The Effective Labour Contraction

One of my failings as a midwife is my inability to assess the strength and effectiveness of a uterine contraction. This presents a problem in the hospital setting as midwives are often asked ‘how strong are her contractions?’ or ‘is she having effective contractions?’ I spent many hours as a student midwife with my hands on women’s abdomens attempting to assess their contractions. Not only was I unsuccessful, but I was probably very irritating (sorry to those women). While it may be possible to find out how often contractions are coming, and how long they are lasting – I dispute the idea that you can assess how effective or strong they are this way. This post will discuss contractions and whether it is possible to determine their effectiveness.

A quick history lesson

The idea that birth should be efficient has its roots in the 17th century when men used science to re-define birth (Donnison 1988). The body was conceptualised as a machine and birth became a process with stages, measurements, timelines, mechanisms etc. This is still reflected in current textbooks, knowledge and practice.

The legacy of Friedman’s curve

In the 1950s Friedman created a graph of labour based on his research with 100 women. These women were subjected to rectal examinations every hour during their labour. You can apparently feel the cervix through the rectum although I’ve never tried this myself. The final graph is the basis for modern assessment of labour progress. However there are variations between hospital policies regarding adequate progress. For example a cervix can open 0.5cm an hour in one hospital and be adequate, whereas in another it must open 1cm per hour to be adequate. Now I could do an entire post (and might do in the future) on the ridiculous notion that you can apply a graph to something as complex and unique as a birthing woman. However, I think the evidence speaks for itself. More than half of all women who experience labour in Australia have their labour induced or augmented. Therefore inadequate progress is the norm… or our definition of adequate progress is wrong.

How a contraction works (overview)

Physical component:

The hormone oxytocin regulates contractions and it is released from the hypothalamus (primitive brain). The uterus has oxytocin receptors which respond to oxytocin by initiating a contraction. Contractions start in the top of the uterus and ‘wave’ downwards. The cervix must be ready (ie. ripe) before it will respond to contractions by opening. This is why induction usually involves preparation of the cervix with prostaglandins before starting a syntocinon (pitocin) drip to create contractions. When the uterus contracts the placental circulation is reduced (more so if the waters have broken), slightly decreasing the oxygen supply to the baby. This is why there are breaks in between contractions – to allow babies to rebalance their oxygen levels before the next contraction. If you’re wanting a reference for the above, any midwifery A&P text book will cover this basic physiology eg. Coad 2005, Stables & Rankin 2010.

Note: Oxytocin (syntocinon/pitocin) administered via a drip is not released in waves and an individual woman’s oxytocin receptor response is unpredictable. This may result in contractions that are too powerful without an adequate gap between them leading to a hypoxic baby – similar to what happens during directed pushing.

The psychological / emotional component:

oxytocin release and therefore contractions are influenced by external factors

Oxytocin is influenced by, and influences feelings and behaviour. There is a growing body of research exploring this aspect of oxytocin and it’s potential uses from treating autism to persuading us to buy products in shops. For real oxytocin nerds like myself, Moberg has written an entire book on how this hormone works. Michel Odent and Sarah Buckley are gurus when it comes to the function of oxytocin in birth, mothering and breastfeeding and I would recommend anything written by them. Basically oxytocin is part of the hormonal cocktail that prepares a mother and baby for bonding and attachment. The hormonal formula is: oxytocin (love) + beta-endorphin (dependency) + prolactin (mothering) = mother-baby-bond.

Note: Oxytocin does not cross the blood brain barrier. Therefore, only oxytocin produced in the brain has these psychological/emotional effects. Syntocinon/pitocin administered via a drip into the blood stream only effects the uterus ie. contractions.

Contraction pattern

Contractions are measured according to how often they occur in a 10 minute period and are recorded as 2:10, 3:10, 4:10 etc. To be considered ‘effective’ contractions need to occur 3:10 or more and last for 45 seconds or more. From a mechanistic perspective it would be impossible to progress through labour with 2 contractions or less every 10mins. I actually believed this for a some time (again sorry to those women).

What I now know is that a woman’s contraction pattern is unique. I have witnessed women birth babies perfectly well with very ‘ineffective’ contraction patterns. The recent ones that stand out in my mind are: A woman with an OP baby whose contractions never got closer than 5 minutes apart and were mostly 7-10 minutes apart. And a first time mother who birth her baby with mostly 10 minute spaces between contractions. When left to birth physiologically women’s labour patterns are as unique as they are. Unfortunately many midwives are unable to witness a variety of contraction patterns because individuality is not tolerated in the hospital setting.

Contraction strength

I have already mentioned that I don’t believe you can do this by touch (cue a hundred comments from midwives who can!). Observing a woman may give you some idea, especially if you have seen a change in her behaviour (sound, movement etc.) over time and/or know her well. But again this is subjective and I’m sure many midwives have been caught out by women who appear to be doing ‘nothing’ but actually are, or appearing to be about to birth when they are not. For example here is a woman in early labour:

And here is woman close to giving birth:

Using dilatation of the cervix to determine the effectiveness of contractions is also unhelpful. Firstly, routine VEs should not be part of labour care. Secondly, the cervix only shows us one piece of the picture – contractions may have done a fantastic job of rotating a baby and moving him down but not opened the cervix much (eg. with OP position). Thirdly, cervixes open so unpredictably and uniquely that you cannot determine what will occur in the future from what a cervix is doing at a set point in time. A woman can go from a 3cm dilated cervix to birth within minutes or stay at 9cm for hours – cervixes can even close back up.

