Episode 225 - Understanding The Labour Process
[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.
[0:25] Welcome to today's episode of the Great Birth Rebellion podcast. Today, I'm going to talk to you about the labor process and labor progress. And here is where I try and explain and describe what labor is like and what you can expect from labor so that you can prepare for it. I would like to personally thank the sponsor of this podcast because that means that you get to listen for free. Poppy Child from Pop That Mama is a doula and hypnobirth practitioner, and she's a sponsor for today's podcast. Poppy has an online course, hypnobirthing course. It's called the Birth Box, and it's already helped thousands of women. I get behind the work that Poppy is doing in the Birth Box. It's practical strategies to help you get ready for labor and birth, but also the challenges of parenting. And with my code, if you type Melanie in at the cart, you'll get 25% off. So if you're preparing for birth, go check it out. You will be so glad you did. The link is in the show notes. Type Melanie at the cart and get 25% off. Thank you Poppy for sponsoring this podcast so that everybody else gets to listen completely free. Let's get started on today's episode. Let's get into it.
[1:45] What can you expect from labor and how can you prepare for it now this is a good one to share with your partner and with people who are part of your support team, so that they know what to expect from your labor too if there's one thing that I've noticed about labor and birth is that no matter how prepared the woman is for her labor and birth and what she knows if her support team and if her partner is unprepared and doesn't really understand what happens in labor and birth, then that can be the unraveling of that woman in labor and birth because the support team gets nervous they don't know how to support the woman properly, and from there you're relying on the fearful instruction of your care team, So, this is a great one to send to a friend, your parents if they're going to be supporting you, your partner, anybody who's going to be in your birth space. And then you'll all know what to do when you're in labour and you'll know what's normal and what's not normal and hopefully this information will give you more confidence throughout labour and birth for both you and your support team. Now, before we start, we are talking about labour progress and the labour process but I have to say.
[2:57] Labor does not unfold in the way that the textbooks or a hospital says. Long labors or delays and pauses in labor are considered pathological in a hospital setting and it's also not realistic to expect that labor is not going to pause and for there to be ebbs and flows. So we're going to talk about the realities of that scenario of pauses in labor and what that means.
[3:26] And the information I'm about to share with you is from my experience as a midwife watching birth unfold for the last 17 years and also from the research about labour the labour process and labour progress, and when you give birth in hospital there's policies and expectations on labour timings and how they understand the process of labour and you have to know that it's not realistic for women. The knowledge about labour and birth that they're using to create hospital policies and practices is based on distorted information from medicine and old research. So instead of reinforcing that message today, I'm going to work very hard to tell you the real story about the labour process and labour progress, to hopefully save you from the unnecessary interventions that occur for women who have labours that don't mimic what a textbook says or what the hospital thinks your labour should look like. So today I'm drawing from research, actual scientific evidence on how labour progresses and also from what I've observed watching births at home that aren't interrupted by moving into hospital or unnecessary intervention. So let's get into it. By the end of this episode, you are going to have an understanding of the labour process and labour progress and how to work with it.
[4:48] So a medical or midwifery textbook will break labour up into three stages. The first stage of labour involves regular contractions of the uterus and also dilation of the cervix. This is how it's defined. I'm not saying I endorse these definitions. This is just how your medical practitioner is thinking.
[5:09] So you're only considered in the first stage of labour if your contractions are regular and they're acting to dilate your 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 episode 148 of the Great Birth Rebellion podcast, it's all about vaginal examinations and you'll already know that within a medical approach to birth, diagnosing the first stage of labor relies on vaginal examinations. So if you're getting contractions and potentially in the early stages of labor, but there's no change in your cervix you would be told that you're not in active labor or you're not in labor that warrants any kind of medical care, but you are experiencing labor so you're not in not labor because you're contracting, so then you're having this experience of labor but you're being told that you're not in labor but you're also not in normal life either so your experience of what's happening to you is different to what the hospital's telling you is happening. So right away, your experience and your needs are being dismissed when the medical way of defining labour is applied.
[6:28] So we're already at the first hurdle and I haven't even started talking about early labour yet. So let's reverse back a little bit to early labour or pre-labour because this is where you might get tripped up from the get-go. So we go back before the established labour phase and talk about early labour first because, medical definitions like to break down the first stage of labour into what's called the latent phase or the early labour phase, which comes before active labour. Which again, you know, I don't really like these terms, how they've broken up labor. We are really trying to get rid of the idea of stages in labor, but this is how they describe it. This is how your care provider might be thinking.
