Understanding and assessing labour progress

I have previously written about how the current framework for understanding and assessing labour progress is inaccurate, not supported by evidence, and fails to incorporate women’s experience of birth. This post is in response to readers asking me to write about how to assess labour progress without vaginal examinations or palpating contractions.

The elements required to assess labour progress are:

  • An understanding physiology – knowing what is going on inside.
  • Facilitating and supporting (not disturbing) physiology.
  • Being focused on the woman and engaging all of your senses: sight, hearing, smell, touch and intuition to read the signs (this requires you to be quiet and receptive rather than busy and ‘doing’).
  • Ideally knowing the woman beforehand – this assists you to assess her individual behaviours and understand her experience better.
  • Accepting that any assessment can be inaccurate, and that individual women may not display the ‘usual’ signals of progress.

The following is a general guide only. Please note that this post is about physiological, undisturbed birth ie. does not apply to women who have altered physiology eg. induction, epidural, etc. Women who are being medically managed require medical assessment.

I am using ‘childbirth as a rite of passage’ as a framework for understanding what is going on during the birth process. The physiology in this post is really an overview and does not delve deeply into the complex hormonal interplay during birth which includes the baby. If you want to know more please see the bibliography/reference list at the end of the post.

Glossary / Overview of key players

  • Oxytocin (OT): love, bonding, reduction of stress; healing; uterine contractions
  • Beta-endorphins (BE): pain relief; activation of reward centres in brain, altered state of consciousness – ‘transcendence’
  • Epinephrine and Norepinephrine (E-NE) aka adrenaline and noradrenaline : stress hormones (shorter-term activation)
  • Cortisol: stress hormone (longer-term activation)
  • Prolactin (PRL): mothering hormone; lactation
  • Eustress: beneficial / physiological stress as opposed to pathological stress

SEPARATION

…the first phase of separation comprises symbolic behaviour signifying the detachment of the individual or group either from an earlier fixed point in the social structure or a set of cultural conditions (a ‘state’).
– Turner 1987, p. 5.

amanda-greavette-water-marked-images-27-350x414

Art by Amanda Greavett: http://amandagreavette.com

The first phase of the childbirth rite of passage involves the mother separating from the outside world and focussing within. Towards the end of pregnancy women begin to focus inwards in preparation for the birth. Physical separation occurs particularly in early labour when the mother secludes herself in her birth space and seeks to minimise distractions (external stimulation). Ritual separation from society during pregnancy and birth is common throughout history, and across cultures.

Physiology (what is happening inside)

Levels of PRL, progesterone and BE rise during pregnancy reaching high levels at the beginning of labour. In addition the maternal stress response decreases. This supports feelings of calm, and a focus that is inwards and towards family.

It appears that the baby initiates labour and the mother’s body responds. OT levels rise and uterine contractions become stronger and noticeable to the mother (the uterus contracts during pregnancy before labour). Initially they can be irregular in length, strength and the time in-between. The cervix is softening and opening, and the baby may begin to rotate and settle into the pelvis. BE increases further in response to the pain of contractions. The excitement/anxiety/anticipation (eustress) of early labour increases the release of E-NE. The balance between inward focus (OT + BE) and alertness (E-NE) allows the woman to remain aware of her surroundings and keeps her neocortex active. This facilitates her ability to do what is needed to ‘separate’ eg. organise her other children, call her midwife, travel to hospital, etc. If her OT + BE / E-NE balance tips towards E-NE her contractions may stop altogether until the balance is restored. This mechanism enables women in early labour to stop contracting in response to danger in the same way as other mammals do.

It can take many hours or even days for this early labour phase to tip over into established labour.

Assessment (what you might see)

  • Eyes open between and during contractions.
  • Evidence of neocortex functioning – the ability to hold a conversation and answer questions and/or to engage with external activities eg. using her iphone to time contractions.
  • Excitement and anxiety.
  • She may be keen to get settled into her birth space (see this post).
  • Contractions slow or stop in response to a journey to hospital or other stressful/distracting situations.
  • A bloody-mucousy show may occur as cervix opens.
  • Posture remains the same as in late pregnancy (pelvis still stable) ie. able to easily walk upright between contractions.