Sensible assessment of contractions

Induced or augmented labour

Over-contraction and/or fetal distress are common complications associated with using syntocinon/pitocin in labour. It is essential that a CTG machine is used to closely monitor the baby’s heart rate. A midwife should also use her hands to assess how often contractions occur, and for how long because CTG machines are not very good at this. Again CTG machines, like midwives can only tell you how often contractions are occurring and hint at how long they are lasting.

Spontaneous labour

Every woman’s contraction pattern is unique and applying graphs routinely does not improve outcomes and leads to unnecessary intervention. A physically obstructed labour is rare and can be identified by frequent, long lasting contractions over many hours without any change in the position of the baby, or the behaviour of the mother, or the cervix. The baby will usually begin to show signs of distress and the mother will ‘know’ that there is something wrong. However, most obstructed labours are psychological/emotional (see above) and if the environment is changed the labour will progress. Indeed observation of the woman and her contraction pattern may actually interfere with her oxytocin release and obstruct her labour.

VBAC: A change in contraction pattern from regular contractions to irregular or uncoordinated contractions may be a sign that the uterine scar is rupturing. Again this is extremely rare (0.5%) and more likely with IV syntocinon/pitocin.

In summary

You cannot assess the effectiveness or strength of a contraction. An effective labour pattern is one where mother and baby are well, and there is some kind of progress over time. Instead of assessing contractions, midwives should concentrate on creating an environment that supports oxytocin release. This may mean not being in the room or not observing the woman. Avoiding talking to a woman during a contraction is very important for all those attending her birth.

About midwifethinking

independent midwife, lecturer and student of all things birthy
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76 Responses to The Effective Labour Contraction

  1. Moominmama says:

    I have just returned home from a nightshift where a woman I was caring for was admitted with irregular contractions 1:10 or less. On VE (which we have to do on admission, or heads roll) she was 3-4 cms, almost fully effaced. Her previous baby was born by Ventouse after 17 hours. She wasnt the ‘magic 4cms’ to warrant a partogram let alone the epidural she was asking for,but didnt want to go home, so I offered her some simple analgesia and a bath to ease the pain..as you do. Within 40 minutes she was fully dilated and involuntarily pushing; normal birth ensued…
    I was essentially made to feel inadequate by other staff, a incorrect VE, misdiagnosis of contraction strength and ‘mismanagement’ of her labour. Although I knew my actions felt right, I was led to feel otherwise; reading this blog makes me feel better about my conduct, and although she and her partner thought I’d made my findings up, even after semi-explaining the physiology of parous cervixes, she was very grateful for the birth they experienced…Worth the comments from so called peers.
    Thanks again.x

    • Thanks – a good example of why routine VEs are pointless. At least the outcome was good for the woman. It’s sad when a woman opts for an epidural based on cervical dilatation because she thinks she is not progressing and then ends up on the intervention rollercoaster when she may have progressed quickly if left alone.

    • Baby Keeper says:

      Amazing. You are amazing. You were ostracized for supporting a natural, vaginal, non-intervention birth? What is wrong with people? Bless you many times over for being there, staying there, and advocating for mothers and babies .. how do you do it?

    • Susan says:

      I, for one, think it sounds like you did a great job. I’m one of those women who dilates all at once, at the very end. Obviously I didn’t know that with my first. I was checked at 3cm, and became very discouraged because I was to the “I can’t” phase of labour (didn’t realise that often signals transition). My son was born under 1.5 hours later, much to the surprise of the midwife. With my second I didn’t have any VEs (home birth, and no time). My contractions were variable, with some lasting nearly a minute, some 30 seconds, and anywhere from 2-6/7 minutes apart. Even so, I only had 2-3 hours of active labour. I was fine with breathing through the contractions until transition, which lasted for 2 contractions before pushing. I was glad the midwives with me were fine with just observing me, rubbing my back, and keeping me calm. :-)

    • Same exact thing just happened to my friend with her second baby! I think it just firmly illustrates that cervical dilation does not follow a prescribed notion!

  2. Amy Lynn Drorbaugh says:

    Wonderful post! With my first baby my contractions never got closer together than 7-10 minutes apart. If I had waited for the instructed 5 min apart contractions lasting 45 secs I wouldn’t have made it to the hospital. One of the reasons I eventually chose a homebirth. :-)

    • This happens all the time. Women wait until the prescribed labour pattern and end up birthing on the way to hospital in the car or carpark. At least if you have a homebirth you don’t have to worry about when to leave for hospital – you can just get on with it.