[7:11] And when I was first trained as a midwife about 17 years ago, women were told they were in active labor. And if they were four centimeters or more dilated if their cervix was four centimeters or more dilated, if they were less than that they were sent home and told you're in early labor go home come back when labor is stronger and then still again if they came back, and labor was stronger they'd been in labor for a few days and they actually wanted some medical care if they again if they weren't dilated beyond four centimeters, they were either told to go home or if the woman didn't want to go home she was offered sedation and pain relief and either sent home with that or put on the antenatal ward to have a rest and a sleep so, no actual sort of human care or midwifery care it was just sedation pain relief, and please stay quiet until you're over four centimeters then we will offer you care that was back when I was training.
[8:13] And I've heard comments before where people explain, well, you know, the hospital can't manage every single labouring woman. There are resource bed and staff shortages. And these prevent hospitals from caring for women during early labour. And there is nothing more true. It's absolutely correct. The hospital system is not resourced or prepared to look after you during early labour. They don't have the capacity to be caring for women in early labor. It's not right, but it's the reality. So you've got to know that, that in the current maternity care system, unless you want them to speed up your labor with medication or sedate you in early labor, they're not going to offer you any other type of care. You're responsible for managing your care in the early labor phase. And the longer you do that at home, the better, because all the hospital has to offer you before you reach four centimetres dilated, is either an augmentation with syntocin on, so like the induction process where they go, right, if you're here, you better be in active labour. If you're not in active labour and you want to stay here, we're going to put you in active labour with an augmentation. Or they'll put you on the antenatal ward sedated and with some pain relief, but you won't actually get intense midwifery care.
[9:34] Don't expect care in early labour from a hospital. I know it sounds really savage, but it's the reality. They're not resourced for that. They're not prepared for that. The policy doesn't support that. So make a plan to have your early labour care at home. And I'm going to talk to you through this episode about what you can do to have that, to have that care at home. And now a quick note for care providers who are out there who have to send women home in early labour. And I know many of you don't want to be doing this, but just know that if a woman is presenting in the early stages of labor, what she's saying is, I need support. I need help. I need to be cared for. Maybe she's scared. Maybe she's worried. And what she's saying is, is that I feel like I'm in labor that needs further support from someone. So they come to the hospital and you can't blame them because the medical messaging is that when you're in labor and during birth, things are dangerous and you need medical care. And so women accept that message and they come to hospital and they're told, actually, you don't qualify yet for the care that's given to women in labor. Your cervix needs to be performing. It needs to be dilated past four centimeters in order for you to qualify for the care that we say that you need during labor.
[10:54] So when women arrive, especially if they're presenting multiple times in early labor, have some sympathy, some comforting words, some simple strategies that you can give them to take away. And I'm going to explain those in a minute, but also asking if she's worried about anything. It's possible that she's come because she's scared or has questions or has really bad support at home or an unsupportive partner or a partner that's busy looking after the kids and the household. And so it's possible that she's just feeling alone and frightened. So perhaps spending some time to ask what she came for. Is she scared? Does she have any questions? Does she have enough support at home? Does she feel safe at home? That might help you how to know how to help her so that she can comfortably go back home in labor. So mums out there listening, please know that if you present to hospital in early labor, particularly if you present more than once, many women will be given sleeping tablets. It's often Panadine 4, Tomazepam or some combination of that.
[11:57] And either sent home or put on the antenatal ward to await induction. It's not like you can arrive there and just wait to go into labor and hang out for days. If you're there, you're using resources and taking staff time and a bed, they want you to be in labor, have your baby and get out.
[12:14] So here's what happens. Women get sedated and silenced and that's what you can expect. But what can you do in early labor to be as prepared as possible to labor at home for as long as possible, and I will summarize them here but we've got lots of podcast episodes too that you can go back and I'll put those in the show notes for you they're linked down below in the show notes for you to click on and go back and listen to that speak to this same topic but I'm going to give a very quick summary here of the things that you can do to be prepared to labor at home for as long as possible to prevent you from needing to go to the hospital early in labor, And you might be listening, actually, if you're having a home birth and wondering, how do I labour at home without my midwife before I call her? All of these things are going to work for the same thing. So what can you do before you actually need to engage with a maternity care provider?
[13:10] So here we go. If you're writing things down, if you've got your notepad, here is your list. So if you're going to be comfortable at home, you need to have lots of easy, nutritious snacks and fluids. So think about good quality electrolyte drinks. You're working very hard. Consider it a marathon. So you've got to keep hydrated, but also your electrolytes up. Try and avoid those really sweet, sickly flavored ones. Go for as natural as possible.
