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Welcome everyone. I'm Rigid Maloney.
And I'm obstetrician doctor Patrick Maloney, and a.
Big thank you for all of our returning listeners. We've got so many listeners that tell us at there hang out every week to hear our voices.
We've been listening since the start, which is awesome.
Yeah, which is nearly This is our sixth year, pat fantastic. We did have one whole year off in twenty twenty.
Two pulled our feet up, but apart from that, yes, so there's quite a lot of back episodes now and it's just terrific that sometimes people find us and binge the whole lot, and some people have been listening all along, yes.
And I know that we might have some new listeners. So perhaps for a little bit of context, let's just give a quick overview of who we are about that perfect all right, I'll start you start, okay, good, Well, we are husband and wife, we have four boys, and we run a women's clinic in our hometown, which is be At Women's Clinic. And in the clinic we've got a couple of O and g's, which are obstricians and gynocologists. That's what Australians call obstrican and gynecologists want.
Obbgyn Lots of people listening in America. We love that. Yeah, yeah, we love Americans. But yeah here called O and g s. Yeah yeah.
And sometimes we talk about well I talk about my full births, so just to put that into context for people, My first birth was an emergency cesarean. This was before I met doctor Pat. The next one was a vback which didn't work, another cesarean, and then in twenty twelve I met doctor Pat and I had two planned cesareans. So sometimes we talk about that and people might be going on a minute like how does that all fit in but you know, it's just so fair.
That's your story, that's our story.
Yeah. So for new listeners, that's us. So we are so thrilled to have you on board.
It is terrific that you're listening, that you are engaging in this super important area and an area that really grabs the interest and focus and imagination of people who are pregnant, perhaps for the first time, perhaps for the second or third time.
Yeah, and I know we have a global audience. Primarily obviously we talk about Australian obstetrics, but you know, pregnant people are pregnant people. Yeah.
Yeah, it's a new universal human experience that's the same the world over, give or take some slight differences in international systems testing the way things are done, but obviously the process itself is same around the world.
Yep. Great, all right, Well, I hope that helps people that are new to us and welcome a big, big, big welcome, thanks for joining us.
What are we talking about today?
Well, we want to talk about a labor that's stalled.
Okay, good, yep.
So I think maybe let's start by defining what part of the labor we're talking about.
It's important that we that we sort of have some sort of understanding about how this works, because it might be very relevant not only to the management of that situation on that day, but future pregnancies and so forth. So if the labor has stalled, there was a sort of the old fashioned term of failure to progress is a bit unfortunate because it includes that failure word. It makes it sound like it's somebody's fault. And so we've kind of moved away from that into ideas into terms
such as non progressive labor. And it could basically it happened at any stage. It could be that the labor never really gets up and going waters break, nothing happens, and then we try and perhaps intervene to bring the labor on and maybe it just doesn't happen, or more commonly, it does start up, cervix does start to open, and at some point the progress is stalled.
Yep. And this is this sort of starts being measured in active labor.
Yeah, it's a good idea to measure the progress to a certain degree, just to make sure that things are moving in the right direction. But there's some debate as to exactly how fast it's supposed to go and exactly where the sort of goalposts is supposed to be to say that's too slow.
Yep.
Then there's some difference of opinion on that.
Yeah, and I really want to get into that.
Yeah, so we will get into that the boat. There's some universal truth that when labor gets up and going, that it should remain somewhat progressive from that point. Yeah.
So we're not talking about when someone may be at home just having sort of niggles, not quite sure whether they're in. Yeah.
Yeah, that's exactly what we're not talking about. And it's super important to know that that that to not be progressing at that stage is perfectly normal.
Yeah.
So so it's not like the cervice starts to open with the first painful contraction and it keeps going at once and any and now from then on. That's that's not right. And there are several hours, sometimes days of relative inactivity of the cervix at the very very start, when we're in that latent phase of of something's happening, but we aren't cooking along yet having regular painful contractions that open the service.
All right. So that's that's what defines this active labor is and when when kind of you go on the clock, let's say.
A little bit. Yeah, so we when we get in to active labor, having regular painful contractions that are opening the cervix, then a degree of forward progression from that point onwards. Is why a question is what counts as normal and what doesn't.
Yeah, what do people tell you that those painful contractions feel like? And what as an obstration are you looking for in those painful contractions.