      • Baby Keeper says:

        There’s the phenomenon of the labor stalling after arriving at the hospital …. but there is also the phenomenon of the woman intending homebirth who upon arriving at hospital easily has birth. I have to wonder if the woman is unconsciously afraid and needing the “safety” of the hospital. Of course, in my field and work, pre and perinatal psychology and trauma healing, we know the baby has something to do with it as well.

        • Absolutely – women need to birth where they feel safest. I cared for a woman planning a homebirth. After her waters broke she spent days with only the occasional contractions. She had a very controlling partner and the atmosphere in the home was really awful. She decided to go to the hospital for a CTG and within 20 minutes of getting into hospital went into labour. She decided to stay in hospital and had a lovely birth. I am sure her labour was obstructed by the home environment.

        • Serena26 says:

          I dilate quickly as soon as the midwife arrives (I had homebirths and midwife lives not so close) and my contractions feel easier to cope with after she has arrived.

  3. Lovely!

    Will share this post on my FaceBook and on my Blog, Inside the Midwife’s Bag

    http://insidethemidwifesbag.blogspot.com

  4. Lauren says:

    I loved this! My planned UBAC last fall ended up being a hospital VBAC because I was one of the physically obstructed women; my cervix stayed at 5 cm for over 24 hours with VERY intense and frequent contractions. Ironically enough, I was only obstructed because my OB from my horrible, unnecessary C-section had manually dilated my cervix during the surgery without my knowledge, leaving me scarred and stalling. :( Thankfully my OB with my VBAC had trained with midwives; she examined me and found the scar tissue; she massaged it to break it up and I had my vaginal birth!! It was so great.

    • Baby Keeper says:

      So happy for you. I’m wondering … is this a little “trick of the trade”? OB induced scar tissue ensuring subsequent cesareans, maybe?

      • Lauren says:

        Thank you so much! It was a victorious day for me!!!!!!
        That may be, yes! But this was in Puerto Rico, where they don’t “allow” VBACs, and I think he did not even consider I’dd try to VBAC in the future. He might have done it out of spite, since he was truly monstrous to me, but I keep having the thought that it did not occur to him that I wouldn’t jump for ERCS.

  5. bonnie says:

    oooh i do love your blog. thank you for helping to make sense of all the contradicting info out there.

  6. thank you so much for this. so beautifully written. I already shared on Facebook and will recommend your blog to all new doulas and parents-to-be. Great resource. Thank you.

  7. Laurie says:

    LOVE this BLOG!!! I am adding it to my blog as well. I teach all of these things in my doula -led childbirth classes, however, you captured every needed detail in a wonderful, interesting format. Thank you for what you do for all of us birthing professionals.

    PS I agree Michel Odent is a genius and routine VE’s should be outlawed!!

  8. Thanks for the positive comments – you inspire me to continue blogging xx

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  10. I love this post. For many years I have been teaching bewildered, disbelieving students in my childbirth education sessions that numbers are pointless in labour, that the watching of a clock or an attachment to a number of openness brings us out of our primal brain and into the external world, thus intefering with our hormone cocktails. As a doula I don’t feel the uterus to assess a contraction, and feel I would never do that anyway. In almost 17 years of practice, I have seen several women almost sent home because they are silent and having contractions every 8 minutes, but have felt that VIBE, spoken up to a nurse to verify our thoughts, to lo and behold find a mother fully dilated.

    One of the hospitals I work at has the unfortunate policy of only allowing a woman into her own room at 4 cm, applying to multips as well. I know this is to discourage women from showing up to the hospital too soon, and in some ways could be considered progressive, but I cannot tell you how many women I have had doing almost all their labour in a triage room full of other ladies, hitting that stupid magic 4, going to their rooms, birthing 2 minutes later to gasps, “Oh, you went so FAST!” I have had nurses look at me like I’m crazy or dumb when I say, “look, the baby is coming soon..can she have a room for some privacy please?”

    I wrote a blog last year called “Throw your Clocks out the Window” addressing this issue of the almighty clock, also talking about how the numbers of the dilation of the cervix only tell you where you’ve been, not where you’re going. I fully believe if we let go of the timing/measuring paradigm as a diagnosis of labour progress, we would eliminate a large percentage of “pathology” in childbirth. Not only that, we would eliminate the oxytocin/endorphin buzz kill that rears its ugly head when a woman is told her cervix is not where she thinks it “should” be given her level of pain, thus reducing the perceived need for medication and all its effects.

    I will be doing a doula training for nurses this fall in one our hospitals, and cannot wait to introduce this idea, which is so obvious if only one observes instead of times.

    Thanks for this awesome post!

    Lesley

    • Thanks Lesley – it is frustrating. So much of modern life centres around time frames and measurements. Birth is no different. I am so pleased you are able to get the information to the nurses. I just hope they can put it into action. I know the hospital midwives struggle to provide the care they know is possible because they are constrained by guidelines and policies. Try telling an obstetrician that you have no idea how strong a woman’s contractions are but you know she is doing great… I prefer homebirth where I can just ‘be’ rather than spend my time measuring and writing. Keep up the good work – birthing women need you!