[13:37] And it's up to your support team. to make sure these are always topped up and within arm's reach and available to you. Think about preparing lots of blankets, pillows, floor mats, soft furniture to lay around on and to get comfortable with. Also consider sometimes your waters have broken or you want to labour naked or whatever you want to do. Consider some easy sort of towels and drop sheets, potentially maternity pads and things like that that you can use to just keep your space as tidy as possible as well. Now, your support people need to help you with everything else in the house and look after your kids if you've got them in there. You only have one thing to focus on and that's yourself. So you'll be labouring and make sure the rest is managed by the people around you. So the only thing you need to do is labour, a rest as much as you can hydrate a snack to keep up your energy and, do regular wheeze and go to the toilet if you need to you know manage your own personal hygiene if you want to have a shower or whatever but the focus is completely on you everything else around you needs to be managed so you need to arrange support people and people who can do that.
[14:56] Making sure you do a wee regularly every two to three hours during labor. The next step is to rest in between contractions. Now, one thing that can really unravel women is when they get tired during labor. And I've seen this happen where women have read all these books and the books say, stay active in labor. And they try and walk around and move around and keep labor going and get contractions going and try and speed it up, but then they get exhausted. So my suggestion in early labor is actually don't try and speed it up, just take the rests between contractions don't do other things let the contraction happen and then try and get comfortable and go to sleep even if it's only for a few minutes if you can accumulate those little naps, they will give you longevity in labor it'll help you have more energy for the more intense stages of labor Don't waste all your energy trying to get labor started. And the next thing is make sure your support people are comfortable with the labor process too. And them listening to some episodes of the Great Birth Repolition podcast could be a way that you prepare them or if you want to make an extensive list or take them to a birth education course, whatever you need to do to prepare your support people, ensure that happens, because if they're not comfortable, you're not going to be comfortable.
[16:17] And I'd also suggest having some backup support people so you can swap them out if it's taking a while or each would have a different role. For example, you might want your partner to be with you for the majority of the time, in which case you need to bring somebody else in to care for your other children or care for your household or do the cooking and tidying and all the things that still need to happen.
[16:38] And this is also where having a doula can really shine and they can help you through the early stages. Before you seek out the care of the rest of your maternity team. So you're already getting the idea that when you're laboring at home, your support team is a really key element. Make sure they're set up early, that you've strategically selected them. I have had clients before who've said, oh, you know, I want to have my mom or my friend, but I think they might be a bit nervous. I think they're not really sure. That's a clear sign they are not the right people. You want to have strong, sure, fearless people in your space. who have your interests at heart. Now the next thing to do is have a toolkit of pain relief options that you can use at home. Think heat packs, a TENS machine, someone who can massage you so some massage oil, there's all kinds of tools like a birth comb, a birth sling, anything that will enhance your comfort during contractions. Maybe some music to set the scene, low lighting, a great support person who can talk you through every contraction you could get in the shower so it's not going to take the pain away that's not the idea, but it's going to give you a tool that you can use to work through each contraction under your own power.
[18:02] The next thing you can do is listen to the other podcast episodes that I will tag in the show notes to help you be mentally prepared.
[18:10] And have all of these things that I've just spoken about, have them all collected somewhere easy to access when you're in labor so everyone can find them. And you might want to write a little note to everybody who's in your care team as a reminder of their role on the day.
[18:25] So that's early labor. And I will say there are no medical rules for how long early labor could last for. It could be a few hours, could be a few days, or some women have early labor experiences that last for over a week. You just don't know. At this point in time, there's no time limit on early labor. There's no point where we go, oh, it's been too long. It's time to get something moving. So definitely play the long game with early labor. Rest, hydrate, keep nourished with lots of high-density nutritional snacks that can support you for as long as possible. Consider it a marathon. It's considered the long haul. It might not last a long time, in which case you'll be overprepared. But if it does last a long time, you're prepared.
[19:17] So then once you move from being in the latent or the early labor phase, then medical definitions will say that you move into active labor. And active labor is where medicine goes, okay, this is our jurisdiction. Now you've crossed the line and we're involved. So as soon as women approach hospital and early labour, big sign in the door, no, no, we don't do early labour here. That's your own jurisdiction. You're responsible for that. We're going to keep giving care to only women who are beyond four centimetres dilated. I know I'm probably being facetious, but it's the weirdness of just finding labour stages, especially every woman has to get a vaginal examination in order to diagnose which labour stage they're in. As a triage system for when you get to access the hospital services.
