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Signs of Second Stage

Pushing for First-Time Moms

Wonderful Article Adapted from Gloria Lemay, Vancouver, British Columbia 

 

[The multiparous (has had at least one baby) uterus is faster and more efficient at expelling those second, third and fourth babies and usually the minimum pushing possible will have great results. This article refers to first babies.]

 

A typical scenario with an unmedicated first birth: the mother has been in labor for about 12-15 hours. Membranes ruptured spontaneously with clear fluid after 8 hours in active phase and mother and baby have normal vitals. There is bloody show and mother says, "I have to push!" This declaration on the part of the mother brings renewed life to the room. The attendants rally and think, ‘Finally, we're going to see the baby. The long wait will be done. We can start the clean up and be home to our families.’ Typically, the nurse does a pelvic exam at this point to see if the woman is fully dilated and can get on with the pushing. It is common to find the woman 8 centimeters with this scenario. The mood of the room then turns to disappointment.

 

My recommendation with this scenario: Don't do that pelvic exam. A European-trained midwife told me she was trained to manage birth without doing pelvic exams. For her first two years of clinic, she had to do everything by external observation of "signs." When a first-time mother says, "I have to push!" begin to observe her for external signs rather than do an internal exam. . The external signs to look for are:

 

1. When she pushes spontaneously, does she begin at the very beginning of the sensation or is it just at the peak? If it is just at the peak, it is an indication that there is still some dilating to do. The woman will usually enter a deep or sleepy trance state at this time (we call this "going to Mars"). She is accessing her most rudimentary brain stem where the ancient knowledge of giving birth is stored. She must have quiet and dark to get to this essential place in the brain. She usually will close her eyes and should not be told to open them.

2. Does she "push" (that is, grunt and bear down) with each sensation or with every other one? If some sensations don't have a pushing urge, there is still some dilating to do. Keep the room dark and quiet as above.

3. Are you continuing to see "show"? Red show is a sign that the cervix is still dilating. Once dilation is complete the "show of blood" usually ceases while the head molding takes place and possibly returns at the point that the head distends the perineum.

4. The rectum will tell you a good deal about where the baby's forehead is located and how the dilation is going. If there is no rectal flaring or distention with the grunting, there is still more dilating to do. 

 

Why avoid that 8 cm dilation check? First, because it is excruciating for the mother. Second, because it disturbs a delicate point in the birth where the body is doing many fine adjustments to prepare to expel the baby and the woman is accessing the very primitive part of her ancient brain. Third, because it eliminates the performance anxiety/disappointment atmosphere that can muddy the birth waters. Birth attendants must extend their patience beyond their known limits in order to be with this delicate time between dilating and pushing.

 

Often when the primiparous woman says, "I have to push," she is feeling a downward surge in her belly but no rectal pressure at all. The rectal pressure comes much later when she is fully dilated, but in some women there is a downward, pushy, abdominal feeling. I have seen so many hospital scenarios where this abdominal feeling has been treated like a premature pushing urge and the mother instructed to blow, puff, inhale gas and so forth to resist the abdominal pushing. Such instruction is not only ridiculous but also harmful. A feeling of the baby moving down in the abdomen should be encouraged and the woman gently directed to "go with your body."

 

When I first started coaching births in the hospital I would run and get the nurse when the mother said, "I have to push." I soon learned not to do this because of the exams, the frustration and the eventual scenario of having to witness a perfectly healthy mother and baby operated on to get the baby out with forceps, vacuum or c-section. I have learned to downplay this declaration from first-time moms as much as possible, both at home and in the hospital. Especially if you have had a long first stage, you will have plenty of time in second stage to get people into the room when the head is showing at the perineum.

 

I recommend that we change our notion of what is happening in the pushing phase with a primip from "descent of the head" to "shaping of the head." Each expulsive sensation shapes the head of the baby to conform to the contours of the mother's pelvis. This can take time and lots of patience especially if the baby is large. This shaping of the baby's skull must be done with gentleness and care and often takes place over time in the midpelvis and is erroneously interpreted as "lack of descent," "arrest" or "failure to progress" by those who do not appreciate it. I tell mothers at this time, "The baby's head is elongating and getting shaped a little more with each sensation. It will suddenly feel like it has come down." This is exactly what happens.

 

Given time to mold, the head of the baby suddenly appears. This progression is not linear and does not happen in stations of descent. All those textbook diagrams of a pelvis with little one-centimeter gradations up and down from the ischial spines could only have been put forth by someone who has never felt a baby's forehead passing over his/her rectum!

 

Often the mother can sleep deeply between sensations and this is most helpful to recharge her batteries and allow gentle shaping of the babe's head. Plain water with a bendable straw on the bedside table helps keep hydration up. The baby is an active participant and must not be pushed and forced out of the mother's body until he/she is prepared to make the exit.

 

The more births I attend, the more I realize how much we (myself included) disturb the birthing woman. Disturbing often comes disguised in the form of "helping." Asking the mother questions, constant verbal coaching, side conversations in the room, clicking cameras, lighting, changing staff, monitoring, beeping, exams, tidying, assessing, chattering, touching, charting, changing positions and so on — there are so many ways to draw the mother from her ancient brain trance into the present-time world. This must be avoided. A cat giving birth to her kittens is a good model to look to for what is the optimal human birth environment: a bowl of water, darkness, a pile of old sweaters, quiet, solitude, privacy and protection from predators. When given this environment, 99.7% of cats will give birth to kittens just fine. 

 

Midwives have lots of research support encouraging them to be patient with the second stage and wait for physiological expulsion of the baby. Recognizing ways in which we can support the mother to enter that deep trance brain wave state that leads to smooth birth is imperative. I find it very helpful to have new language and concepts for the process. The "fetal ejection reflex" is like a sneeze. Once it is there you can't stop it, but if you don't have it, you can't force it. While waiting for the "fetal ejection reflex," I imagine the mother dilating to 11 centimeters. This concept reminds me there may be dilation out of the reach of gloved fingers that we don't know about, but that some women have to do in order to begin the ejection of the baby. I also find it valuable to view birth as an "elimination process" like other elimination processes - coughing, pooping, peeing, crying and sweating. All are valuable for maintaining the health of the body. None require the “thinking mind.”  A friend is fond of saying, "Birth is a no brainer." After all "elimination processes" are finished, we feel a lot better until the next time. Each individual is competent to handle her bodily elimination functions without a lot of input from others. Birth complications, especially in the first-time mother, are often the result of helpful tampering with something that simply needs time and privacy to unfold as intended.

 

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