(Meant for student midwives, apprentices and doulas.)
… from my experiences over the last 27 years, including discussions with others; ymmv.
Sitting with my mama the other day, watching her wander around, leaning over every few minutes, I knew, even without a vaginal exam, that she wasn’t past 3 centimeters dilated. She’d been contracting since the night before and had been passing bloody mucous, but her demeanor, her movements and even her scent were not of a woman in active labor.
Definitions:
- Labor – When regular contractions dilate the cervix somewhat continuously… typically after 3-4 centimeters; anything before would be considered early labor as opposed to active. I am not wont to use the phrase “false labor,” because, to me, any contraction serves a purpose, even if it is merely to draw the mother’s attention to her baby.
- Gloppies – a term I use to describe bloody show or even extra mucous. I use it tenderly and women immediately know what I mean when I ask, “Do you have gloppies?” Gloppies can begin well before labor, but ramp up considerably as labor progresses. Big globs of mucous and blood are typical at about 6-8 cms. If you see this and you aren’t doing exams, this would be a great time to consider moving into the hospital if you are a doula or preparing for a birth if you are in the home setting. I am aware that some people think the term is juvenile at best and gross at the worst. You are free to use your own terms.
Women in early labor can be somewhat chatty. They are in the here and now plane as opposed to the other-worldly plane of active and advanced labor. Some women are rooted in the here and now for a long time, well into what dilation would consider “transition,” but most women fall into their hypnotic, spacey place around 6 centimeters; some sooner, but that is pretty rare. They might be quiet and introspective, but not in that high place.
(Mom at 7 centimeters.)
(The same mom at 9 centimeters.)
Some women can mimic heavy labor, yet be in the early phase. I was one of those… dramatic, needing attention; whining. A woman in good, active labor has a contraction like this: Walking, walking, slowing down, slowing, stopping, leaning, leaning and swaying, beginning to moan, moan and sway, moan and sway… throughout the contraction. As the contraction wanes, the woman stays hunched over, holding on, allowing the last quakes to recede before taking a deep breath and moving very slowly to a stand, then slowly moving again… the movement picking up as the contraction is totally gone. Whereas a more dramatic woman (and there is certainly nothing wrong with a woman who tends towards drama) stops and starts suddenly… like this: walking, walking, walking upright... either sits, leans sideways on a wall when the contraction comes… her vocal tone is even different, being more breathy than deep. And once the contraction is over, she bops right back up and into the activity she was doing or the conversation she was having.
A nurse told me about a woman who presented at the hospital in “serious” labor; she was 2cm. They sent her home and she came back in hard labor twelve hours later; she was still 2cm and got an epidural soon after. That’s dramatic and wanting help/attention for lack of support, playing out childhood issues or habit. Trying to fix it (whatever "it" is) in the moment can be frustrating (and unfair if resolving deep issues isn’t your specialty), so attending to the woman where she is is usually easier for you and the mom.
In my experience, dramatic women tend to whine. “It huuurrrrts.” “Make it stop.” “I hate this.” This isn’t the “I can’t do this anymore” of transition (and we’ll get back to this in a few), but a whiny, negative attitude right from the beginning. It would seem counter-intuitive that this type of woman would choose a homebirth where anesthesia isn’t an option, but she gets a different type of attention from a midwife; more motherly than what she perceives the hospital to be… punitive. The psychology of birth is absolutely fascinating and I hope someone explores the dynamics, the relationships, the motivations and resolutions someday.
Whiny women take longer to get into the labor high, being so in their heads, it can be a challenge for them to let go enough to be swept up into labor’s current. When she does, amazingly, she stops whining, but usually becomes very introspective and often moans very softly, whereas other women might be loud vocalizers.
I picture dramatic women as stomping around loudly, boots making all kinds of ruckus. It takes purpose to lift the legs up and clomp them down, but it’s worth it to have someone pay attention to her. Movements are sweeping, large and abrupt. As labor moves her deeper, she takes the boots off and slides softly across the floor, her movements closer to her body, her voice singing mostly to herself. (I hope this makes some sort of sense.)
Another type of women who struggles to get out of her head is the academic. She will read every pregnancy and birth book she can find, sure she will be able to “out-think” this labor thing. If she just knows how to breathe/move/visualize, she will conquer the birth experience. In fact, these types of women have a hard time letting go of the (supposed) recipe the books talked about, confused when labor doesn’t follow the pattern she was led to believe it would be. Fumbling along, lurches and stops, I’ve seen these women with furrowed brows and shoulders up, as if they’re shrugging… trying to figure out where they’re going wrong.