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  13. Sara says:

    During my first labor I didn’t know what to expect and thought that I would have hours of early labor (that’s what the books said!). My contractions started at 10 minutes apart and weren’t very painful, and then were sporadic for the next few hours- 10 minutes, 6 minutes, 7 minutes. Then 3 hours in they changed Very quickly to every 2 minutes. However, they weren’t very long- never longer than 45 seconds. I almost didn’t make it to the hospital because I couldn’t beleive that it would go that fast. My daughter was born less than 5 hours after my first contraction, and only 15 minutes after we got to the hospital.
    I think the environment helped a lot- I was completely relaxed in my tub at home and alone with my daughter for one last time (I let my husband sleep because it was 2:00 am). It wasn’t until we got to the hospital that I started to feel stressed. I really just couldn’t believe that labor was so different than what I had heard. Now I try to tell everyone I know who is thinking of having a baby that they should really consider a home birth, and labor might not be so bad!

  14. ultrasound technician says:

    I’ve recently started a blog, the information you provide on this site has helped me tremendously. Thank you for all of your time & work.

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  16. Emily says:

    I am a student midwife, and have seen a mama hang out at 9 cm for 16 hours (due to OP presentation, but he never showed any distress and mama was determined), and I actually caught my first baby when I acted as doula for a friend and her midwife went home because she wasn’t in active labor. She was at 3 cm, and happy. Clearly not active labor. 30 minutes later, baby was born. So yes! Thank you for reminding us that each woman will look very different.

    I only recently discovered your blog, and I’m working on reading through the whole thing! Thank you!

    • Karanya says:

      Reminds me of my first labor — arrived at the hospital to be told I was only 3 cm. but they had some open rooms so went ahead and admitted. 30 minutes later, I’d given birth.

      This story scared my next OB so much that she induced me at 37 weeks. Awful experience, but still fast (about 6 hrs).

      #3 will be born at a nearby midwife-staffed birth center or — if I don’t make it in time — at home.

      • Wow! Now that is a new indication for induction ‘unpredictable cervix’. Enjoy your next birth and perhaps decline vaginal examinations because clearly they are totally unreliable in assessing when you will birth.

  17. Keri says:

    Have just read three different entries and I am loving your blog.

    My first child was OP. 4 Weeks early (though OB insisted there was no way possible a first time mom would deliver early…) Contractions started at 4am and after calling the doc at 10am, he wanted me in immediately. I stalled anyways, did laundry, took a shower, straightened my hair and got there around noon. Water broke immediately after getting there. After being nagged for 6 hours about pitocin, I finally agreed. I was bed ridden and told I could ONLY deliver on my back. They insisted on monitoring me the whole time. My contractions never got closer then 5-7 minutes apart. Finally, 5 and a half hours later, my 6lb baby was born and tore me twice!

    My second child (making an extremely long story super short) showed up unassisted at home, breech. After 36 hours of labor, a 2 weeks delay, and another 6 or so hours of labor. Born on her due date, by only 5 minutes (didn’t want to be late I guess, but still not in a hurry!), 7 pounds. No tears, no pitocin, no help whatsoever. My contractions with her were not regular at all. Nor did they ever get closer then 7-10 minutes until I was within 15 minutes of giving birth to her (at that point I had them so frequently I could not leave my spot). I delivered her standing and my husband caught her. We ended up going to the hospital because it was not planned to have her at home and we didn’t think we were equipped to go from there. However everything that they told us to do over the phone, I’d already done. My midwife was quite happy that I had her at home, they would have sent me straight in for a Cesarean at the hospital. I regret going to the hospital, should of stayed home… and we will next time!

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  21. I would love to get your references for this article. Great and important work…i can you post your research citations?

    • Thanks for visiting my blog. I try to avoid a reference list and instead link to the sources in-text – I spend way too much time with reference lists in my line of work! I’ve have provided more links to sources in the text of this post. So I hope they are helpful and what you are looking for. I’m not sure which research citations you are after but if they aren’t there let me know. Some of the post is based on my own observations of labour or my opinion (ie. that you cannot assess the strength of a contraction). There has been no research looking at whether contraction assessment is possible, or to support the idea that there is a particular ideal contraction pattern… hence the post. A lot of our knowledge and practice is based on assumed concepts.

  22. Andrew says:

    I think there is a lot of sense in your post. What I have observed as an obstetric doctor who is always around on the obstetric ward, is similar to what you have described.
    There are a couple of comments that I disagree with you though.
    1. VE’s are useless and should not be done routinely. I disagree. Certainly I agree that they should be limited and in many cases I do not do one at all for a lady in spont labour who is low risk. However, many times, esp primips have spurious labour and one needs to be able to give some advice about labour progress. A VE can give some information here.
    2. Using dilation of the cervix to assess labour contractions is very useful. I totally agree that woman will often labour in their own way and progress can vary dramatically. However, genuine labour contractions dilate and efface the cervix and you will not know this without doing a VE.

