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Managing second stage labor-AWHONN webinarWhen I was working in the hospital, I came across data and research that supported managing second stage labor in a different way than what I was taught. In the hospital, we were taught to start pushing as soon as the mom was 10cm. We were to have the woman laying on her back semi-reclined with her feet pulled up. With every contraction, the mother was to hold her breathe and push as hard as she could while counting to ten. This was done three times.  But the research I came across indicated that there were problems for both the mom and baby when pushing was done in this fashion. 

The research I found was presented by AWHONN, the professional organization for labor and delivery nurses.(Association for Women’s Health, 2008).  It was a complete change for me, because normal definitions were challenged and a world view redefined.  Below is a brief synopsis of what is discussed in the webinar.

How should we be managing second stage labor

Our current definition of second stage labor is when the woman becomes 10cm dilated, regardless of any other factors.  At this point, they are to begin bearing down efforts, and a time limit is imposed.  There are two problem areas with this way of viewing of  labor.  1) Some women have the urge to push, but are not dilated enough, and 2) women have no urge to push, but are told to push because they are 10cm dilated.

Women who fall in these categories are either told to stop pushing or are given arbitrary direction based on dilation.  This type of practice presents these concerns:

  • There is a disruption of involuntary pushing.
  • There is ineffective directed pushing.
  • It may cause poor fetal descent.
  • It can cause maternal exhaustion.

In reality, women who have the urge to push, but are not dilated, should be given supportive care.  They should be given information and encouragement, rather than being told to not push in a more directed fashion.

Pushing when a woman is 10cm, but has no urge can cause its own set of problems.   Research is showing that pushing before there is an urge may cause:

  • increase in lacerations and episiotomies
  • increase in the use of forceps
  • increase in perineal trauma
  • increase in maternal fatigue
  • increase in nerve injuries for the mother
  • increase in the signs of hypoxia

The research presented in this webinar is quite startling, and would cause anyone who saw  it to completely rethink why we do pushing the way we do.

In reality, this point in labor should be thought of as an early pushing phase.  This is defined by Ina May Gaskin as the Early Pelvic Phase and is characterized by no or small urge to push, small or no bearing down efforts, the fetus is descending and rotating still at this point.  Instead of forcing a woman to push, this stage should be prolonged until conditions are optimal to assist the mother with her bearing down efforts.

These optimal conditions include:

  • the cervix is at least 9cm dilated
  • the fetus has rotated to OA
  • the fetus is at a +1 station
  • the woman has 3-5 bearing down efforts with several breathes in between

At this point, involuntary efforts are usually adequate and the woman should be allowed to push as she feels the urge.  While waiting for these optimal conditions a woman should be given supportive care rather than directive care as is the norm.  Instead of telling her what to do and how to do it, she should be provided with information on what is happening and how she is doing.  Instead of given ritualistic care where she is told how to do things just because that’s how we do them, she should be given verbal encouragement for her own efforts and provided with feedback.  At this point, she should also be encourage to use positions that are upright and to change those positions frequently.

What I’ve discussed is just a small amount of information presented in the webinar.  To see action steps a doula can take to help when medical professionals are managing second stage labor, take a look at our handout in our shop.

Additional resources you may find useful:

Handout: Action Steps for Second Stage Labor

ebook: Rethinking the stages of labor

blog: How my course teaches normal birth


Association of Women’s Health, Obstetric and Neonatal Nurses. (2008). Nursing care and management of the second stage of labor. Evidence-based clinical practice guideline (2nd Ed). Washington, DC: Author.
Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., & Leveno, K. (2006). A randomized
trial of coached versus uncoached maternal pushing during the second stage of labor.
American Journal of Obstetrics & Gynecology, 194(1), 10-13
Simpson, K. R., & James, D. C. (2005). Effects of immediate versus delayed pushing during
second-stage labor on fetal well-being.  Nursing Research, 54(3), 149-157.
Follow Rachel Leavitt:

Rachel has worked as a register nurse (BSN from University of Utah) since 2004 with a work history in Labor and Delivery, NICU and Postpartum Care. She is also the founder of New Beginnings Doula Training which she organized in 2011. When she's not busy being a mother and grandmother, she can be found reading research papers related to some aspect of childbirth.

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