[20:11] But it's what happens. I mean, the hospital says, look, we don't do early labor here. So if you need us for early labor, we'll either send you home with medicine and don't come back until you're over four centimeters. Or if you do want early labor management, we will manage you by dragging you into active labor because that's our jurisdiction. They won't let you just sit there.
[20:35] So let's move through. You're done with early labor. You're feeling like, yep, I'm ready to go to hospital or I'm ready to call my midwife to come to the house if you're having a home birth.
[20:46] And I'm going to offer you some very vague rules here.
[20:50] I don't normally do rules, but if you're looking for some objective information that can help you work out if you're moving through labor to a point where it's time to go to hospital or it's time to call your midwife. If your contractions are regularly five minutes apart from the beginning of one contraction to the beginning of the next, they last longer than a minute each and have been that way for more than an hour, you're probably in labor that is not going to stop and start. You're probably going to progress on to move into labor and have your baby. That is a little external measurement to assess what your labor is doing, but you don't have to be counting and recording every single contraction. But if you start thinking to yourself that your contractions are feeling closer and stronger and longer, and you're starting to think, oh, is it time to go to hospital? Is it time to call the midwife? You can do this little counting and recording exercise, or hopefully your support people can do it. You should just concentrate on labour. But this could help with the decision-making process and prevent you from going to hospital too early or it could confirm your feelings and give you confidence that it is time to transfer to hospital or call your care provider. So it's not always this straightforward because you might feel like you don't meet that criteria for being in a labour stage that would send you to hospital or call your care provider, but it's a little tool that you could apply.
[22:17] So that is if your contractions are regularly five minutes apart from the beginning of one to the beginning of the next, lasting longer than a minute each and have been that way for more than an hour, then you know you're probably moving into the more active labour phase.
[22:34] Okay, so let's say you've done that little assessment. You think, yep, definitely ready to go. So as I said earlier, admission to hospital usually involves a vaginal examination, unfortunately, because that's how they triage women to know who can stay and who goes home. You don't have to accept that vaginal examination, by the way. But when I was trained...
[22:56] It used to be that if you arrive to hospital, they're doing a vaginal exam. And if you're more than four centimeters, that's it. You're admitted. You're on the books. You have a folder. You've got a care provider. You're tagged as being in active labor. It's officially started. But that was based on really old research. And obviously, I trained 17 years ago. And there's now a newer research by a team that was led by Zhang. And all of these research papers will be in the resource folder. For anybody who's been listening to the podcast for a while, you'll know that this podcast has a resource folder and every single research paper that we use to create all the podcast episodes are in the folders. They're categorized in topics and podcast episode numbers, so you can find them. Or to get access to that, you've just got to join the mailing list, the Great Birth Rebellion podcast mailing list, and the details for that are in the show notes. So the new research suggests that women are actually not in active labour, well, you know, what we're going to call active labour, that's a medical definition, and not in the medical jurisdiction until they're five to six centimetres dilated. And this is catching on at hospitals. I've found that they're more likely to admit women at five or six centimetres and maybe if you're four centimetres send you back home and, you know, wait till you're further along in the labour process before they nominate you as active labour.
[24:25] And this could actually work in your favour. And I feel like it's a positive change where they're not putting women on the clock as early as they used to. So back when I trained, women were coming in, they were four centimetres, and if you hadn't had your baby within a certain number of hours, then you would be offered augmentation or something to speed your labour up or, a caesarean section if they feel like your labour's stalled. So this means that women are already further along in labor when they arrive at the hospital for care and.
[24:57] And that means are less likely to get interventions for slow, slow labors. Then now, as part of this first stage of labor, you're in the active labor part. You finish the early or latent phase of labor, and now you're in active labor, which is defined from five or six centimeters and goes all the way to when you're fully dilated. And I'm going to skip over this largely because we did a full episode of progress in labor. It was episode 82, which again is tagged in the show notes.
[25:30] And on that episode, we invited a researcher. Her name's Marina Weckend, and she spoke about the research that she's doing on plateaus and pauses during labor, which we now recognize to be a normal part of labor. We now know that labor doesn't progress at the same pace the whole time. Your body will have rest and recovery periods, and your cervix will dilate at different speeds at different times of the labour, which we now know to be normal. But most care providers will tell you that women who have had a baby before should progress around one to one and a half centimetres per hour and first-time mums about one centimetre every two hours.
