Second Stage of Labor
The passage toward the fetus ejection reflex is inhibited by any interference
with the state of privacy. It does not occur if there is a birth attendant who
behaves like a "coach," observer, helper, guide or "support person."
It can be inhibited by vaginal exams, by eye-to-eye contact, or by the imposition
of a change of environment. It does not occur if the intellect of the laboring
woman is stimulated by the use of rational language ("Now you are at complete
dilation--you must push"). It does not occur if the room is not warm enough
or if there are bright lights.
A typical fetus ejection reflex is easy to recognize. It can be preceded by a
sudden and transitory fear expressed in an irrational way ("kill me,"
"let me die"). In such a situation the worst attitude would be to reassure
with words. This short and transitory expression of fear can be interpreted as
a good sign of a spectacular increase of hormonal release, including adrenaline.
It should be immediately followed by a series of irresistible contractions. During
the powerful last contractions the mother seems to be suddenly full of energy,
with the need to grasp something. The maternal body has a sudden tendency to be
upright. The fetus ejection reflex is usually associated with a bending-forward
posture. When a woman is bending, the mechanism of the opening of the vulva is
different from what it is in other positions. The risk of dangerous tears is eliminated.
After a typical ejection reflex, the placenta is often separated within some minutes.
- Michel Odent, MD, excerpted from "Insights into Pushing: The Second
Stage as a Disruption of the Fetus Ejection Reflex," Midwifery Today Issue 55, Autumn 2000
The question begs to be asked: How many gloved hands have reached up inside
women, followed by the declaration "You're complete! You can push now!"
followed by hours of exhausting effort, frustration, and intervention?
As midwives, we're making a huge assumption that "completly dilated"
equals "time to push." In the instant that this realization became clear
to me, I made a vow to myself and the women in my practice that I would never
do a vaginal exam to determine complete dilation or tell a woman it was time to
I honestly believe that in our well-meaning attempt to tell a woman when we think
she is at the pushing stage of her labor, we encourage her to push way too soon.
The consequence is that when a woman begins pushing before a strong and irresistible
urge is present, she uses her energy to accomplish a task that her body would
do more effectively on its own if she was listening to her body's cues rather
than her birth attendant. Maternal exhaustion, a swollen cervix, fetal distress,
and sometimes a transport for vacuum extraction or a cesarean section often follow.
This is too high a price to pay!
When the women in my practice get "grunty" or "pushy,"
very few ask me what they should do because they already know the answer lies
within. If they ask, I simply remind them to "keep listening to your body--you
know what to do." So far, without exception, the women I've served have never
actively pushed for more than about 30 minutes before holding their baby in their
arms. This includes primagravidas, "big babies," and VBACs, moms of
all ages giving birth in every imaginable position, on land and in water.
- Lois Wilson, excerpted from "When to Push: Listening to the Body's
Cues," Midwifery Today Issue 55 Autumn 2000
After hours of full dilation with dwindling sensations, what if the mother
is languishing? The sense of anxiety and fatigue in the room builds, and nothing
is served by allowing this to go on too long. In this kind of situation the midwife
can help by changing the direction of the flow. Normally we think of the baby
coming "down and out." In this scenario, nothing is moving. It's a bit
like having your finger stuck in one of those woven finger traps. The more the
mother attempts to bring the baby down the more tired and tight the process becomes.
At this point, it can be helpful to get the mother into knee/chest position and
tell her to try to take the baby's bum up to her neck for a few pushes. This will
sound like strange instruction but, if she has learned to trust you, she will
give it a whirl. Reversing the energy and moving it the opposite direction can
perform miracles. After five or six sensations in this position with minimal exertion
of the mother, the fetal head often appears suddenly at the perineum. For those
of you who know Eastern martial arts, you will understand this concept of reversing
directions in order to gain momentum. This is midwife tai chi!
- Gloria Lemay, excerpted from "Pushing
for First-time Moms," Midwifery Today Issue 55 Autumm 2000
SECOND STAGE is the theme of Midwifery Today Issue 55, a mini-textbook on the subject.
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as well as birth films to show clients. As for the birth films, I'm looking for
one that shows unmedicated labour as well as the actual birth.