    Thanks for stimulating my thoughts because like you I have found that palpation of a uterus a poor way of assessing the adequacy/strength of contractions and agree with much of your comments in this blog.

    • Hi Andrew.
      It appears that we are actually in agreement about VE’s. You state “in many cases I do not do one at all for a lady who is in spont labour who is low risk’. Therefore you are not routinely doing them but selectively. You must bear in mind that my post (and most of my writings) are about physiological birth ie. what you would call low risk because this is my area of knowledge as a mw. Once intervention is initiated eg. induction or augmentation etc. then routine VEs become part of the management plan. You must assess the intervention you are making ie. is it working. Therefore the skill of VE is useful for mws but essential for obs. Considering that the majority of women in hospital are induced or have their labour augmented (perinatal stats) – then you probably do need to perform a lot of VEs as part of the labour management. Obs must also be able to accurately assess the descent/position etc to perform instrumental deliveries.
      The research I am currently writing up is about midwifery practice during birth and the ways that midwives assess labour progress (in physiological birth) involve much more than a VE and rely on external observation. But I guess this is their area of expertise having spent many hours just watching women journey through labour. Obs don’t often get the opportunity to watch a physiological birth unfold and instead get called in to deal with problems – therefore must rely on assessments such as VE. Also as you state primips can have ‘spurious labour’ although I wouldn’t use that term. This is only of concern in a hospital setting because you can’t have women taking up room if they are not labouring. It is not an issue at home. Although some women do want a VE to ‘see what’s happening’ and I will do one – for them not me.
      So I guess what I am saying is that routine VEs have no place in a physiological birth without boundaries of time or progress requirements, or need for hospital beds. According the cochrane review on partograms = not recommended for these women therefore no need to assess their cx.
      I’m pleased you are finding my posts thought provoking. I think if obs and mws could stop fighting and instead respect and share their different areas of expertise we could better serve the needs of the real birth experts – the women. Ultimately both professions want the same thing. I do miss the UK where we could work with mutual respect along with the occasional good natured difference of opinion… sigh.

  23. AP says:

    Thanks for this clarification.
    I understand more where you are coming from. You are wholely correct – sadly, I don’t often deal with low risk spont labours – which you would term physiological births (although there are plenty that come thru, many are at night and I don’t work nights).
    I have also had the situation as you describe where a lady has requested a VE, even though I didn’t plan to do one, but she wanted to “know where she was at”. Mostly I would oblige, but sometimes I don’t if the request is totally unnecessary (eg a preterm lady wanting a social induction) which I believe is potentially dangerous to entertain, and would not do either a VE or IOL.

    I do appreciate being challenged in my thinking. If I do not allow this, there is little or no room to grow, or to respect another person’s opinion. So thank you for allowing this, and being respectful of my right to hold a different opinion. I am enriched by your comments and thoughts.

    I’d be interested in hearing more about your experiences in the UK. Sounds like Aust is different from the UK in many ways? Perhaps that needs to be a private conversation rather than taking up your blog space…

  24. Anna F says:

    Thank you for this wonderful resource. I just found your blog yesterday and am reading post after post and then emailing links to friends who just had or are having babies soon. After reading Ina May’s Guide to Childbirth, I went from the prospective of “I will use drugs when it gets to hard” to “I WILL have a natural, un-medicated birth!” and I did it! Thanks to the wonderful doula and midwifes at our local birthing center (located within a hospital, which made my husband at ease) I achieved a birth experience that I hope to repeat.

  25. I love your blog – I really do!

    Since I am training to be a midwife myself, it is very helpfull to me.

    I also made the same experience during my two births: contractions until the end not something you could call “birthcontractions” – lasting 10-15 seconds at the most, but giving me almost no break coming every minute or even less. Also, I am a all-at-once-dilating-woman, it seems.

    It is a sad thing this is not known by midwifes all around the world.

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  27. Laura says:

    Absolutely LOVE your writings here.
    I’m a medical student in Germany and spent my last months in L&D – how it makes me crazy when someone says to a laboring woman that she is not having “real” contractions.
    Is what she feeling unreal? Is what keeps her probably from sleeping for some days already and that she needs all her strength to cope with not real?
    All those women are afraid because they start thinking – how bad must it be once it starts to be “real” or “effective”. But often it’s not getting “worse” just different.

    I wish people working with birthing women would start thinking more about the power of their words.

    And one thought – the early contractions are often “not real”, “you are not having contractions”, “birth did not start yet”. But so many women experience light contractions for days or hours so there must be a reason for them and yes, they are real and they are birth! Even if that means that birth may take five days…

    • You are so right about the power of words! All contractions are ‘real’.

    • Louise says:

      As a midwife I think it’s wonderful that you’re going to be a doctor with such a perceptive understanding of the power of words to affect physiology. Keep up the good work!

