Failure to progress (dystocia) is the main reason for performing a cesarean section in low-risk mothers who labor for the first time. Evidence suggests that some physicians recommend a cesarean too soon during the labor process when in fact labor has not “failed” and the surgery could have been avoided. Many caregivers still follow guidelines from the 1950s when considering a cesarean for failure to progress. However, based on current medical guidelines for dystocia from the California Maternal Quality Care Collaborative (CMQCC), women themselves can ask key questions of their caregivers if a cesarean is recommended during labor or birth to make an informed decision about continuing to labor or to have a cesarean.

The California Maternal Quality Care Collaborative, affiliated with the Stanford University School of Medicine has developed guidelines to help physicians avoid unnecessary cesareans and improve health outcomes. One of the key evidence-based tools developed for maternity care professionals is the Labor Dystocia Checklist. If followed, the recommendations would help caregivers to avoid performing an unnecessary cesarean section. The key questions that mothers can ask are based on this checklist.

The cesarean rate for failure to progress for low-risk, first-time mothers varies widely among physicians and hospitals. So mothers may want to take an active role in deciding with their care providers if they want to proceed with a cesarean or continue to labor.

For all women, if you are experiencing labor contractions, here are the key questions to ask if a cesarean is recommended:

1. Have my membranes (bag of waters) ruptured?
2. Has my cervix dilated to 6 centimeters or more?
3. Have I labored at least 4 hours with strong uterine contractions but have not made any progress?
4. Since I was first given oxytocin to augment labor, have I been laboring for at least 6 hours without making progress?

If the answer to any one of these questions is “No”, it may be too soon to have a cesarean for failure to progress.

The CQMCC suggests that as long as progress is being made women laboring for the first time may need more than 20 hours and women who have had a vaginal birth before may need more than 14 hours to reach the active phase of labor ( 6 centimeters). If the mother and baby are not at risk, a cesarean for failure to progress is considered inappropriate if labor has not yet reached the active phase.

The second stage of labor (pushing the baby through the pelvis) begins at full dilation (10 centimeters). Again, many physicians recommend moving ahead with a cesarean without giving mothers enough time to complete the pushing phase.

If this is your first labor and you are pushing without an epidural, here is the key question to ask if a cesarean is recommended:

1. Have I been pushing for at least 3 hours without progress? (Progress is being made if the baby is gradually moving down through the pelvis and is making the internal rotations necessary for birth.)

If this is your first labor and you are pushing with an epidural, here is the key question to ask:

1. Have I been pushing for at least 4 hours without progress?

If you have had a vaginal birth before and you are pushing without an epidural, you should ask:

1. Have I been pushing for at least 2 hours without making progress?

If you have had a vaginal birth before and you are pushing with an epidural, you should ask:

1. Have I been pushing for at least 3 hours without making progress?

If the answer is “No” to any one of these questions, it may be too soon to have a cesarean for failure to progress.

If you and your baby are not at risk, discussing these questions with your caregivers may help you to avoid a cesarean.

Additional Resource from the CMQCC