a well-known fact that anxiety increases the fight-or-flight response, which causes inefficient contractions, thereby slowing or stalling labor. Overweight women are more likely to have body image issues, in my opinion, and therefore are more likely than thin-average size women to experience anxiety and the physical exposure that happen during the typical hospital labor and birth. Very often, thin women need privacy to birth normally. How much more true is this for women who have been taught their whole lives by society that they are ugly and unhealthy? To what extent do their doctors' beliefs that fat women can't birth naturally affect the women during labor? I'd like to see a study done on fat women who are told by their care providers throughout pregnancy they are beautiful, healthy, and strong, and are given proper physical and emotional support during labor in a dark environment with minimal dilation assessment (MAJOR EXPOSURE = MAJOR ANXIETY) and minimal fetal monitoring (OMG THEY CAN'T FIND THE HEARTBEAT EASILY BECAUSE OF MY BELLY FAT = MAJOR ANXIETY). I suspect the fact that fat women have longer labors has more to do with how they are made to feel about their bodies than their BMI numbers.

Anonymous said...

i LOVED reading this. I am 36 weeks in my second pregnancy and facing the breech issues now,and im over 270lbs, and therefor doing extensive research on everything i can to be more informed this time around. During my last birth 3 years ago, i was 50%effaced and a couple cm dilated at a doctors visit on my 39th week and so he wanted to induce because he said my amniotic fluid was low. Not having done much research, only knowing i wanted to avoid c-section, i agreed. What followed was a terrible 2 days of petocin, laying in bed, a painful water break, and a constant feeling that i just wasnt ready. They actually stopped the drip over night and when they went to start it the next day i had an emotional breakdown crying and saying it just didnt feel right and if my body had been ready i wouldnt be going through this. I dont know at what point i "slowed" progression, but having read this article, it really wouldnt surprise me if it were in the 4-6cm. At that time i was around 220lbs before birth, and around the same at full term (i lost a ton of my own weight during pregnancy.)Thankfully i had a great support system that knew i didnt want a csection and helped me hold the dr to that as long as my baby was safe. This time, even if my baby boy stays breech im making the doctor wait for decisions until my body says its ready, because being much heavier this time, and the B word, I am aware of what kind of pushing for a csection is on its way with my next 4 visits. Thank you for posting great information. As long as baby and i are healthy, i wont be swayed.

Well-Rounded Mama said...

Anonymous, if you have a breech baby, you might want to consider seeing a chiropractor who specializes in pregnancy, one who knows either the "webster technique" or the "bagnell technique". Getting your pelvis in alignment can often help a breech baby turn itself and get into a head-down position for birth.

You can read more about this on my main website, Look for the articles on chiropractic in pregnancy and finding a good chiropractor. They'll have info on how to find one that specializes like this.

Jerenda said...

I believe this is what happened to me with my last baby. I was crowning and having difficulty pushing out the baby. The doctor didn't even try forceps, vacuum, or episiotomy she just wanted a c-section. She guessed that the baby was too big (I knew this couldn't be after I had previously delivered a 8lb 2oz baby naturally), baby was coming at wrong angle, etc. I had labored for 12 hours (induced) and pushed for 1 1/2 hours. Doctor pressured for a c-section and I folded. Baby ended up being only 4oz bigger than my last. Also want to note my doctor's shift was over and she wanted to get this baby delivered before she went home. I am pregnant again and seeing a different doctor. He told me after reviewing my previous experience and hearing my story that my baby should have never had to be born c-section and he will try everything to make sure I have a successful VBAC.

Anonymous said...

Why do you keep using the word fat in this article. If midwives want to be seen as the professionals that they are then they should be consistently using the term obese or overweight. I found this very distracting for the content of the article.

Well-Rounded Mama said...

Anonymous, read the "terminology" link at the top of the blog. That will explain it to you.

Basically, "overweight" and "obese" are highly biased and stigmatizing terms.

"Overweight" refers to extremely arbitrary weight guidelines that don't even speak to risk; those in the "overweight" category actually have the lowest risk of dying, see Flegal's recent study of millions of people. If this weight group has the lowest risk of dying, shouldn't they be referred to as "normal"?

"Obese" comes from the latin that means basically "that has eaten itself fat." It assumes that you can tell something about how a person eats based simply on weight, when weight is highly genetic too. Yes, some fat people eat poorly, but not all do, and some thin people eat poorly but are still thin. You just can't look at size and make accurate assumptions about nutrition and intake.

"Fat" is simply a description of size. It's been used as a term of hate, yes, but many stigmatized groups reclaim terms like this as part of their empowerment process. So have we.

The fact that you were so bothered by the terminology speaks volumes about your own issues. It's okay if you don't want to use the term; you get to use the terms you want. But that you found it so distracting and bothersome when it's simply a description of size says that perhaps you need to do some exploring of this issue.