Midwifery Today Lecture on Second Stage
I continue to learn from the scholarly and technical lectures from the International Midwifery Today conferences. These midwives are so amazingly knowledgeable and their discussions start way beyond the basic, re-inventing-the-wheel topics on natural childbirth that are repeated again and again in the public debates. It is fascinating to hear them teach one another about the techniques they use as they remain PRESENT with women throughout their labors. Many of these midwives attend only out-of-hospital births, making them witnesses and professional care providers of thousands of laboring women. The lecturers also constantly refer to research and the latest studies in the field.
Here are notes from two favorite lecturers, midwives Sarah Wickham and Ina May Gaskin on Second Stage Labor, including comments of the midwives they are addressing.
DIRECTED VS. SPONTANEOUS PUSHING
Second Stage of labor is defined by some as full dilation, by others as the mom’s spontaneous urge to push (NOT someone telling her to push).
Research shows that if all is satisfactory, there is no justification to interfere with 2nd stage. No need to impose limits. We must eradicate the concept of Time Limit on physiology and change 2nd stage so that there are No Orders or Time Limits when she is following her own body.
Addressing Biomedical concerns about a) asphyxia, b) maternal exhaustion:
Research shows that a longer 2nd stage does NOT create more fetal distress. Cord is usually on the side of the soft parts (tummy, face) not the hard chest & back. If the mom has no urge to push and does not, the length of 2nd stage has no effect on the baby.
In contrast, the semi-sitting position (compresses the vena cava> reduced blood flow > fetal distress) and a mom who is pressing too hard with no sound can create more internal pressure. When we use the Valsalva Maneuver (chin down, big breath, big push), we may shorten 2nd stage but is this what we need to achieve? Is shorter better? The research shows it is NOT OF BENEFIT to shorten second stage by forced pushing and time limits.
Maternal exhaustion is likely to result from being told to push & making strong efforts when the baby’s head is still high. When we wait for the spontaneous urge to push we rarely see maternal exhaustion.
When women push spontaneously they push for 5-6 seconds each time, then breathe. When directed they push for 9-15 seconds (less O2 to baby).
When self-directed they don’t immediately start pushing in the first seconds of the contraction. The uterus does ITS work, taking up fibers, THEN the woman pushes.
When we direct her to push immediately with the contraction, she is wasting her efforts. Longer efforts (15-20 sec) cause longer fetal decells. Baby is not recovering the same as from a 5-6 second push.
Research: Spontaneous pushing does not have significant negative effect on fetal heart but forceful long push has more marked effect on fetus. Also, directed pushing reduces oxygen, which can cause cramping and muscle tightening.
In 2nd stage the wall of the vagina normally becomes taut (protecting the bladder). If she’s forced to push, this wall isn’t tightened. Can lead to bladder problems, incontinence. Myth: vaginal birth causes incontinence. Truth: directed, forced pushing causes incontinence; increased pressure causes more perineal trauma.
* Directed pushing should be considered an intervention. Research comparing spontaneous to directed shows it is more dangerous to the baby.
Mom can be fully dilated but the baby is not all the way down, thus there may be no spontaneous urge to push. It has long been observed by midwives that mom is often sleepy and dozing at full dilation (in an undisturbed environment). (Also a tired mom after a long labor wants to sleep in between pushes.)
She needs the transition. Let her sleep. Acknowledge “transition” as a transition.
Physiologically this “rest” period is a regrouping of uterine fibers. They need to collect and pull up, for effective pushing down efforts.
Sometimes a “panic” - compelling feeling of “it’s coming down & out;” sometimes “now I know what to do.”
LENGTH OF SECOND STAGE
Midwives in the UK and in hospitals protect women by 1) not documenting the actual time that they were at 10 cm as the beginning of 2nd stage 2) not examining her (gives her more time). Instead of exam, they watch and LISTEN to her sounds 3) not documenting little pushes
The problem is that though this protects women from time limits, the evidence that says 2 hours pushing is average is based on lies. If they said she was 10 cm and baby was born 4 hrs later, the truth would be known, but no one allows women that much time.
The Declared Limits are not based on real observation of normal labor (with mom & baby ok).
OCCIPUT POSTERIOR PRESENTATIONS
If slow descent, check to see why. We need to acknowledge OP positions & increase the time frame, NOT use intervention (rupture her membranes, Pitocin, push, vacuum). OPs then get stuck. We must challenge hospital policy. Flat on back and “push push!” creates big problems especially for OPs (episiotomy, vacuum, c-s)
We must use transition time to let LOP or ROP babies rotate. One benefit of epidurals is that the staff then LET the baby labor way down until its very low or crowning. They realize the time it takes. This should apply to a non-epidural 2nd stage as well.
Sometimes there is a really big baby and a truly tight fit & she needs to work with it, perhaps push harder or longer. Its hard work, like moving a boulder. Being upright helps or pulling something from above her head with her arms (the hang-from-something instinct)
For the woman who doesn't know how to push, its a learning process. Praise what she is doing that is good. Get her upright.
If she is doing little pushes, don’t count them as pushes (in the time limit environment).
Gentle pushes before ACTIVE 2nd stage may be necessary- nudging baby’s head into position. Then maybe rest until uterus starts bearing down.
When any position is allowed, women usually choose upright, forward leaning or squatting. In the sitting position the baby’s head is pushed into the sacrum > narrower pelvis. Double hip squeezes (pelvic press) during push are good. Also sideways lunge (both ways). Left lying and forward leaning helps the baby's head move down. Leaning forward vs. leaning back increases the dimension of the sacrum-to-pelvic arch. Stair climbing. Kneeling with one foot on floor: “one knee kneeling”
3rd trimester - she should get on all fours a lot! NOT armchairs with knees higher than hips & shoulders back. Her knees should be lower than her hips & her shoulders further forward than her hips. This encourages the baby’s back (heavy part) to roll around. When sitting for periods of time, keep knees 4” lower than hips!
OPTIONS FOR PROLONGED 2ND STAGE:
Emotional causes often manifest in late transition. She needs psychological clearing. Remove presence of someone who needs to be removed. Check for fear (past abuse?). Labor must be safe place to give up control.
Some women need tough love (if acting whiny or helpless). "Dad as Partner" has been overdone. Various midwives admit that women-only births have been fabulous.
Send her to the toilet so she will a) get up b) pee c) sit on toilet (relax)
Most of blood is not in head/brain, it’s in crotch. Increase blood flow to vagina. Vagina enlarges & swells when aroused > kissing, sexual play. Relax face, mouth, jaw, throat. Midwives discuss what they have witnessed as helpful: movement, walk, squat, kiss, dance
“lower chin, tip pelvis” (NOT “chin down, push HARD”), hot packs to perineum, man behind, lower her down, swaying,
“this is the way to have a baby”
Let go to the forces of your body & release the baby.