Second Stage of Labor: Birthing the Baby

What’s happening:

Cervix. Mom’s cervix is completely effaced, and dilated to 10 cm.

Position: During second stage labor, the baby completes a series of “cardinal movements.” Typically, a baby begins facing the mother’s side, so the largest dimension of his head (front to back) enters the widest dimension of her upper pelvis (side to side.) As he descends, he tucks his chin to his chest (called flexion) and rotates his head 90 degrees so that he is facing toward his mother’s back (anterior position). During birth, this allows the largest dimension of his head to pass through the widest dimension of the pelvic outlet (front to back). After his head has passed through the vaginal opening, he again rotates so his shoulders will slip out easily.

(If the baby rotates to face the mother’s front instead of her back, this is called occiput posterior, and may lead to back labor, as the back of his head presses against her sacrum. See back labor.)

Station: During labor, the baby descends into the pelvis. The measurement of this is “station.” When the baby is “floating” high above the pelvic inlet, that is station -4 or -5, because he is 4 or 5 cm above the mom’s ischial spines (the bony knobs at the bottom of your pelvis; sometimes you can feel these when sitting on a hard surface.) The baby is defined as 0 station, or engaged, when his ‘presenting part’ (usually his head) is even with the ischial spines. Many women are at 0 station when labor begins. At +2 or +3, his head is at the vaginal opening, and the perineum is bulging. Crowning, when his head is emerging, is considered +4 or +5 station.

Urge to push. During second stage contractions, the pressure of the baby in the vagina, and the pressure on the rectum, can cause a strongly felt need to grunt or to hold breath, and to bear down. This urge can be as irresistible as the urge to sneeze or the urge to vomit; resisting it can be more difficult than simply surrendering and letting it happen. The urge may come several times during each contraction. Not all women experience the urge to push, even when unmedicated. With epidural, the urge may be minimal or non-existent.

Duration: Anywhere from 5 minutes to three or more hours is “normal.” Textbook average is 1.5 hours for first time moms, and physicians may encourage interventions past this point.

Mom’s Mood. Some women describe pushing as a relief. Others describe second stage as the most difficult and uncomfortable stage of labor. For many, it’s a combination of both of these reactions. Many years ago, a friend of mine described second stage as “it feels like I’m pooping a watermelon.”

Phases of Second Stage.

• Latent. Not everyone experiences the latent stage. For those who do, it’s a time when contractions become less frequent, and there’s no strong urge to push. Pushing during this phase doesn’t accomplish much, it’s better to wait until contractions intensify again. Don’t try to rush the birth. If latent phase lasts more than 20-30 minutes may want to try more upright positions to encourage the urge to push.
• Active / Descent. Contractions are strong and frequent. Irresistible urge to push. May pass stool or gas. Many women become vocal: grunting, growling, yelling.
• Transition / Perineal. Fetal head on perineum (crowning), then emerging. Great deal of pressure and stretching, some women describe the “rim or fire”, a burning and stinging sensation in the perineum. If you feel this, some caregivers recommend that you stop pushing for a few minutes to allow the tissue to stretch and open gradually.

Positions for Pushing

• The most common position for second stage in most hospitals is semi-sitting (a distinct improvement over the lithotomy position with feet up in stirrups that was common in the 1950’s and 60’s.) However, research and anthropological evidence have found advantages to other, more upright positions. An ideal position would: open the pelvic outlet as widely as possible, provide a smooth path for the baby to descend through the birth canal, use the advantages of gravity to help the baby move down, and give the mother a sense of being safe and in control of the process.
• Try out a position for a few contractions. If it works, stay with it. If not, switch to a new position in between contractions.
• Changing positions is good not only for the mother’s comfort, but also to change the shape of the birth canal to help the baby make the required movements prior to birth, and to ensure on-going oxygen supply to the fetus.
• Depending on the caregiver, they may ask you to move to a specific position just prior to the birth.
• The most common position is semi-sitting. With pillows underneath knees, arms, and back. During contractions, mom can wrap hands around knees and pull knees up toward shoulders (as in squatting). Most common in hospital setting. For mom and baby: some help from gravity moving the baby down; mom feels more in control than in lithotomy position. Benefits for caregivers: good view of perineum, easy access to perineum.
• For lots of other options, see positions.

Spontaneous vs. Directed Pushing vs. Laboring Down

Spontaneous Bearing Down. For a mom who has the urge to push, she can sense when her uterus is contracting, and can add her efforts into that. When she feels a contraction coming on, she tucks her chin, curls her shoulders forward, and opens her legs wider. When she feels the urge to push, she gently bears down and pushes. She stops pushing when the urge passes.

