How to Keep Normal Labor Normal – Part 2 – The Costs of Abnormal Labor

This blog series is designed to help women who are developing a birth plan join together with like-minded birthing professionals so as to have a shorter and safer labor and birth. Today we’ll look at the costs of “abnormal labor.” Although written primarily for professional birth attendants, I hope information will be helpful to lay women planning their birth.

The medical literature has many, many articles that discuss the potential risks and costs for not keeping normal labor normal; including:

  • increased dystocia (dysfunctional, abnormal labor),
  • increased fetal distress, and
  • the increase in unnecessary operative deliveries.

(1)  Increased dystocia

Although, “… dystocia has remained a poorly defined term,”(1) for the purposes of this paper “… dystocia is divided into two major categories.

The first category of dystocia, true cephalopelvic disproportion, is characterized by failure of descent of the head after complete dilation and includes the diagnosis of persistent occiput posterior.

The second category, inefficient uterine action, is defined as failure of the cervix to dilate (<1cm/h with no more than 7 contractions per 15 min) and the head to descend … (and) is divided into four subcategories:

  1. unsuccessful attempt at induction,
  2. error in the diagnosis of labor (defined as regular painful uterine contractions that are accompanied by one or more of four additional criteria:
    • dilation,
    • effacement in primiparas,
    • rupture of the membranes, and
    • loss of the mucous plug or bloody show(3)),
  3. inadequate response to treatment, and
  4. oxytocin not given.”(2)

Undoubtedly “ …the most significant step toward a solution to the problem of dystocia … has been the recognition of certain fundamental differences between nulliparous and parous women…”(3) and recognizing that dystocia can be caused by certain management practices.  However, “… lack of objectivity (in defining dystocia) may result in variations in practice patterns seen for dystocia.”(1)

Preventing dystocia will, by definition, help keep normal labor normal.

(2)  Increased fetal distress and “fetal distress”

To diagnosis fetal distress when it does not exist is not in the best interest of the laboring woman.

“Like dystocia, fetal distress has remained a poorly defined term.”(1) Surgical or operative intervention “for the diagnosis of ‘fetal distress’ appears to vary depending on institutional and other nonclinical factors,”(1) and “…the observation that cesarean deliveries for ‘fetal distress’ peak during nighttime hours raises the possibility that the interpretation of fetal monitoring tracing is influenced by physician and patient fatigue or other clinical factors.”(1)

Much reliance for the diagnosis of fetal distress has “been placed on the interpretation of fetal monitor tracings, which has been shown to have great interrater variability.”(4) This has caused some to critically question the routine use of continuous electronic fetal monitoring (EFM).(5-13)

“Of concern is not only the lack of benefit (of EFM) to women in labor, but also the high false-positive rate of electronic recording resulting in more diagnosis of ‘fetal distress’ and increased intervention in labor, including cesarean section.”(13)

Clearly, preventing true or false fetal distress will, by definition, help keep normal labor normal.

3)  Increased cesarean delivery rate

There have been strong calls in the literature for physicians to improve their cesarean rates.(5,6,1326)

For example, “In the US in 1992, 22.6% of deliveries were C/S (of 3.97 million births). The projected optimum would be 5-12%, and in 1992 only 90 hospitals in the US were <15%: 35% (were for) previous CS (50-55% should be VBAC, instead of 25.4%), 34% (for) dystocia (abnormal progress in labor), 12% breech (version should work about 66%), 9% “Fetal distress” (50-90% reduced with intermittent auscultation).”(14)

If these projections are correct, keeping normal labor normal by avoiding, as much as possible, dystocia and false diagnosis of fetal distress could reduce cesarean rates by 20 – 40%.

In the US, the cesarean section rate is “iatroepidemic”(17) according to Emanuel Friedman, MD, who says, “physicians should be forbidden to do a cesarean in the latent phase of second stage labor … 70% of cesareans are unnecessary for women with protraction disorders and 50% are unnecessary for arrest disorders.”(17)

Others would say, “The most common indication for a first cesarean section is dystocia (difficult or prolonged labor), which accounts for about one third of all cesarean sections in the United States, approximately twice as high a rate as in other countries with similar medical care systems.”(15)

With labor dystocia, “…provider, payer, and institutional biases have been implicated in causing variations in cesarean delivery rates.”(1,22,23)