[26:14] But this is an outdated and a medically-based assumption about labour. It's used frequently as a yardstick for measuring labour progress, But the more evidence-based clinicians have moved on from that, we don't use that anymore. If you're up to date on the research, you're not using that one centimetre to 1.5 centimetres per hour for multiples and one centimetre every two hours for primates. It's old and it's not used by up-to-date clinicians. So for more information on that including all of that research please do go to episode 82 and see the resources for this episode which I've lumped in together so you'll be able to actually read the papers so that's active labor that's first stage.
[27:00] And then there's this little part at the end of the first stage of labor and it's called transition. And it typically happens around eight centimeters dilated to fully dilated. Again, I apologize for using cervical dilation as a measuring sort of tool. It's just what the hospital is going to be using as their metric unless you actively object against it. So I'm just trying to prepare you for what to expect. I'm not endorsing it by any means. Okay.
[27:28] But at this time in transition, your hormonal flow in your body is going to change. Your body is winding up to get ready to give birth to your baby. So you get a boost of adrenaline because you need a little bit of that to be more alert and to power up, to prepare for what's about to happen. And that's what's happening in your body. But subconsciously, we recognize adrenaline in our body as a time, usually of fear, shock or stress. And so when women feel that, when you feel adrenaline taking over, you can sometimes start to panic and it's just a subconscious response from your body wondering what's going on, why are we frightened, what are we supposed to be scared of? But then if you can understand that this adrenaline is purposeful, it's the moment that comes before you're going to push your baby out.
[28:21] So that's what happens during transition. but there is a stage of transition that's not recognized in textbooks or in hospitals, it's not recognized and it's actually not even welcome but marina does talk about this in her research about physiological plateaus and certainly private midwives have known about this stage of labor, for a long time and we call it the rest and be thankful stage and honestly in a physiological birth, I probably see the rest and be thankful stage 50 or 60% of the time. Women are really good, strong labor. And I think, great, we're progressing on. The baby's going to be born soon. And then suddenly they fall asleep in the pool or something. They lie down on their side and start snoring. And there's like no contractions for half an hour, an hour, sometimes even longer.
[29:11] And I see this as a normal part of labor. I welcome it as normal so long as the woman and the baby are well, of course. And this correlates with this idea that adrenaline comes in. What we do know about adrenaline is that it can have an impact on oxytocin and reduce the number of contractions. It's also why the number of contractions reduce when the woman's in the pushing phase. So for midwives out there, you'll see the women are having regular contractions and all of a sudden they get to the pushing phase of their labor and their contractions space out. Well, that's because adrenaline's come in as well to give them more power, but it can dampen down some of the activity of oxytocin. This is normal, all right? It's not some kind of weird shutdown of the body that is pathological, right?
[30:04] But in hospital, if all of a sudden your contractions stop and you go to sleep and your body stops laboring, they consider that to be a stall in the labor progress. And they see that as a reason to accelerate or augment the labor with oxytocin, which is artificial oxytocin. In Australia, it's called syntocin. In the US, they call it pitocin. Same medicine, just different names. So if women stop contracting in hospital, this is seen as divergent. It's not normal. And they will likely try and get things started again. But this is the rest and be thankful stage. It's so purposeful. The woman's about to do something really big. She's about to push a baby out of her body. Her body knows that. It's giving her a rest. In fact, it's also giving her baby a rest, who's going to have some time to recover from the labor process. Fully re-oxygenate be well perfused ready to go for the stress of being pushed out of its mother's vagina, so this is my message to anyone the women support team care providers if the woman's laboring and it's going on and on and on and then she feels all of a sudden like falling asleep.
[31:19] Just fall asleep. Don't think to yourself, oh gosh, I'm so sleepy. What do I do? Should I keep moving? Should I keep going? No. If you feel sleepy and your body wants to go to sleep, 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 a 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. Does she need anything? No. She needs to be left alone to have a sleep. Her body is doing very, very important work. The rest is as important as the effort. Don't interrupt it. If the woman's well and the baby's well and they're sleeping, this isn't something that needs managing. This is something that needs to be left. It's not pathological, it's just labor. And it's time for the support people now to step in and protect this rest phase really at any time in labor if the woman is sleeping protect those rests and I hear you out there care providers out there saying ah you know, it's our workplace policy I have to be doing a blood pressure every four hours I have to be doing a vaginal exam every four hours I have to be checking on the woman's contractions if the contractions stop I'm supposed to augment her.
