Rena Geibel, Senior DCBD Doula

Our doula client birthed her baby kneeling and leaning over the back of the hospital bed, instinctually bearing down, breathing and vocalizing as she needed to, with limited and gentle guidance from her medical team. The attending doctor congratulated her and her partner on the birth of their daughter, “You did an amazing job, you made our day,” the doctor said. During our postpartum visit, our doula client asked me, “What did Dr. ABC mean? Do they say that to all their patients?” 

No, the doctors don’t say this to all their patients. The doctor was commenting on how special this birth was – to have a birthing person listening to her body and to birth in an upright position. As a doula, it’s an honor to be part of the team that facilitates and witnesses such a birth. According to the Listening to Mothers III Survey, a very small proportion of pregnant persons in United States hospitals birth in a kneeling (1%), squatting or sitting (4%) or a side lying (6%) position. The other 91% of hospital patients will birth semi-reclined or laying on their back. What enabled this person to birth in a position and in a fashion they desired? Here are some things to consider. 

What is Second Stage Labor?

The Second Stage of labor is the time period from when the cervix completely opens (10cm) to the birth of your baby. There may be a passive and active portion of this Stage. During the passive portion of Stage Two, baby is rotating and descending lower in the pelvis towards the birth canal. This is sometimes referred to as laboring down or breathing your baby down. You may feel a growing amount of pressure, but not a strong, spontaneous urge to bear down – not yet anyway. In the active phase of Second Stage the Ferguson Reflex kicks in. This is a positive feedback loop where nerve impulses from the opened cervix and birth canal travel to your brain where the pituitary gland secretes and releases oxytocin. A high level of oxytocin surges to the uterus activating even stronger contractions, which in turn helps your baby’s head enter the upper vagina, causing more sensations.

All of these biological feedback loops culminate so when the baby is low enough, you should feel the spontaneous urge to push. With these instinctual impulses, you may not need any guidance as you listen to your body and follow your urges. For those choosing to utilize an epidural, lower pelvic pressure and the urge to push can still be felt, but may be less intense. You may appreciate some extra support to help you figure out what positions work best for you.

We are surrounded, from a young age, by media showing a certain type of birth – one where other people are barking orders to a panicked pregnant person in a recumbent position. (My children had to evict me from the room when Monica Rambeau told Wanda it’s time to push. What? That is NOT how this goes! She’s unmedicated. She’ll know when it’s time to push. Listen to your body, Wanda! Even the Marvel Cinematic Universe missed the mark.) So, is Second Stage intuitive? Do people really feel this Ferguson Reflex? Are the directives helpful and necessary? What does the evidence say? 

Are there best practices when it comes to Second Stage?

Evidence shows that birthing in upright positions (being upright during the pushing and/or during the actual crowning and birth) can reduce pain, increase satisfaction with your birth, and slightly decrease the length of Second Stage. Why, then, do so few birthers in American hospitals birth this way? In general, obstetricians may be more comfortable, as a result of their training, to support a birther in a recumbent position. It’s how they were taught. Midwives tend to be trained differently. They are more comfortable supporting births in a variety of upright positions. As a result, midwifery patients, whether birthing in your home, at a birth center, or in a hospital, are more likely to birth in an upright position than an OB patient. 

How will my provider support me in Second Stage? 

Much of how Second Stage looks and sounds may depend on your provider’s willingness to support the labor positions you choose, their experience with upright birth positioning, your baby’s position and head angle as they descend through the pelvis, how you and baby are coping with pushing, if you have utilized an epidural or not, and if you know your options. 

Providers may give instructions on how to breath and how to position your body – sometimes this is necessary to aid in baby’s rotation or for the safety of your baby. In most singleton births, current evidence and professional bodies such as the World Health Organization, The American College of Obstetricians and Gynecologists, and The Association of Women’s Health, Obstetric, and Neonatal Nurses all state that the birthing person should have the freedom to choose positions and breathing patterns that are comfortable. 

The evidence is not comprehensive enough to state one method is more beneficial to birther and baby over another. A Cochrane systematic review on bearing down methods states, “For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort. In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.” The BJOG systematic review concurs with “…encouraging women to choose their own method of pushing should be accepted as best clinical practice.