Yeah, it's a good question because it varies enormously from woman to woman and pain tolerance to pain tolerance and so forth. What most people will tell you is that if they've been through a period of latent phase where they're getting some tightenings, some painful contractions at home, and then later come into the real deal, they can tell
you in hindsight that it's very different. Yeah, that the pain is worse, that the intensity is much stronger, and they can tell you eventually that Okay, once I hit three or four centimeters and really started to cook along, then that was very qualitatively different to the contractions at home, you know, six hours ago.
Yep. Now, in my first labor, I had a very wishy, washy sort of stalled labor, and my contractions happened a lot, but weren't useful. I know that I'm degrading myself here that they were useful, but you know, they just weren't going anywhere. So it's it's time and pain, is it? Like, how can you tell a good contraction?
Well you really can't, and so that because there's such variation between what people are experiencing. So so it's terribly, terribly painful. It must be doing something. Sometimes people look at that at a ctging a fiddle heart rate trace, and it can show that there's a great big loop in the in the trace at the time of a contraction, and that just tells you that there is a contraction.
It's not a measure of intensity. Oh god. So on that piece of paper coming out of that machine, if it looked like a really big deviation, that just means that the belt around your tummy's a bit tight, and if you loosen off the belt a little bit, it'll look like a little bump on the trays. So it doesn't measure intensity. It just says whether there's a contraction or not.
Oh my god, that is just like a light bulb moment for me, because in my v back I had to wear a CTG the whole time. Sure, and I thought I was having these big, massive contractions and I was really proud of myself because I couldn't feel it.
Yeah yeah, right, well there you go. So it was just saying that there's a contraction there, because when your uterus contracts, it changes the attension on that belt around your tummy, and the machine can pick that up, but it can't tell you how strong the contraction is, just whether it's there or not. So the whole point is we don't know. And this is why if someone appears to be in good labor, there's some value in internal examinations because nobody loves to stay in that latent phase forever.
And it's very common for someone to say, well, I'm getting a lot of paint and I'm still clearly in Latin face. It's not kicking on. You know, how long do I have to put up with this? So eventually we you know, we are in discussion with the with the woman, we might perform a vaginal examination to say is the cervice opening or not, And if it's getting to the point where it is opening, then to a certain degree, the whole it's it's hard to avoid the
concept of being on the clock from then on. Yeah, because once the service starts to open, we are looking for forward progress from that point on.
Yeah. Yeah, and sort of what what time frame like it might be worthwhile for our listeners to sort of talk about the timeframes that you're looking for in an active labor.
Yes, sure, so, so what we might do if we'd established that the cervix was definitely starting to open would be to talk to that about that woman at that point about to confirm her plans, her desire for to just wait and let the situation progress entirely naturally or or whether there's whether there's room or need or evidence for intervention, and then, assuming everything's fine, check again four hours later.
And so for first time berths, I know that they're a little bit different in terms of the active labor stage than second time. How many hours for the whole active labor phase is what an obstric or a midwife is looking for in first and second time births or subsequent births.
Yeah, sure. So again, there's some variation in opinion on this, but I would think that it would be safe to say that if that once the labor is active enough that the woman is having regular painful contractions and the cervix has started to open, then it's reasonable to expect half to one centimeter of progress per hour from that
point onwards for someone happened there first baby. And we'll get in a little bit later into the different ways of measuring that and the evidence behind that being reasonable progress. But that would be the sort of progress that we would really like to see. It doesn't mean that if that progress is not there, we give up and do a section or something. No, there are ways of intervening to assess that or and there's some flexibility in waiting
if mother and baby are well. For second and subsequent babies, that's very different, so there's a lot more variation and when. Whereas the progress for our first time it tends to be somewhat linear, the progress for a second and subsequent tends to be sort of nothing, nothing, nothing, nothing campower. Yeah, so you can have a very little change in the cervix and then when the labor really really kicks in, you could go from three centimeters to fully dilated in one hour very easily.
Yeah. Well, okay, so why did we start timing this fas?
Yeah, that's a really good question. That dates back to observations made in the I guess the early part of the twentieth century when they started to apply some scientific principles to the concept of labor and birth. And that's because in a lot of the world, the outcomes were pretty poor for a natural physiological process, and the number of women and babies not surviving the process of childbirth was unacceptably high, and in parts of the world that's
still somewhat true. So they started to look at the process and one of the first things that they really observed was that was that labors that took way too long had the poorest outcome. So then for better or worse, they started to say, what can we do about that?