“There is general agreement that a solution to the problem of dystocia would go a long way toward resolving the contentious issue of high cesarean birth rates.”(2)

In addition to dystocia, “…cesarean delivery for fetal dystocia is responsible for some of the increase in cesarean section rates.”(1,24,25)

Mortimer Rosen, MD points out, “Managing labor is still an art…the rising cesarean rate suggests that the art of patient care may be in jeopardy.”(17)

Here’s the entire series:

  1. Philosophy,
  2. Partners,
  3. Professionals,
  4. Pain control,
  5. Procedures,
  6. Patience,
  7. Preparation,
  8. Positions,
  9. Payment, and
  10. Prayer.
    (1) Hueston WJ, McClaflin RR.  Variations in cesarean delivery for fetal distress. J Fam Pract 1996;43:461-7.
    (2) Byrd JA, Lytton DE, Vogt SC, et. al.  Diagnostic criteria and the management of labor. J Fam Pract 1988;27:595-599.
    (3) O’Driscoll K, Foley M, MacDonald D.  Active management of labor as an alternative to cesarean section for dystocia. Obstet Gynecol 1984;63:485-490.
    (4) Tussing AD, Wojtowycz MA.  Health maintenance organizations, independent practice associations, and cesarean section rates. Health Serv Res 1994;29:75-93.
    (5) Smith MA, Acheson LS, Byrd JA, et. al. A critical review of labor and birth care. J Fam Pract 1991;33:281-292.
    (6) Cibils LA.  On intrapartum fetal monitoring. Am J Obstet Gynecol 1996;174:1382-9.
    (7) Paneth N, Bommarito M, Stricker J.  Electronic fetal monitoring and later outcome. Clin Invest Med 1993, Apr 16:159-65
    (8) Rosen MG, Dickinson JC.  The paradox of electronic fetal monitoring: more data may not enable us to predict or prevent infant neurologic morbidity. Am J Obstet Gynecol 1993;168:745-51.
    (9) Sandmire HF.  Whither electronic fetal monitoring? Obstet Gynecol 1990;76:1130-4.
    (10) Snydal SH.  Responses of laboring women to fetal heart rate monitoring. A critical review of the literature. J Nurse Midwifery 1988;33:208-16
    (11) Prentice A, Lind T.  Fetal heart rate monitoring during labour–too frequent intervention, too little benefit? Lancet 1987;2(8572):1375-7.
    (12) Neilson JP. EFM vs intermittent auscultation in labour. [revised 04 May 1994] In: Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. Available from BMJ Publishing Group, London.
    (13) Scherger JE.  Management of normal labor and birth. Primary Care 1993;20:713-719.
    (14) Horton R.  Unnecessary caesarean sections in USA. Lancet 1994;343:1351-2.
    (15) Paul RH.  Toward fewer cesarean sections: the role of the trial of labor (editorial). NEJM 1996;335:735-6.
    (16) Lumley J, Astbury J.  Birth rites, birth rights.  Sphere Books, 1980.
    (17) Young D. Crisis in obstetrics – the management of labor. Int J Childbirth Education 1987, August: 13-5.
    (18) Sakala C.  Medically unnecessary cesarean section births: introduction to a symposium. Soc Sci Med 1993;37:1177-98.
    (19) Sakala C.  Midwifery care and out-of-hospital birth settings: how do they reduce unnecessary cesarean section births? Soc Sci Med 1993;37:1233-50.
    (20) LoCicero AK.  Explaining excessive rates of cesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development. Soc Sci Med 1993;37:1261-9.
    (21) Burns LR, Geller SE, Wholey DR.  The effect of physician factors on the cesarean section decision. Med Care 1995;33:365-82.
    (22) Goyert BL, Bottoms SF, Treadwell MC.  The physician factor in cesarean birth rates. N Eng J Med 1989;320:706-9.
    (23) McCloskey L, Pettitti DB, Hobel CJ.  Variations in the use of cesarean delivery for dystocia: lessons about the source of care. Med Care 1992;30:126-35.
    (24) Placek PJ, Taffel SM. Recent patterns in cesarean delivery in the United States. Obstet Gynecol Clin North Am 1988;15:607-27.
    (25) Farrell SJ, Anderson HP, Work BA. Cesarean section: indications and postoperative mortality. Obstet Gynecol 1980;56:696-700.