ļ»æEpisode 11 - The Labour Process
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Yeah. Hi, Bea. Hi, Mel. Hi. We're doing episode 11 today and this is a bit of a piggyback off episode 10 because we couldn't fit everything else into episode 10.
Mel:
[0:40] We talked about vaginal exams and cervixes for an entire hour. So here we are kind of piggybacking off that and talking about the labor process and labor progress but in a rebellious way yeah
B:
[0:54] And in a succinct way being succinct is not my strength but it is going to be today let's do this succinct let's.
Mel:
[1:00] Do it okay succinct okay so before we start we're talking about labor progress and the labor process but I just have to say that labor does not unfold in a way that the textbooks or a hospital says so first up all that stuff is not how it happens so this knowledge about labor and birth that me and Bea are about to bring you is it's rebellious because it's different and The knowledge about labour and birth is distorted by medicine. The medical way of managing birth labels and puts boundaries on birth because they wanted to medicalise it. So today we're drawing from research about how labour progresses and also what we've observed watching births at home that aren't interrupted by moving into the hospital and having unnecessary interventions.
B:
[1:51] You know, and if you think about birth as a physiological event, well, what's a physiological event? because we don't normally use that word outside of medicine, right? What's physiological? Well, weaning is physiological, breathing is physiological, pooing is physiological, you know, to really undo because what people who believe that it needs to go by a textbook, they've been conditioned to believe that. That is a belief system that they hold. It's not aligned with the truth,
B:
[2:19] which is physiological. And the way your body does something is going to be very different to the way my body does something. We're not all the same we're all very different and so just like we are made differently physically physiologically we perform differently too you know the language we use around birth really plays into these belief systems and what we tell our friends around our births and what we talk about as midwives and doctors then filters into the community and comes up with this belief that labor and birth is meant to go this way and it's meant to look that way now you and I know what physiological birth looks like but I've cared for the same woman over and over again I've been at her second and third births and they never that woman's never birthed the same each time I mean I've had two births you've had two births I had a 12-hour labor then a one-hour labor tell me what where that would fit in the textbook it doesn't so understanding physiological is really important here to then see what has happened to birth and how it got put in a textbook in the first place And.
Mel:
[3:20] So physiological means just the normal functioning of your, a normal function of your body. So if you look at birth from, without a fear perspective or a medical perspective, we're all just saying birth's just a normal part of what our body can do. Whereas when it got medicalized, it got defined and broken up and like this mechanic, some kind of mechanical process that follows a linear step-by-step process to get to having a baby. So if we look at what the textbook says about...
B:
[3:50] Which is, I've got to interrupt you there, Mel, that is medicine. Yes. Right? So step-by-step approaches are how we handle pathophysiological events, so sickness and disease, and we want those because they keep us safe when we're unwell. So that's what's been applied to birth to help us in the medical world understand it and manage it. And what we say is birth doesn't need to be managed, it needs to be observed. And then if something happens that needs to be managed, then we manage it. But what often happens is birth is managed from the start. It's not just observed. And when you observe birth, you learn a heck of a lot.
Mel:
[4:27] Well, and I think with physiological labor too, the midwife and care provider needs to manage themselves so that they don't do anything unnecessarily. And the place for intervention is when something goes wrong. There's an amazing ability to correct that with medicine or medical procedures.
Mel:
[4:46] But if you don't need to treat a labour or manage a labour that's unfolding physiologically. So if we have a look at what medicine says labour should look like, and this is what we're told in our training as midwives, and then it's reinforced in the workplace. So I don't actually believe that the physiological process of how labour unfolds is even shared with student midwives either at university. A textbook or medicine would have labor broken up into three stages. So there's the first stage of labor, and that involves regular contractions of the uterus and also dilation of the cervix. So we've already met a problem here because they've started defining the first stage of labor in relation to what the cervix is doing. So if you heard last week's episode on VEs, diagnosing the first stage of labor relies on vaginal examinations.
