Second Stage
Sensations from the uterus during labor are communicated on two pathways
to the brain. Visceral (organ) pain is carried by the hypogastric nerves
which are part of the sympathetic nervous system. One theory is that the
source of pain impulses carried on these nerves, such as cramping with menstruation
and labor pains, is due to hypoxia in the muscle itself when blood vessels
are compressed. The second pathway involves sensations carried on nerves
located directly on the surface of the uterine muscle, broad ligaments,
fallopian tubes, and so on. These nerves communicate to the central nervous
system in the spinal cord at T-11 through L-1 and often translate into referred
pains in the lower back and/or sides.
Specialized nerve endings called stretch receptors are located throughout
the body to communicate changes in tone, volume and tension. The stretch
receptors located in the lower uterine segment and cervix probably account
for the complex variety of sensations that accompany the end of first
stage. These messages are carried by the somatic nerves which become "louder"
than the earlier sensations of the hypogastric nerves as the presenting
part stretches the cervix to its greatest capacity just before slipping
through into the birth canal. This stretching also causes the pituitary
gland to release more oxytocin, leading to the long duration and close
frequency of contractions at the end of first stage.
Stretch receptors again play an important role as the baby's presenting
part moves into the birth canal. Receptors in the wall of the vagina,
rectum, and ultimately the perineum communicate the pressure of the baby's
presence, especially during these surges. It may be that a combination
of the uterine surges, increased abdominal pressure, and activation of these sensors, translates into the "overwhelming urge to push"
described by many women.
An additional, often overlooked, important physiological aspect of second
stage is the action of the vaginal walls themselves. Most birth practitioners
have a clear image of the disadvantages of active pushing before the presenting
part has cleared the cervix. The possibility of cervical edema or tearing
or damage to the transverse cervical ligament is obviously to be avoided.
Once second stage has started, there is a parallel issue to be considered
involving the anterior wall of the vagina. The baby's downward movement
during second stage can cause an anterior vaginal fold to descend in front
of the presenting part. This can produce a shearing action which may result
in damage to the bladder fascia with potential complications such as incontinence
and bladder prolapse. It appears that the normal mechanism which can prevent
this occurs at the start of the contractions, before the surges are felt.
The musculature of the vagina, along with the uterus, draws up and tightens
the lining of the birth canal, or vaginal mucosa. This provides a taut
surface against which the baby may slide downward....When women are told
to push immediately at the onset of their contractions, this important
pulling-up of the vaginal wall may be prevented, leading to possible damage
and actually slowing progress in the descent.
- Mari Sagady, Midwifery Today Issue 33
Excerpt from "Pushing for First-Time Moms" by Gloria LeMay
A European-trained midwife I know 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. Reassure her that
gentle, easy pushing is fine and she can "Listen to her body."
No one ever swelled her own cervix by gently pushing as directed by her
own body messages. The way swollen cervices happen is with directed pushing
(that is, being instructed by a midwife or physician) that goes beyond
the mother's own cues. It has become the paranoia of North American midwifery
that someone will push on an undilated cervix. Relax, this is not a big
deal, and an uncomfortable pelvic exam at this point can set the birth
back several hours. The external signs you will be looking for are as
follows:
1. When she "pushes" spontaneously, does it 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 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. Then
you can get another gush of blood from vaginal wall tears at the point
that the head distends the perineum.
4. Watch her rectum. 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. A dark red line extends straight up from the rectum between
the bum cheeks when full dilation happens. To observe all this, of course,
the mother must be in hands and knees or sidelying position.
I use a plastic mirror and flashlight to make these observations. The
mother should be touched or spoken to only if it is very helpful and she
requests it. Involuntarily passing stool is another sign of descent and
full dilation. Simply put, where there is maternal poop there is usually
a little head not far behind.
Why avoid that eight-centimeter 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 primip birth waters. Birth attendants must
extend their patience beyond their known limits in order to be with this
delicate time between dilating and pushing.
Click here to read this article in its entirety
[The fetal ejection reflex] is the necessary physiological reference
from which one should try not to deviate too much. During the powerful
and irresistible contractions of an authentic ejection reflex there is
no room for voluntary movements. A cultural misunderstanding of birth
physiology is the main reason why the birth of the baby is usually preceded
by a second stage. All events that are dependent on the release of oxytocin
are highly influenced by environmental factors.
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").
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-to-be seems to be suddenly full of energy, with the need to
grasp something. The maternal body has a sudden tendency to be upright.