      • Hannah says:

        Hi! Just came across this article. Its so great to read all of these wonderful experiences. I totally agree about the power of words to affect physiology! When I went to the hospital to deliver my son, I was told, “You will probably have a baby tonight”. That was around 6 a.m. or so. By the time I was in transition around noon, I was totally loosing it, thinking there is NO WAY I can last HOURS in this pain to deliver this baby TONIGHT. I almost ended up taking pain killers that I didn’t want or need because I was so discouraged by that one small comment. Thank goodness baby was born just 15 minutes or so later! This next time I will know to listen to my own body instead of other’s comments!

  28. autum says:

    i am a little different. i have contractions that are two mine with 30 sec apart. with my first this went on for three days. it was a home birth. and at the every end i went form 6 to pushing and baby out 1hour. my next it was only one day but same kind of contractions. with her i went from 7 to pushing and baby out in 15 min. she was a little bruised up, from coming out so fast. we all are so different.

  29. dececcokm says:

    I will be referencing this post in my magazine called Home Grown in the Bellies and Babies article. But also I would like to thank you so much, I am currently taking Bio 235 A&P through Athabasca and this post has explained so much to me. I love your blog. Thank-you so much.
    -Kayleigh May

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  32. Tinks says:

    I was at a birth recently where the woman was having three short pushes on a contraction that lasted about 20-30 seconds. Every 2-3 minutes. She wanted to have a hospital birth. When we got to hospital she was pushing, ctx were 7-8 min apart. Dr said baby was just “sitting there” after an hour and wanted forced pushing. With that it took approx 2 hours for baby to be born (coached pushing, episiotomy, hands on delivery). My interpretation is that had ctx continued at home, at 2-3 min apart she would have been able no doubt to continue beautifully but with all the intervention, oxytocin was much lower and hence “help” almost required. Have you seen this sort of pattern in homebirth?

    • The move to hospital most likely inhibited her oxytocin release = more spaced out contractions. I’m impressed that her baby coped with 2 hours of directed pushing without developing hypoxia… I usually warn women that a healthy baby can generally cope with around 30 minutes of valsalva pushing.
      I have seen all kinds of ‘pushing’ patterns at homebirth. Probably the most memorable/unusual was a woman having her first baby and contractions were never more than 10-7 mins apart. She birthed just fine and slept in-between contractions.

  33. Stephanie says:

    I have an honest question– I get the whole point about how every woman labors on her own timetable, but is there a point where the baby has to come out? When do you call that?

    For instance, my sister (36) is currently in the hospital since Wednesday at 8 pm. It is currently Friday at 3:40 p.m. She is 1 cm dilated, not progressing, had 3 rounds of cytotec and lt I heard was up to -5 units of pitocin.

    O.k. Let me back up a minute. You can’t tell this sister anything… She marches to the beat of her own drummer, is diagnosed bipolar and is emotionally 13 and can’t handle a lick of pain. She has an OB and a midwife. She was convinced the baby was going to be here 2 weeks ago and even scheduled the baptism for tomorrow (obviously cancelled). My mother has been there since the 7th, and her OB wanted her delivered before the 41st week because that is how he rolls, so they both talked her into this. Obviously she wasn’t about to go into labor.

    Her water broke on its own around 1 pm today.

    Obviously I’m not asking for a diagnosis or anything, but at this point my other sister and I are starting to get slightly worried because her midwife comes by once a day and it just doesnt seem like anyone is running this. It doesn’t help that my sister is a very difficult patient… Taking the fetal monitor off, etc. my mom overheard the nurses asking who wanted her room number and no one wanted it. Did I mention my sister is a difficult patient?

    She is clearly on the road to a c-section… She began wanting natural childbirth but the minute she agreed to be induced, this became a train wreck.

    So in referencing this situation with my sister… My question is: is there a point where extended labor or extended pregnancy (say post 42-43 weeks) could cause fetal death? I’m asking in reference to a midwife attended, non intervention birth. In what situations have you had to call it off (or maybe you haven’t) because things just took too long and hospital intervention was necessary (aside from prolapsed cord, which I experienced)?

    Throw out the clock, sure, but is there a point where it all comes to a head and the timeframe does become an issue?

    Thanks. I appreciate your time and your blog.

    ST

    • Stephanie says:

      That is 15 units of pitocin. They told her the max is 30. She also has a history of endo and infertility. The nurse on duty refused to administer cytotec cervically (25 mg)– the other 3 doses of 25 mg was orally. Anyway, just to clarify the pitocin thing….

    • Hi Stephanie. Like I always say, I can’t give advice or suggestions for individual situations. However, I’ll try and answer your question…
      Firstly there needs to be a clear distinction between physiological birth and non-physiological birth. Your sister is not having a physiological birth. She is having an induced birth. Inducing a labour is done because the baby is considered at risk if it remains inside. So, once you start an induction you are committed to getting the baby out safely and fairly quickly – because you have decided it is at risk. If induction is not working a c-section is the next step. Of course there is much debate over the real risks of postdates and you can find out more here: http://midwifethinking.com/2010/09/16/induction-of-labour-balancing-risks/
      An induced labour needs to be medically managed. The baby needs to be monitored and the progress of the labour needs to be monitored… more about the process here: http://midwifethinking.com/2011/07/17/induction-a-step-by-step-guide/
      As a homebirth midwife I work with physiological birth unless it becomes pathological, then we transfer to hospital for intervention. The woman labours according to her ‘own timetable’ and if mother and baby are well, time does not matter. However, if a woman was having full on, strong contractions for a prolonged time (actual time would depend on her individual circumstances ie. previous baby, etc.) and no signs of progress – I would be asking the question ‘what is going on’. I wouldn’t like to see two nights during a birth with good strong contractions. Occasionally, a woman’s labour does not progress and she needs intervention. However, this is rare when the physiology of birth is supported.
      Hope that kind of answers your question. Good luck to your sister :)

