Image courtesy of Parentingupstream on Pixabay.com
Continuing on from part 1 – the first stage of labour.
The second stage of labour, commonly referred to as the pushing stage, is the stage when you are soon to, and will, meet your baby. It is divided into two sections – the latent or passive phase when the woman is fully dilated but not yet ready to push/not yet feeling the urge to push and the baby is beginning to descend through the pelvis and starts to rotate and flex to find the best and easiest position for birth of the head; and the active phase when the woman and her body is actively pushing (this is when most women feel the urge to push) to expel the baby from the uterus.
In a physiological second stage (with no interventions or time limits on pushing and allowing the uterus to work on its own to expel the baby) it can take anywhere from seconds, to minutes, up to and potentially even exceeding several hours for the baby’s head and body to be born. More commonly in a hospital setting however an arbitrary time limit, set by hospital policy or a care provider and often being a different time limit given from one care provider to another, of 1-3 hours of pushing is imposed on the birthing mother after which interventions in the form of the ventouse (vacuum extraction), forceps and possibly even an episiotomy are tried and usually as a last resort (or next resort if baby is starting to show signs of possible distress and other interventions have failed) an “emergency caesarean” will be performed, sometimes an “emergency caesarean” will be the first and only option offered. Which of these options that are usually offered and tried is very dependent on the particular maternity staff’s skills (both obstetrician/registrar and midwife/nurse), on the staff that are on duty at the time (obstetrician/registrar, midwife/nurse, anaesthetist etc), on the availability of an anaesthetist and a theatre for potential surgery and on the personal wishes (consent or non-consent) of the birthing mother and/or her family if she is unable to make a decision herself.
To continue with the description of the second stage of labour – during this stage the baby is moved down through the pelvis and through the dilated cervix and vaginal canal, causing the babies malleable skull to be compacted by the surrounding pressure, the surrounding bodily tissue is stretched outwards and, in the case of the front or anterior part of the pelvic floor, drawn up, the depth of the vaginal canal is shortened by the stretching. In some cases – for example sometimes in a fast pushing stage, sometimes in coached pushing or more commonly in an instrumental delivery - the tissue may be stretched too quickly without being allowed to adapt to the changed conditions and stretch at its own pace and can result in varying degrees of damage (grazing or tearing) to the tissue including light grazing (similar to a graze on a knee or elbow when you fall over/scrape against something), a labial, clitoral or perineal tear or combinations of any or all. Sometimes even with the best preparations and actions to promote no tearing the tissue will still tear anyway – if this occurs it is just because your body’s tissues reached their own personal limits on stretching during the time between the beginning of crowning and babies head being born. As the babies head enter the vaginal canal and begins to crown the rectum is also compressed and this is when many women will defecate (in laymans terms – do a poo), do not stress about this as midwives and doctors have seen it all and really do not care (and you likely won’t even know if you did or not if someone doesn’t tell you about it).
The muscles of the fundus (the muscles making up the top section of your uterus) contract causing the contents of the uterus to be pressed “down” towards the cervix and the vaginal canal while the muscles of the lower uterus (including the cervix) will have already been pulled upwards towards the fundus resulting in dilation and effacement. The pelvic floor muscles will also be working to help move the baby further down through the vaginal canal.
During each contraction (generally lasting a minute or 2 with a space of anywhere from 1-5 minutes between each contraction) the uterine muscles are compressed/tightened, this pushes the blood out of the uterine veins, preventing fresh blood from entering them, and reduces the amount of oxygen available to the placenta and as a result to the baby. It is considered a normal variation for a baby’s heart rate to drop slightly during contractions of the second stage in response to the reduced blood flow and oxygen supply and pressure on the head as it is pressed into the cervical opening and the vaginal canal, however if the baby’s heart rate is slow to increase after the contraction has eased or does not recover it may be indicative of early stages of fetal distress, your care providers will be monitoring this and will be able to inform you of anything that they feel isn’t right and if any intervention is needed.
As babies head crowns you may feel a strong sense of “pressure” and/or a stinging or burning type of pain (the “ring of fire” as described by many women), this is normal and is from baby stretching the lower end of the vaginal canal and the perineum. During and just prior to the crowning part of the later second stage of labour baby will likely turn a bit or make a “corkscrew” kind of movement to find the widest points in the pelvis in order to descend (in laymans terms – finding the easiest way out via the path of least resistance that has the most room to move around in).
When babies head is born there is still the body to be birthed. First one shoulder, and then the other shoulder will come out allowing the arms to emerge, again baby will semi-rotate one way or another to get the shoulders through the pelvis. In rare circumstances the shoulders may get a bit stuck (shoulder dystocia) or be a bit “sticky” making it difficult to get them through. This can usually be solved with position changes although sometimes more medical approaches (forceps, physical force, cesarean etc) may be needed. If you are concerned about the possibility of this happening please speak to your care provider and ask lots of questions about it to help put your mind at ease.
Once the body has emerged your baby is born though it is still connected to you via the umbilical cord and placenta.
The umbilical cord is usually cut within minutes of birth although it is now becoming more common to do what is known as “Delayed Cord Clamping” (DCC) which has been scientifically shown to have many benefits for your baby and means that the cord isn’t cut until it has stopping pulsating and baby has regained all of the blood that was present in the cord (approximately 1/3rd of your babies total blood volume).