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Question of the Week
Q: I have a lady who really wants a homebirth. It
is her first birth and she has multiple sclerosis but is in remission, not taking
any drugs, and is symptom-free. Do you know any reason why she should not have
a homebirth? Have any of you had any experience with MS and birth? From my textbooks,
it seems to me to be OK. She is due in three weeks and the pregnancy is fine.
- Ilana Shemesh
Send your responses to:
Question of the Week Responses
Q: I am 22 weeks pregnant with my third child and
was just diagnosed with a pregnancy hernia. My baby is growing normally. I have
few complaints except for the hernia pain and backache. I am looking for information
about birthing naturally with a hernia. I gave birth naturally both previous times
and intend to do the same this time.
- Christine Staricka
A: Explore the option of hypnotherapy. I suggest that you find a hypnotherapist
who has advanced training in pain management. The training a certified clinical
hypnotherapist receives goes far beyond an individual that is only trained to
do programs like HypnoBirthing. You will need to go beyond deep relaxation and
be show advanced pain management techniques. Contacting the American Council of
Hypnotist Examiners - Hypnosis Certification would be a great resource for finding
someone who is properly trained.
- Aaron Aldridge, C.Ht.
A: I don't know exactly what type of hernia you are referring to, but
I had inguinal hernias during four pregnancies without mishap. The first appeared
when I was having my first baby. It was repaired surgically and three years later
it reappeared in my second pregnancy. By the time I was pregnant for the third
and fourth times I had bilateral inguinal hernias. They caused some pain and discomfort
in pregnancy but no problems for labour.
- Mary Murphy, RN, RM, homebirth midwife
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Know a strong woman? Helping empower one? If you haven't already done so, please
forward this issue of Midwifery Today E-News to one or two of your friends or
business associates. Thanks so much!
I am a midwifery student interested in doing research about why nipple sores
are still prevalent in breastfeeding mothers, even with guidance in breastfeeding
e.g., proper latching techniques and any other ways to prevent it. I would be
glad if there are some journals or research papers pertaining to this topic that
can be forwarded to me for reading.
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enthusiasts with an exclusive newsletter. You can share your thoughts, ideas,
make connections and possibly visit midwives from countries around the world!
What criteria do midwives use to decide which moms with cardiac problems are
safe for home delivery, which ones are safe to have a midwife-attended hospital
birth, and which ones should only receive direct care from obstetricians? Many
cardiac patients in hospitals are encouraged to have early epidurals because a
high level of pain is known to cause stress on the heart. However, I often wonder
how actually the fluid boluses required to receive epidurals affect these women
whose hearts may not particularly handle excess fluid volumes in the body very
well. Also, with epidurals, moms may not be able to assume positions that would
work best for them, which in the long run may be greater work on the heart. Bearing
down with pushing is very stressful on the heart--an epidural can prevent this
urge, but is it possible at all for a woman to ignore the urge and allow the baby
to descend on his own? What is the better option--performing an episiotomy so
the baby has more room to come with less stress on mom's heart or going without
one to prevent infection at all costs to someone who is at risk for developing
endocarditis? I have read the pros and cons in the past between c-sections and
vaginal births for cardiac patients, and c-sections often seemed the better alternative,
but I feel this could be a result of the mode of transportation and not the route
that was so stressful to mom's heart. Any good articles/books or personal experiences
- Laura L., (RN)
More on herpes:
Has anyone heard of red marine algae as a treatment for herpes, and specifically,
is it safe to use in pregnancy? I used it to treat periungal (along the edges
of my fingernails) warts that were refractory to conventional treatments (cryo,
lazer, and bleomycin) and they were gone in one month. A friend was taking it
for herpes, and I figured that herpes is a virus, warts are caused by a virus,
and this stuff is antiviral, so maybe there would be a cross-sensitivity, and
it seemed to work. I would love to do an RCT on this stuff--especially looking
at its effect on bad Paps (LGSIL/HGSIL) and rates of cervical cancer.
- Anne Schnedl, CNM, MN/MPH
There are a couple of things essential in managing a pregnancy with a history
of genital herpes. The first is to eat the most complete and nutritionally packed
diet possible (i.e., the Brewer diet). In addition to this, take 2000 mg vitamin
C, 500-600 mg L-lysine, and 50 mg zinc daily. This will help prevent eruptions.