Mel:
[5:43] And then also they're only allowing the first stage of labor to be defined by effective contractions that are creating dilation. So if a woman's getting contractions and potentially in the earlier stages of labor, but there's been no change in her cervix, she would be told you are not in labor. But the problem is, is she is in labor because she's not in not labor because she's contracting. So then all of a sudden the woman's having this experience of labor and she's been told you are not in labor, but she's not in normal life either in her experience. Women's experience of labor immediately from the get-go is different to what medicine is told, is telling them is normal or any kind of productive labor. So we're already at the first hurdle. So then medicine likes to break down this first stage of labor into like what we call the latent phase or early labor phase. Then active labor, which again, you know, I don't really like the terms how they've broken it up. But anyway, active labor, again, diagnosing active labor relies on doing a vaginal exam. So previously, when I first started my training, women were told they were in active labor. I'm doing speech marks again. If they were four centimeters or more dilated in their cervix, if they were less than that they were sent home and told you're in early labor go home come back when labor's stronger so again like just this total dismissal of the early parts of labor this
B:
[7:10] Is all bed management issues because if a woman's presenting in earlier stages of labor, What she's saying is, I need support. I need help. I need to be cared for. I'm scared. I'm worried. You and I go, well, yes, send her home so that she, because we know the sooner you present to hospital in your labor, the earlier you present to hospital in labor, the more interventions you are likely to receive. So you and I are like, yeah, great. Send her home. And she might get that in
B:
[7:34] a visit. But what she's saying is, I feel like I'm in labor and I need something here.
Mel:
[7:39] And then get sent home.
B:
[7:40] And that dismissal is often what holds charge for people afterwards in the birth. And it can really cause ripple effects in that person's labor because then they're thinking, well, I'm not in labor, so how long is it going to be and, you know, what's going to happen next? And so what we're getting is, you know, the prefrontal cortex where we do all our thinking is now dominating rather than that beautiful middle brain that needs to be dominating in labor. What we get is adrenaline. What happens then is oxytocin decreases. What happens then, the body picks up, it's not really safe to have a baby today and it draws the process out.
Mel:
[8:11] These things that I'm telling you now is a summary of what the textbook would tell you.
B:
[8:15] And the language we're using isn't language you and I would use in normal, in the care we provide. Because what you're saying here is labor needs to be diagnosed simply by what the cervix is doing. And so the medical definition of labor is purely based on the cervix. Whereas you and I know the definition of labor is based on many things from the woman and how she's feeling to the noises she's making to the, what the uterus it's doing to the position of the baby. But if a baby rotates from the side to all the way at the front, that's huge progress for me. That's incredible. But all the textbook sees and all the policies in the hospital see are cervical dilatation, which is heartbreaking because it really messes, A, with physiological labour. It increases intervention, but it also changes the person's experience and their memories or their experience of their labour.
Mel:
[9:08] And what else it does is it de-skills midwives to know anything about labour without doing vaginal exams. And so what happens is that midwives are kind of expected to diagnose all the different stages of labour for the medical records and to manage each woman's
Mel:
[9:28] labour and to know what to do next because everything is based on how far her cervix is dilated. Midwives then don't hone the skills that that are possible and we will talk about how to diagnose if we're going to use that word diagnose labor progress using other different techniques other than putting your fingers into women's vaginas every two to four hours
B:
[9:49] And this is a huge maternity system issue because really what we're doing is we're raising obstetric nurses we're not raising midwives in the system because really if you are working on an understaffed birth suite and all you're doing is inductions and you know you're looking after two or three women in labor you don't get to sit and observe and if you're not working with a mentor midwifery mentor that really understands physiological labor You don't get to learn that.
Mel:
[10:15] So once women move from being in the latent slash early labor phase, then medicine says that they move into active labor. And now active labor is where medicine goes, well, okay, this is our jurisdiction. We have not brought early labor or latent labor into the jurisdiction of medicine. So soon as women approach the hospital in early labor, there's a big sign on the door. No, no, we don't do early labor. That's your jurisdiction. We're going to keep giving that to women. Don't be scared of early labour. But the minute you're in active labour, you're in danger and you need to come to hospital and that's our jurisdiction. We can look after you in active labour. But before that, go home, right? That's the weirdness of defining labour stages is they've also defined the jurisdiction.
B:
[11:02] If women present more than once or if the place is quiet, early labour can be medically managed too. So women will be given sleeping tablets they'll be given panadine fort often so the the good old panadine fort into maz and sent home with that sent.
Mel:
[11:20] Home so women get sedated and silenced
B:
[11:23] Yeah early yeah and really what they're saying at that time is i need support and so what we give them is sleeping tablets and pain relief and so that early labor stage especially if it is long for some people can be a number of presentations. And then what that can look like is early labor being managed with intervention. And so if you become a nuisance to the system, then all of a sudden you get admitted. That sounds awful. I hope everyone took that the way I meant to speech marks.
Mel:
[11:54] Well, and that's what happens is the hospital says, look, we don't do early labor here. So if you need us during early labor, we will send you home with medication so you don't come back anytime soon. Or if you want to be here for early labor management, we will manage you. We will drag you into active labor because that's our jurisdiction. So you'll either get augmented with Centosanon like an induction. Or like Bea said, water's broken. They won't just let you sit there in early labour and be cared for because that's not in the medical jurisdiction or the boundaries of what hospital will offer.
