The Second Stage of Labor

According to popular belief, a woman reaches her second stage of labor at a definable moment, and she is told that is now time to push.

In reality, few women experience such a clear-cut transition to the second stage of labor. Technically speaking, the second stage begins when the cervix is fully dilated at 10 centimeters. The transition into the second stage, however, begins somewhere between 8 and 10 centimeters of dilation.

Transition into the Second Stage
For many women, transition is marked by a sudden intensity of contractions that begin to follow each other quite rapidly. The contractions may become erratic and don’t seem to follow the neater wave pattern they had before. Other signs of transition might include:

• Discouragement, feeling as though you just can’t manage labor anymore
• Disorientation or dizziness
• Shaking and shivering—some women find their legs shake
• Prickly skin
• Hot and cold flashes
• Nausea or even vomiting
• Hiccups
• Sleepiness in between contractions
• Feeling like you are going to have a bowel movement, or that there is pressure on your anus

This is the time when you will need support most of all. Some women are tempted to ask for medication at this point, even when they have managed without it up to this point—yet, the pain is almost past.

If you are feeling fear or anger, or feeling overwhelmed, ask your birth attendant about these aids:

• Chamomilla is a homeopathic remedy that can help with unproductive labor pains, irritability, and an inability to relax. Aconitum napellus can also soothe a fearful woman who is hot and restless.
• Gelsemium is another homeopathic remedy good for fear, especially for women whose symptoms include trembling and chattering teeth.
• Rescue Remedy is a blend of five Bach flower essences. Add a few drops to a glass of water and sip as needed. This is good for labor attendants too!
• Try some essential oils in a diffuser or on a warm compress for your forehead. Lavender is always a good choice.

Sliding the Baby Out
The trend in labor and delivery in recent years is to begin pushing the moment a woman is fully dilated, whether or not she feels a particular urge to do so. Women are directed to bear down with all their might, holding their breath for as much as ten to thirty seconds and straining until each contraction is over. Some women actually break blood vessels around their eyes and cheeks from straining.

In fact, there is no evidence that pushing right from the very start is particularly effective in speeding labor along. It may actually have the opposite effect, or might put the baby into transverse arrest, where he gets stuck.

There is also evidence that holding the breath and sustained bearing-down may seriously reduce the amount of oxygen the baby receives, or affect maternal blood pressure.

Birthing doesn’t have to be so rough and tough. In one study, women were allowed to bear down spontaneously during the second stage and were given no directions on how or when to do so. The women tended to hold their breath for no more than six seconds at a time and bore down briefly only two or three times during each contraction. The average length of second-stage labor was only 45 minutes for these women, and none of them went longer than 95 minutes.

Many women will not feel an instant urge to push once they are fully dilated. Some may experience a kind of holding pattern at the beginning of the second stage, taking a bit of a break before they are ready to push the baby down the birth canal. Some women, especially second-time moms, may not ever feel a strong pushing urge during their whole labor. All of these scenarios are normal.

Occasionally, a woman will feel a strong urge to push before her cervix is fully dilated. Bearing down before full dilation can bruise or tear the cervix. It can help to pant softly to avoid bearing down. You can also get on your hands and knees or lie down on your left side for a moment to slow things down a bit. <!--pagebreak-->

Here are a few tips to help you through the second stage of labor and get you to the moment when your baby will slide out and be placed into your arms:

• As you begin to reach the second stage, think of your body as opening up like a flower.
• Think of relaxing your pelvic floor, as you would when doing a Kegel exercise, and just allow the release to continue. Sitting on the toilet for a few minutes can help create this feeling.
• Your position is most important at this stage. Squatting, kneeling, or standing are the ideal positions for pushing and delivery. Follow your body’s cues.
• Push at will. You don’t need to bear down at every contraction. Take a rest if you feel like it.
• Hold your breath if it feels appropriate. Try not to do so for longer than three to six seconds. Think of slowly releasing air as you bear down. Many women find it helpful to grunt the air out.
• Make other noises, such as moaning or singing if you feel like it.
• Take a couple of deep cleansing breaths between contractions.