LIMINALITY

The attributes of liminality or a liminal personae (“threshold people”) are necessarily ambiguous, since this condition and these persons elude or slip through the network of classifications that normally locate states and positions in cultural space. Liminal entities are neither here nor there; they are betwixt and between the positions assigned and arrayed by law, custom, convention, and ceremonial.
– Turner 1969, p. 95.

birth4

Art by Amanda Greavett: http://amandagreavette.com

After the separation phase, a person undergoing a rite of passage enters the liminal phase (or transitional phase) where they are often said to ‘be in another place’ (Turner 1967, p. 98). The intense experience of labour requires mothers to ‘undo’ their usual state of consciousness, behaviours, and their connections to the external world. They often describe being ‘in their own world’, in an altered state of consciousness. This space is located within the labouring mother. As mothers progressively move more deeply into this internal world they shut out the external world further, maintaining and increasing separation. The physiological processes involved in birth create a naturally liminal state – the rhythmic contractions + birthing hormones. Both mother and baby are journeying in this ‘in-between’ world.

During the liminal phase, Turner (1987, p. 5) suggests that a person is unstructured, at once both de-structured and pre-structured. Women in labour act in ways that reflect their unstructured nature. The extreme physical process of birth involve the body functioning in a way that is unlike the everyday functioning of the body. In addition, behaviours are often inconsistent with the ‘everyday’ cultural norms. For example, making ‘animalistic’ noises, as being naked in front of strangers, lying down in hospital corridors, etc.

As the liminal phase peaks there is an undoing, dissolution and decomposition of self (Turner 1987). This point in labour is traditionally known as ‘transition’.

Physiology (what is happening inside)

As OT increases contractions become stronger and more powerful. In response, cortisol and BE increase to very high levels to relieve pain and reduced stress. The natural BEs (opiates) help to create a trance-like state where the woman’s focus is within and she is drowsy and less aware of her surroundings. Her neocortical functioning is reduced and her limbic system (instincts) are heightened. Her labour is now established.

The baby is rotating around and moving down through her pelvis. The Rhombus of Michaelis moves up and backwards to increase capacity in the pelvic mid cavity and outlet. As the pelvis ‘opens up’ it becomes unstable – and the woman moves instinctively to accommodate the movement of her pelvis and baby. The waters may break as the cervix opens enough for the forewaters to bulge into the vagina.

As labour progresses and reaches it’s powerful ‘peak’ there is a surge of E-EN to counter-act some of the BE effects. This prepares the mother to be alert enough protect her baby immediately after birth. The body’s response may be the fetal ejection reflex resulting in very powerful contractions and a quick birth. However, for most women this surge of E-EN is experienced as ‘transition’ – a feeling of fear, overwhelm and general freak out.

Once the cervix is fully open there may be a lull in contractions as the uterus ‘reorganises’ itself around the baby as he/she moves down. As the baby descends further pressure is applied to nerves deep in the pelvis resulting in spontaneous pushing. Contractions become increasingly expulsive as soft tissue stretches increasing the release of OT. The pain generated from the perineal tissues stretching initiate instinctive behaviours that protect the perineum. PRL, OT and E-EN levels increase further as the birth approaches ready to assist the initial bonding process.

Once the baby’s head is born there is likely to be a pause allowing the baby time to rotate or change position to get the shoulders through the pelvis. The baby is usually born with the following contraction.

Once labour has established a strong pattern you would usually expect the baby to be born within 18 hours (depending on contraction pattern and the individual situation).