  34. Fantastic ! Thank you so much for this article. I discovered your blog through a doula, professional contact of mine in Shropshire. I work with pregnant women, particularly in pre labour preparation as a specialised Reflexologist. I have great respect for midwives, especially all those (who just like you) strive to do their job with Mom and baby’s wellbeing always in mind. One of my aims during the pre labour treatments is to encourage the release of oxytocin by working on the hypothalamus and pituitary reflexes found on the big toes. It has been fascinating to learn more about the natural production of oxytocin and conditions of labour in your article. Once again, thank you.

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  36. Jim says:

    I enjoyed your post, however do your readers realize that labor morbidity and mortality have been profoundly reduced secondary to physician intervention and practices. Go back 60 years and examine the numbers. And by the way, to the conspiracy theorists who think OBGYNs make more money from c-sections: check payments from every insurance carrier;its the same for vaginal or c section. And the literature is rich concerning the benefits of epidural anesthesia compared to analgesics (which cross the placenta and affect the baby). The generalized hostility towards modern medical practice is baffling to me. Particularly from midwives that should know better.

    • Thanks Jim

      I agree that medical intervention is life saving and I am very pleased to live in a country where it is readily available. However I think it can be argued that medical intervention is now overused. For example only 37% of women in Australia labour without induction or augmentation (according to government stats). The pendulum has swung too far the other way and we are now causing harm by overusing medical intervention. I have worked in private and public maternity systems, and I am well aware of what goes on in them. I don’t think it is a conspiracy, but a cultural norm of medicalisation of a physiological process which is not underpinned by current literature, nor does it reflect what (most) women want (according to the numerous government reports into what women want). We have practitioners, including midwives who have never seen a physiological birth. How can they then understand pathophysiology and judge when to intervene appropriately?

      I disagree with your statement that c-section is not more profitable in private practice. It goes against a recent presentation by Dr Michael Koutsoukis (a OBGYN) who gave a very honest account of his experience in private obs. A spontaneous physiological birth = less money for the private institution and on-call/unpredictability for the dr. No fee for the anaesthetist, or the increased hospital stay, etc. I am guessing you may be from the US… in which case entire hospital wings depend on the income generated from c-sections. Obs are told to reduce their unassisted birth rates to increase revenue.

      As for epidurals… the literature is also rich in how epidural effects the normal physiology of the birth process and increases the chance of further medical intervention (which effect the baby). When the physiological process of birth and bonding is understood, the impact of interfering with this interplay can be considered. Unfortunately many care providers do not fully understand the physiology in the first place. And the jury is still out on the effect to the baby and there is literature linking epidural to problems with breastfeeding and other studies finding no link. Epidurals are great in the right circumstances and with the consent of the woman – which includes and understanding of how it changes birth.

      I am sorry that you take my attempts to open up debate and explore birth culture/practice as ‘hostility towards modern medical practice’ and I’m not sure why ‘midwives’ ‘should know better’. It is midwives who are seeing the effects of increasing intervention on womens’ births and beyond. I suggest you read some of my other posts and perhaps this interview: http://www.baby-birth.com/articles/84-childbirth-professionals/816-rachel-reed.html#.UlHxKBYp8so to get a better understanding of where I am coming from. In particular, read the comments on my posts from women about their experiences of the topics discussed.

  37. Katherine says:

    Fantastic perspective!!! As a birth doula I am only able to rely on what I can hear, see, and smell when with a mother in deteining how she’s progressing and it seems to work a WHOLE LOT BETTER that way! I try to emphasize to families that numbers really have no informative value when it comes to birth and often times will only lead to anxiety measures, including interventions and emotional distress. I think helping women understand their bodies and to practice listening to their intuition is critical for an effective, low intervention, and positive birth.

  38. Jessica says:

    The rule about having to have 3 contractions in 10 min to be productive is so not true. I don’t think my contractions ever got closer than 4-5 min apart and I delivered after 4.5 hours of labor and like 3-4 pushing contractions.

