Second Stage Considerations

Standard of Care Series Part Six

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Water Birth

Water immersion during labor has many known benefits for the birthing person without any extra risks to the newborn, but what about water immersion during the pushing stage and birth of the baby? 

Water birth, when a person stays in the water for the pushing phase and the actual birth of the baby, has been shown to have both benefits and risks. The benefits to the birthing person include higher rates of normal vaginal birth (fewer interventions used), lower rates of episiotomy, fewer severe perineal tears (3rd-4th degree), less use of pain medication, a greater likelihood of birthing in an upright position, and higher rates of satisfaction with the birthing experience compared to those who birthed on land. The risks to the birthing person include a higher rate of mild (1st-2nd degree) tearing. There has been no difference found in the rate of infection for the mother when comparing water birth to land birth.

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In terms of newborn risks and benefits, “large observational studies have not shown any increase in the risk of newborn death or any other bad health outcome for newborns, including neonatal intensive care admissions, low Apgar scores, breathing difficulty, need for resuscitation, or infections. There have been some case studies of bad outcomes for newborns” (Dekker, 2019, p 29). However, the side effect of water aspiration has not been observed since 1999, and almost all of the infants in the individual case reports made a full recovery.

 Overall, the evidence we do have on water birth has shown that water birth is a reasonable option for low-risk birthing people provided that true informed consent is taking place, and there is a discussion about the risks and benefits of water birth. In order to reduce some of the risks associated with water birth, practice guidelines suggest using pools that are easy to disinfect, filling tubs close to the time of birth, and performing regular bacterial tests on the water supply, hoses and birthing tubs in a hospital setting. While the American College of Nurse Midwives (ACNM), American Association of Birth Centers (AABC), and the Royal College of Obstetricians and Gynecologists (RCOG) in the United Kingdom all support water birth as an option for healthy women, the American Congress of Obstetrician and Gynecologists (ACOG) continues to recommend that birth take place on land, though they do acknowledge the benefits of water immersion during labor and support informed choice. While evidence has shown water birth to be a reasonable option, a barrier to water birth remains in the fact that it is not offered as an option or supported in most hospital settings in the US.


For more information on the benefits and risks of water birth, you can visit Evidence Based Birth®’s Evidence on Water Birth.

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Pushing Positions

In an earlier post, we discussed the benefits of freedom of movement throughout labor. Today we will focus on positions for second stage, or positions for pushing. Second stage begins with the cervix completely dilated to ten centimeters and ends with the birth of the baby. The preferred positions for pushing for most providers around the world include the birthing person on their back or in a semi-seated position. In many cases, it is the most convenient position for the provider and it may be the position the provider was trained in and therefore most comfortable with. Some other reasons why these positions are more popular may be contributed to the use of continuous monitoring. We’ve mentioned previously how continuous fetal monitoring can lead to restricted movement for the birthing person (and that continuous monitoring is not an evidence based practice). Additionally, we’ve mentioned how the majority of people birthing in the US are receiving epidurals during labor. Epidurals also may contribute to restricted movement and giving birth lying on one’s back.

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Although lying down on one’s back or semi-seated positions are popular in most hospitals, they are also some of the least effective means for pushing. When the birthing person is flat on their back or semi-seated, the tailbone loses its ability to flex, meaning the tailbone is restricted, causing less room for the baby to move down and out through the pelvis. Meanwhile, gravity is working against the birthing person and the baby in these positions. 

Evidence does support upright positions for second stage and the birth of the baby. These positions include standing or squatting using your partner or a prop for support, kneeling, hands and knees, or using a birth seat. Upright positions are beneficial for the physiology of birth. Gravity is working in the birthing person’s favor with upright positions, helping to bring the baby down. Without the tailbone being restricted, the baby has more room for rotating to get into the optimal positioning for navigating the descent through the pelvis and out into the world. Contractions are more effective too in upright positions, encouraging better positioning for the baby to move down and out through the pelvis. Lastly, there is less risk of compressing the birthing person’s aorta, which ensures better oxygen for the baby (why pregnant people are told not to sleep on their backs). Not to mention that maternal satisfaction is typically higher with upright birthing positions.

For those birthing without epidurals, those who use upright positions are less likely to have an episiotomy, less likely to have a forceps/vacuum assisted birth, less likely to have abnormal fetal heart rate patterns, the pushing phase is shortened, and upright positions may decrease pain. For those with an epidural, the side-lying position can be helpful. “Giving birth in a supported side-lying position with an epidural has been shown to reduce the length of the active pushing phase and make it less likely that the mother will have an episiotomy or give birth with vacuum or forceps” (Dekker, 2019, p 30). 

In the American Congress of Obstetricians and Gynecologist’s (ACOG) Committee Opinion on the Approaches to Limit Interventions During Labor and Birth, it is stated that “the traditional supine position during labor has known adverse effects such as supine hypotension and more frequent fetal heart rate decelerations (44, 45). Therefore, for most women, no one position needs to be mandated or proscribed” (2017).

