WEBVTT - Why Did My Labour Stall? 0:00:00.080 --> 0:00:03.560 The information in this podcast is provided for education and 0:00:03.600 --> 0:00:07.560 research information only. It is not a substitute for professional 0:00:07.600 --> 0:00:08.280 health advice. 0:00:12.240 --> 0:00:15.320 Welcome to the Kick your Expert led podcast, helping you 0:00:15.400 --> 0:00:19.800 explore and learn everything about getting pregnancy, birth, and becoming 0:00:19.840 --> 0:00:20.240 a parent. 0:00:20.560 --> 0:00:24.280 On the podcast and our online pregnancy program grow My Baby, 0:00:24.520 --> 0:00:27.440 we share my experience of helping more than four thousand 0:00:27.520 --> 0:00:28.080 babies to. 0:00:28.040 --> 0:00:30.760 Be born and our experience of running a women's health 0:00:30.760 --> 0:00:32.479 clinic and parenting for boys. 0:00:32.720 --> 0:00:35.680 We're here to help everyone to feel empowered in pregnancy 0:00:35.840 --> 0:00:38.680 and birth with real life, practical information. 0:00:42.520 --> 0:00:44.840 Welcome everyone. I'm Rigid Maloney. 0:00:44.560 --> 0:00:47.959 And I'm obstetrician doctor Patrick Maloney, and a. 0:00:47.960 --> 0:00:50.959 Big thank you for all of our returning listeners. We've 0:00:50.960 --> 0:00:53.599 got so many listeners that tell us at there hang 0:00:53.640 --> 0:00:55.120 out every week to hear our voices. 0:00:55.160 --> 0:00:57.160 We've been listening since the start, which is awesome. 0:00:57.200 --> 0:01:01.520 Yeah, which is nearly This is our sixth year, pat fantastic. 0:01:01.600 --> 0:01:04.240 We did have one whole year off in twenty twenty. 0:01:04.000 --> 0:01:06.800 Two pulled our feet up, but apart from that, yes, 0:01:06.880 --> 0:01:09.959 so there's quite a lot of back episodes now and 0:01:10.040 --> 0:01:12.560 it's just terrific that sometimes people find us and binge 0:01:12.600 --> 0:01:15.280 the whole lot, and some people have been listening all along, yes. 0:01:15.360 --> 0:01:17.520 And I know that we might have some new listeners. 0:01:17.520 --> 0:01:20.600 So perhaps for a little bit of context, let's just 0:01:21.600 --> 0:01:24.600 give a quick overview of who we are about that 0:01:25.000 --> 0:01:28.880 perfect all right, I'll start you start, okay, good, Well, 0:01:29.560 --> 0:01:33.160 we are husband and wife, we have four boys, and 0:01:33.360 --> 0:01:36.280 we run a women's clinic in our hometown, which is 0:01:36.280 --> 0:01:39.640 be At Women's Clinic. And in the clinic we've got 0:01:39.720 --> 0:01:42.880 a couple of O and g's, which are obstricians and gynocologists. 0:01:42.920 --> 0:01:46.360 That's what Australians call obstrican and gynecologists want. 0:01:46.280 --> 0:01:50.400 Obbgyn Lots of people listening in America. We love that. Yeah, yeah, 0:01:50.440 --> 0:01:54.280 we love Americans. But yeah here called O and g s. 0:01:54.360 --> 0:01:55.520 Yeah yeah. 0:01:55.640 --> 0:01:59.200 And sometimes we talk about well I talk about my 0:01:59.560 --> 0:02:03.240 full births, so just to put that into context for people, 0:02:04.000 --> 0:02:07.760 My first birth was an emergency cesarean. This was before 0:02:07.840 --> 0:02:11.400 I met doctor Pat. The next one was a vback 0:02:11.560 --> 0:02:14.639 which didn't work, another cesarean, and then in twenty twelve 0:02:14.639 --> 0:02:18.680 I met doctor Pat and I had two planned cesareans. 0:02:18.960 --> 0:02:20.840 So sometimes we talk about that and people might be 0:02:20.960 --> 0:02:22.880 going on a minute like how does that all fit 0:02:22.960 --> 0:02:24.280 in but you know, it's just so fair. 0:02:24.320 --> 0:02:25.840 That's your story, that's our story. 0:02:25.919 --> 0:02:29.040 Yeah. So for new listeners, that's us. So we are 0:02:29.120 --> 0:02:30.520 so thrilled to have you on board. 