That idea that the progress should be half to one's ameter an hour, that's called a Freedman rule, named after doctor Friedman who who first described that, and it led to an understanding amongst medical care as in the birth space, that there should be some a quantifiable progress of about
that amount in a healthy labor. And a common criticism of that is that it probably made too many rules, too narrow a definition of normal progress, and probably too much intervention in labors that might have been normal but slow.
And I did read in that was in nineteen fifty five, and the people that he studied were presumably white women in their twenties who were thinner. Yeah, yeah, a bit different from the cohort today. So does that make any difference.
Well, I think it would probably make a huge difference. So if he was studying a very healthy cohort of thin, healthy young women, then firstly they would have been more likely to labor well in the first place, and then the ones that didn't were a more obvious outlier who probably had a more genuine problem. He wasn't dealing with the same cohort that we're dealing today, when the first time is older and heavier, and where there are more proven,
justifiable indications for induction of labor. Oh yeah they're so. You know, the data for induction of labor for severe obesity very strong. You are better off if you're severely OBEs, give or take. With a term induction. There's more gestational diabetes, yes, so more people being induced. And that's that's where we're perhaps not comparing apples with apples between that even cohort and today. But for all the criticisms of making rules about labor supposed to go this fast, It should go
this fast. One thing they did achieve were colossal improvements in safety, yeah, for women and babies by applying some scientific principles to the birthing process throughout the developments that were made in the twentieth century.
Because it is still a criticism today that you know that births monitored too hard and then decisions to intervene it made too fast. But there was another person that studied it later, isn't it doctor Zang in twenty ten.
Yeah, this is interesting. So that the Zang approach was to say, was to try and make a new partogram and a new way of assessing labor, a progressing labor that allowed for the different curves between first birth and have latent progress at the start active progress at a certain point. And they were hoping that that that new way of analyzing normal progress might have created a new safety pathway that was that would result in less intervention
and in particular less Toeserian sections. And I think that way of looking at it does take into consideration the actual physiological process of normal first birth and certainly the normal physiological birth progress of second and subsequent births, But unfortunately it hasn't led to fewer interventions, and it hasn't led to fewer cerian sections, and you know, that's a bummer.
It would have been really nice if it did. But what I think it's highlighted is that there's a signific that there is benefit in understanding the physiological process as best we can before we start putting limits on it and saying what's normal and what's not.
Yeah, and not being so heavily protocolized and saying, Okay, so that woman came in at this time, and therefore we expect her to have done got to ten centimeters dilated in eight hours time. Whatever.
Yeah, that's right, because what I think the holy grail of modern obstetrics is that we should be trying to be, you know, as cautious as we can about unnecessary intervention, but also practicing obstetrics in a way that maintains the safety gains, Yeah, that were achieved in the twentieth century. Do we go backwards in safety? And I think that's how that's our big challenge, how to keep the safety and the awesome outcomes in the developed world without overdoing intervention.
Yeah, all right, So I think this part of the podcast has all been for perhaps birth care workers themselves and women who are really motivated to find out the nuts and bolts. And we've got a lot of people that like to hear all.
That our if anyone's new to the podcast our a lot of our listeners don't shy away from the nitty gritty Yeah that's right. Yeah, and they're actually listening to hear an expert and experienced medical practitioners view. But we try not to give only that.
Yeah. So what we're going to move on to is for those people who either had a birth where the labor stalled and then all this intervention happened and they want something to explain that, or someone that's going into a berth and what should they expect labor has still confirmed stalled label? Are you? Are you worried about the progress being too so or a stored labor.
More installed labor more? But if we you know, if we're thinking about not just identifying that, but to sort of say that personal we ender next, this is where we have to stop, take a big breath and try and take a whole woman and baby view of what's going on and why and why this appears to have happened, right, And one of the dangers of an entirely protocolized flow chart approach is that you might say, oh, well, this lady was four centimeters at three pm, and she's still
four centimeters at seven pm, and yet she's been having regular painful contractions that whole time. What are we going to do? Okay, well, we'll break the waters and put up some sintost on try and push her along harder, But there may be limited benefit of doing that if she's already been having terrifically strong contractions. So we might say, well, hang on a minute, what's what appears to be the problem here? And you take a step back from the end of the bed and you can see that, hang on,
this appears to be enormous baby. Yeah, petite woman, Maybe this is a square peggan a round whole problem, and this boast to be to fit out. So we have to sort of have it at least a go at assessing, at least an attempt at assessing why the problem might be happening, and then making a sensible suggestion of an intervention based on what we think the problem is. Yeah, and this is where obstetrics is a little bit of
science and a little bit of art. Sometimes you can tell from experience that, Okay, here's a problem that I think we can fix by improving the contractions, and here's a problem that perhaps I don't. I think we can't fix it all.