B:
[12:27] And if you are, because sometimes it happens, you'll be put into an assessment space. So it's not that you don't go into the birth space often. So bigger hospitals will have birth suites. They'll also have assessment wards, attorney assessment units. So you might be there. It might not be a single room. Often you'll have to share the room. often it won't have the things in it that you would want a birthing space to have in it, like a fitball, a bath, a nice shower. It's just basically a really stock standard small hospital room. And so it doesn't have the tools that you may want to utilize.
Mel:
[13:02] Although this is not the topic for today, this is a really good reason to prepare
Mel:
[13:07] your support people to support you during early labor, because that most of it's done at home. And so you only you present to the hospital when you're considered to be in, again, speech marks, active labor.
B:
[13:17] Get a doula, have a doula at home. If you don't have midwifery continuity of care, you're not birthing at home, you're birthing in the system. Everybody needs a doula. Don't cut that bit out because that was epic.
Mel:
[13:30] Okay, I won't. Can I say too that doulas fill gaps for women
Mel:
[13:37] That haven't already been met. So if you've got a super involved and confident partner who's on board or a friend who's given birth in the way that you would want to be supported, you can replace the work of a doula with super keen, prepared support people who've done it before and who are on board. So I've seen that happen. And the guys are, you know, the partners are just the biggest advocates for the women. But certainly if you think there's a gap in your support network, then a doula is the person who's going to advocate for you particularly in that early labor phase and and hold you and help you stay at home and hold you in that space before it's time to go to hospital so if we start talking about then you're you're done with early labor you feel like yeah i'm ready i'm coming into labor of what they would call active labor again speech marks i don't use any of these words these are textbook words before it used to be if you arrived in hospital, they do a vaginal exam. And if you are more than four centimeters, that's it. You're admitted, you're on the books, you have a folder, your labor, your active labor has officially started. But that was based on really old research and newer research now by Zhang. And again, all of these research papers will be in the folder that you get access to if you are on the Great Birth Rebellion podcast mailing list. So get on that at www.melaniethemidwife.com. I'm going to say it every episode because everybody's looking for the mailing list.
Mel:
[15:02] So the new research suggests that women are actually not in active labor and so therefore not of the medical jurisdiction until they are five to six centimeters dilated. This is catching on at hospitals I found. They're kind of happy that women are coming in later more in advanced labor. If you're not using vaginal exams as a way of diagnosing where women are up to in labor, a very, very basic and blanket rule that it doesn't apply to everybody. But when women ask me, how do I know that things are progressing? I'll often say, you know, you can gather a lot by the pattern of contractions, not always because this deviates wildly, but very generally, if your contractions have a regular pattern, so they're happening at regular intervals. So when you count contractions, if you want to count contractions, you'd count from the beginning of a contraction.
Mel:
[15:56] And then the gap is you count to the beginning of the next contraction. So if somebody rings me and says, oh, they're six minutes apart, that's because they've counted from the beginning of a contraction to the beginning of the next. Then if they're regular, so if you're counting them for like half an hour to an hour and they're every four minutes regularly, then you know you're probably in a pattern of labour that's going to progress on to full dilation and to you having your baby. It's probably not going to stop and start from that point. Again, super generalized. And then what will happen is once you're in a regular pattern, the contractions of active labor, again, saying that hesitantly, are usually a minute or more. So if your contractions are lasting less than a minute, it's possible that you're still in early labor. And if they're more than that, then you're probably in labor that's going to progress on. And then they will get periodically closer together and the contractions become longer, which gives you less of a gap between contractions of rest. That's not what happens to everybody. I've been at births where a woman has had a contraction every 10 minutes and then had her baby. Yeah.
B:
[17:05] We've all been at those births where, you know, and you're always like, what's going to happen with second stage? And it does. Or they just push it out in one contraction. But yeah, for some people, their physiological labor looks like 10 minute contractions or five minute contractions. Well, here's the thing. You're going to know when they get closer together. You're going to know when they're stronger. You're going to know when you really want to go to the hospital because you're going to think it. If your partner or support people want to project manage, that's cool that you
B:
[17:33] don't have to do it from the start. You don't have to time your contractions when they're 10 minutes apart. These people who are caring for you are intelligent. They're able to go, wow, yeah, it's really heightened up here. Wow, she's starting to not talk to you anymore. She's starting to give me some daggers. She's squeezing my hand a lot more. She's really stomping her feet I think these contractions are close together it needs to be less about time and more about how you're feeling go to the hospital when it feels like you don't need to go to the hospital we're also scared that these babies are going to drop out in the car on the way there like there's just there's so much panic and stress around when to get to the hospital and it's going to be different for everyone yeah okay I'm down I'm off my high horse right I'll mute myself.