0:02:31.720 --> 0:02:36.000 It is terrific that you're listening, that you are engaging 0:02:36.200 --> 0:02:41.040 in this super important area and an area that really 0:02:41.120 --> 0:02:44.920 grabs the interest and focus and imagination of people who 0:02:45.000 --> 0:02:47.079 are pregnant, perhaps for the first time, perhaps for the 0:02:47.160 --> 0:02:48.000 second or third time. 0:02:48.160 --> 0:02:51.680 Yeah, and I know we have a global audience. Primarily 0:02:51.720 --> 0:02:56.600 obviously we talk about Australian obstetrics, but you know, pregnant 0:02:56.600 --> 0:02:57.679 people are pregnant people. Yeah. 0:02:57.720 --> 0:03:02.080 Yeah, it's a new universal human experience that's the same 0:03:02.240 --> 0:03:05.360 the world over, give or take some slight differences in 0:03:05.360 --> 0:03:10.680 international systems testing the way things are done, but obviously 0:03:11.600 --> 0:03:14.800 the process itself is same around the world. 0:03:15.000 --> 0:03:17.440 Yep. Great, all right, Well, I hope that helps people 0:03:17.480 --> 0:03:20.120 that are new to us and welcome a big, big, 0:03:20.200 --> 0:03:21.560 big welcome, thanks for joining us. 0:03:21.600 --> 0:03:22.600 What are we talking about today? 0:03:22.680 --> 0:03:26.560 Well, we want to talk about a labor that's stalled. 0:03:26.960 --> 0:03:28.160 Okay, good, yep. 0:03:29.240 --> 0:03:33.000 So I think maybe let's start by defining what part 0:03:33.000 --> 0:03:34.200 of the labor we're talking about. 0:03:34.360 --> 0:03:36.160 It's important that we that we sort of have some 0:03:36.200 --> 0:03:39.360 sort of understanding about how this works, because it might 0:03:39.400 --> 0:03:41.840 be very relevant not only to the management of that 0:03:41.920 --> 0:03:45.600 situation on that day, but future pregnancies and so forth. 0:03:46.080 --> 0:03:49.800 So if the labor has stalled, there was a sort 0:03:49.800 --> 0:03:54.040 of the old fashioned term of failure to progress is 0:03:54.080 --> 0:03:56.760 a bit unfortunate because it includes that failure word. It 0:03:56.800 --> 0:04:00.600 makes it sound like it's somebody's fault. And so we've 0:04:00.680 --> 0:04:05.200 kind of moved away from that into ideas into terms 0:04:05.200 --> 0:04:09.320 such as non progressive labor. And it could basically it 0:04:09.360 --> 0:04:12.040 happened at any stage. It could be that the labor 0:04:12.200 --> 0:04:16.280 never really gets up and going waters break, nothing happens, 0:04:17.760 --> 0:04:21.800 and then we try and perhaps intervene to bring the 0:04:21.960 --> 0:04:26.279 labor on and maybe it just doesn't happen, or more commonly, 0:04:26.320 --> 0:04:29.320 it does start up, cervix does start to open, and 0:04:29.400 --> 0:04:32.080 at some point the progress is stalled. 0:04:32.560 --> 0:04:36.320 Yep. And this is this sort of starts being measured 0:04:36.520 --> 0:04:37.640 in active labor. 0:04:38.040 --> 0:04:40.479 Yeah, it's a good idea to measure the progress to 0:04:40.560 --> 0:04:42.920 a certain degree, just to make sure that things are 0:04:42.960 --> 0:04:44.960 moving in the right direction. But there's some debate as 0:04:44.960 --> 0:04:47.960 to exactly how fast it's supposed to go and exactly 0:04:48.000 --> 0:04:51.160 where the sort of goalposts is supposed to be to 0:04:51.240 --> 0:04:52.320 say that's too slow. 0:04:53.040 --> 0:04:53.240 Yep. 0:04:53.360 --> 0:04:55.360 Then there's some difference of opinion on that. 0:04:55.600 --> 0:04:56.919 Yeah, and I really want to get into that. 0:04:57.080 --> 0:04:59.880 Yeah, so we will get into that the boat. There's 0:05:00.120 --> 0:05:04.040 some universal truth that when labor gets up and going, 0:05:04.480 --> 0:05:07.719 that it should remain somewhat progressive from that point. Yeah. 0:05:07.720 --> 0:05:09.800 So we're not talking about when someone may be at 0:05:09.800 --> 0:05:13.080 home just having sort of niggles, not quite sure whether 0:05:13.080 --> 0:05:13.800 they're in. Yeah. 0:05:13.960 --> 0:05:16.160 Yeah, that's exactly what we're not talking about. And it's 0:05:16.160 --> 0:05:18.279 super important to know that that that to not be 0:05:18.360 --> 0:05:20.480 progressing at that stage is perfectly normal. 