Many doulas have told me of great frustration during the second stage of labor. "There really isn't anything for me to do" is a common statement. And this is true, because most of what doulas do during second stage is based on what we have taught or discussed with our client during prenatal meetings.

Helping laboring mothers find the right position is an important task. The bed is usually a safety zone for her so many of the positions you suggest might be with the bed in mind. She can assume the traditional semi-sit or "C" shaped position, side-lying (this is especially good if the movement of the baby down the birth canal is swift), all - fours (hands and knees)or squatting on the bed with the help of the squat bar. She may choose to begin early pushing by squatting at the side of the bed, dipping into a low squat while hanging onto a support person or bearing down while on the toilet. Sitting on the toilet causes us to immediately relax the pelvic floor muscles, while the long bone of the leg and the buttocks are supported by the seat. If you have ever seen a birthing stool or birthing chair, you will notice an amazing similarity in structure.

Much of what we do during second stage is observing. We can only observe her for external signs rather than do an internal exam. Reassure her that gentle, easy pushing (such as slow exhalation pushing or physiologic pushing) is fine and she can be in tune to her body. In childbirth education classes and prenatals, I teach about tearing or swelling the cervix. This typically happens during directed pushing that goes beyond the mother's own physiologic cues.

Observation is then a true key to reading your client! When she "pushes" spontaneously, does she push during the entire contraction or only at the peak? When she pushes at the peak only, it could be an indicator that the cervix is not dilated fully. There could be a "lip" of the cervix left or she may only be dilated to 8 or 9 cms. The woman in second stage will usually "zone" and be quiet and turning inward (often closing their eyes) to find the instinctual and ancient knowledge. Women know how to birth! Another observation: is there still bloody show? Bloody show is a sign that the cervix may be still dilating and effacing. Once complete, this usually stops as the head molds. Her rectum is a great indicator as to the station of the baby's head and how close she is to being complete. Oozing of stool is yet another sign of low station and being complete. When you see no rectal flaring or distention with the push there is still more work to be done.

What is the doula's role during a prolonged second stage? In The Labor Progress Handbook, Penny Simkin and Ruth Ancheta provide a look into the causes of a prolonged second stage, cultural differences (US vs UK), and some useful positions to enhance this stage. Ideally, the doula takes her cue from either the physician or nurse, brainstorming as to position changes and helping to keep the birthing environment a positive one. Admittedly, there are times when the doula's hands are figuratively as well as politically tied and thus she takes part in the waiting game.

During the last contractions before birth of the head, many (unmedicated ) women feel the rush of endorphins and flow of energy. This may cause them to grab something (like a birth attendant!!) and pull up to an upright position. This is an instinctual response to avoid the vena cava syndrome - where the contents of the uterus press on the vena cava and impede the flow of oxygen to both the uterus and the baby. During prenatal visits, doulas can explain this reaction during second stage and offer to both client and partner several options for upright positioning. It is important, however, to know the policies and routines of the birthing facility so as to not present unrealistic expectations about positioning to the client.

The second stage of labor is often the shortest and most empowering for the laboring mother. When faced with a mother who feels as if she could have never done this without her doula, or indicates that feels negatively about any of the interventions used, the doula can still empower this mother with phrases such as "this birth was the way it needed to be" or "you made the right decisions based on the information that you had at the time." This will keep the birth memory intact and healthy, making a positive imprint on her parenting and bonding.

References:

1. Bobak, I., Jensen, M. Maternity & Gynecologic Care: The Nurse and the Family. (1989) St. Louis: Mosby Publishers.
2. Nichols, F., Humenick, S. Childbirth Education: Practice, Research & Theory (2000) Saunders & Co.
3. Whitely, N. A Manual of Clinical Obstetrics (1985) Philadelphia: J.B. Lippincott Company.
4. Reeder, S., Martin, L., and Koniak-Griffin, D. Maternity Nursing: Family, Newborn, and Women's Health Care. (1997) Philadelphia: J.B. Lippincott Company.