Doula Support for The Second Stage

The second stage of labor begins, according to the medical definition, when the cervix has reached ten centimeters of dilation, and ends when the baby emerges from the body. In other words, in the second stage of labor, the birthing person pushes their baby out.

The second stage is often shorter than the first, but, like the first stage, it can include a range of physical and emotional experiences and can be extremely demanding of the birthing person. Here are some things that might be useful for you (and your clients) to know about the second stage:

• Medical care providers often have preferred routines when it comes to the second stage. It is helpful for the birthing person to find out beforehand how their care provider likes to handle the second stage, so that they have an idea of what they will be dealing with and can prepare accordingly. If a care provider’s standard procedures conflict with your client’s preferences, you can support them through the asking questions/making decisions process with their care providers.

• A classic sign that the second stage is beginning is a sensation of rectal pressure -- pressure that feels like the need to have a bowel movement -- and perhaps also an urge to push. Doulas and other support people may also notice more “grunty” vocalization/ breathing, catches in the breath, or spontaneous bearing down during contractions (that the birthing person may be aware of or not). Rectal pressure and the urge to push is often noticeable even with epidural anesthesia; however, it could also happen that a birthing person with an epidural does not have any sensation at all, in which case the second stage will be diagnosed by cervical exam.

• Sometimes, as labor enters the second stage, contractions may back off or stop altogether for a little while; some birth workers refer to this as the “rest-and-be-thankful” phase. If you see contractions slowing down or stopping after what you would have said was the most intense part of labor so far, it is likely that your client has gone through transition and is now in the rest-and-be-thankful phase. You don’t have to do anything to encourage labor; everyone can just rest and be thankful, and the labor is likely to pick back up on its own in a little while.

• Not everyone feels the urge to push right away. If the birthing person does not have an epidural, the likelihood is that the urge to push will eventually come; as long as neither they nor the baby are showing any signs of medical trouble, they can just rest and wait. If the birthing person does have an epidural, they may wish to ask the anesthesiologist to turn it down to see if they can pick up the feeling. If the epidural continues to inhibit the pushing sensation, the medical staff may need to guide the birthing person through the pushing process.

• There are three categories of positions available in the second stage (you can look at illustrations online or in birth books): Sitting/squatting; forward-leaning (the baby comes out the back this way); and lying down, either on the side or on the back. Of all of these, lying on the back may be the least biomechanically efficient; it’s also the most culturally familiar for many people, and, depending on the setting, may be the most familiar to the medical care providers. All of these positions can be achieved on a hospital bed; with a little support, and depending on the exact situation, they can all potentially be achieved even with epidural anesthesia.

• Spontaneous pushing, where the birthing person pushes how and when their body tells them to, might be considered to be the most efficient, “natural” way for the second stage to happen. However, there are a wide variety of reasons that a medical care provider may instead prefer directed pushing, where they tell the birthing person how and when to push. There may be a need for directed pushing due to epidural anesthesia or other medical issues; it may just be the routine that that care provider is most comfortable with; and there may be a variety of reasons in between. If the birthing person prefers not to be directed in their pushing, you can support them through the asking questions/making decisions process with their care providers.

• If there appears to be a problem with progress in the second stage, the simplest first step is to change positions. Even slight adjustments, such as adding a pillow under one hip or leaning slightly to one side or the other, or raising or lowering the head of the hospital bed a little, can make positive change.

• While pushing, some people may feel encouraged by gentle suggestions, some might prefer more forceful cheerleading-style coaching, some might prefer focused silence. As with the other parts of labor, use your discernment and intuition to see what is working for your client. Whatever support you give during the contractions, remember to help the birthing person relax and release between contractions -- the second stage is often extremely physically active, and they will need to take every opportunity to rest and gather energy.

• Even when pushing has been more or less spontaneous with little direction, many care providers prefer to direct the process a little more as the baby’s head is crowning, telling the birthing person not to push for a few contractions, or giving them very specific instructions about how to push. The purpose of this direction is usually to allow a gentler stretching of the perineum, to avoid tearing. If your client is having a hard time not pushing, panting or blowing (as though blowing out a candle) through contractions may be helpful.