When you see a woman like this during pregnancy, it’s so important to let her know how labor isn’t a head experience, but a body one, that the head is better left aside. I really encourage these types of moms to stop reading everything after 37 weeks; that seems to help.
It takes reminding in early labor, but usually around 4-5cm, they “get” the mind-body dis-connection and fall into the rhythm of labor.
Women who exercise a lot frequently have similar issues even though it would seem they can tolerate more pain and are in touch with their bodies more. However, they know their bodies in exercise, not in labor, which is a different type of runner’s high. Of all the labor-challenged women, I find these women find their place in the contractions quicker than anyone else. Once they have surrendered their bodies, they can tolerate labor easier than others, although I have known plenty of extreme sports’ women to have epidurals. Athletes include any of the sports you might find at the Olympics, but also ballerinas, cheerleaders, dancers and the like.
Some women have problems physically dilating. These women include those who’ve had procedures on their cervix… cone biopsy or laser surgery, for example… women working through sexual or physical abuse issues (whether they are aware of them or not) and women who are very modest. They are like the dramatic women who act like they are much further along in labor or, more commonly, have terrible, if not excruciating, pain, even in early labor. The hope, of course, is that the body takes over, leaving the mind (even if it is subconscious) behind to fend for itself. Even the scarred cervix can often open without intervention if contractions are long and strong enough. (As a midwife, I have “snapped” scar tissue on cervices before. VERY painful, but can dilate the cervix several centimeters once they are broken.) When these women are able to scale the hurdle, whatever it is, they quickly find themselves where other women would be without those impediments.
On the same subject, helping a woman feel safe or a modest woman remain covered, these kindnesses help women to be able to fall into their labors, allowing them the freedom to open and prepare for birth. It isn’t fair to tell a mother, “It’s just us girls, so don’t worry about that,” or “You don’t have anything I haven’t seen before,” because she is not the midwife/doula, she is the laboring woman, baring her very spirit in front of relative strangers; the least we can do is provide her the privacy she requests. Not every woman tells you she’s modest, but even if you don’t see it in pregnancy, she might try to keep herself covered, a blanket around her or shutting the bathroom door from even her spouse. It’s our responsibility to read our clients; their actions are just as loud as their voices… and often, more so.
There are fewer of the above types of women than there are run-of-the-mill women (not that every woman isn’t unique of course), so it can be pretty easy to pick them out of the group.
For most women, the more typical pattern resembles the one mentioned at the beginning of the piece, from able-to-communicate (3-5 or so cm.) to high and floaty (5-10cm).
Scent is another way to tell where a woman is in labor. I thought everyone could smell a woman in active labor, but apparently that isn’t the case. Pay attention and see if you are one of those that can. When I smell that special scent, I know, for sure, she is in active labor and progressing. What’s interesting is women who are not progressing do not have the scent (for me). I have a heightened sense that something isn’t right and investigate further what it might be. Now, I’ve not smelled the scent and women have birthed perfectly fine, so I don’t really know why some women have it and some women don’t.
Thinking about it (and it isn’t a thinking thought, but a sensory thought), it isn’t a scent on the woman, but a scent that comes from a woman. I’ve tried to figure out where it comes from, but have determined it isn’t directly from the vagina. I mean, it isn’t the heavy, musky, oozie scent you get when you are between her legs or changing a Chux pad and, as far as I can tell, it isn’t the smell of ketones on a woman’s breath, that sweet smell that comes from not having eaten for hours on end. It seems to come more from her breasts, her chest area. It’s a “deep” scent… not musky, necessarily, but primal and vaguely familiar (and not just from having smelled it before).
Why would women have a scent in deep labor? Would it be an ancient clue to get the woman to a safe place? Get her into “the red tent”? Is it a sign to step back and let the woman fall deeply into herself so she might be one with the baby as they work to bring him into the world?
The scent can be fleeting, a whiff gotten and then it vanishes, but the woman labors on and births triumphantly.
There was one time when “birth” walked into the room. When Beth was in labor, right before she delivered, The Scent came from beyond and came to her instead of from her; it was almost tangible. When I smelled it/felt it, the assistants and I went to wash our hands quickly and, as we came back, the baby began to be born. I was high from that ethereal moment for weeks!
So, now we have a mom in heavy labor. How can you tell where a she is?