Directed Pushing. For a mom without the urge to push, a caregiver will observe when she’s having a contraction (by watching the monitor, or by resting a hand on mom’s belly), and will coach her on when to push. When a contraction begins, mom takes a deep breath in and releases it, then takes in another deep breath, tucks chin and bears down for six seconds. She gently pushes downward with abdominal muscles, while visualizing the baby moving down and out. (Some women exhale while pushing, others may hold their breath for five to seven seconds. It may help to grunt or vocalize while exhaling.) Then she relaxes and takes a few breaths, then bears down again. Generally, do about 3 pushes per contraction, following the urge to push when possible.

Val salva maneuver/prolonged pushing. The mother holds her breath, and pushes for ten seconds, then exhales, breathes in again, and pushes for ten seconds. Repeat this sequence several times during a contraction. Some caregivers believe that this results in a faster second stage than spontaneous bearing down, but there is a greater stress on mom and baby. Causes fluctuations in mom’s blood pressure, which decreases the amount of oxygen available to the fetus. This can cause fetal distress, and lower Apgar scores at birth. It can also lead to a failure to rotate, and slowed descent for the baby, and more perineal tears for mom.

Laboring Down / Delayed Pushing. Some caregivers recommend that mothers with no urge to push, and particularly mothers with an epidural in place, just rest and relax. They recommend waiting to actively push until baby is crowning at the perineum; this may be an hour or more after you reach 10 cm dilation. Laboring down will lead to a longer second stage than a more active, directed pushing, but it’s not as exhausting, and some studies have shown that it leads to fewer instrumental deliveries. Some caregivers are not familiar with this method. If you and your baby are doing well, and tolerating labor well, you may ask if this is an option for you.

How to Avoid Pushing, if necessary.

Some women may have an early urge to push at only 8 to 9 cm. Research indicates that involuntary pushing is not harmful at this stage if 1) the cervix is soft and retracting, 2) the fetal station is 0 to +1 or more, 3) the baby is transverse or anterior. However, you don’t want to be pushing actively at this point, so your caregiver may tell you not to push. Also, during crowning, while you’re pushing the baby out, the doctor may occasionally ask you to stop pushing. It is very difficult to convince your uterus to stop pushing at this point!

However, you can do all you can to not actively push.

If your caregiver has told you that you need to pause in pushing, this breathing technique may help reduce the urge to push. Lift your chin, lean back, and arch your back a little. Pant, blowing lightly. Visualize a feather, and blow just enough to keep the feather bouncing up and down in the air above your lips.

How hard to push. Enough to push the pain away and maintain the feeling of being open but not so much that you produce additional pain. It’s better to think of yourself “opening” and “helping the baby move down” and “easing the baby out” than to think of “pushing.”

Making Noise. Many women have the instinctive need to vocalize during pushing: grunts and low-pitched groans. These are a natural part of the effort of pushing, and should be welcomed and encouraged by partners.

Practicing for Second Stage. First, empty bladder. Get into a semi-sitting position, either propped up by pillows, or in partner’s arms. Place your hands beneath the lower curve of your abdomen; partner can also place his hands there by reaching around you. Take in a deep breath and hold it for six seconds (holding your breath for longer than this can be dangerous for babies, as it reduces the oxygen content of the blood.) Drop your chin forward onto your chest, and allow the bulge beneath your hands to press downward and forward, pushing your hands out and forward. You will feel your perineum move too, bulging very gently outward, and then the tissues of the vagina spreading out. Then exhale and relax.

Can also be practiced while sitting on the toilet, as this is where you are familiar with releasing pelvic floor muscles. Can also be practiced in other birthing positions. Inhale, put chin on chest, and curl body forward; bear down gently as if having a bowel movement, pressing from the inside steadily out, slowly and gently; then exhale and relax. The goal of this practice is to release the muscles and feel what the relaxation of those muscles feel like. Do not practice hard pushing!!

After practice, do some Kegel exercises to tone your pelvic floor muscles.

Practice a few times a week.

See Comfort Techniques for Second Stage.

Compiled by Janelle Durham, 2004. Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (2001 edition). The Labor Progress Handbook by Penny Simkin and Ruth Ancheta. “A Window to Second Stage” by Elaine Szeto, IJCE, 11:1. “Myths about Second Stage” by Nancy Held, Childbirth Instructor, 1994. Methods of Childbirth, by Constance Bean, 1990.

Interventions in Second Stage

Third Stage: The Placenta