Failure to progress refers to when labour is not developing at a satisfactory rate. This increases the risk to the fetus and the mother. It is more likely to occur in women in labour for the first time compared with those that have previously given birth.
Progress in labour is influenced by the three P’s:
- Power (uterine contractions)
- Passenger (size, presentation and position of the baby)
- Passage (the shape and size of the pelvis and soft tissues)
Psyche can be added as a fourth P, referring to the support and antenatal preparation for labour and delivery.
First Stage of Labour
The first stage has three phases:
- Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
- Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
- Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
Delay in the first stage of labour is considered when there is either:
- Less than 2cm of cervical dilatation in 4 hours
- Slowing of progress in a multiparous women
Women are monitored for their progress in the first stage of labour using a partogram. It is worth becoming familiar with partograms and how they are recorded.
Recorded on a partogram are:
- Cervical dilatation (measured by a 4-hourly vaginal examination)
- Descent of the fetal head (in relation to the ischial spines)
- Maternal pulse, blood pressure, temperature and urine output
- Fetal heart rate
- Frequency of contractions
- Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
- Drugs and fluids that have been given
Uterine contractions are measure in contractions per 10 minutes. When the midwife says “she is contracting 2 in 10”, it means she is having 2 uterine contractions in a 10 minute period.
There are two lines on the partogram that indicate when labour may not be progressing adequately. These are labelled “alert” and “action”. The dilation of the cervix is plotted against the duration of labour (time). When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines.
Crossing the alert line is an indication for amniotomy (artificially rupturing the membranes) and a repeat examination in 2 hours. Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.
The second stage of labour lasts from 10cm dilatation of the cervix to delivery of the baby. The success of the second stage depends on “the three Ps”: power, passenger and passage. Delay in the second stage is when the active second stage (pushing) lasts over:
- 2 hours in a nulliparous woman
- 1 hour in a multiparous woman
Power refers to the strength of the uterine contractions. When there are weak uterine contractions, an oxytocin infusion can be used to stimulate the uterus.
Passenger refers to the four descriptive qualities of the fetus:
Size refers to the size of the baby. Large babies (macrosomia) will be more difficult to deliver, and there may be issues such as shoulder dystocia. The size of the head is important as this is the largest part of the fetus.
Attitude refers to the posture of the fetus. For example, how the back is rounded and how the head and limbs are flexed.
Lie refers to the position of the fetus in relation to the mother’s body:
- Longitudinal lie – the fetus is straight up and down
- Transverse lie – the fetus is straight side to side
- Oblique lie – the fetus is at an angle
Presentation refers to the part of the fetus closest to the cervix:
- Cephalic presentation – the head is first
- Shoulder presentation – the shoulder is first
- Breech presentation – the legs are first. This can be:
- Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)
- Frank breech – with hips flexed and knees extended, bottom first
- Footling breech – with a foot hanging through the cervix
Passage: the size and shape of the passageway, mainly the pelvis.
When there are problems in the second stage of labour, interventions may be required depending on the situation. Possible interventions include:
- Changing positions
- Instrumental delivery
- Caesarean section
The third stage of labour is from delivery of the baby to delivery of the placenta. Delay in the third stage is defined by the NICE guidelines (2017) as:
- More than 30 minutes with active management
- More than 60 minutes with physiological management
Active management involves intramuscular oxytocin and controlled cord traction.
Management of Failure to Progress
Experienced midwives and obstetricians will manage failure to progress. The main options for managing failure to progress are:
- Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
- Oxytocin infusion
- Instrumental delivery
- Caesarean section
Oxytocin is used first-line to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.
The condition of the fetus needs to be monitored throughout labour and delivery. Fetal compromise may mean delivery needs to be expedited, or example, with emergency caesarean section.
Last updated September 2020