[32:36] But midwives, you can also advocate for women in this time. And I know there's outside pressure to make sure that you're doing all of those tick box things. So if someone's like, you know, have you done the woman's blood pressure yet? How's she going in that room? It's okay to say, actually, she's sleeping and I'm not going to wake her up. And then educate your colleagues. You know, she's probably having a rest and be thankful phase. This is an important part of her labor to have a rest. And I'm going to allow that. There's nothing wrong with this woman. She hasn't had any previous observations that have been out of sorts. The baby's well. Let's give her some space to do that. She doesn't need her blood pressure done this hour. Could be done next hour. And if she isn't currently experiencing a blood pressure issue, it's unlikely to suddenly occur in the next hour or two. So I'll take a bit of a chance now to give some evidence around this because your colleagues might not be happy with just you saying, yeah,
[33:31] I'm just going to leave it a rest. I don't need to do all that stuff that we normally do. But there is some actual research around these things. So how did we get here? How did we get to the point where we're defining labor stages and progress and, you know, long labors with regards to cervical dilation?
[33:49] Well, it starts around the 1950s, 1955 to be exact. And there's also some research done in 1969 by a fellow named Friedman. And he said that normal dilation, when he plotted it, the cervical dilation on a graph, he says it occurs at 1.2 to 1.5 centimeters per hour.
[34:13] And a little bit more for women who haven't had babies before. And so that's what practitioners have been using to define normal labor for a long time now, which I mentioned earlier.
[34:26] By the way, Friedman, when he was doing this research, he wasn't doing vaginal exams. He was doing rectal exams on women to assess their cervical dilation. It wasn't through their vagina. He's putting the fingers in their anus to feel their cervix, obviously, which is through the wall, the rectal wall, and determine their dilations. Just a fun fact. But, you know, this is what our labor progress understandings currently are based on.
[34:57] So thank goodness for Zhang, Zhang et al., and their research, which, again, is in the resource folder if you're on the main links. So Zhang challenged this idea of 1.2 to 1.5 centimeters per hour and concluded, that, and the paper I'm referring to is called Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes. So Zhang looked at labors where the baby and the woman were well at the end. So we're not looking at labors here where the clinician's like, oh my gosh, we're just going to let it go on forever and now something's happened to the baby. So these are babies that all had good outcomes. So he tried to work out how long can it go on for without still anybody being in danger.
[35:44] And what Zhang said was that labor may take more than six hours to progress from four to five centimeters. So imagine if you got admitted to hospital at four centimeters, it can 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. So let's hypothetically think if you could arrive to hospital, you know, at six or seven centimetres, you've potentially done, what's that, six, you've potentially done nine hours of labouring at home that doesn't put you on the labour clock in hospital. So definitely arriving at hospital in the later stages of labour is going to expose you to a lot less intervention. So Zhang is saying in normal labours where babies come out perfectly fine, it may take more than six hours to progress from four to five centimetres, and then more than three hours again to progress from five to six centimetres. And Zhang is also the one who has started, you know, this definition of active labour as five to six centimetres, whereas Friedman started the four centimetre thing, from four centimetres near an active labour, and saying that 1.2 to 1.5 centimetres per hour was the expected trajectory. Yeah.
[37:08] And Zhang has changed that classification, saying, you know, five to six centimetres. And I love this research because it gives women permission to labour longer. I know what I'm saying, permission to labour longer. But we've got to remember the constraints of the hospital system and how obsessed they are with time. And this is actual research that can replace Friedman's circus. So I love this research because it gives women permission to labour longer and
[37:36] still be defined as having a normal labour pattern. But there's a few problems with it. So although it's great, of course there are some problems with it. So firstly, all the births were in hospitals. That's the main thing that happens with research. And the other problem is that although all the women started labour spontaneously, and None of them actually started their labour with an induction. They were still included in the data if the women ended up having an epidural, which we know can change the length of labour.
[38:08] Or if women ended up having an augmentation with syntocin on or artificial oxytocin. So now you've kind of, although the women started labor without being induced, they still had all these other interventions and they've been lumped all together. The women who were augmented and who'd also had a epidural. So we still didn't get an accurate picture of what normal labor progress is if labor's just left alone to progress. So the data is a bit muddy and some would argue, though, that these findings make the findings more generalizable in that that's the reality is that there will be a whole bunch of women having different experiences in hospital. But usually research would try and compartmentalize the findings and not lump everything in together. So, my point for now is that there is better research than Friedman's research, which by the way, he also included women who were induced to work out, what labor progress was about and put his fingers in their bum instead of their vagina to check their cervical dilation. But, yeah.