Assessment (what you might see)

  • Her contraction pattern becomes increasingly stronger (based on her response to them). Note that contractions may not necessarily become closer, but they will become increasingly powerful. There should be a shift in the pattern/power every 2 hours (as a general rule).
  • She will be in ‘her own world’ – she may have her eyes closed and doze off between contractions ie. look stoned. She may cover her eyes with a cloth or bury her head into something (eg. pillow).
  • She is less able to respond to questions or anything else that requires her neocortex to function. Her communication (if there is any) will be short and to the point eg. ‘water!’ rather than ‘Can you please pass me the water’. If you ask a question (best not to) it might take a while for her to answer and she will not speak during a contraction.
  • Her movements and sounds will be instinctive and rhythmical. She is likely to vocalise during contractions – often the same noise with each one, and/or make the same movements each time.
  • Her inhibitions reduce. It is during this phase that the previously shy woman rips all her clothes off and crawls about naked.
  • At this point the hormonal symphony is in full swing and it is very, very difficult to stop or slow contractions. A significant stress at this point may generate a fetal ejection reflex but it is unlikely to stop contractions.
  • As the baby moves downwards and her pelvis becomes less stable (opening), her posture will change. She will want to hold onto things (and people) when standing/walking. She will not be able to sit directly on her bottom. She will walk leaning slightly with a ‘waddle’ as the pelvis tips.
  • If she is in an upright/ forward leaning position, you may be able to see / feel the ‘opening of her back’ as the Rhombus of Michaelis moves.
  • purple line might be visible between the woman’s buttocks as the baby’s head descends.
  • During transition you may see fear as she reaches out for reassurance and support. However, some women do not, and instead feel this on the inside without their care provider being aware of it.
  • During transition E-EN can cause a dry mouth and she might suddenly be very thirsty. High levels can also cause vomiting as the stomach empties in the fight or flight response.
  • As the cervix opens to its full capacity you might see a bloody/mucous show and the waters break.
  • There may be a ‘rest and be thankful’ phase after transition where contractions slow and the woman rests as the baby descends into her pelvis.
  • She might mention pressure in her bottom, or that she need’s to poo. And you may see poo as the baby compresses the rectum and squeezes it out.
  • Contractions become expulsive and the pattern will change. Her noises and behaviour will also change.
  • If you are able to visualise her perineum (and you really don’t need to) you will see signs of the baby’s head descending through the vagina – gaping anus and vulva, flattened perineum, bulging bag of waters (if still intact), the baby’s hair/head, etc.
  • As the baby’s head stretches her perineal tissue she will hold back her pushes, gasp, scream, close her legs, and/or hold her baby’s head in – protecting her perineum.
  • One the baby’s head is born you may see him/her rotate or wriggle then be born with the next contraction (there should be some movement or change with the next contraction).

INCORPORATION

Undoing, dissolution, decomposition are accompanied by the processes of growth, transformation, and the reformulation of old elements in new patterns.
– Turner 1987, p. 9.

01-1

Art by Amanda Greavett: http://amandagreavette.com

In all rites of passage, the third phase involves re-assimilation or incorporation of the person back into society in their new state (van Gennep 1909/1960). The state of motherhood and personhood (for the baby) happens immediately following birth. However, the reintegration of mother and baby back into society occurs progressively. In some cultures women have extended periods of separation from society following birth before being reintegrated. However the transformative nature of birth is not limited to a change of status to ‘mother’. Turner (1987) also identified the power of the liminal phase as a process for inner growth and transformation. Mothers incorporate the birth experience into their sense of self, resulting in empowerment, and for some, healing.

Physiology (what is happening inside)

At the moment of birth both mother and baby have high levels of and BEs, OT and E-NE. Along with PRL, this combination provides the perfect recipe for mother-baby bonding and connection – BEs (pleasure, reward, dependency) + OT (love and bonding) + PRL (mothering behaviours) + E-NE (alertness). Skin-to-skin contact and mother-baby interactions enhance the production of OT and PRL priming the breasts for milk production. High BEs contribute to the euphoria that many women experience following birth.

The placenta transfers the baby’s blood to the baby and the process of placental separation begins. The baby instinctively seeks his/her mother (looking into her face) and crawls to the breast – feet stimulating the uterus to contract. Skin-to-skin contact regulates the baby’s temperature, breathing and heart-rate and provides a sense of safety reducing stress hormones produced at the end of labour.

