Failure To Progress, and CPD
- What causes failure to progress?
There is a debate about whether cpd (cephalo-pelvic disproportion) actually exists unless a woman has had rickets, pelvic fractures or there is some foetal obstruction like hydrocephalus or a very post-dates baby with cranial sutures already fused. Some midwives also speak of emotional dystocia. Me, I’m still learning.
The physiological principle is that with good contractions, with minimal interference and with time for moulding the presenting part, babies are born safely. It is interesting that there use to be only a 4% c/section rate in UK back in the times when c/s was considered more dangerous than giving birth normally. Maternal and neo-natal morbidity was higher but apparently not with hugely significant differences when you take into account neonatal malformations and a lack of medical treatment for some pathological conditions. I’m still keen to find a “Marjorie Tew-like analysis” that compares, discusses and explains now and then. I don’t believe that there is a simple connection between more obstetric intervention in the UK of an average c/s of 20% and decreased maternal mortality and morbidity.
I’m not going to go into all the births here where I’ve seen the normal happen supposedly against the odds. But if any happen in the next few months I’ll get permission from the women to discuss them in detail.
I’ve only had that intuitive feeling about something being seriously wrong about four times so far in 6 years. On two occasions, there was undiagnosed pinpoint cervical stenosis both women having had laser treatment, unrecorded on the notes. Both I picked up fairly quickly after I took over care. Both women had been labouring several hours and one woman had been told that she was 5cms dilated and one woman was sent to the ward for the night. Both women needed emergency L.s.c.s. (lower segment caesarean section)
The two other times were to do with serious foetal bradycardias (on CTGS, women using entonox, one woman had gross polyhydramnios) both were in the middle of the night when I was seriously tired and stressed. To this day I don’t whether those women may have delivered normally with a well baby in someone else’s care but looking back I felt the need to ask the doctors to become involved and proceeded to c/s. As it was the women and babies did okay. All women told me that they were fine about the outcomes.
Some midwives also speak of emotional dystocia. Me, I’m still learning.
So am I. Over the last 18 years I have been studying failure to progress and I am convinced that the flight or fight mechanism has been largely responsible for this condition. This survival mechanism is present in all mammals and in my experience it is often under recognised.
We are the only species which permits relative strangers in the birthing environment. Even family members can precipitate f or f if there are unresolved hostilities between birthing mother and family present.
I have devised some strategies for discharging the adrenalin or for avoiding this stimulation. If anyone is interested I can refer them to a web site where an article is printed or post here. I would be most interested in hearing from anyone concerning these observations.
The physiological principle is that with good contractions, with minimal interference and with time for moulding the presenting part, babies are born safely.
I agree. Unless complications occur, patience is the key.
Rayner Garner, The Nurturing Centre
I remember really clearly diagnosing caput as an advancing head! Several times before the ward round came round and the Obstetrician was suspiscious and double checked at which point the woman was prepped and whisked off for an emergency caesarean. This was when I was a student and the midwife I was working with was happy about me performing the vaginal examinations. I have learned to be more thorough in my observation and examinations now. It is very hard as a student to forgive yourself errors but it is important to do so. It is one of the aspects of how we learn.
What is labouring too long, or longer than necessary? Did any injury result? Was the woman upset with the way you cared for her, giving her the benefit of the doubt and plenty of the three cardinal virtues of a midwife (patience, patience and patience)?
Women are different, labours are different, and what is right for one is all wrong for another. It is usually not risky to let labour take its course rather than acting on a suspicion or fear that it won’t work.
Rachel Myr, midwife, Norway
It is often quoted that when a woman assumes a vertical position for birth, or squats, her pelvic diameter increases (by up to 2cm?). Does anyone have a research reference that supports that statement?
Russell JGB 1982 Rationale for primitive delivery positions BJOG vol 89 pp 712-715
This article cites increases of 1cm in transverse and 2 cms to the a-p diameter of the outlet, when the mother is in squatting position Other references are found in the article.
Quilling – a traditional method of augmenting labour
This birth story is from a transcript of a series of radio programs which were broadcast on the Canadian Broadcasting Corporation (CBC) in l985 called “Doctoring the Family”. They combed the Canadian archives for stories about midwives and birth from the pioneer days.
David Cayley (the writer):
Not all of the country doctors chose to cover their ignorance with a show of authority. For those who were not too proud, there was the possibility of learning from the midwives. Often, a midwife would be willing to accept the status of assistant, while actually functioning as a teacher. And, in this way, the doctor was able to learn without compromising his claim to authority. Some of this rather delicate protocol is evident in this next story, recalled years after it happened by Dr. W.A. Bigelow.
As I entered the small, isolated farmhouse, I was immediately aware of an old midwife sitting on the chair with her feet on the hearth of the stove, looking into the fire–the door of the stove was open–smoking a clay pipe. She seemed absorbed in her thoughts and not excited at all when I came in. She scarcely looked up.
She was quiet elderly, and as I entered, I said “How long have the pains been on?” “Started yesterday morning, doc, and she is not getting anywhere.” I got my fur coat off and got warmed up. I asked her if the pains were coming very often, and she said “No, they are not. I think we will have to quill her.”
I did not know what quilling was. I had never heard of it before or since. I did not want to show my ignorance to her personally, so I said “Well, we will wait awhile. I hope we can get along without quilling.”
I took my time and examinations of the patient showed almost a full dilation, with pains, not severe, coming on every 6 or 7 minutes. I gave her a half grain of codeine hypodermically to relax the cervix, and then went and sat down and waited.
During this period, the midwife remained sitting, watching the fire. I had given no anaesthetic, the labour was not progressing, and two or three times she looked up and said, “Doc, I think we will have to quill her.” I would go in and feel the uterus–it was fairly hard.
There was certainly not much progress being made. I think also I was inquisitive as to what this “quilling” process was. So I said “Perhaps you’re right. We might as well quill her. I said “You go ahead and do it, and I’ll get cleaned up.”
She immediately got up from her chair and pulled down the wing of a goose which was hanging on a nail behind the stove. She got a nice, long goose quill, a wavy one it was, and cleaned the inside of the quill, cutting off both ends. She went to the cupboard and dipped one end of the quill into a small package of cayenne pepper. I wondered what the devil was coming next, so I followed her into the bedroom.
She took the quill and inserted it into the nostril of the patient, then gave it one big blow, and away went the cayenne pepper into the poor woman’s nasal cavity. I knew what was liable to happen. She began to sneeze immediately.
With the sneezing, the midwife said “Doc, you’d better get ready.” By the time I had taken a look at things, the perineum was bulging, and with another few sneezes, the baby was born. The midwife made only this remark: “I knew, Doc, that this would make her let go her holt.” I have never forgotten this way of conducting a quick labour.
AH updated 23 June 2001