Mel:
[18:15] I think what Bea's trying to say is when you're trying to decide what to do next, should I go to the hospital or is it time to ring my midwife? Think about what you need, not where you're up to. When my clients ask me, oh my gosh, when should I call you? I'm like, well, that is completely up to you because you need to decide when you think you need me. There are some clients who need me in early labor and there are some clients who didn't feel like they needed me and then they felt like they needed to push and still didn't feel like they needed me. And so it's like- Yeah,
B:
[18:48] It's such a beautiful way to put it. It's what you need. Right.
Mel:
[18:51] It's less about how dilated your cervix is and more about what do you need.
Mel:
[18:57] Then that's what matters in terms of where you're up to in your labor. Are your needs being met? So then when the textbook talks about first stage, we've already talked about early labor, which is technically textbook anywhere from one to five or six centimeters.
Mel:
[19:12] Then active labor goes from five or six centimeters to being fully dilated. And then there's this stage, this phase called transition. Women typically get to transition. You can be anywhere with your cervix, but typically you're getting close to pushing out your baby if you're feeling transitional. Sometimes, you know, when I was working in hospital, they used to say, you know, women are transitional between nine and 10 centimeters or so, or at the time where you're fully dilated, but not yet pushing. Now, this transitional phase, if I could talk a little bit hormonally, is in hospital characterized rise by women kind of losing the plot. Again, I don't, that's not to say insultingly, but your behavior changes from what you were doing previously.
Mel:
[19:58] Women start to panic a little. They can. The reason they do that is that at, in that time of transition, your body is winding up to get ready to give birth to your baby. So you need an injection of adrenaline because you need to be a little bit more alert and you need to power up to prepare for what's about to happen. That's what your body's doing. But as people, we recognize an adrenaline shot in a time that's usually fearful or stressful in our lives. And so when we feel the adrenaline taking over, women can sometimes start to panic and wonder what's going on and why are they feeling frightened and why are they feeling frazzled. But if women understand that actually this adrenaline is purposeful in this moment because adrenaline gives us strength and capability and power. So that's part of it as well. And this power is what your body is going to use to bring your baby out and also to immediately care for your baby with full presence and with hypervigilance.
B:
[20:58] Which is why if you've ever had a baby, everyone in the house falls asleep and you're there going, if you've ever had a baby physiologically and you've truly experienced all the hormones to their complete power, this is why you cannot sleep. That is why you're so crisp.
Mel:
[21:13] Exactly. Because the baby needs care now and And you've got to look after it. So that's transition.
Mel:
[21:19] But there's a stage of transition that's not recognized in textbooks or in hospitals, or it is recognized and it's not welcome. So it's called the rest and be thankful stage. And honestly, in a physiological birth, I probably see the rest and be thankful stage 60 or 70% of the time. Women will be in good, strong labor that I think is progressing on to a baby being born. And then suddenly they fall asleep in the pool or something, or they lie on their side and start snoring. And it's like there's no contractions for half an hour, an hour, sometimes even longer. Now, is that seen in the hospital and all of a sudden your contractions stop and your body shuts down? They consider that to be a stall in the labor process that needs to be accelerated and augmented with oxytocin or the artificial oxytocin, which is syntocin or pitocin in America. So if women stop contracting in hospital, that's seen as divergent and not normal. And they will likely try and give you an induction at that point. But what that is, if you observe it from a position of not interrupting things, that's the rest and be thankful stage. That's the body going, right, we've done labor. We're nearly fully dilated or are fully dilated. And we need to get ready to push this baby out, power down, gather energy. we're getting ready to do this
B:
[22:44] And i would say the body's not even thinking about full dilatation no no no so yeah it's not thinking about the cervix no.
Mel:
[22:52] It's not thinking about, it's not, it's just thinking it's doing its thing, right? So if, so this is a message to anybody, if you're laboring and you're going on, on, on, and then all of a sudden you feel like falling asleep or you feel just fall asleep, don't think to yourself, oh my gosh, I feel so sleepy. What do I do? Just fall asleep. Let your body go to sleep. And if you're a midwife looking after that woman, do not under any circumstances, wake that woman up. Don't wake her up to do her blood pressure. Don't wake her up because it's time for her next vaginal exam. Don't wake her up to see if she's okay. She's okay. Her body is doing a very, very important thing. Don't interrupt. Okay, full stop, rant over.