References:
Anatomy & Physiology for Midwives, Second Edition, by Jane Coad, Melvyn Dunstall, forward by Rona McCandlish, published 2006, pages 335-337
https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-labour
https://www.matermothers.org.au/journey/childbirth/the-three-stages-of-labour
http://www.babies.sutterhealth.org/laboranddelivery/labor/ld_push.html
The second stage of labour, commonly referred to as the pushing stage, is the stage when you are soon to, and will, meet your baby. It is divided into two sections – the latent or passive phase when the woman is fully dilated but not yet ready to push/not yet feeling the urge to push and the baby is beginning to descend through the pelvis and starts to rotate and flex to find the best and easiest position for birth of the head; and the active phase when the woman and her body is actively pushing (this is when most women feel the urge to push) to expel the baby from the uterus.
In a physiological second stage (with no interventions or time limits on pushing and allowing the uterus to work on its own to expel the baby) it can take anywhere from seconds, to minutes, up to and potentially even exceeding several hours for the baby’s head and body to be born. More commonly in a hospital setting however an arbitrary time limit, set by hospital policy or a care provider and often being a different time limit given from one care provider to another, of 1-3 hours of pushing is imposed on the birthing mother after which interventions in the form of the ventouse (vacuum extraction), forceps and possibly even an episiotomy are tried and usually as a last resort (or next resort if baby is starting to show signs of possible distress and other interventions have failed) an “emergency caesarean” will be performed, sometimes an “emergency caesarean” will be the first and only option offered. Which of these options that are usually offered and tried is very dependent on the particular maternity staff’s skills (both obstetrician/registrar and midwife/nurse), on the staff that are on duty at the time (obstetrician/registrar, midwife/nurse, anaesthetist etc), on the availability of an anaesthetist and a theatre for potential surgery and on the personal wishes (consent or non-consent) of the birthing mother and/or her family if she is unable to make a decision herself.
To continue with the description of the second stage of labour – during this stage the baby is moved down through the pelvis and through the dilated cervix and vaginal canal, causing the babies malleable skull to be compacted by the surrounding pressure, the surrounding bodily tissue is stretched outwards and, in the case of the front or anterior part of the pelvic floor, drawn up, the depth of the vaginal canal is shortened by the stretching. In some cases – for example sometimes in a fast pushing stage, sometimes in coached pushing or more commonly in an instrumental delivery - the tissue may be stretched too quickly without being allowed to adapt to the changed conditions and stretch at its own pace and can result in varying degrees of damage (grazing or tearing) to the tissue including light grazing (similar to a graze on a knee or elbow when you fall over/scrape against something), a labial, clitoral or perineal tear or combinations of any or all. Sometimes even with the best preparations and actions to promote no tearing the tissue will still tear anyway – if this occurs it is just because your body’s tissues reached their own personal limits on stretching during the time between the beginning of crowning and babies head being born. As the babies head enter the vaginal canal and begins to crown the rectum is also compressed and this is when many women will defecate (in laymans terms – do a poo), do not stress about this as midwives and doctors have seen it all and really do not care (and you likely won’t even know if you did or not if someone doesn’t tell you about it).
The muscles of the fundus (the muscles making up the top section of your uterus) contract causing the contents of the uterus to be pressed “down” towards the cervix and the vaginal canal while the muscles of the lower uterus (including the cervix) will have already been pulled upwards towards the fundus resulting in dilation and effacement. The pelvic floor muscles will also be working to help move the baby further down through the vaginal canal.
During each contraction (generally lasting a minute or 2 with a space of anywhere from 1-5 minutes between each contraction) the uterine muscles are compressed/tightened, this pushes the blood out of the uterine veins, preventing fresh blood from entering them, and reduces the amount of oxygen available to the placenta and as a result to the baby. It is considered a normal variation for a baby’s heart rate to drop slightly during contractions of the second stage in response to the reduced blood flow and oxygen supply and pressure on the head as it is pressed into the cervical opening and the vaginal canal, however if the baby’s heart rate is slow to increase after the contraction has eased or does not recover it may be indicative of early stages of fetal distress, your care providers will be monitoring this and will be able to inform you of anything that they feel isn’t right and if any intervention is needed.
As babies head crowns you may feel a strong sense of “pressure” and/or a stinging or burning type of pain (the “ring of fire” as described by many women), this is normal and is from baby stretching the lower end of the vaginal canal and the perineum. During and just prior to the crowning part of the later second stage of labour baby will likely turn a bit or make a “corkscrew” kind of movement to find the widest points in the pelvis in order to descend (in laymans terms – finding the easiest way out via the path of least resistance that has the most room to move around in).
When babies head is born there is still the body to be birthed. First one shoulder, and then the other shoulder will come out allowing the arms to emerge, again baby will semi-rotate one way or another to get the shoulders through the pelvis. In rare circumstances the shoulders may get a bit stuck (shoulder dystocia) or be a bit “sticky” making it difficult to get them through. This can usually be solved with position changes although sometimes more medical approaches (forceps, physical force, cesarean etc) may be needed. If you are concerned about the possibility of this happening please speak to your care provider and ask lots of questions about it to help put your mind at ease.
Once the body has emerged your baby is born though it is still connected to you via the umbilical cord and placenta.
The umbilical cord is usually cut within minutes of birth although it is now becoming more common to do what is known as “Delayed Cord Clamping” (DCC) which has been scientifically shown to have many benefits for your baby and means that the cord isn’t cut until it has stopping pulsating and baby has regained all of the blood that was present in the cord (approximately 1/3rd of your babies total blood volume).
References:
Anatomy & Physiology for Midwives, Second Edition, by Jane Coad, Melvyn Dunstall, forward by Rona McCandlish, published 2006, pages 335-337
https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-labour
https://www.matermothers.org.au/journey/childbirth/the-three-stages-of-labour
http://www.babies.sutterhealth.org/laboranddelivery/labor/ld_push.html
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