Chapter 1
Introduction

Lisa Hanson, PhD, CNM, FACNM, FAAN and Emily Malloy, PhD, CNM

• Causes and prevention of labor dystocia: a systematic approach
• Notes on this book
• Note from the authors on the use of gender-inclusive language
• Conclusion
• References

CAUSES AND PREVENTION OF LABOR DYSTOCIA: A SYSTEMATIC APPROACH

Labor dystocia, dysfunctional labor, failure to progress, arrest of labor, arrested descent-all these terms refer to slow or no progress in labor, which is one of the most vexing, complex, and unpredictable complications of labor. Labor dystocia is the most common medical indication for primary cesarean sections.1 Some have suggested that the use of the term "dystocia" be abandoned in favor of more precise definitions since one clear explanation is lacking.1 The modern course of labor is very different than in the past, and optimal strategies to reduce unnecessary interventions while providing interventions when needed and appropriate are still under investigation.2 Dystocia also contributes indirectly to the number of repeat cesareans, especially in countries where rates of vaginal births after previous cesareans (VBAC) are low. Thus, preventing primary cesareans for dystocia decreases the total number of cesareans. The prevention of dystocia also reduces the need for many other costly, time-intensive, and possibly risky interventions, and spares the laboring person from discouragement and disappointment that often accompany a prolonged or complicated birth.3

The possible causes of labor dystocia are numerous. Some are intrinsic:

• The powers (uterine contractions).
• The passage (size, shape, and joint mobility of the pelvis and the stretch and resilience of the vaginal canal).
• The passenger (size, shape, and flexion of fetal head, fetal presentation, and position).
• The pain (and the laboring person's ability to cope with it).
• The psyche (emotional state of the laboring person).

Others are extrinsic:

• Environment (the feelings of physical and emotional safety generated by the setting and the people surrounding the laboring person).
• Ethno-cultural factors (the degree of sensitivity and respect for the person's culture-based needs and preferences).
• Hospital or caregiver policies (how flexible, family- or person-centered, how evidence-based).
• Psycho-emotional care (the priority given to non-medical aspects of the childbirth experience).

The focus of Simkin's Labor Progress Handbook is on prevention, differential diagnosis, and early interventions to use to prevent labor dystocia. We emphasize relatively simple care measures and low technology approaches designed to help maintain normal labor progress, and to manage and correct minor deviations before they become serious enough to require technologic interventions. We believe this approach is consistent with worldwide efforts, including those of the World Health Organization, to reserve the use of medical interventions for situations in which they are needed: "The aim of the care [in normal birth] is to achieve a healthy mother [birth parent] and baby with the least possible level of intervention that is compatible with safety."4

The suggestions in this book are based on the following premises:

• The timing of dystocia is an important consideration when establishing cause and selecting interventions.
• Sometimes several causal factors can occur simultaneously.
• Clinicians and caregivers are often able to enhance or maintain labor progress with simple non-surgical, non-pharmacological physical, and psychological interventions. Such interventions have the following advantages:
  • Compared to most obstetric interventions for dystocia, they carry less risk of harm or undesirable side effects to laboring person or fetus;
  • The laboring persons is autonomous with the right to accept or refuse interventions. These suggestions treat the laboring person as the key to the solution, not part of the problem;
  • They build or strengthen the cooperation between the laboring person, their support people (loved ones, doula), and their clinicians;
  • they reduce the need for riskier, costlier, more complex interventions;
  • They may increase the person's emotional satisfaction with their experience of birth.

• The choice of solutions depends on the causal factors, if known, but trial and error is sometimes necessary when the cause is unclear. The greatest drawbacks are that the laboring person may not want to try some interventions; they may take time; and/or they may not correct the problem.
• Time is usually an ally, not an enemy. With time, many problems in labor progress are resolved. In the absence of medical or psychological contraindications, patience, reassurance, and low- or no-risk interventions may constitute the most appropriate course of management.
• The clinician may use the following to determine the cause of the problem(s):
  • Objective data: vital signs; fetal heart rate patterns; fetal presentation, position, and size; cervical assessments; assessments of contraction strength, frequency, and duration; membrane status; and time;
  • Subjective data: person's affect, description of pain, level of fatigue, ability to cope using self-calming techniques:
  • Essential components:
    • - Attentive listening
    • - Informed consent and refusal
    • - Shared decision-making with the laboring person

Chart 1.1 illustrates the step-by-step approach followed in this book-from detection of little or no labor progress through graduating levels of interventions (from simple to complex) to correct the problem.

Chart 1.1. Care plan for the problem of "little or no labor progress."

If the primary physiologic interventions are contraindicated or if they are unsuccessful, then secondary-relatively low-technology-interventions are used, and only if those are unsuccessful are tertiary, high-technology obstetrical interventions instituted under the guidance of the physician or midwife. Other similar flow charts appear throughout this book showing how to apply this approach to a variety of specific causes of dysfunctional labor.

Many of the interventions described here are derived from the medical, midwifery, nursing, and childbirth education literature. Some of the strategies described in this book lend themselves to randomized controlled trials, others do not. Others come from the psychology, sociology, and anthropology literature. Suggestions also come from the extensive wisdom and experience of nurses, midwives, physicians, and doulas and other labor support providers. Many are applications of physical therapy principles and practices. The fields of therapeutic massage and chiropractic provide methods to assess and correct soft tissue tension and imbalance that can impair labor progress. We have provided references for these, when available. Some items fall into the category of "shared wisdom," where the original sources are unknown.

During the past half-century, extensive scientific evaluation of numerous entrenched medical customs, policies, and practices, intended to improve birth outcomes, has determined that many are ineffective or even harmful. Routine practices, such as enemas, pubic shaving, routine continuous electronic fetal monitoring, maternal supine and lithotomy positions in the second stage of labor, routine episiotomy, immediate clamping of the umbilical cord, routine suctioning of the newborn's airway after birth, and separation of the newborn from parent/s are examples of care practices that became widespread before they were scientifically evaluated. Scientific study now shows that these common practices were not only ineffective, they increased the risks for the birthing person and neonate.5

Other valid considerations, such as the laboring person's needs, preferences, and values, also play a large role in the selection of approaches to their care. Our paradigm is one of respectful maternity care, although we recognize that throughout history and around the world, laboring people have been subject to racism, sexism, gender discrimination, disrespect, and other abusive and harmful behaviors. It is our expectation that laboring people are treated using a respectful maternity care and human rights model.

Racism and white supremacy are pervasive in obstetric care. Scholars have identified that many of the people identified as early founders of obstetrics and gynecology learned their skills through experimentation, coercion, and abuse of black, brown, and poor birthing people.6 Therefore, in this book, we will avoid using the names of those early experimenters in favor of descriptive terminology, for example, left side lying, or runner's lunge for the position formerly called by a gynecologist's name. Additionally, for one hundred years, nurses, midwives, and physicians were taught a system of pelvic classification with the aim of predicting difficult births that was overtly racist, and based only on pseudoscience.7 Therefore, in this book, we recognize that humans and pelvises are dynamic, and there is not one perfect pelvis. Rather, our goal...