[39:15] Now there is better research. Zhang is better than Friedman. So if you're thinking about applying any kind of cervical dilation strategy to labor progress, you know, Zhang's one offers women more flexibility and time than Friedman's, even if it's a bit flawed, still better. And it gives women's bodies a more realistic time frame. Now, in a previous podcast episode, I did talk about how it takes about 17 years for new research to translate into clinical practice. So there's a very good chance that you will still be confronted with maternity care workforce who sees Friedman's work as more authoritative than Zhang's work. So if you're a care provider and you're still thinking that one to two centimeters, per hour is the progress you should be expecting and that women should be experiencing. It's based off a little study done way back in the 1950s and 60s. And if you don't know about Zhang's research, you haven't updated your practice in at least 15 years because Zhang started talking about this a long time ago, early 2000s.
[40:27] So have a look at the resource folder. All the studies are there.
[40:31] You can do a quick refresher and get up to speed. Now, women would have more time in labor without having interventions. And what you need to know as a woman here is that if your body doesn't conform to this rule and expectation that medicine has placed on your labor, it could be because they're basing it on old research. And then they might tell you that you've failed to progress. Oh, when it's used to describe deviance, you've failed to progress in the way we expect you to progress. So if your cervix doesn't dilate at the expectation of freedmen.
[41:10] Then you're described as failed. Oh, it's horrendous. But so we're going to think it's not failure to progress. You've not failed. Your practitioner has failed to wait. And they're using old, old, old research to use the yardstick on how long your labor should go for. So that's what I call failure to progress. I call it failure to wait. And then when the people are yelling down the speaker now, No, no, what about labor dystocia? Yes, sometimes a woman's labor fails to progress. I just used the words. Fails to progress because there's a complication and there's something that we call labor dystocia. So if for some reason there's a complication in your labor where the baby gets stuck or is in a position that's not ideal for the baby to come down, you've experienced dystocia. but no one's failed, but there's been a dysfunction in the process. And we can just call this labor dystocia. We can let go of failure to progress altogether, completely get rid of that terminology, stop writing it down. You don't have to put it in the computer. And women can stop telling themselves that they failed. Maybe they just experienced labor dystocia. It's just a nicer way to define it, failure to progress. We don't need to tell that. So that's what I want to say about that.
[42:35] What we still don't know, there's still no research on how normally labor progresses if you don't augment it where the woman doesn't have an epidural and there's still a normal outcome. So, but it is what it is. That's what we've got.
[42:52] Okay. So now we are at the end of the first stage and we're moving into the pushing phase of your labor. It's time to push your baby out. You're fully dilated. the cervix is out of the way and the textbooks would call this the second stage, so second stage of labor is again unfortunately based on vaginal examinations how many times do they put their fingers in there, you might be interested to listen to the why do they put their fingers in your vagina episode episode 149.
[43:24] But this second stage is often diagnosed when your cervix is fully dilated and it ends when the baby's out. And I know I said that this is in the textbook, it's defined by vaginal examination that you're fully dilated and therefore in the second stage. But for those of us who work in a way that diagnose, like I can diagnose second stage of labor without a vaginal examination, there are so many other signs.
[43:51] So here are a few signs that a woman has arrived at the pushing phase of her labor where she's ready to have her baby. And I'm letting go of second stage language because that just means the woman's fully dilated. So I like to call it the pushing phase, not the second stage, where the woman is exhibiting signs that she's actually ready to push her baby out and not just fully dilated. So fully dilated in my books, in a physiological book, doesn't mean you're at the pushing phase. You're still in the first stage of labor, the early phase of labor, just laboring. You're not yet at the pushing phase. You're not yet in the second stage if you're fully dilated because there's a lot more that needs to happen once your cervix gets out of the way for you to be in the pushing phase of labor. So again, if women don't want a vaginal examination, you are going to need other strategies to be able to diagnose where she's up to because you work in a hospital and you need to let everybody else know what's going on. So how do we know that she is indeed ready to have her baby or has entered the second stage or the pushing phase?
[44:58] So for me, it feels like a really easy diagnosis. If she's in the pushing phase, then she's got an urge to push her baby out. She may also feel pressure and it feels like you want to do a poo. It feels like there's a poo sitting there and it just won't come out and it's so annoying. So if a woman says, oh, just like I need to poo, that's probably because the baby's moving lower in her pelvis, putting pressure on that same area that it feels like. and you need to do a poo. So it's a good sign. And if the baby's really low, you might see her anus and vulva kind of pouting or kind of bulging out a little bit during a contraction because the baby's head is behind there. And during the contraction, it's getting pushed down a little bit. So you can see a bit of bulging. Also, you'll notice that the contraction pattern spaces out. So if she's been having two or three minutely contractions, she might start having five to six minutely contractions for the pushing phase. That's all really normal.
