My New Years resolution is to stop colluding in the myth of stages of labour. Will you join me? This may be a little difficult as a midwife and an educator but I’ll give it a go – will you?
The stages of labour
In current midwifery texts labour is divided into three distinct stages, and further divided into phases within those stages. The first stage of labour involves regular and coordinated uterine contractions accompanied by cervical dilatation. This stage includes three phases: latent, active and transitional. The second stage of labour begins when the cervix is fully dilated and ends when the ‘fetus is fully expelled from the birth canal’ (Stables and Rankin 2010, p.533). Again, the second stage is further broken down into three phases: latent, active and perineal. ‘The third stage of labour is the period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding’ (Stables & Rankin 2010, p.547).
This concept of birth reflects the scientific, mechanistic model of how the body works (see ‘a quick history lesson’ ). It does not reflect women’s experience of birth or the physiology of birth.
Problems with assessment and categorisation
The idea of stages of labour contradicts what we know about the physiology of birth. Physical changes in the cervix and uterus occur during pregnancy and the onset of labour is a gradual happening without a distinct start time. The definition of ‘established labour’ includes regular rhythmic contractions (3:10 or more, lasting 45 secs or more) and progressive dilatation of the cervix (1cm per hour). However, women’s natural contraction patterns vary, and the idea that a cervix will follow a graph is outdated – see ‘the effective contraction’. What about a woman who only ever has contractions 2:10 but births her baby? Did she skip the first stage of labour? Women with OP babies often have different labour patterns that will not fit this definition.
The definition of the first and second stages of labour also assumes that a vaginal examination will be carried out because everything hinges on what the cervix is doing. However, this doesn’t quite work. If I examine a woman at 3pm and find out her cervix is fully dilated does that mean her second stage started at 3pm? What if her cervix had been fully dilated at 2pm but I didn’t know? The only time measurement we can know for sure is the end of the second stage of labour – because the baby emerges (assuming we remember to look at the clock). We could get a time for the birth of the placenta, but the end of the third stage ends with ‘control of bleeding’ which is open to interpretation.
The impact of collusion
Care providers have accepted this categorisation despite the lack of evidence or sense to support it. The stages of labour are like the emperors new clothes. We educate women on the stages of labour; we assess their progression through these stages; and we fill in documentation about their progression through the stages (eg. time of 2nd stage). Perinatal data forms require the precise hours and minutes that a women spends in each stage of labour.
How this translates into practice is that midwives basically make it up. There is a box to fill, so we fill it. This results in some comical paperwork conversations between midwives/midwifery students eg.: ‘What time would you say second stage started?’ ‘Umm not sure – she was making grunty noises around 5.30pm…’ ‘OK, I’ll put 6pm.’ Midwives also massage the paperwork to fit policies eg. ignoring that the woman was actually ‘pushing’ for 3 hours and only documenting a 1 hour second stage to avoid trouble.
These made up times are carefully recorded and then sent to organisations that collect and analyse the stats to provide information about labour and birth. By making our records fit the myth, we are colluding in maintaining the myth that labour can be compartmentalised into distinct stages and measured accurately.
Perhaps more importantly by colluding we are re-defining women’s birth experiences – often in contrast to their own experience. Have you tried explaining to a woman why we only record ‘established labour’ and disregard the hours or days that she experienced contractions before being assessed as in established (real) labour?
I guess I have it easier than those working in hospitals with hospital documentation. I’m in control of my own paperwork and have already excluded the stages of labour from the birth notes I write at homebirths. However, I still have to complete perinatal data forms. So, the question is do I put a ‘?’ in the box or draw a line through it?
Merry Xmas readers and thanks for following my blog in 2010
*Update: This post has been expanded into an article for AIMS. You can read it here.