If active lesions do occur, the amounts of the above supplements should be doubled
to ease and shorten the outbreak.
The other essential thing is to learn effective stress control. Deep relaxation
and visualization techniques are invaluable in any health problem as well as wellness,
and are effective in controlling mental, emotional and spiritual stressors. Physical
stressors must also be considered, including things such as sun exposure, which
stresses some cells into viral replication.
"The Ramp Maneuver" [Issue 3:29] is described very well with a picture
in the Journal of Nurse-Midwifery Vol. 39, No. 6, Nov./Dec 1994 p. 387. It needs
three people to make it work effectively and is used in anticipation of shoulder
dystocia or when the "turtle sign" appears or the baby does not restitute
or externally rotate. The author of this letter to the editor, Cydney L. Afriat,
CNM, MSN (Brown University School of Medicine), claimed to have been using the
"Ramp Maneuver" in her practice for three years. I would be happy to
describe it in a future issue but feel the picture is very valuable to the article
and that it can probably be easily looked up at most university/college libraries.
Perhaps the author might even be available to describe what has happened with
the procedure since 1994.
- Ellie Allyn
As a homeopath with 20 years experience, the remedy I have found that most often
helps women with ligament pain [Issue 3:30] is Ruta. I would suggest you take
it in 30c potency starting with 3 doses daily and try reducing the frequency as
the symptoms improve.
My wife is nearly 36 weeks pregnant and the baby is in breech position. I have
read that breech babies tend to have more genetic defects and other abnormalities
such as cerebral palsy. Obviously this scares us. The baby seems to be doing OK
in terms of size and heart rate, and he moves around a lot. Because my wife is
nearly at full term, the baby will not be premature. Given these circumstances,
what is the likelihood that there will be a problem with our baby? I read that
breech babies tend to have more problems, but I haven't seen the statistics.
I am going to be the doula at a birth in November. The mom is a 27-year-old
primip who had no fertility treatments. She had hoped for a homebirth but because
of the two babies has opted for a midwife-attended hospital birth. She is taking
great care of herself and has a great diet. What can we expect at a hospital birth
for twins? And what can we do to make the experience as intervention-free as possible?
- Shonti, doula, breastfeeding counselor
I recently caught twins. One weighed 9 lb. 2 oz and the other 7 lb. 1 oz. The
mom labored for only four hours and had them within 10 minutes of each other.
It was the perfect labor and birth. Only a few pushes--about two each and they
were out. There were no complications, no bleeding, her blood pressure stayed
perfect, and she was cheerful and pleasant the whole time.
When I assessed the situation in relative terms, I realized she lost almost
a third of her body weight within 10 minutes. WOW!
How long should it take a mom to get back on her feet after birthing twins?
We tried to rehydrate her with every kind of fluid, but she was still dehydrated.
Although her blood pressure stayed fine, she would get very light-headed and passed
out once or twice trying to get up to urinate. Can anyone offer suggestions? We
ended up transporting her for IV fluids. The boys stayed home, and she was back
within four hours looking much better. The hospital was amazed at how perfect
her body and story were. They said they found it hard to believe she had had a
homebirth, and they could not find one thing wrong. They even said they hated
to admit that it actually sounded really good about how well it went.
For the woman who had retention of lochia: I would suggest finding a seasoned practitioner
of Oriental Medicine in your area. Chinese herbology has many herbs that can help
treat toxicities in the blood.
Thank you to J. Costa [Issue 3:28] for her tip about being cautious of how you
treat your children when they reach the age you were when the abuse started/ occurred.
I have done much healing and am generally quite aware of my issues, but this is
a huge issue that had not occurred to me. It rings so true. I hope this advice
travels far and wide.
- Colleen Morris, L.Ac.
EDITOR'S NOTE: Only letters sent to the E-News official email address,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will
not be considered.
Experienced licensed midwife needed beginning late September 2001 at Northern
New Mexico Women's Health and Birth Center, Taos, NM. A combined direct entry
midwifery and OB/GYN practice. Visit our website www.womenshealthandbirth.org
or call 505-758-1216
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