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Caregivers will vary in their definition of dystocia and whether or not a cesarean is needed. Some
cesareans are performed when the cervix has dilated to only 1 or 2 centimeters others after 10 cm. Most experts today
suggest that for first labors, a cesarean should not be performed for dystocia before the cervix has dilated to 3 or 4cm and
has effaced (thinned out) almost 100%. For mothers who have labored before, it's 4 to 5 cm and 80% effaced.
A study of over 700 women who gave birth
by unplanned cesarean in 30 Los Angeles County and Iowa hospitals
between 1993 and 1994 found that contrary to ACOG (American
College of Obstetrics and Gynecologists) recommendations,
nearly one-quarter of the operations were performed too early
for lack of progress. The women had a cesarean when cervical
dilation was 0 to 3 centimeters. Physicians either disagreed
with recommendations made by ACOG or interpreted them differently.
Researchers suggests that physicians may be more comfortable
with the risks associated with labors that do not progress
as rapidly as expected. (Gifford, et.
al. 2000. Obstetrics and Gynecology)
Many women worry that if the once had a
cesarean birth because labor did not progress or the
baby was too big they may not be able to labor for a VBAC.
Studies show the the majority of women who had a cesarean
for lack of progress do have a vaginal birth next time. Sometimes,
the VBAC baby weighs more.
The Society of Obstetrics and Gynaecologists
of Canada states that "the slightly lower level of success
of VBAC following a primary Cesarean section for dystocia
as compared with breech, may be more a reflection on the attitude
of the women and her caregivers than of uterine function."
ACOG and the SOGC state that measuring the
size of the pelvis and the fetus by ultrasonography in the
third trimester to see if the baby will "fit" is
not a reliable predictor of which women will and which won't
be able to give birth vaginally. (ACOG
and
SOGC [acrobat
pdf]
guidelines)
The factors that influence labor progress
and complex and include: the laboring woman's physical and
emotional status; the position of the fetus in the pelvis;
use of medical interventions and anesthesia; time limits placed
on labor progress; a woman's ability to change positions and
walk around in labor; availability of social support; the
quality and adequacy of nursing care.
Laboring after a prior cesarean for "lack
of progress" when any one or more of these factors may
be different may make a difference.
The Society of Obstetricians and Gynaecologists
of Canada (SOGC) recommend the following as clearly beneficial
in avoiding or treating dystocia:
- It is best to avoid an induction when there is no medical justification.
- If induction is necessary, prostaglandin E2gel* is preferable to oxytocin to ripen the cervix.
- Women should be encouraged to use upright postures in the first stage of labor.
- Women who choose to have an epidural should have a low dose which provides efficient pain relief with minimal motor block.
- During the pushing stage, there should be no time limits set if there is progress and the baby's heart rate not compromised.
*Induction or augmentation of labor with agents such as pitocin,
Prostaglandin E2gel or misoprostol has been associated in
some studies with an increased risk for uterine rupture. Women
are encouraged to discuss the options carefully with their
caregivers.
Recommended Reading
The Labor Progress Handbook by Penny
Simkin and Ruth Ancheta.
Blackwell Oxford: Blackwell Science, 2000.
Understanding and Teaching Optimal Foetal
Positioning by Jeane Sutton and Pauline Scott. Tauranga,
New Zealand: Birth Concepts, 1996.
Mothering the Mother by Marshall
H. Klaus, John H. Kennell, and Phyllis Klaus. New York:Addison-Wesley,
1993.
Dystocia and “Failure to Progress”
in Laboby Emanuel a. Friedman in Bruce L. Flamm and E.J. Quilligan,
Editors, Cesarean Section: Guidelines for Appropriate Utilization.
New York: Springer-Verlag, 1995.
(DONA) Doulas of North America's Position
Paper: The Doula's Contribution to Modern Maternity Care,
1998. www.dona.org
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