A 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, Midwifery Today Issue 55
Midwifery Today Issue 55 is a complete book about second stage.
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Question of the Week
Does anyone know how often to do moxibustion to turn a breech baby? I have read 10 minutes two times per day. My patient's acupuncturist said 10 times per day!
- Anon.
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Deadline: March 31, 2001
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Suzanne Arms to research in Holland for upcoming video and new edition
of book: Suzanne and homebirth midwife (CPM) Sally Kane from Colorado
will be traveling to Holland, Paris and Germany March 20th of this year
to research midwifery and the details of maternal-child health policy
and care. We're focusing on Holland and would appreciate any contacts
in Amsterdam in public health and also help financing the on-land travel
costs. Tax deductible. For more info: contact Sally at Sallyk@paonia.com
I am in my masters program and writing my thesis on maternal self confidence
and the role it has on successful breastfeeding. I would appreciate any
information that you might have on this topic. Thank you.
- Karen Hoffmann
hoffmann@means.net
I am a psychology student researching grief, from a midwives' perspective,
on pregnancy loss. Can anyone offer a point of view or suggested reading
about strategies for dealing with patients' grief, dealing with your own
grief, hospital protocol to help with the grieving process and inspiring
stories to share? I have been privileged to be cared for by such wonderful
professionals as yourselves in the above-mentioned circumstances. Thanking
you in anticipation,
- Karen Wickham
Reply to: thewickhams@onenet.com.au
Editors Note:Issue
41 of Midwifery Today has terrific articles on miscarriage, infertility,
supporting mothers who miscarry, processing grief and healing, recurrent
spontaneous abortion, homebirth after infertility, and all the emotions
of loss.
Regarding the use of suggestion to stop postpartum bleeding: I have used
this frequently and successfully for postpartum hemorrhage even before
I understood the nature of hypnosis. Back then, I only knew that it worked;
now I know why--it is hypnosis! In general, the nature of midwifery care
is that it supports the use of the trance state in birth. Trance happens
when the brain wave patterns slow to the alpha or theta state, a common
daily occurrence (i.e. driving a familiar route, playing a musical instrument,
athletics).
In trance, women are very receptive to suggestion, during the birth and
even after the birth. A postpartum woman in trance, especially one bleeding
excessively, responds to trance very well. Personally, I like the image
of a golf ball--small and hard, combined with the command to stop bleeding.
It works brilliantly, and medication is rarely needed.
In the hypnosis sessions I provide to pregnant women, I always include
the suggestion that the placenta delivers completely and quickly after
the birth of the baby, and that the uterus contracts hard after the baby
and placenta are born. Even birth attendants making casual comments about
how firm and well contracted the uterus is will be providing hypnotic-like
suggestions that will then be used by the mother's subconscious mind to
maintain normal blood loss (the opposite works, too!). Of course, sometimes
PPH is connected to deep, unresolved emotional issues that are better
dealt with before the birth, and hypnotherapy can be very effective for
this, as well.
The power of suggestion is only recently being explored in medicine as
an effective modality for healing. Isn't it interesting that randomized
control trials are effectively designed to factor out the power of suggestion?
If it is effective in as much as 70% of disease, why have we focused so
much on pharmaceutical and surgical medicines and not on harnessing the
power of the mind? Certainly there are fewer side effects when women are
empowered to use their inner resources and I believe that women find making
the transition to being a mother easier.
- Shawn Gallagher, registered midwife, certified hypnotherapist
Toronto, Canada
To Debbie (English trainee midwife): In reply to your request in E-News,
I am an English childbirth educator (NCT-trained) living in Madrid. I have some contacts with midwives in different parts of Spain, so write
to me at dycealex@yahoo.com and
I can help you get in touch.
- Hilary
More on apprenticeship: I am using a system that I like very much. I
am living in a place where any other method of study would be impossible.
The National College of Midwifery in New Mexico offers a sort of distance
study through an official "preceptorship" (very similar to apprenticeship)
with a midwife, CNM, obstetrician, etc. (your choice). There is formal
study in your home and weekly meetings with the tutor/preceptor, as well
as module tests. The clinical part may begin some time after a jump start
with the formal study has begun. It is both mentally fulfilling, with
very good texts and a wide variety of birth professionals as authors yet
there is a very intimate personal hands-on part with the preceptor. Contact
Elizabeth Gilmore if you are interested, it is also quite inexpensive
and fits wonderfully into difficult working schedules or baby's needs
elizabet@taosnet.com
- Aiyana G.
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