0:05:20.720 --> 0:05:20.960 Yeah. 0:05:21.600 --> 0:05:24.800 So so it's not like the cervice starts to open 0:05:24.800 --> 0:05:27.440 with the first painful contraction and it keeps going at 0:05:27.520 --> 0:05:29.360 once and any and now from then on. That's that's 0:05:29.440 --> 0:05:35.520 not right. And there are several hours, sometimes days of 0:05:36.880 --> 0:05:40.159 relative inactivity of the cervix at the very very start, 0:05:40.680 --> 0:05:44.440 when we're in that latent phase of of something's happening, 0:05:44.680 --> 0:05:48.200 but we aren't cooking along yet having regular painful contractions 0:05:48.200 --> 0:05:49.000 that open the service. 0:05:49.560 --> 0:05:52.920 All right. So that's that's what defines this active labor 0:05:53.200 --> 0:05:55.279 is and when when kind of you go on the clock, 0:05:55.640 --> 0:05:56.320 let's say. 0:05:56.240 --> 0:06:00.119 A little bit. Yeah, so we when we get in 0:06:00.120 --> 0:06:04.240 to active labor, having regular painful contractions that are opening 0:06:04.279 --> 0:06:08.080 the cervix, then a degree of forward progression from that 0:06:08.080 --> 0:06:11.120 point onwards. Is why a question is what counts as 0:06:11.120 --> 0:06:12.000 normal and what doesn't. 0:06:12.160 --> 0:06:16.000 Yeah, what do people tell you that those painful contractions 0:06:16.120 --> 0:06:19.320 feel like? And what as an obstration are you looking 0:06:19.400 --> 0:06:21.000 for in those painful contractions. 0:06:21.240 --> 0:06:24.480 Yeah, it's a good question because it varies enormously from 0:06:24.560 --> 0:06:27.560 woman to woman and pain tolerance to pain tolerance and 0:06:27.600 --> 0:06:30.560 so forth. What most people will tell you is that 0:06:30.600 --> 0:06:34.720 if they've been through a period of latent phase where 0:06:34.760 --> 0:06:38.280 they're getting some tightenings, some painful contractions at home, and 0:06:38.320 --> 0:06:41.560 then later come into the real deal, they can tell 0:06:41.600 --> 0:06:44.680 you in hindsight that it's very different. Yeah, that the 0:06:44.720 --> 0:06:50.000 pain is worse, that the intensity is much stronger, and 0:06:50.080 --> 0:06:53.640 they can tell you eventually that Okay, once I hit 0:06:53.680 --> 0:06:55.880 three or four centimeters and really started to cook along, 0:06:56.200 --> 0:07:00.600 then that was very qualitatively different to the contractions at home, 0:07:01.360 --> 0:07:02.640 you know, six hours ago. 0:07:02.839 --> 0:07:09.240 Yep. Now, in my first labor, I had a very wishy, 0:07:09.360 --> 0:07:14.200 washy sort of stalled labor, and my contractions happened a lot, 0:07:14.560 --> 0:07:19.760 but weren't useful. I know that I'm degrading myself here 0:07:19.840 --> 0:07:21.840 that they were useful, but you know, they just weren't 0:07:21.840 --> 0:07:26.880 going anywhere. So it's it's time and pain, is it? Like, 0:07:27.080 --> 0:07:28.520 how can you tell a good contraction? 0:07:28.680 --> 0:07:31.720 Well you really can't, and so that because there's such 0:07:31.800 --> 0:07:35.080 variation between what people are experiencing. So so it's terribly, 0:07:35.160 --> 0:07:39.880 terribly painful. It must be doing something. Sometimes people look 0:07:39.920 --> 0:07:42.119 at that at a ctging a fiddle heart rate trace, 0:07:42.440 --> 0:07:46.040 and it can show that there's a great big loop 0:07:46.120 --> 0:07:48.360 in the in the trace at the time of a contraction, 0:07:49.320 --> 0:07:52.040 and that just tells you that there is a contraction. 