[45:59] The other thing that might be, if she's approaching fully dilated and getting ready to have her baby, is the purple line. And it doesn't happen to everybody. There is some research on this that showed that about 70% of women will get a purple line. Obviously, it relies on the woman having pale skin because it's purple. And it's a lot more obvious on paler skin. So if she's tan or dark skinned.
[46:25] Often you won't be able to see that. But it extends from the anus up to sort of just above the butt crack and the longer it is seems to correlate with the dilation. There was some research in 2010 and they found that vaginal exam accuracy was less accurate than the purple line. So they looked, it was a small study but they didn't need huge numbers to be able to determine this but there was 140 women and they determined that 109 women, so 76%, had the purple line in this study. And then they did vaginal exams and then also measured the purple line to see if there was a correlation. And they said, firstly, that yes, the purple line does exist. It is a thing. And they said there is what they call a medium positive correlation between the length of the purple line and the woman's cervical dilation, but also the position of the baby's head in the pelvis. Which they believe is what creates the purple line. Not so much the cervical dilation but the progress of the baby down is what creates the purple line. So then they said that obviously it's a thing and we can possibly use the line to diagnose labour progress but there needs to be more research of if it can be an objective measurement that we can use, as midwives in place of vaginal exams and...
[47:51] And then, you know, finally, the undeniable fact that you're in the pushing phase is that you can see the top of the baby's head at the opening of the vagina. You go, oh, there we go. We can absolutely, without a doubt, confirm that the woman is not only fully dilated, she's also getting an urge to push, so she's in the pushing phase of labor. And I can see the top of the head, so we're most definitely in this second stage. And if you're at home, this is the time, hopefully, your second midwife has already arrived.
[48:21] Now, another way for you to objectively work out the progress of a woman's labour, where is she up to, is by her positioning, how she's moving her body. So, this is very exciting. When I was a baby researcher and I started my academic career when I was 24, my very first research project was the birth position study. And it was my job to enrol the women into this study. And we wanted to watch what women did during physiological labor. So what was their positioning? What did they naturally do? And I won't tell you all the details, but one of my roles was to go to all the births for the women that were enrolled in this study and they were recruited from both hospital, birth center and home birth. So I was just living on call, going out to birth. So my whole job was to watch them and record, you know, every single position change they made and the timing and all that. So I watched their whole labour. And I did things. I knew I didn't want to interrupt their labour process by being in the way. So I made every effort to be really unobtrusive. And I used to get in the cupboards at hospital births, really low down so the woman couldn't actually see me. I was a lot smaller then. I could fit in cupboards. And I'd just peek out and see what she was up to.
[49:44] And so that's what I did. And then when we had a look at the data, what we noticed is that women started off in early labor. They were walking more and moving a lot more, more upright. They were able to do that kind of thing. And then as their labor progressed further along, they got closer and closer to the ground. So.
[50:06] In the more active parts of labor, kneeling a lot more, like sort of hunching over more over or leaning on couches and benchtops and tables, still standing. But again, as it got further and further along, coming down to their knees and getting closer to the ground. So if you're thinking, am I in early labor, sort of the middle of labor or coming to the end stages of labor, think about the types of positioning that you're favoring are you still able to walk around does that still feel comfortable when you're standing for contractions do you feel like you need to lean on something during a contraction maybe kind of midway through if you feel like you need to get to the ground and be grounded on your knees and hands and low down it's possible that you're moving further and further and deeper into labor land you can no longer stand up and you feel like your body needs to be fully supported through contractions, you're probably getting close to having your baby you probably in this stage don't want to talk to anybody anymore you're kind of really getting quite internal eyes are shut you can't have conversations in between you're fully focused, that's a woman who's getting close to having her baby.
[51:21] So when you combine all of that knowledge and the other external signs of the woman's entering the pushing phase then do we really need to do vaginal examinations to diagnose when it's time for a woman to start pushing.
[51:36] There is so much more that I could say about this. This is just the tip of the iceberg and some of what I want to say is covered in other episodes and they're all tagged in the show notes below. There's a stack of resources in the resource folder. So click through to get a full picture of this. Click through and listen to all those podcasts that are linked below and until next time rebels share this with the people who are going to be with you for labor and i will see you in the next episode of the great birth rebellion podcast, 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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