B:
[23:30] Yeah, but they're going to have to, right? Because that's what the policies are. And so this is part of really, you know, because it's very easy for us to sit on a podcast and say, don't do it. But the reality is observations are based on time. What will generally happen in that time is you won't be left to rest. You will be seen as your labor isn't progressing and you will interpret that as a bad thing the only thing that needs intervention in labor and birth is when you or your baby are unwell so if you your baby is well and you are sleeping this isn't a lay this isn't something that needs to be managed in labor this is not pathophysiological this is a time management issue so having this knowledge and going to birth and going I'm not willing to accept for my labor to be sped up with drugs or interventions like a breaking of waters because this is often when the waters get broken. So knowing that this is a really critical point of your labour where you may be offered unnecessary intervention. Do you want intervention at this really crucial, transformative part of your labour? Or do you want to be respected?
Mel:
[24:34] Midwives can also advocate for women at this time. So if somebody's like, have you done that woman's blood pressure yet? It's okay to say she's actually sleeping. I'm not going to wake her up. And then educate their colleagues about she's probably resting and being thankful. And let's allow that. Let's give her some space to do that. She doesn't need her blood pressure done this hour. It could be done next hour.
B:
[24:55] And even more importantly than that, bring this to meetings. Bring this to policy development. Let's start talking about it. Plant the seed and then by the time you need the fruit the tree's grown like have these conversations before you need to advocate that was a really good analogy I'm just gonna say it was beautiful I know I'm really proud hey what I want to talk about is and I don't know if you've done the research so we may cut this bit out but how the stages of labor actually got defined to get into textbooks was actually by a very very small study on one population of women and it was what was Friedman's wasn't it I've.
Mel:
[25:36] Got that's my very next section B we've got a whole discussion about
B:
[25:40] So in tune with you that I know what we're going to so should we go there now we.
Mel:
[25:45] It was it's literally after transition is a note saying talk about Friedman
B:
[25:51] Epic but it's in transition is such a sacred time it is labor's way of saying hey you're about to be a mom, let's pause you know it's a real it's like it's this time where you need to be nourished you need to be nourished before you're about to do the nourishing
B:
[26:12] it needs to be honored and respected and seen as sacred it doesn't need to be tampered with so.
Mel:
[26:19] Take home rules never wake a sleeping baby and never wake a sleeping laboring woman. If you live life by those two rules, you'd probably be fine. So that's the first stage. I feel like we've talked about the first stage. So first stage ends in medical terms, ends when you're fully dilated. But how did we get here? How did we get to the point where we were defining labour in stages and progress and cervical dilation? Around the 1950s, but there's some research that was done in 1969 by a fella named Friedman. And he said that- Who do you
B:
[26:57] Hear that one? I just had to do it.
Mel:
[26:59] 69 oh it's happening okay oh 69 my first
B:
[27:05] Real six string.
Mel:
[27:06] Well okay Friedman was also rocking out doing some research bringing it back in 1969 said that normal dilation when he plotted this and by the way did you know Friedman when he did his research it was based on rectal exams on women to detect vaginal cervical dilation. It wasn't vaginal exams. It was rectal. So anyway, fun fact. So he said that dilation occurs at 1.2 to 1.5 centimeters per hour. And that is what practitioners have been using to define the normal progress of labor for a long time now. But thank goodness for Zhang, Zhang et al. and their research, which again, will go in the folder for the mailing list.
Mel:
[27:55] Zhang challenged this idea of 1.2 to 1.5 centimeters per hour and concluded that, and the paper that I'm referring to is called Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes. So Zhang looked at labors where the baby and women were well at the end. So we're not looking at labors that were like, oh my gosh, we let it go on forever. And then now something happened to the baby. So we're looking at well, but babies that had good outcomes. And what Zhang said was that labor may take more than six hours to progress from four to five centimeters and then more than three hours to progress from five to six centimeters. Now that is a huge difference. So with Friedman saying 1.2 to 1.5 centimeters per hour from active labor, from four centimeters, this is what Friedman said, from four centimeters, women should progress at 1.2 to 1.5 centimetres per hour. What Zhang is saying, and Zhang defines active labour as five to six centimetres, what Zhang had found is that it can take more than six hours, so probably four times longer than what Friedman said, to go one centimetre, so four to five centimetres, and then more than three hours to go from five to six centimetres. So if we
Mel:
[29:15] Apply the upper limits of what Zhang observed. So six plus three is nine, good math. Nine hours to go from four to six centimeters is considered normal from Zhang's research. Well, there's a few problems with it. So they were all hospital births, obviously. The problem was all the women started labor spontaneously. So none of them started being induced. But then they still included in the data, women who had ended up having an epidural and women who ended up being augmented with syntocin or an artificial oxytocin. So this lumped together, even women who were augmented in their labor were included in a study that was supposed to try and plot reasonable progress that we could expect.
B:
[30:02] Yeah, but what they've done is they've made it generalizable to hospital birth because what they've done is they've shown what happens in hospital which is people accept epidurals or their labour is augmented. So what they've done is they've made the data able to be more generalised to the overall population.