After birth E-NE declines significantly but cortisol declines slowly. Cortisol may promote PRL effects on milk production (extreme stress levels inhibit milk production).

Assessment (what you might see)

  • Immediately following birth the mother may appear ‘stunned’ and there may be a moment (or 2) before she picks up her baby and brings him/her towards her.
  • Baby is alert and instinctively interacts with mother and seeks the breast
  • Mother and baby interact.
  • You may see a gush of blood as the placenta separates (more about placental birth here).
  • After some time focussing on baby, the mother may begin to shift her focus back to the outside world; often beginning with her partner/family, then other birth support (including midwives etc), before moving on to those outside the room.

The above information is not rocket science, and anyone who has spent time with women during physiological birth will already know it (even if using the technocratic approaches to assessment). I think it is time to own our (women’s) knowledge and start shifting the discourse of ‘stages of labour’ and cervical measurements. This means changing how we talk/write about labour with women, other care providers and students.

References / Bibliography

Dixon, L, Skinner, J & Foureur, M 2013, ‘The emotional and hormonal pathways of labour and birth: integrating mind, body and behaviour’, New Zealand College of Midwives, vol. 48, pp. 15-23.

Sakala, C, Romano, AM & Buckley SJ 2016, ‘Hormonal physiology of childbearing, an essential framework for maternal-newborn nursing’, JOGNN: http://www.sciencedirect.com/science/article/pii/S0884217515000520

Reed, R, Barnes, M & Rowe, J 2016 ‘Women’s experience of birth: childbirth as a rite of passage’ International Journal of Childbirth, vol. 6, no. 1, pp.46-56.

Reed, R, Rowe, J & Barnes, M 2016 ‘Midwifery practice during birth: ritual companionship’ Women and Birth, vol. 29, no. 3, pp. 269-278.

Turner, V 1967, The forest of symbols: aspects of Ndembu ritual, Cornell University, New York.

Turner, V 1969, The ritual process: structure and anti-structure, Transaction Publishers, Rutgers, New Jersey

Turner, V 1987, ‘Betwixt and between: the liminal period in rites of passage’, in LC, Mahdi, SF Foster, & M Little (eds), Betwixt and between: patterns of masculine and feminine initiation, Open Court Publishing Company, Illinois, pp.3-19.

————–

How monkey mama does it – Kate Evans

Hormonal physiology of childbearing (resources) – Transforming Maternity Care

Dr Sarah Buckley’s website

Womb Ecology – Michel Odent

About midwifethinking

Midwife and Senior Lecturer
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7 Responses to Understanding and assessing labour progress

  1. Lea Ouai says:

    Dear Rachel,

    You are doing so much to promote undisturbed birth. I forward a lot of your thoughts to prospective clients.

    Without any coercion towards which birthplace, my clients have increasingly opted for homebirth and this year all my bookings are for home. Your writing goes a long way to instil that confidence in these wonderful women.

    Thank you so much for all your hard and brave work and your eloquence.

    Love and best wishes, Lea thamesdoula.co.uk

  2. Noreen Mckenna says:

    Brilliant! I see this all the time. I direct my clients & my students to your blogs. Thank you

  3. Jennifer Childress says:

    Thank you. This is clearly and lovingly stated. I’ll share it with my apprentice and clients!

  4. Sharon jones says:

    Absolutely love this US women and our bodies are incredible ,in the right conditions and without interference we are fully equipped to bring life into the world ☺ amazing,empowered ,women’s choice.

  5. Helena Wu says:

    Thank you for your good research and writing about birth. I train doulas and refer them to your site.

  6. Charis says:

    Thank you for enriching our understanding of birth. This is a beautifully accurate description of the marvelous labor experience I’m blessed to journey three times. (awonderfulbirth.blogspot.com)

  7. Bernice Gyapong says:

    This is very interesting and informative. It makes some of us from places where physiological birth happens only with unskilled attendance appreciate physiological birth. I hope one day we will be able to practice that. A woman’s body can do so much.

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