Episiotomies
An episiotomy is a surgical enlargement of the vagina by means of an incision in the perineum, which is the skin and muscles between the rectum and the vagina. An episiotomy is done with either scissors or a scalpel. There are two types: midline (straight) or mediolateral (diagonal). A pressure episiotomy is an episiotomy done at the last minute, as the baby’s head is crowning.

Although episiotomies are not done with anywhere near as much frequency as they once were, many experts still think they are overused. The World Health Organization (WHO) advises against the routine use of this procedure, noting that alternative methods of perineal protection should become the norm. The WHO claims that the evidence only supports episiotomy rates of between 5 and 20 percent.

Episiotomies are not risk free:

• Recovering from an episiotomy is painful. Some women report the pain to be so strong that they feel they need pain medication to deal with it.
• As many as 25 percent of women experience some infection at the site, and a few develop abscesses.
• Some women will experience excessive blood loss with an episiotomy.
• Vaginal swelling is common.
• Some women experience problems with sex for months to come.
• Having an episiotomy can actually increase your chances of tearing further.
• Some women feel mutilated by this routine procedure—and many others feel betrayed or violated by doctors who did not ask permission before performing episiotomy.

There are times, of course, when an episiotomy is absolutely necessary. If there is fetal distress or cord compression during the second stage of labor, or the presence of meconium (fecal matter from the baby’s intestines) in the amniotic fluid has been observed, then an episiotomy is appropriate. If the second stage of labor proceeds very rapidly, it may not have been possible to allow for gradual stretching. Other appropriate times include: premature birth (although even then it is not normally necessary), certain breech births, true cephalopelvic disproportion, before a necessary forceps or vacuum, extraction delivery, or if there are signs that tears are occurring near the woman's urethra.

How to Avoid an Episiotomy:

• Statistics show that episiotomy rates are related to who assists in a birth and where it is done. In some countries, episiotomy rates are a third of those in the United States.
• Choose your health care practitioner carefully, and ask what percentage of patients actually receives an episiotomy.
• Find out how your health care provider feels about epidurals. Having an epidural increases your chances of having an episiotomy, since it may inhibit your ability to push your baby out.
• Practice good nutrition during your pregnancy to keep your tissues supple. It is especially important to get enough vitamin E and omega-3 fatty acids.
• Get plenty of exercise. Being in good shape increases your body’s ability to perform well during labor. Be especially vigilant about doing Kegel exercises.
• Practice perineal massage during your pregnancy, especially in the last six weeks. First, wash your hands. Then lubricate your fingers with oil. Insert both of your thumbs into the vagina and gradually stretch the perineum downward and out. Stretch only until you feel a slight tingling, and then hold the stretch until the sensation subsides.
• Massage and oil the perineum during delivery. Have a brand-new bottle of oil set aside for labor to help cut down on the possibility of spreading bacteria around.
• Apply hot compresses during the second stage to help soften the tissues.
• Ask your midwife or doctor to perform perineal support when they notice the perineum turning white from stretching. This means that your practitioner will apply light pressure with the fingers on the perineum. This is when he or she may also suggest you slow down and refrain from bearing down for a bit.
• Use a variety of birth positions, emphasizing those that take advantage of gravity.

Tears do sometimes happen during normal birth, no matter how careful you and your practitioner are. Many care providers have observed that small, naturally occurring tears heal more quickly than the straight cuts of an episiotomy.

As Birth Approaches
When the second stage begins, optimize the environment in your birthing room in preparation for the baby’s arrival. This is a good time to dim the lights, or light any special candles you’ve saved for this moment, and you might want to use some fragrant essential oils.

This is also the time to make sure you are surrounded only by people who you are comfortable with. Hospitals, particularly, are notorious for having a constant flow of personnel in and out of patients’ rooms. Do not hesitate to ask people to step outside for a time, whether you are in a hospital or at home. Your partner and other birth attendants can handle this for you.