Remembering that everything is merely a guideline, I find women get deeper and deeper into themselves the further they move towards delivery. When women are unable to communicate anymore… unable to answer even simple questions, they are moving beautifully towards meeting their baby. We are so used to offering choices to each other, family members and even doulas will ask, “Do you want some water? Juice?” “Do you need to go to the bathroom?” Instead, offer a sip or take mom for a walk. When we ask a question, it pulls mom back to the real world when she should be permitted to stay inside her bubble of labor energy.
So, your mom is now in that incommunicative place and then she begins talking again, telling you she can’t do this anymore, that she’s so, so tired, she just wants to sleep.
This is the time to throw a party! (Not literally.) She is on the cusp of pushing when she says these statements. Women do not need to be taken to the hospital or given an epidural during this time, they need to be supported, encouraged that they are almost finished. I find that telling them they will be able to sleep once the baby’s born, his body cradled against hers, helps women keep going.
When we watched Lynsee give birth live on the Internet back in November 2009, many natural birth supporters, myself included, were terribly dismayed when she got to that point, reaching out and asking for help, telling her providers she just couldn’t do it anymore. Instead of looking her in the eye, staying with her while she rode the wild waves, touching her, letting her squeeze their hands… instead of this type of non-interventive, but extremely important support, Lynsee was whisked out of the tub she was in and nearly thrown onto the bed in the fetal position so the anesthesiologist could get at her spine. Before we could even type, “STOP! You’re doing great!” to her, she was numbed from the waist down, at 8 centimeters, and her dreamy hormones abated, she then able to chat and laugh as if she wasn’t even in labor anymore.
I wish I could show pregnant women the difference, how Lynsee was moaning beautifully, somewhat scared, but reassured with tender words and hand-holding versus her demeanor after the epidural. All ethereal qualities vanish with an epidural.
As women come through the last of her uterus’ dilation, after she believes you that she can do it and doesn’t moan, “I can’t” anymore, watch… many women’s contractions start to spread out (not slow down as some would describe it), she being able to rest more inbetween contractions. (Not all women have this happen! Don’t teach/counsel women that this will occur; it very well may not.) I have often heard women snoring softly at this point. Do NOT, under any circumstances, tell a woman she is snoring and try to keep anyone else from saying it. Women can be humiliated knowing they snore. And, most women would argue with you that she did not even go to sleep, so how could she possibly be snoring?
Watch for this subtle spreading out of contractions and listen carefully as mom begins the slight Nnnnn of the beginnings of pushing. It really takes a learned ear to catch the earliest nudgings, but it gets easier with time. It is not hard to notice when she begins the familiar “catch” at the height of the contraction. By that time, she has been moving from first to second stage… not a solid shift, but a more fluid evolution from pregnant to birthing.
When women have vaginal exams, this can be a time when she’s 9 to 9+ centimeters dilated. Sometimes there is moulding of the baby’s head, part of the skull crossing over itself and pushing downward before she is dilated completely. So if she isn’t pushing full of gusto, she, most likely isn’t complete.
There was a recent discussion about cervical lips. This is my take on them. I believe (and have never read proof) that the cervix does not dilate in a spherical fashion, but more on a rolling opening, the left side being 7, the right being 7+… the top being 5, the bottom being 4. I believe this because, when a mom is moving around, the head and the pelvis are in a state of flux, adjusting each other and themselves so the head can get into a great position to birth. Especially when a mom is in bed, we see the cervix dilating at odds with itself, often having to turn her from side to side to get each side even with the other.
I believe that a cervical lip is merely the last stage of a woman dilating unevenly (but correctly) and if we didn’t have our fingers in there, we would never know there was a lip.
Now, I’ve felt my share of cervical lips, so don’t get me wrong that I think all lips would be avoided with no exams, but I feel they are over-“diagnosed” and we’d be better letting the woman work through the end of her labor on her own.
So, when she’s doing the small Nnnnn’s, I believe she’s dilating that last little bit, some of the head already without cervix and nudging downward while the other side still working to eliminate the rest of it. Once she is complete, the pushing tends to begin in earnest.
When we don’t do vaginal exams on second and subsequent birthing women, especially when they’ve previously birthed in the hospital, the question invariable comes up: “How will I know when I’m 10 centimeters?” My answer is: “You’ll know.” Women rarely miss the pushing phase.
(Pushing & the Birth of the Placenta next.)
Friday, January 29, 2010 at 12:43PM 