0:07:52.080 --> 0:07:57.280 It's not a measure of intensity. Oh god. So on 0:07:57.320 --> 0:07:59.280 that piece of paper coming out of that machine, if 0:07:59.720 --> 0:08:03.200 it looked like a really big deviation, that just means 0:08:03.240 --> 0:08:06.520 that the belt around your tummy's a bit tight, and 0:08:06.560 --> 0:08:08.280 if you loosen off the belt a little bit, it'll 0:08:08.280 --> 0:08:11.520 look like a little bump on the trays. So it 0:08:11.560 --> 0:08:14.480 doesn't measure intensity. It just says whether there's a contraction 0:08:14.560 --> 0:08:14.760 or not. 0:08:15.200 --> 0:08:17.480 Oh my god, that is just like a light bulb 0:08:17.560 --> 0:08:20.560 moment for me, because in my v back I had 0:08:20.600 --> 0:08:23.600 to wear a CTG the whole time. Sure, and I 0:08:23.760 --> 0:08:26.400 thought I was having these big, massive contractions and I 0:08:26.400 --> 0:08:28.080 was really proud of myself because I couldn't feel it. 0:08:28.200 --> 0:08:30.480 Yeah yeah, right, well there you go. So it was 0:08:30.560 --> 0:08:32.640 just saying that there's a contraction there, because when your 0:08:32.840 --> 0:08:36.640 uterus contracts, it changes the attension on that belt around 0:08:36.679 --> 0:08:38.200 your tummy, and the machine can pick that up, but 0:08:38.200 --> 0:08:40.800 it can't tell you how strong the contraction is, just 0:08:40.840 --> 0:08:43.080 whether it's there or not. So the whole point is 0:08:43.080 --> 0:08:45.559 we don't know. And this is why if someone appears 0:08:45.600 --> 0:08:48.240 to be in good labor, there's some value in internal 0:08:48.280 --> 0:08:53.560 examinations because nobody loves to stay in that latent phase forever. 0:08:55.000 --> 0:08:58.880 And it's very common for someone to say, well, I'm 0:08:59.480 --> 0:09:02.960 getting a lot of paint and I'm still clearly in 0:09:03.040 --> 0:09:05.560 Latin face. It's not kicking on. You know, how long 0:09:05.559 --> 0:09:07.439 do I have to put up with this? So eventually 0:09:07.480 --> 0:09:12.360 we you know, we are in discussion with the with 0:09:12.400 --> 0:09:15.520 the woman, we might perform a vaginal examination to say 0:09:15.559 --> 0:09:18.079 is the cervice opening or not, And if it's getting 0:09:18.080 --> 0:09:20.040 to the point where it is opening, then to a 0:09:20.080 --> 0:09:23.320 certain degree, the whole it's it's hard to avoid the 0:09:23.360 --> 0:09:25.520 concept of being on the clock from then on. Yeah, 0:09:25.600 --> 0:09:27.880 because once the service starts to open, we are looking 0:09:27.920 --> 0:09:29.319 for forward progress from that point on. 0:09:29.760 --> 0:09:33.440 Yeah. Yeah, and sort of what what time frame like 0:09:33.480 --> 0:09:35.760 it might be worthwhile for our listeners to sort of 0:09:35.760 --> 0:09:38.240 talk about the timeframes that you're looking for in an 0:09:38.280 --> 0:09:39.200 active labor. 0:09:39.880 --> 0:09:42.679 Yes, sure, so, so what we might do if we'd 0:09:42.720 --> 0:09:45.920 established that the cervix was definitely starting to open would 0:09:45.960 --> 0:09:48.840 be to talk to that about that woman at that 0:09:48.840 --> 0:09:55.240 point about to confirm her plans, her desire for to 0:09:55.440 --> 0:09:59.959 just wait and let the situation progress entirely naturally or 0:10:00.200 --> 0:10:03.200 or whether there's whether there's room or need or evidence 0:10:03.200 --> 0:10:07.720 for intervention, and then, assuming everything's fine, check again four 0:10:07.720 --> 0:10:08.280 hours later. 0:10:08.760 --> 0:10:11.439 And so for first time berths, I know that they're 0:10:11.440 --> 0:10:13.600 a little bit different in terms of the active labor 0:10:13.679 --> 0:10:16.680 stage than second time. How many hours for the whole 0:10:16.679 --> 0:10:20.760 active labor phase is what an obstric or a midwife 0:10:20.800 --> 0:10:23.720 is looking for in first and second time births or 0:10:23.720 --> 0:10:24.600 subsequent births. 