Mel:
[30:21] Now we still don't understand what normal labour does.
B:
[30:26] So why does the time matter?
Mel:
[30:29] Well the time matters because there's another medical term called labour dystocia which is the definition given to labour that is for somehow some reason stalled or stuck and then
B:
[30:42] Also it's called failure to progress which is an awful awful term because you haven't failed it's just stalled but in this case when this happens we see pathophysiological events arise yeah right in true labor dystocia you see either pathophysiological pain they get a temperature the baby's heart rate starts to change there is no normal it's weird because you want to I want to use the word progression but you it's you don't see labor unfold as it would physiologically unfold we see blood in urine we see all these things that tell us hey yeah something needs to be managed here and.
Mel:
[31:22] Labor dystocia at any point regardless of where your cervix is can happen and is diagnosable without a vaginal examination and And I know that because it actually still labour sometimes does not progress at home either. So there has been times where I've wondered to myself, what is going on? I don't know.
B:
[31:47] It's the first sign, right? Like as a midwife, when you truly know physiological labour, That's the first sign. You're like, hold up. Like, what's going on here? That's called relationship-based care. That's true midwifery. That's intuitive care. And so, yeah, we see it. The woman's not well anymore. She recognizes it. There's always, when you really, when you debrief your birth, those thoughts were there. Whether they were vocalized or not, they were there. And that's true labor dissociative because guess what? Your body and your baby are communicating, right? So the body knows.
Mel:
[32:21] That's the obsession. with trying to work out how many centimetres women are at and how long has she been there and is this dystocia and do we need to do something to intervene in that process?
B:
[32:34] All of this was based on very, very small old research. So research from the late 60s and new research which really doesn't show physiological labour and it does, you know it is the results can be generalized more widely because of the how they've done the study now as a care provider what have you learned because really we should if we're doing something to every single person in labor which is what we're doing with progressive labor we're expecting it from every single person it should be backed by a hell of a lot of research to be able to do what we're doing because what we're doing is interventions we are changing it based on the research we have but the research we have is from two studies one in 1969 one Zhang was 2010 wasn't it?
Mel:
[33:20] So Zhang's done a lot more research since 2000 as well but the issue is is that the majority of the work for maternity care workforce is still using Friedman's very small old study so if your care provider or you are still thinking that one to two centimeters is the progress per hour that a woman should be experiencing. It's based off a tiny study done way back in the 1950s and 60s because Zhang started talking about this a long time ago.
B:
[33:51] Yeah and then say what is your expectation of my labor and how it will progress because knowing what their expectations are is going to guide you on what kind of care they're going to provide you and if you're not if you don't align with that and you're not willing to change care providers because remember you can change care providers up until when you're in birth and I know lots of you are and you're contacting us about it which is wicked we love that you're being rebellious and doing what you need but if you're not willing to do that then you need to have a plan around that right am I willing to accept their definition of progress of labor and am I willing to accept intervention even if it's not going to feel necessary to me or if I'm not what am I going to do about it.
Mel:
[34:29] And if we talk about this phrase of failure to progress,
B:
[34:34] Spit on it, hate it.
Mel:
[34:37] Spit on it, put it away, lock it up in the freezer,
B:
[34:41] Erase it.
Mel:
[34:42] So this is how medicine will describe your body. If your body doesn't conform to this rule and expectation that medicine has placed on your labor, they will tell you that you have failed to progress. And it's used to describe the deviance if a woman's cervix doesn't dilate to the expectation of Friedman oh his original research was 1955 it's just come to me so so now medicine now Zhang's trying to redefine redefine what labor crop progress is and when have women truly failed to progress I'm speech about so but what it is it's not failing to progress you've not failed your practitioner has failed to wait. So that's what I call failure to progress. It's not failure to progress, it's failure to wait. And then if for some reason there is a complication in your labor where the baby gets stuck or the position is not ideal for the baby to come out, you've experienced some kind of dystocia. No one's failed, but there has been a dysfunction in the process. So we're going to let go, completely get rid of failure to progress. Stop writing it down, Stop putting it in the computer. Stop telling yourself you failed because it's so derogatory. Anyway.
B:
[35:54] Please stop using it in the workplace. Really, that's one of our rules. If you're going to keep listening to this podcast, you're not allowed to use it on any whiteboard. Do not abbreviate it to FTP.
Mel:
[36:04] No, no.
B:
[36:06] And if it's not in the computer, tick other and write Labor Dyssocia. That's how I started being really rebellious in the workplace. I just wouldn't accept what the computer, the computer says no. B says yes, write it in the notes instead.
