The Unacknowledged Part of Labour?
The passive phase of 2nd stage of labour
We're told that once a cervix is dilated to 10cm that we're "in 2nd stage of labour" which is the "pushing stage". Once hearing the words, “fully dilated” many women think they have to hop (or maybe haul themselves) onto the bed, adopt that position that we see on the TV (sitting leaning back on your tailbone, clinging onto your shins) and then "push like you're doing a big poo" for England, or another big place, for possibly a very long time until their baby is born.
There's a lot to unpick here...
Do you really need to push the moment you're fully dilated? What's the hurry?
Is being on the bed necessary or helpful?
What's the best way to give birth? Is there a best position?
Do you need to push push push as if you're doing a big poo? (And will you actually do a big poo?!)
Today I'm musing on the first one of these, the potentially unacknowledged, forgotten, or perhaps the ‘never-even-heard-of-it’ part of labour, that is known as the passive or latent phase of 2nd stage.
It's the quiet, the lull, the 'space between' that some (but certainly not all) women experience between being fully dilated and being ready to begin to birth their baby. It's also known colloquially as the ‘rest and be thankful’ phase (not to be confused with transition, by the way, which is different).
According to guidelines, this passive phase is a recognised part of 2nd stage of labour - or at least it should be. It is included in NICE guidelines (more on that later) but my concern is that perhaps it's not being recognised as much as it should and some women are being encouraged to push before their body and baby are ready, potentially causing problems for them both. Some people haven't heard of this part of labour and so may worry when their baby doesn't start to put in an appearance the moment full dilation is reached.
So what causes this lucky break for some women, this passive phase of second stage?
All our anatomies are slightly different and all our babies are different in size, proportion and position in the womb, pelvis and birth canal. Sometimes it's possible to reach full dilation (so technically to arrive at 2nd stage of labour) but to feel that nothing at all, or nothing very much, is happening. Contractions can fizzle out or stop altogether and you might have no urge or compulsion to push, to give birth to your baby. Your midwife will be checking regularly on yours and your baby’s wellbeing and, providing both of you are healthy and coping well, there should be no need to try and hurry things along. You really can rest and breathe.
Because of these differences in all our anatomies, some babies can remain a little higher than others in the pelvis even when the cervix has pulled right up over the baby’s head and you're said to be at “10cm” or “fully dilated”. These babies need a bit more time to negotiate the twists and turns required to wriggle down lower. When the baby’s head is low enough that it touches your pelvic floor muscles and nerves lower in the pelvis, this pressure causes contractions to return, gradually building in intensity and with one, two, sometimes three short pushing urges within each one. (Having said that, there are always exceptions to the rule. I had no urge to push at all when birthing my first baby, yet with my second they built up quickly to tsunami status!) When contractions return they will probably feel different to the ones that caused your cervix to open. Now you're in the ‘active’ part of second stage of labour, which continues until your baby is born.
If you're lucky enough to experience this pause, this passive part of second stage, and you're encouraged to push, before your body and baby are ready, you're both more likely to become exhausted and depleted of energy before birth occurs. The monumental efforts that some women are encouraged to make in the absence of any physical signs of readiness mean that you're using up valuable energy reserves. Holding your breath for any prolonged amount of time (as often happens with directed pushing) means that the baby’s oxygen supply can also become compromised; babies get oxygen when their mothers breathe. Pushing when you're not ready isn't generally the healthiest option for either mum or baby. It probably won’t do much in the way of bringing the baby to birth either if the baby hasn’t had a chance to align head and shoulders well in the pelvis.
Of course sometimes there’s a reason why birth needs to be hurried along if one of you is unwell, but in healthy circumstances this is usually unnecessary.
So, what if you’re fully dilated, contractions fizzle out and become weak or stop altogether and you and your baby are healthy and well? What do you do?
You might not have to do very much at all other than get as comfortable as possible, perhaps in an upright, forward-leaning position to get gravity working for your baby, and wait. You might like to sip a drink and perhaps have a nibble of something to eat to help with your energy levels. You also might need to pee. A full bladder can take up valuable space in the pelvis so it’s important that women pee frequently during labour. Sometimes it can be hard to feel when your bladder is full because of all the other sensations and pressure in that area, so your midwife might offer a catheter if she suspects a full bladder is in the way of your baby.