So big baby or and small palvis, those things you sort of you probably have an idea about the big baby before the labor, but you wouldn't know what the size of that woman's palvis.
Some people think that they can tell we're looking at the woman on the outside. Yeah, but if you look at someone's hips on the outside, that's just a bony part of their hips. You can't see the inlet where the baby comes down, So we don't know how white that is at all.
Yeah, And I have a sister who's twelve years older than me. I should know off the top of my head, but I don't. And back in her day, they would take X rays of pelvis's. She had an X ray of her pelvis to see whether her pelvis was too small.
Yeah, right, so that yeah, so the old that's the old pel vimetry. And it didn't work. No, Yeah, as a science it didn't hold up. Yeah, yeah, all right, it didn't take into consideration stretching of the pelvis, squishing of the baby's head and so forth. Yeah, so we don't do that anymore. Yeah, not to mention, you're given a baby an X ray.
Yeah, oh that's right. So you've talked about somebody that's having what you see as good contractions, what's another reason why they may not be progressing?
So a lot of this, most of this perhaps is male position of the fetal head, so that the baby is just not in a good position to be coming down with its chin tuck down against the chest and the small diameter of the baby's head presenting down into the pelvis.
Yeah.
Remember, a baby's head looks more like an Australian football which is oval shaped than a than a than a socer ball of the football whether it's round and so it's got a long diameter and a short diameter, and the baby wants to be tucked in so that the small, the small aspect of the head is presenting down into
the pelvis. So if we think that's the problem to a certain degree, that can be assessed by vaginal examination, by external examination, and sometimes by ultrasound examination, and then in for example, the example I mentioned before where where the woman might be having terrific contractions but the progress
is not there. Then on vaginal examination we may also be able to find through the partially dilated cervix that the baby's head is developing what's called capput, which is like swelling around the head or molding where the bones
of the head seem to be overlapping each other. And if we're in a position where we think there's a lot of capput and molding the and the there's no progress, then that may be an uncorrectable situation that definitely needs a Caesarean section on By contrast, we might have somebody who's made very little, very little progress over four hours, but the contractions have been a bit ordinary, and on
examination there's no cap, but there's no molding. The fetal position looks good, and the problem seems to be the power of the uterus to push babia. Well, in that situation, we might be very wise to break the walls, put up some sintosinon and improve the quality of the contractions, and that could put the whole thing back on track.
Yeah, that's an equals one, but that's what I wish had have happened in my first birth when you weren't around, pat.
Where were you? Well, yeah, that is a danger of a very hands off approach, and there are some people who really come into that first berth fully wanting a hands off approach, entirely hands off approach, but perhaps not understanding the benefits of a hands on approach if the progress is poor.
Yeah.
Yeah, So sometimes people are very surprised to hear that they may benefit from intervention. Yeah, which is really strange because I don't know why intervention would ever have been invented if it wasn't with benefit in mind.
Yeah.
Yeah, So we we've lost a sort of educational battle there as obstetricians, because if intervention is seen as as as such a problem and only a cause of problems, then we then we've we've failed in the task of
educating people about the potential benefits. So, for example, if someone's having a labor where they're clearly cracking along listening to the fetal heart after every contraction, baby is totally happy, woman's huffing and puffing gets to fully dilate and push the baby out, what are we going to inter intervened in that late before entirely are necessary, and in fact,
interventions in that labor could only cause up. But if somebody's labor is stuck at force entemes over six seven, eight hours, intervention is only going to help that person get that labor back on track and get to their original goal, which was a vaginal birth.
Which kind of the first vaginal birth does help to set up your second and subsequent births as well, doesn't it, you know entirely?
Yeah, yeah, so if we look at the whole situation, not just for that birth, but over the woman's obstetric lifetime, then some judicious, judicious intervention to get that labor back on track. If that results in that baby born being born vaginally, then give or take, the other babies will come vaginally as well. Yeah. The clincher is the is the mode of delivery the first baby.
I want to go back to the intervention that you may use. If there is mele positioning of the baby's head, is there anything else you can do or can You only have to wait until it gets in the actual birth canal and the pushing phase to perhaps tuck the head in.