  39. Awesomely written! I love when you say “Therefore inadequate progress is the norm… or our definition of adequate progress is wrong.” I will share this post on my Facebook page. Thanks for the insights

  40. Haydee Cowper says:

    I have been with women having babies now since 1987 and have three of my own. My experiences over this time have led me to believe that all assessments of labour cannot be taken in isolation. Strength, frequency and duration of contractions and vaginal exams are so often used by midwives and doctors to manage labour and advise women about their progress of labour. Actually I have found if you stay with women and watch, listen, smell and touch them ( I do draw the line at tasting) the women will tell you how they are progressing in labour. When I was a student midwife I recall a senior registrar at a large Tertiary training hospital telling a woman, who had previously birthed 4 babies, that she was breaking her waters because the woman had not established in labour. As the registrar was explaining the plan to commence a syntocinon infusion if labour hadn’t established, the woman’s leant forward and said ‘ the baby is coming’ . ‘Oh no dear, not yet’, Said the registrar. The woman leant back in bed and pushed and a beautiful baby girl slid out under the covers. A red faced registrar apologised to the woman. I learned a valuable lesson that day that I always listen to women in labour and I share this experience when working with student midwives . I am still learning my craft as a midwife and my teachers (the women I have the privilege of being with) generously allow me to share their journeys as I learn.

  41. Jen Stevens says:

    I love your blog. If you are even coming to the US, please let me know!
    I have a question about your statement “oxytocin does not cross the blood brain barrier” as far as I have read it does, which is why natural oxytocin is important as it crosses from the mother, to the uterus and even to the fetal brain. It is synthetic oxytocin, or pitocin here in the states that does not cross the bold brain barrier. An interesting, albet difficult, research would be- by giving synthetic oxytocin Are we decreasing a woman’s endogenous production, and also decreasing the baby’s experience of that? Please let me know if I am not correct.

    Thank you again for all you do!

    • Thanks Jen – I hope to visit the US again and I’ll let everyone know :)
      Yes you are correct… and maybe I didn’t explain clearly. Endogenous oxytocin is produced in the brain therefore effects the brain. It is transported via the bloodstream through the body. Synthetic oxytocin is administered directly into the bloodstream and cannot pass through the blood-brain barrier but it does pass through the placenta and into the baby’s blood stream. The fetal blood-brain barrier is more permeable than the adult mother = synthetic oxytocin can cross. The concern is that large amounts of synthetic oxytocin bathing the fetal brain during the time of birth may alter the brain and oxytocin system. Hope that is clearer :)

  42. Sophia says:

    I recently had a long and confusing labor experience. I was experiencing strong contractions sporadically from an hour apart to 1.30 min apart.They were more consistent at night, and really only spaced out during the morning. This occurred over 4 days with my baby eventually being delivered by c section. I was at home for 3 days – with check up trips to the hospital – the final day was at a birth center then transferred. I’m still abit confused about what actually happened and why, and need to go in to the hospital to clarify some of the details.
    I just wanted to thank you for this post, it has helped me feel a bit better about the experience, and a bit clearer on some of the forces at play during the labor. One of the things i felt after the labor was a sense of shame and a lot of confusion about what i had experienced. I was in so much pain, and the contractions were very real and strong, but nothing was happening. The midwives changed during my time in the birth center. One midwife had me pushing – and we all felt like the birth was close by, then with the change of staff the next midwife was telling us i was only 3 cm dilated and no where near birthing, and that i needed to be transferred. Her attitude was totally demoralizing, and i felt completely lost and freaked out.
    Afterwards i questioned my reaction to the pain, somehow internalizing the judgement that the contractions must have not been real, because i was not progressing..I also didn’t understand how things could shift so dramatically from one midwife to the next.

  43. I’ve been trying to understand the diagnosis of “failure to progress”. Obstetric guidelines say that there are three reasons for it – ineffective uterine contractions, malposition of the baby or the baby being too big for the pelvis. I can understand how labour could be truly obstructed (rarely) by the baby being too big for the pelvis. And I can see why positioning is important (though I should think that the knowledge presented in spinning babies could do a lot to avoid the need for C-section, but I really don’t understand how “ineffective contractions” could cause a bad outcome. What do doctors fear will happen if the contractions aren’t strong enough? Will the baby just never be born…? According to the active management protocol, first-time mothers are often assumed to have ineffective uterine contractions. This is a quote: “O’Driscoll et al believed that primigravida uterine action is ‘‘often insufficient to overcome the soft-tissue resistance in a woman having her first vaginal delivery.’’ The treatment for this is artificial oxytocin drip. It seems so strange that a majority of women would NEED an intervention so as to avoid obstructed labour. Are first time mothers really incapable of overcoming the soft-tissue resistance by themselves? Obviously that’s not true, but I’m still confused as to what people think will happen if they do not intervene when contractions are thought to be weak?

    • It is about resources. An institution does not have the resources – staff, rooms, etc. – to support a long stay/labour. A uterus will contract until the baby is birthed. However individual women’s pattern of contraction will vary. A woman who’s contraction pattern is spaced out or more gentle (often because the baby needs this) may take days to actually birth. I have attended births where contractions stop and everyone gets some sleep then they start up again. This is normal. However, when birth care is institution-focussed interventions are used to ensure the maximum efficiency of time and resources.
      The more concerning scenario is extremely strong, close together contractions for many hours (like syntoncinon induced ones)… baby’s can become distressed if subjected to this. A long spaced out, gentle labour is not a concern for the baby or mother.

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