The bottom line: it is the birthing person’s right to choose what position they would like to labor and give birth in, which is supported both by evidence and ethical guidelines. One way to reinforce the ethical guideline for the birthing person’s right to choose labor and birthing positions is to include various upright positions in provider training so that more and more providers become increasingly comfortable with upright birthing positions and encourage them to be used.


For more information on upright birthing positions, you can visit Evidence Based Birth®’s Evidence on Birthing Positions.

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Coached Pushing

Coached pushing, also sometimes referred to as “purple pushing,” is when the birthing person is told when (to hold their breath and) to push. There are some providers who begin this method of pushing as soon as the birthing person enters second stage, meaning they reach ten centimeters dilation. However, this can be harmful to physiologic birth. There is a lovely episode on The Birthful Podcast titled “Rethinking the Pushing Stage” where Whapio engages in an insightful discussion about the physiological process of second stage and what we can do to best facilitate physiologic birth. In the episode, Whapio talks about the missing stage between reaching ten centimeters dilation and second stage. Whapio refers to this pause between transition and pushing as “The Quietude.” Generally speaking, the birthing person does not go from ten centimeters dilated to ready to push. There are some things that need to take place before active pushing occurs, including baby’s positioning and internal rotation and giving time for the birthing person’s body to rest. 

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 Additionally, if we push too soon as directed rather than listening to our bodies and pushing when we feel the spontaneous and overwhelming urge to push, there is the potential for pushing baby down before the baby has had time to optimize positioning and before rotating so that baby is entering and moving through the pelvis in a less ideal position. 

 In my first birth experience, a hospital birth with a CNM, the quiet space between transition and entering second stage was respected. No one rushed me or instructed me to push. When contractions resumed and picked up again, I was breathing through the contractions, not yet experiencing the urge to push. The midwife, I believe trying to be helpful, instructed me on how to actively push. Thinking this is what I was meant to be doing, I engaged in active pushing before my body (and possibly my baby) was ready. I feel that this interfered with my ability to listen to my body for the remainder of second stage, unable to understand when and how much effort to put into pushing. In other words, I had turned my thinking brain on and overrode my instinctual spontaneous urge to push. My experience with my second, a home birth with a CPM, was different. I did go from one intense contraction in transition to feeling the urge to push at the very end of the next contraction. However, this time, I waited and listened to my body, only actively pushing when I had the undeniable urge throughout the contraction. The ability to listen to my body and birth in an upright position (I was on my back for the birth of my first baby) led to a much easier and more positive second stage.

 The bottom line: “There is no evidence that coached pushing provides any benefits over spontaneous pushing (often called “mother-directed pushing”) for women with or without epidurals” (Dekker, 2019, p 30). In the American Congress of Obstetricians and Gynecologists (ACOG) Committee Opinion on the Approaches to Limit Interventions During Labor and Birth, it is stated that “when not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each woman should be encouraged to use her preferred and most effective technique” (2017). It should be the birthing person’s preference, comfort, and individual circumstances that determine how to push.

You can listen to The Birthful Podcast episode, “Rethinking the Pushing Stage,” here. (It truly is a fascinating and intriguing episode!)

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Time to Push

Failure to progress, an outdated term that refers to slow labor during first or second stage, is one of the leading causes of Cesareans today. Often times, failure to progress (a vague term no longer used in the new guidelines) may be better labeled as “failure to wait” on the part of the provider. “Labor arrest in the second stage can be diagnosed if there has been no improvement of descent or rotation of the baby after: 4 or more hours in first-time mothers with an epidural, 3 or more hours in first-time mothers without an epidural, 3 or more hours in experienced moms with an epidural, 2 or more hours in experienced moms without an epidural” (Dekker, 2017). 

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Supportive and individualized care that is evidence based may help labor to progress normally. This may include freedom of movement, upright birthing positions, eating and drinking during labor, limiting interventions (particularly if they restrict movement and are not medically necessary), support and access to non-drug comfort measures, and ensuring the birthing person feels safe, supported and respected. 

Providing the birthing person and baby are healthy and labor has not qualified as an arrested labor (per the new definitions and guidelines), then the birthing person should be treated as though labor is progressing normally. Giving time to labor and birth is one of the best gifts we can give to birthing people.

For more information, you can visit Evidence Based Birth®’s article on Friedman’s Curve and Failure to Progress: A Leading Cause of Unplanned Cesareans.

Sign up for our EBB Childbirth Class today to gain the knowledge and confidence for an empowered birth! 

*Disclaimer: These posts are not intended to be construed as medical advice and are for educational purposes only. Each pregnancy and labor is unique. If you have questions or concerns, please consult your provider.