March 7, 2001
Volume 3, Issue 10
Midwifery Today E-News
“Second Stage”
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Quote of the Week:

"Let us not forget the natural gifts that Mother Nature has given us, for in these gifts lies the wisdom which brings forth all life."

- Jill Cohen

The Art of Midwifery

I use this herbal tincture in the mountains of Lima, Peru, so I really, really, really trust it! I trust it more than Pitocin so you can imagine I wouldn't go anywhere in the world without it: Shepherd's purse, blue cohosh, beth root, all equal parts, and mixed. Fill half of a jar with it and pour vodka, or any other strong 40 to 50% alcohol, over it and close it very tightly. Keep it under the moon, charge it, or just keep it in your kitchen (it's still going to work, trust me!) for four weeks, decant and keep in brown or dark bottle.

It works beautifully. But beware of clots--shepherd's purse loves to make clots. After the bleeding has stopped and mom has breastfed a while, help her squat on a bucket and push with contractions, and PLOP! The placenta will come and the mom can resume breastfeeding.

- Ana Montero

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News Flashes

Based on a meta-analysis of available literature, chorioamnionitis appears to be associated with an increased rate of cerebral palsy in premature infants and, to a lesser degree, in full-term infants. A growing body of evidence supports the notion that inflammation of the fetal membranes caused by maternal infection contributes to neonatal brain injury; according to the analysis, an intrauterine infection can cause a "robust inflammatory response which leads to central nervous system damage in the fetus, and subsequent cerebral palsy."

- JAMA, Sept. 20, 2000

Editors Note: Could we be inadvertently causing more cerebral palsy with the epidemic inductions? See the great induction article in Having a Baby Today (our newest newsletter), premiere issue coming soon. Subscribe Today!

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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

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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.

Editors note: Please also share other ways you know of to turn a breech.

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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

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.

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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
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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 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

- Aiyana G.

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