0:10:24.880 --> 0:10:29.840 Yeah, sure. So again, there's some variation in opinion on this, 0:10:30.400 --> 0:10:32.320 but I would think that it would be safe to 0:10:32.360 --> 0:10:36.040 say that if that once the labor is active enough 0:10:36.080 --> 0:10:39.160 that the woman is having regular painful contractions and the 0:10:39.200 --> 0:10:42.800 cervix has started to open, then it's reasonable to expect 0:10:42.880 --> 0:10:46.920 half to one centimeter of progress per hour from that 0:10:46.960 --> 0:10:52.280 point onwards for someone happened there first baby. And we'll 0:10:52.320 --> 0:10:54.520 get in a little bit later into the different ways 0:10:54.559 --> 0:10:59.320 of measuring that and the evidence behind that being reasonable progress. 0:10:59.520 --> 0:11:01.400 But that would be the sort of progress that we 0:11:01.440 --> 0:11:04.520 would really like to see. It doesn't mean that if 0:11:04.520 --> 0:11:06.640 that progress is not there, we give up and do 0:11:06.720 --> 0:11:09.880 a section or something. No, there are ways of intervening 0:11:09.920 --> 0:11:13.080 to assess that or and there's some flexibility in waiting 0:11:13.679 --> 0:11:19.800 if mother and baby are well. For second and subsequent babies, 0:11:19.800 --> 0:11:24.680 that's very different, so there's a lot more variation and when. 0:11:25.120 --> 0:11:28.120 Whereas the progress for our first time it tends to 0:11:28.120 --> 0:11:33.079 be somewhat linear, the progress for a second and subsequent 0:11:33.160 --> 0:11:37.240 tends to be sort of nothing, nothing, nothing, nothing campower. Yeah, 0:11:37.440 --> 0:11:40.560 so you can have a very little change in the 0:11:40.600 --> 0:11:44.520 cervix and then when the labor really really kicks in, 0:11:45.200 --> 0:11:47.480 you could go from three centimeters to fully dilated in 0:11:47.480 --> 0:11:48.520 one hour very easily. 0:11:49.000 --> 0:11:55.160 Yeah. Well, okay, so why did we start timing this fas? 0:11:56.240 --> 0:11:59.000 Yeah, that's a really good question. That dates back to 0:12:00.800 --> 0:12:05.000 observations made in the I guess the early part of 0:12:05.080 --> 0:12:10.400 the twentieth century when they started to apply some scientific 0:12:10.520 --> 0:12:17.240 principles to the concept of labor and birth. And that's 0:12:17.360 --> 0:12:20.920 because in a lot of the world, the outcomes were 0:12:20.960 --> 0:12:26.080 pretty poor for a natural physiological process, and the number 0:12:26.120 --> 0:12:29.119 of women and babies not surviving the process of childbirth 0:12:29.760 --> 0:12:33.600 was unacceptably high, and in parts of the world that's 0:12:33.600 --> 0:12:38.120 still somewhat true. So they started to look at the 0:12:38.200 --> 0:12:42.080 process and one of the first things that they really 0:12:42.120 --> 0:12:45.839 observed was that was that labors that took way too 0:12:45.880 --> 0:12:52.160 long had the poorest outcome. So then for better or worse, 0:12:52.480 --> 0:12:55.000 they started to say, what can we do about that? 0:12:55.000 --> 0:12:59.880 That idea that the progress should be half to one's 0:13:00.000 --> 0:13:03.600 ameter an hour, that's called a Freedman rule, named after 0:13:03.640 --> 0:13:08.720 doctor Friedman who who first described that, and it led 0:13:08.800 --> 0:13:14.000 to an understanding amongst medical care as in the birth space, 0:13:14.480 --> 0:13:19.360 that there should be some a quantifiable progress of about 0:13:19.400 --> 0:13:24.680 that amount in a healthy labor. And a common criticism 0:13:24.720 --> 0:13:28.240 of that is that it probably made too many rules, 0:13:29.200 --> 0:13:33.679 too narrow a definition of normal progress, and probably too 0:13:33.760 --> 0:13:38.640 much intervention in labors that might have been normal but slow. 0:13:38.800 --> 0:13:41.920 And I did read in that was in nineteen fifty five, 0:13:42.040 --> 0:13:46.080 and the people that he studied were presumably white women 0:13:46.400 --> 0:13:50.160 in their twenties who were thinner. Yeah, yeah, a bit 0:13:50.200 --> 0:13:52.840 different from the cohort today. So does that make any difference. 