Why “Managing” Labor Often Stalls It: The Science of Safety

What is a stall in labor, really? Is it an arrest of dilation, a hold up in the rotation and descent of the baby, or a misfire of hormones resulting in a dystotic contraction pattern?  There is no one answer, because like most things when it comes to birth, the real answer is: it depends.

What’s really happening in most labors is subtle, but the more you look for patterns, the more you begin to notice one thing: that for the labor to unfold, there has to be a sense of safety.  Safety in the internal environment: that the adrenaline is not putting the brakes on the oxytocin.  Safety in the external environment: both the physical and the social environment.

As a labor and delivery nurse, there is a lot that is out of your control.  You cannot control whether people take childbirth ed classes prenatally or what the staffing is like on your next shift.  You can, however, control your own growth edges–learning to deepen your labor support skills and ability to read the room.  You can hold to facilitating that sense of safety as a cornerstone of your practice.  This makes our work more enjoyable and sustainable.

The paradox of modern obstetrics is that it seeks progress through management.  And as we get more algorithms, more bedside huddles, more updated guidelines (Pitocin up 6 by 6?!) – we still miss the mark.  There are so many tools that seek to improve care, and in fact DO improve outcomes in many ways.  BUT we do families (and our profession) a disservice when we don’t equally look at the tools that involve doing LESS.  Instead of seeing dystocia as a mechanical failure, what if we saw it as a regulatory state?

Midwife Anne Frye famously said, “Don’t just do something!” and I think that’s really something to chew on.  There are times when the labor is asking for more, and there are times when the labor is asking for less.  Knowing which one it is, and when to step forward versus when to step back…well, that is the art of birth work.  

This is the realm of SUBTLE skills.  This is the realm where that one nurse that always has patients that go fast lives-–what is she doing exactly?!  In the therapy world, they might call it attunement.  The superpower of attunement creates safety through presence and perceptiveness, and allows someone to feel seen, understood, and heard.  The attuned nurse does this through the tone or their voice, their body language, and the pacing of their questions.  And for the birthing mother: the breath deepens, lengthens, sighs, and the body softens.  

So, let’s look at the most common nervous system responses that stall a labor, and how hospital caregivers can facilitate a change–not to manage the labor, but to make space for it to unfold.  To be clear, this is a framework coming from polyvagal theory (note THEORY) that I’ve found helpful to apply to people in labor, their support people, my colleagues, and myself.  It isn’t meant to diagnose or pigeonhole, but it can give us a way to orient around behaviors that we commonly see.  Birth is a profoundly neurobiological event. 

Freeze / Functional Freeze

Freeze may take the form of a visible shutdown (acute freeze) or appearing compliant, doing “fine” but not progressing (functional freeze). A freeze response is immobility in the face of perceived overwhelm.  Think of the patient whose dilation stalls after a cervical exam (so common!) or whose contractions space as more people fill the room.  Things may seem calm, but the labor is going nowhere.   

What is the typical response?  We increase coaching, add position changes, or add Pitocin.  We add more stimulation, more input–but the nervous system is already perceiving threat, adding more drives it deeper into freeze.  

What do we do instead?  This is where we want to remove input–less people, less procedures or tasks, less talking.  If you are adding anything, it might be containment and warmth (Aren’t those warm blankets the best?).  We speak less, but what we do say becomes more purposeful.  “You don’t have to do anything right now.”  “Your body can take its time.”  “I’m going to make this room quieter.”  “I’m going to stay here with you.”  And of course a nice jiggle can go a long way here!

When there’s a sense of safety, the pulse of oxytocin returns, the contractions can coordinate, and the labor can move.

Fawn

This is one of the most common, yet most overlooked nervous system responses.  This is a response of appeasement or “making nice” to a perceived threat.  It’s common because many women are socialized this way: be a good girl, don’t make waves, it’ll be easier that way.  And common because of the imbalance of power between physicians and patients–even with the nicest physician, the imbalance can exist because of the power society gives this role.  In fact, I was shocked (!) to find as a new nurse that I would fawn over physicians, and that it took me a couple years to gain confidence and approach them as an equal.  Who wants to be the “difficult” patient?  Doesn’t it make sense, from a survival perspective, that you would want your caregivers to like you?  Better to be agreeable and not make waves.  Again, this can be subtle, but if you watch for it, you’ll see it everywhere.  

What does it look like?  She just told you she didn’t want her water broken, but now the physician is in the room and she says yes.  “Whatever you think.”  She smiles but her eyes don’t match, or nods quickly when options are presented.  Then the labor slows after a cascade of decisions that she didn’t feel ownership over.  The situation has a completely different feel to it than the person who has a congruent, clear “yes” to an intervention.

What typically happens?  We tend to praise cooperation–just go with the flow, those uptight moms with birth plans always go to the OR.  We take their verbal consent as embodied consent, when those are two separate things that don’t always match.  We assume understanding, agreement, and move quickly.

What can we do instead?  If someone has agreed to a cervical exam, instead of saying, “Are you ready?” I might shift my language to, “Let me know when you’re ready.”  This creates a little extra space where the body can find its “yes.”  I might even ask someone, “What does a ‘no’ feel like in your body?  How do you know whether it’s a ‘yes’ or ‘no’ for you?” or “If you didn’t have to worry about anyone else’s opinion, what would you want?” or “It’s totally okay to change your mind.”

Flight

There is a point in labor we’ve all seen where someone will say, “I can’t do this” “I’m dying” or “I’m outa here!!” and this is often that transition where they are getting a physiologic hit of adrenaline.  Totally expected and normal.  So this is not to pathologize that transition phase, because in fact that is extremely productive, in that the mobilization energy is part of what gets the baby born.

So I’m speaking about a different kind of flight response.  You’ve seen this.  The mom who is agitated, restless, anxious, or hyperfocused.  It is movement, but it is not productive movement, as far as labor is concerned.  Because it is movement driven by a sense of threat; it is movement away from something.  And if the team is not prepared for it, the energy can really escalate: it’s uncomfortable to be around, so something must be wrong.  Urgency begets more urgency.  Dilation stalls despite strong contractions.  The room is moving faster than the labor.

What can we do?  Just like we tell people in labor when their moans are high and their shoulders are tense, keep it low and slow.  Orienting, anchoring statements and actions.  “One contraction at a time.  Just this one right now.  Breathe with it.  I’m breathing with you.  Here we go.”

Putting it all together…

When we begin to see labor dystocia as a regulatory state, as a response to the environment, as something dynamic (rather than fixed), we open up our possibilities.  Where labor management often offers more input, more intervention, we can become more nuanced, asking the question…What is really needed here?  Is it more Pitocin?  Is it quiet?  Is it a change of shift and a new care provider?  Is it a Cesarean?  Sometimes the dystocia is about mechanics, sometimes it is relational, and most often it’s a combination of many things.  And the relational is not woo-woo, it’s learnable and it’s practical.  That nurse with the “Pit fingers” whose patients always have fast births–watch what she’s doing.  The body opens when it feels safe.  When a labor stalls, the question is not, “What’s wrong with her body?” it’s “What is needed to facilitate safety?”