If after a rest you’re still not experiencing much in the way of contractions, maybe it’s time to move.
Lifting one side of your pelvis and then the other can sometimes help babies to wiggle down a bit. I call this “Sumo steps”. However, you don’t necessarily need to stand. You could kneel on one knee, ‘lunge’ a bit and then swap knees. This might be much easier if you’re in a birth pool. (Do avoid anything asymmetrical like this if you have PGP.) If you are up to standing, you could try lifting one foot onto a stool or step, rotating or swaying your pelvis, and then changing sides and doing the same again. You can go up and down stairs sideways, although this might be more convenient if you’re birthing at home. You can wiggle and jiggle as you feel the need, following your instincts and doing what you feel you need to do.
If your midwife or doctor is encouraging you to, “Push!” and you don’t feel ready because nothing seems to be happening to indicate that you’re ready, then do what feels right for you. Your birth partner can ask, “Is my partner ok? Is the baby ok?” If the answers are, “Yes” then they could then ask, “Why does she need to push? What’s the hurry?” A lot of women say, “I need to push” when they feel the need, which is often a good clue as to whether or not they feel ready! If the woman and baby are healthy and well there’s often no need to do anything other than be patient.
Having said that, it could be argued that there is a limit – how long is it ok to wait with nothing much happening?
Here’s where we look at the NICE guidelines that I mentioned at the start. If you want to read the version for the public yourself you can find them here: https://www.nice.org.uk/guidance/cg190/ifp/chapter/What-happens-during-labour
All that these guidelines say about how long second stage of labour should last is: “Even when your cervix is fully dilated, you may not have an urge to push with your contractions straight away – this is called the passive second stage.
The active second stage is when you have an urge to push with most contractions, and ends when your baby is born. The birth is expected to take place within 3 hours of the start of active pushing in most women having their first baby, and within 2 hours for most women who have had a baby before.”
There is no mention in the public’s guidelines of how long the passive part of second stage might take, only the active part.
The full intrapartum (during labour) guidelines aimed at health professionals can be found here: https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#second-stage-of-labour
The professionals’ version of the guidelines say that for a woman having her first baby, “birth would be expected to take place within 3 hours of the start of the active second stage in most women” and that delay in the active second stage should be diagnosed, “when it has lasted 2 hours and refer the woman to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent.”
For someone who has given birth before NICE says, “birth would be expected to take place within 2 hours of the start of the active second stage in most women” and that delay in the active second stage should be diagnosed, “when it has lasted 1 hour and refer the woman to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent.”
Again, this just talks about the active part of second stage, not passive second stage. The guidelines do, however, say: “Inform the woman that in the second stage she should be guided by her own urge to push.” So if she has no urge to push, then she needn’t do so.
Elsewhere we do get a mention of the passive second stage, albeit briefly: “If full dilatation of the cervix has been confirmed in a woman without regional analgesia, but she does not get an urge to push, carry out further assessment after 1 hour.” (Regional analgesia generally refers to an epidural.) This seems to say then, that you can ‘rest-and-be-thankful’ for an hour before health professionals might decide a syntocinon drip, for example, is needed to stimulate contractions. Of course, you could try the self-help ideas above.
Interestingly, if an epidural is in place, NICE states: “Upon confirmation of full cervical dilatation in a woman with regional analgesia, unless the woman has an urge to push or the baby's head is visible, pushing should be delayed for at least 1 hour and longer if the woman wishes, after which actively encourage her to push during contractions.”
I wonder why women without epidurals can experience a passive second stage for an hour before further assessment is recommended, whereas with an epidural she can wait for “at least” an hour and longer if she wishes?
I’d be interested to know how many women, who reach full dilatation and then everything stops, are supported to wait calmly and patiently for an hour or so before investigation and discussion takes place? Did this happen to you? I’d love to know if you’ve experienced this lull, this breathing space. How was it? How were you supported? How did you feel? You can leave your comments below.
Finally, I’d like to have left a picture of a really comfortable way to relax in an upright, forward-leaning position. It can be useful in all sorts of moments, not just whilst waiting for your baby to descend in passive second stage. However, having searched the internet for a decent picture to include and annotate, I was disappointed. Perhaps I’ll have to photograph myself to explain what I mean and include it as a separate post some time. Alternatively you could always book an antenatal class with me and then I can show you and help you get comfy!