And yeah, interventions to improve that tend to be focused on before full diletation, then they're focused on the fact that if you improve the contractions in a lot of cases, then the uterus will push their head down better, and the pelvic floor is shaped in such a way that it usually but not always or will get the fetal head in a good position. So the interventions before full didtation are usually focused on improving the strength and efficiency of the contractions.
Yea.
If someone's at full diletation and the heads are way down and the head's not pointing in the right direction, there are some interventions that can correct that with the use of force us and vacuums, but that's a different subject in.
Different episode topic.
Yeah.
Good, all right, So we've talked about the tools in your toolkit. The obstrics talk it if there's intervention, So just to recap, it's breaking the waters.
Yeah, that seems to help in itself improve the quality of contractions, probably by removing the water that's between the head and the cervix and letting the head push more effectively against.
The putting up a sintosinin drip.
Yeah, so careful and safe in judicial use of sintocinon to make the contractions come more strongly and efficiently try and get up to contractions that last at sixty to ninety seconds four to five in ten minutes.
What about I know we've talked about previously. Sometimes an epidural can do the opposite of what we all think, and that is that it can if at that stage it can help someone relax.
There's a few schools of thought on how epidurals will work. Will work, I mean, they take the pain of way, that's brilliant, But how do they work to make labors seem go better? Seem to go better, certainly achieve a state where because the pain's gone. If we're using sintosinon, we can use more, but we can use enough to get contractions that are longer and more frequent, and that can put a labor back on track. And that's easier to do if by blasting that sintosin on you are
not causing the woman excessive pain. Then there are some abnormalities of a fetal heart heart rate trace, which for example, the fetal heart rate appearing to go too fast, which you might see if the woman's heart rate is going too fast, which you might see if she was excessively stressed or in pain, and so you can use any in that situation to in a sense or relax the
woman and things that seem to go better. And lastly, of course the epi can be used to sort of block some of the pain of painful painful interventions that might be done at full dilatation. Now, these are all of the ways in which an eppie might actually improve your chances of having a vaginal birth. Again a controversial statement. It's not what people expect to hear. Because we know that there are some issues with using an epidural and
then requiring more intervention. There are just as commonly some situations where the careful use of an epidural might get you might help you to get to full dibertation in the first place, which, in fact, which kind of gets you to the starting line of a vaginal birth. And if had you never had that epidural, you may have had a section for various reasons. So there aren't bad tools,
they're just bad ideas. And the right tools used at the right time may actually get us back on track and back on track for the desired vaginal birth.
One other thing, you know, it's always these are what happens to a woman. But there's things that she can do as well, Like she can move, ye, yeah, change positions. Listen to what the midwife's saying about. You know how you've been on your back for a long time. How about we swap it around and get back on her swiss ball or you know, if she's been in the bath forever, like, maybe it's time to get out of that bath and how about we stand for a little bit or have your partner support you.
Absolutely, we know that changes in position can certainly help at full dialtation to get to a point where you develop an irresistible urge to push. Whether changes in position are very important during the dilating phase of the cervix first stage of labor is less clear, but we think that for as long as possible, being mobile helps.
It also helps from a psychological point of view. I think you know, it makes you feel like you're doing something and.
It's a long time right. Yeah, it's very very unusual that we would spend ten to fifteen hours in one room in one place.
I think that that is all I wanted to ask you about if a labor stalls. If we haven't actually answered your question about a stored labor, we're still here. Pop it on the speak pipe. I think that would be a really great idea and just say, hey, what about in this situation if I was to do blah blah.
We love those questions, yeah, or or tell us about your labor did this and that stopped? What was that all about?
Yeah?
Because it's common for me to meet people who've had a labor that didn't do what they wanted it to do the first time around, and they still have an incomplete understanding of that a couple of years later when they're ready to have another baby. So you know, if you've got a story and a question, we'd be keen to hear it.
All right, everyone, Well that's it for this week. I hope you've enjoyed this episode and if you enjoy the type of education that we provide any free podcast, you might also enjoy the free newsletter, which is a week by week newsletter which marries up with your week of pregnancy and that can lead to our program which is a more in depth discussion on each topic as well.
So all of that can be found at our website which is grow Mybaby dot com dot au, or just pop into the show notes in either past Apple Podcast or Spotify, and the links will be all there. We hope that you have a wonderful week and will be in your ears next week.
Thanks for listening, everybody, Bye for now.