0:13:52.960 --> 0:13:56.320 Well, I think it would probably make a huge difference. 0:13:57.160 --> 0:14:00.240 So if he was studying a very healthy cohort of thin, 0:14:01.240 --> 0:14:08.280 healthy young women, then firstly they would have been more 0:14:08.360 --> 0:14:12.120 likely to labor well in the first place, and then 0:14:12.360 --> 0:14:15.439 the ones that didn't were a more obvious outlier who 0:14:15.440 --> 0:14:19.640 probably had a more genuine problem. He wasn't dealing with 0:14:19.680 --> 0:14:21.720 the same cohort that we're dealing today, when the first 0:14:21.720 --> 0:14:26.800 time is older and heavier, and where there are more proven, 0:14:27.360 --> 0:14:30.800 justifiable indications for induction of labor. Oh yeah they're so. 0:14:32.240 --> 0:14:37.440 You know, the data for induction of labor for severe 0:14:37.480 --> 0:14:41.200 obesity very strong. You are better off if you're severely OBEs, 0:14:41.800 --> 0:14:51.280 give or take. With a term induction. There's more gestational diabetes, yes, 0:14:51.360 --> 0:14:56.680 so more people being induced. And that's that's where we're 0:14:56.720 --> 0:15:00.760 perhaps not comparing apples with apples between that even cohort 0:15:01.080 --> 0:15:06.359 and today. But for all the criticisms of making rules 0:15:06.600 --> 0:15:09.640 about labor supposed to go this fast, It should go 0:15:09.720 --> 0:15:15.080 this fast. One thing they did achieve were colossal improvements 0:15:15.240 --> 0:15:20.720 in safety, yeah, for women and babies by applying some 0:15:20.840 --> 0:15:24.800 scientific principles to the birthing process throughout the developments that 0:15:24.840 --> 0:15:27.000 were made in the twentieth century. 0:15:27.440 --> 0:15:30.760 Because it is still a criticism today that you know 0:15:30.840 --> 0:15:36.840 that births monitored too hard and then decisions to intervene 0:15:36.880 --> 0:15:40.560 it made too fast. But there was another person that 0:15:40.560 --> 0:15:43.200 studied it later, isn't it doctor Zang in twenty ten. 0:15:43.840 --> 0:15:47.160 Yeah, this is interesting. So that the Zang approach was 0:15:47.200 --> 0:15:49.640 to say, was to try and make a new partogram 0:15:49.680 --> 0:15:53.160 and a new way of assessing labor, a progressing labor 0:15:53.800 --> 0:16:00.120 that allowed for the different curves between first birth and 0:16:00.200 --> 0:16:03.720 have latent progress at the start active progress at a 0:16:03.760 --> 0:16:09.240 certain point. And they were hoping that that that new 0:16:09.280 --> 0:16:14.040 way of analyzing normal progress might have created a new 0:16:15.680 --> 0:16:20.120 safety pathway that was that would result in less intervention 0:16:20.200 --> 0:16:23.440 and in particular less Toeserian sections. And I think that 0:16:23.520 --> 0:16:28.040 way of looking at it does take into consideration the 0:16:28.080 --> 0:16:32.480 actual physiological process of normal first birth and certainly the 0:16:32.520 --> 0:16:36.360 normal physiological birth progress of second and subsequent births, But 0:16:36.480 --> 0:16:39.320 unfortunately it hasn't led to fewer interventions, and it hasn't 0:16:39.360 --> 0:16:42.280 led to fewer cerian sections, and you know, that's a bummer. 0:16:42.280 --> 0:16:43.920 It would have been really nice if it did. But 0:16:44.320 --> 0:16:47.200 what I think it's highlighted is that there's a signific 0:16:47.240 --> 0:16:51.640 that there is benefit in understanding the physiological process as 0:16:51.680 --> 0:16:54.000 best we can before we start putting limits on it 0:16:54.400 --> 0:16:55.560 and saying what's normal and what's not. 0:16:55.920 --> 0:16:59.800 Yeah, and not being so heavily protocolized and saying, Okay, 0:16:59.840 --> 0:17:02.240 so that woman came in at this time, and therefore 0:17:02.400 --> 0:17:06.440 we expect her to have done got to ten centimeters 0:17:06.440 --> 0:17:08.440 dilated in eight hours time. Whatever. 