Failure to progress or just normal - how doulas can support and normalise physiological plateaus in labour

A physiological plateau or pause during the process of labour is something we see a lot as doulas supporting people to have physiological births (that’s unmedicated and unaugmented). There are many reasons they can occur and can occur at different points within labour … naturally not because something or someone has intervened.

There is no technical term for this process and it is often referred to as a failure to progress which is an awful phrase to throw at a woman or birthing person in labour. The term “rest and be thankful” is also used or physiological plateau.

This well known, and well researched rest and be thankful stage is something that is heavily pathologised in maternity care (particularly within hospital settings) where up to 40% of first time birthers are having their labours augmented due to a failure to progress (M. Weckend 2023)

There is a clear understanding that physiological birth is not a linear upward curve (the Friedman’s curve created roughly 70 years ago). And whilst that may be the “average” that does not mean it’s normal. Normal labour for the individual may vary considerably from this outdated notion, and yet still not be problematic unless we make it so because it doesn’t fit the medical model of average. Pathologising normal physiological labour leads to the increasing use of augmentation during labour and unplanned Caesarean birth. For example, “Failure to Progress was the cause of about 42% of Cesareans in Queensland, Australia, and 34% of Cesareans in the United Kingdom. (Nippita et al. 2015). In the United States, Failure to Progress is the most common reason for primary (first) Cesarean deliveries (Boyle et al. 2013) as well as the most common reason that people who give birth at home with midwives are transferred to the hospital (Blix et al. 2014).” (Evidence based birth 2022)

So what can those of us who support and understand physiological birth help our clients to do when these physiological plateaus occur? 

Like most doulas, experienced home birth midwives will be well aware, and extremely comfortable, with such pauses and it is likely you’ll all do, what appears to be nothing, as the birther rests (not uncommon to see women/ birthing people fall asleep after labouring well). 

However, midwives and doulas will be quietly assessing the situation. By closely observing the birther it is simple to gauge whether someone is perhaps tired and requires an energy boost (food and water), is holding onto something psychological which means she/they don’t feel ready to meet their baby quite yet, or if there is obvious fear that may be preventing the physical progress of labour (something that is often verbalised).

It is incredibly important that as doulas we are comfortable that labour is not a continuous linear progression and that we familiarise our clients with this as well. It’s particularly important to normalise the fact that for many this is completely normal as long as the clinical picture remains the same (not your job …. midwives job). 

So doulas … talk to your clients antenatally about what a physiological pause can look like, how it may feel (rest and be thankful after your body has worked incredibly hard), things they may want to look out for during this time (are they holding tension, fearful, not ready to meet their baby, or simply physically tired). Help your clients to embrace all that labour has to offer. 

Have you seen physiological plateaus in labour as a doula or as a birther?