Mel:
[36:20] That's what I want to say about that. And we, but we still don't know, there's no research on how labour normally progresses if you didn't augment it and where that would still be a normal outcome.
Mel:
[36:29] So that's what I want to say about the research on progress. So we've gotten to ourselves to the end of labour and we're moving on to the next stage. This is the second stage that the textbooks will define in labour. Second stage of labour is, The textbook tells you, again, it's based on vaginal exams, that second stage is when your cervix is fully dilated and it ends when the baby is fully born, which is totally bogus too, by the way. Bogus, bogus, bogus because...
B:
[36:58] And it ruins us. It ruins us physiologically and it ruins us in postpartum because what it leads to is coach pushing and us telling you to push your baby out before your body has said it's ready to because your body knows how to push a baby out. We're telling you to do it before it said it's ready which leads to trauma emotionally and physically and and it leads to fetal distress for your baby it leads to longer stage of actually pushing and it leads to higher rates of episiotomy and that was nigel lee's study and we're doing i need like i told mel don't even get me don't even allow me to talk in this stage because i need a whole episode so i'm going to stop it there but it's not then we just need to get rid of the stages of labor they serve absolutely no purpose whatsoever they do not benefit us i don't even understand why they're there why do we need them they're not beneficial no.
Mel:
[37:48] Medical it's been medicalized that's why it's
B:
[37:50] There it allows us to categorize and tick boxes which is not what birth needs birth does not need any boxes to be ticked yeah.
Mel:
[37:58] So this is what the textbook would tell this is what the textbook would tell you that second stage is cervix fully dilated to baby being born but yeah of course it assumes that midwives are sticking their fingers in women's vaginas every two to four hours to determine if you're fully labored if you're fully dilated but if we don't do that and we shouldn't be doing that offering routine vaginal exams
B:
[38:20] Because they're not by evidence shown to be beneficial in spontaneous physiological labor.
Mel:
[38:26] Correct go back to episode 10 will give you all the information by why we shouldn't be doing that so then how do you work out when a woman is ready to push out her baby? How do you know that she's exited the stage of labour of cervical dilation and her cervix is fully open and ready to move a baby through and out? I'll tell you how because private midwives are experts at working out where a woman is up to without putting their fingers inside a woman's vagina because we have to have two midwives at birth. Legally, you have to plan to have a second midwife at your birth. And so we call the second midwife when we think the woman's getting close to having her baby, when we think there's a birth about to occur.
Mel:
[39:10] But we don't do routine vaginal examinations. We don't even check and hold your hats, midwives. We don't even check if a woman is fully dilated when she starts bearing down or showing signs of having an urge or if we think she's ready we don't check we just let them push however they want to push oh it's so bad
B:
[39:32] Ass i know.
Mel:
[39:33] Apparently that so we need to work out other ways how do we know this woman is about to have her baby so i can fulfill the requirement of having a second midwife at the birth We get really, really good at it and very, you know, occasionally the second midwife misses the birth if the baby's coming sooner. But it can vary almost 100% of the time sort of go, yep, there's a baby about to be born. I'm going to call my second midwife. And depending on where that midwife is, determines if she actually gets there in time. So how do we work out full dilation or that a woman is about to have her baby without actually putting your fingers inside her?
B:
[40:12] Can I say my favourite one?
Mel:
[40:13] Yes. where
B:
[40:14] The anus starts winking at you.
Mel:
[40:15] Yes or pouting
B:
[40:17] To give you a good kiss.
Mel:
[40:18] It's called anal pouting so
B:
[40:20] It's my favorite thing.
Mel:
[40:21] Anal pouting so if you just poo
B:
[40:24] Because then we know we always get scared about pooing in labor it's like don't be scared of the poo poo is magical the poo tells us that guess what comes next.
Mel:
[40:32] My baby because the baby's making way the poo's got to get out of there so the baby can come through basically the baby comes down through what's in your pelvis called the curve of caris okay as it comes around the curve it pushes on your bum hole and it's
B:
[40:50] Basically your sacrum and your tailbone right like it pushes down along that.
Mel:
[40:54] A little curve and so if your anus is pouting out and it looks like it's coming out to meet us we know there's a baby behind there and probably we're about to see it at the opening of your vagina so if we see anal pouting but also the woman starts to make sounds like so we know what sounds it sounds birth sounds different to labor and pushing out a baby sounds different to labor if physiologically a woman starts bearing down or feels an uncontrollable urge to do something different to what she's been doing before and so we know what that sounds like and you'll only know that if you watch physiological birth you won't know what that sound is if you're doing what we call coach pushing which we're going to talk about in another episode yeah the favorite
B:
[41:40] Thing i love is the purple line.