Here are some prompts that may help you have a conversation with your provider about how they will be prepared to support you: 

  1. What can I expect from your management of Second Stage?
    • Do you have standard practices on when pushing should begin? Answers may include: automatically at 10cm, when baby is midpelvis or lower, when you feel the urge.
    • As long as I and my baby are fine, I’d like to begin pushing when I feel a spontaneous urge to do so. Do you find there are advantages or disadvantages to that?
  2. Does your practice have any guidelines or protocols on birthing positions?
    • Are you comfortable for me to birth my baby in whatever position feels best to me? Kneeling, side, bed squat?
    • Can upright or side lying positions be accommodated, even if I use an epidural?
  3. In your practice, what type of breathing method for pushing is standard  – directed/breath holding or more open glottis/vocalization?
    • I’m not sure what method will be most effective for me, are you happy to explore various breathing/pushing styles with me at the time of birth?
  4. What methods do you use to help reduce the amount of perineal tearing?
    • Answers may include: laboring down, helping you to ease the baby out when crowning with shorter breaths (hee, hee, hee or pants) or controlled small pushes, warm compress on perineum, perineal massage at the time of birth.

How do doulas support the Second Stage? 

I’ve been involved in birth communities in Kenya, Zambia, Minnesota and the DMV area for over ten years. Birth looks and sounds differently depending upon client preferences, culture, medication use, choice of provider, and birth location. The ability to create a safe and comfortable space to listen and follow your body is key to your autonomy and a vital role of your support team and doula. 

For the client at the beginning of this article who birthed in a kneeling position, I do what all of our doulas do during the Second Stage of labor. First, I validated what they felt (intensity, pressure, nervousness) and explored concerns. Second, I facilitated a process to help my client reach a place of acceptance (normalized, reassured), and restored trust in the birth process (you’ve listened to your baby and body and it brought you here, continue to do that and you’ll meet your baby soon). Third, I brought tools and comfort measures within reach (birth bar in place, stool at side of bed, cool compress) and remained a non-anxious presence in the room. There’s some other steps we take prior to and during Second Stage, but I don’t want to give away all our doula tips for Marvel Cinematic Universe to pick up on 😉 

What else can I do to prepare?

Those who take a childbirth education class are more satisfied with their birth experience than those who do not take a comprehensive class. Those who practice positioning in pregnancy are more likely to use positional changes in labor. Our childbirth education classes also touch on other realities of Second Stage: what you may say or do, what your support person can do to help, what pushing may look and sound like with and without an epidural. We welcome you to learn more by joining one of our live, virtual classes

About the Author, Rena Geibel

Rena is a former Peace Corps Volunteer, science teacher, and an international public health specialist with over 12 years’ experience in Africa working on reproductive health and HIV-related issues particularly for children and women. Rena has a Master of Public Health from Tulane University’s School of Public Health and Tropical Medicine (2000). She obtained her doula certification through DONA International in 2010 and became a Lamaze International Certified Childbirth Educator (LCCE) in 2011. She loves facilitating trainings for future childbirth educators and doulas, all over the globe! Rena strives to help families have safe and healthy birth journeys in the Washington, D.C. area, where she lives with her husband and two daughters.

ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth. (2019). Obstetrics and gynecology, 133(2), e164–e173. https://doi.org/10.1097/AOG.0000000000003074

Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2019). Nursing care and management of the second stage of labor. Third edition. Washington, DC: AWHONN

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2014). Major Survey Findings of Listening to Mothers(SM) III: Pregnancy and Birth: Report of the Third National U.S. Survey of Women’s Childbearing Experiences. The Journal of perinatal education, 23(1), 9–16. https://doi.org/10.1891/1058-1243.23.1.9

Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia. The Cochrane database of systematic reviews, 5(5), CD002006. https://doi.org/10.1002/14651858.CD002006.pub4

Lemos, A., Amorim, M. M., Dornelas de Andrade, A., de Souza, A. I., Cabral Filho, J. E., & Correia, J. B. (2015). Pushing/bearing down methods for the second stage of labour. The Cochrane database of systematic reviews, (10), CD009124. https://doi.org/10.1002/14651858.CD009124.pub2

Prins, M., Boxem, J., Lucas, C., & Hutton, E. (2011). Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. BJOG : an international journal of obstetrics and gynaecology, 118(6), 662–670. https://doi.org/10.1111/j.1471-0528.2011.02910.x

Thies-Lagergren, L., Kvist, L. J., Christensson, K., & Hildingsson, I. (2011). No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC pregnancy and childbirth, 11, 22. https://doi.org/10.1186/1471-2393-11-22