0:17:08.680 --> 0:17:11.080 Yeah, that's right, because what I think the holy grail 0:17:11.160 --> 0:17:16.399 of modern obstetrics is that we should be trying to be, 0:17:17.600 --> 0:17:20.960 you know, as cautious as we can about unnecessary intervention, 0:17:21.960 --> 0:17:27.040 but also practicing obstetrics in a way that maintains the 0:17:27.119 --> 0:17:29.840 safety gains, Yeah, that were achieved in the twentieth century. 0:17:29.880 --> 0:17:32.520 Do we go backwards in safety? And I think that's 0:17:32.560 --> 0:17:35.879 how that's our big challenge, how to keep the safety 0:17:35.960 --> 0:17:40.240 and the awesome outcomes in the developed world without overdoing intervention. 0:17:40.560 --> 0:17:43.600 Yeah, all right, So I think this part of the 0:17:44.080 --> 0:17:49.120 podcast has all been for perhaps birth care workers themselves 0:17:49.840 --> 0:17:53.639 and women who are really motivated to find out the 0:17:53.760 --> 0:17:55.080 nuts and bolts. And we've got a lot of people 0:17:55.240 --> 0:17:56.560 that like to hear all. 0:17:56.520 --> 0:18:00.080 That our if anyone's new to the podcast our a 0:18:00.160 --> 0:18:03.000 lot of our listeners don't shy away from the nitty 0:18:03.000 --> 0:18:05.280 gritty Yeah that's right. Yeah, and they're actually listening to 0:18:05.400 --> 0:18:12.080 hear an expert and experienced medical practitioners view. But we 0:18:12.280 --> 0:18:13.200 try not to give only that. 0:18:13.400 --> 0:18:15.840 Yeah. So what we're going to move on to is 0:18:17.119 --> 0:18:19.399 for those people who either had a birth where the 0:18:19.480 --> 0:18:21.600 labor stalled and then all this intervention happened and they 0:18:21.640 --> 0:18:25.280 want something to explain that, or someone that's going into 0:18:25.320 --> 0:18:31.840 a berth and what should they expect labor has still 0:18:32.119 --> 0:18:36.480 confirmed stalled label? Are you? Are you worried about the 0:18:36.560 --> 0:18:39.240 progress being too so or a stored labor. 0:18:39.359 --> 0:18:44.679 More installed labor more? But if we you know, if 0:18:44.720 --> 0:18:47.520 we're thinking about not just identifying that, but to sort 0:18:47.520 --> 0:18:51.160 of say that personal we ender next, this is where 0:18:51.240 --> 0:18:54.160 we have to stop, take a big breath and try 0:18:54.200 --> 0:18:57.680 and take a whole woman and baby view of what's 0:18:57.760 --> 0:19:00.440 going on and why and why this appears to have happened, right, 0:19:01.920 --> 0:19:06.720 And one of the dangers of an entirely protocolized flow 0:19:06.880 --> 0:19:10.399 chart approach is that you might say, oh, well, this 0:19:10.520 --> 0:19:16.120 lady was four centimeters at three pm, and she's still 0:19:16.160 --> 0:19:19.920 four centimeters at seven pm, and yet she's been having 0:19:19.960 --> 0:19:23.080 regular painful contractions that whole time. What are we going 0:19:23.119 --> 0:19:24.720 to do? Okay, well, we'll break the waters and put 0:19:24.760 --> 0:19:26.560 up some sintost on try and push her along harder, 0:19:27.119 --> 0:19:30.080 But there may be limited benefit of doing that if 0:19:30.160 --> 0:19:35.199 she's already been having terrifically strong contractions. So we might say, well, 0:19:35.200 --> 0:19:36.960 hang on a minute, what's what appears to be the 0:19:37.000 --> 0:19:38.560 problem here? And you take a step back from the 0:19:38.640 --> 0:19:39.840 end of the bed and you can see that, hang on, 0:19:40.680 --> 0:19:45.240 this appears to be enormous baby. Yeah, petite woman, Maybe 0:19:45.320 --> 0:19:47.399 this is a square peggan a round whole problem, and 0:19:47.480 --> 0:19:49.720 this boast to be to fit out. So we have 0:19:49.840 --> 0:19:53.240 to sort of have it at least a go at assessing, 0:19:53.320 --> 0:19:56.919 at least an attempt at assessing why the problem might 0:19:56.960 --> 0:20:03.359 be happening, and then making a sensible suggestion of an 0:20:03.359 --> 