Mel:
[41:41] Purple there's research b i've got it
B:
[41:44] Yes tell me i love it.
Mel:
[41:46] So it there's a purple line it doesn't happen to everybody the research showed that about 70 percent of women will get a purple line and it can depend on skin skin
B:
[41:56] Color yeah because i've worked a lot with um you know in with Aboriginal women and women with darker skin and you just don't see it as well or at all.
Mel:
[42:07] Paler skin tends to be a lot more obvious and we call it a purple line it extends from the anus up to the sort of the nape of the back up to the
B:
[42:18] I don't know. Just above the butt crack.
Mel:
[42:20] Above the butt crack. So there's been some research done on this around. There was a few papers. And again, they'll be in the mailing list folders. In 2010, there was one.
Mel:
[42:31] And it found vaginal exam accuracy to be less accurate than the purple line. It's amazing. So they looked at 144 women. and they determined in this study that 109 women, so 76% had a purple line. In this study, they did vaginal exams and then also measured the purple line to see if there was a correlation. What they said was that the purple line does exist and there is what they called a medium positive correlation between the length of the purple line and a woman's cervical dilation, but also the position of the baby's head in the pelvis, creating the purple line. So then they've said, it's a thing. And actually we can, there's a possibility that we can use it to diagnose labor progress. And there just needs to be more research on if it can become an objective measurement that we could use as midwives in place of vaginal exams and how acceptable it is to women. The other reason though, that I see the purple line so often is that at home, women are using active birth positions. So more often I can see their bum than their belly because they're in a forward or standing position.
Mel:
[43:46] Whereas the predominant position of women in hospital percentage wise, they're actually on their back or bottom. So you can't even see it. So a lot of the signs that Bea and I are talking about might not be visible in a hospital birth if a woman is on a medically induced birth position like laying on your back because women will not physiologically get on their back.
B:
[44:08] The other thing, Mel, and I know you've probably got a few other things you want to talk about here, but you're talking about how we know that a woman's ready to have a baby. But really you and I, and so many other midwives out there are very skilled at knowing that labor is physiologically progressing. Labor is chugging along beautifully well before transition. There are things that you and I know, and your care providers will know that labor is actually progressing without doing a vaginal examination there's also things that you will know as a woman like i remember being in labor and being like you know if you talk to him like yeah, contractions got closer together I'd started getting harder my mental thoughts started changing you know I stopped talking in between contractions I needed to rest more you know there's so much that actually happens that isn't the cervix everyone's different you know and so many women who are beautifully in the zone but may not be demonstrating labor as we want them to demonstrate it often get palmed off as well you're not in labor because you're not making these noises and not doing this and they're not and they're like well it feels a lot stronger I feel like I've progressed and often these women are like eight or nine centimeters and you know they're not even believed that they're in labor because they haven't been observed they haven't um no one's watched that transition that's happened for them some women do literally breathe their babies out some women don't feel it as painful but.
Mel:
[45:31] Even uh so when I was a baby researcher when I my very first research project that I was on was the birth position study with Hannah Darling. And my job was to, so we enrolled all these women in this study because we wanted to watch what women do in physiological labor. What's their positioning? What do they naturally do? And I won't tell you the details, but I did hide in cupboards and all kinds of things so that I could unobtrusively observe
Mel:
[45:59] These labors. And it was my job to record the time and every single movement of these women to see what they were doing as their labor went on. And what we noticed is that women started off walking, moving,
Mel:
[46:13] Doing all these things during labor. And the further along that they got and the closer they got to having their babies, they became more hunched, so more closed into themselves and closer to the ground. So for women standing upright and walking and talking to you, in my mind, we are in an early part of labor. The minute she can stop engaging with the outside world between contractions
Mel:
[46:37] and has gone into what we call the zone, she's probably moving further deeper into labor land. And then when she can no longer stand up and feels like her body needs to be supported through contractions, she's probably well and truly getting quite close to having her baby and will likely not want to talk to anybody or make eye contact and is very very closed into her own body so that's a very rough guide of how women act as they progress through labor and so when you combine that with all the other sounds and sights and people say that labor and birth has a smell if you're attuned to it then we can work out what labor's doing we don't need vaginal exams we don't need a textbook that tells us how many centimeters per hour we don't even need research we can actually just learn from the women for ya that's
B:
[47:30] It let's end it on that because that was epic all right get rid of the stages of labor bang they're gone that's our rule for today.
Mel:
[47:37] There's going to be a stack of resources in the resource folder including the work of Rachel Reid from midwifethinking.com who her thesis was on stages and the abolishment of said stages so I can recommend her stuff as well and we will see you in the next episode of the Great Birth Rebellion. To get access to the resources for each podcast episode join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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