0:20:06.680 intervention based on what we think the problem is. Yeah, 0:20:07.280 --> 0:20:09.240 and this is where obstetrics is a little bit of 0:20:09.320 --> 0:20:13.640 science and a little bit of art. Sometimes you can 0:20:13.720 --> 0:20:17.480 tell from experience that, Okay, here's a problem that I 0:20:17.520 --> 0:20:20.400 think we can fix by improving the contractions, and here's 0:20:20.440 --> 0:20:22.200 a problem that perhaps I don't. I think we can't 0:20:22.200 --> 0:20:22.640 fix it all. 0:20:23.960 --> 0:20:28.800 So big baby or and small palvis, those things you 0:20:28.920 --> 0:20:31.640 sort of you probably have an idea about the big 0:20:31.720 --> 0:20:34.760 baby before the labor, but you wouldn't know what the 0:20:34.840 --> 0:20:36.040 size of that woman's palvis. 0:20:36.920 --> 0:20:39.000 Some people think that they can tell we're looking at 0:20:39.040 --> 0:20:42.119 the woman on the outside. Yeah, but if you look 0:20:42.160 --> 0:20:44.800 at someone's hips on the outside, that's just a bony 0:20:44.840 --> 0:20:47.320 part of their hips. You can't see the inlet where 0:20:47.359 --> 0:20:49.680 the baby comes down, So we don't know how white 0:20:49.720 --> 0:20:50.400 that is at all. 0:20:50.760 --> 0:20:53.480 Yeah, And I have a sister who's twelve years older 0:20:53.480 --> 0:20:55.240 than me. I should know off the top of my head, 0:20:55.240 --> 0:20:59.800 but I don't. And back in her day, they would 0:20:59.800 --> 0:21:02.879 take X rays of pelvis's. She had an X ray 0:21:02.920 --> 0:21:05.440 of her pelvis to see whether her pelvis was too small. 0:21:05.600 --> 0:21:08.280 Yeah, right, so that yeah, so the old that's the 0:21:08.359 --> 0:21:12.040 old pel vimetry. And it didn't work. No, Yeah, as 0:21:12.080 --> 0:21:14.919 a science it didn't hold up. Yeah, yeah, all right, 0:21:15.000 --> 0:21:17.679 it didn't take into consideration stretching of the pelvis, squishing 0:21:17.720 --> 0:21:20.879 of the baby's head and so forth. Yeah, so we 0:21:20.960 --> 0:21:23.440 don't do that anymore. Yeah, not to mention, you're given 0:21:23.480 --> 0:21:24.199 a baby an X ray. 0:21:24.480 --> 0:21:28.080 Yeah, oh that's right. So you've talked about somebody that's 0:21:28.119 --> 0:21:32.080 having what you see as good contractions, what's another reason 0:21:32.160 --> 0:21:34.520 why they may not be progressing? 0:21:35.600 --> 0:21:39.040 So a lot of this, most of this perhaps is 0:21:39.160 --> 0:21:41.119 male position of the fetal head, so that the baby 0:21:41.240 --> 0:21:44.240 is just not in a good position to be coming 0:21:44.320 --> 0:21:47.800 down with its chin tuck down against the chest and 0:21:47.920 --> 0:21:51.320 the small diameter of the baby's head presenting down into 0:21:51.359 --> 0:21:51.760 the pelvis. 0:21:51.960 --> 0:21:52.160 Yeah. 0:21:52.359 --> 0:21:56.320 Remember, a baby's head looks more like an Australian football 0:21:56.320 --> 0:21:59.320 which is oval shaped than a than a than a 0:21:59.400 --> 0:22:03.760 socer ball of the football whether it's round and so 0:22:04.600 --> 0:22:08.000 it's got a long diameter and a short diameter, and 0:22:08.200 --> 0:22:11.879 the baby wants to be tucked in so that the small, 0:22:12.400 --> 0:22:15.800 the small aspect of the head is presenting down into 0:22:15.800 --> 0:22:18.800 the pelvis. So if we think that's the problem to 0:22:18.840 --> 0:22:21.560 a certain degree, that can be assessed by vaginal examination, 0:22:22.160 --> 0:22:29.400 by external examination, and sometimes by ultrasound examination, and then 0:22:30.560 --> 0:22:33.880 in for example, the example I mentioned before where where 0:22:34.040 --> 0:22:37.520 the woman might be having terrific contractions but the progress 0:22:37.600 --> 0:22:41.160 is not there. Then on vaginal examination we may also 0:22:41.240 --> 0:22:44.159 be able to find through the partially dilated cervix that 0:22:44.440 --> 0:22:48.440