Let's take a typical scenario with an unmedicated first birth at home. The mother has been in the birth process for about twelve hours. The attendants have spelled each other off through the night. Membranes ruptured spontaneously with clear fluid after eight hours in active phase and mother and baby have normal vitals. There is dark red show (about two tablespoons per sensation) and mother says, "I have to push!" This declaration on the part of the mother brings renewed life to the room. The attendants rally and think, Finally, we're going to see the baby. The long wait will be done. We'll be relieved to see baby breathe spontaneously. We can start the clean up and be home to our families. Typically, the midwife does a pelvic exam at this point to see if the woman is fully dilated and can get on with the pushing now. It is common to find the woman eight centimeters with this scenario. The mood of the room then turns to disappointment.
My recommendation with this scenario: Don't do that pelvic exam. A European-trained midwife that I know told me she was trained to manage birth without doing pelvic exams. For her first two years of clinic, she had to do everything by external observation of "signs." When a first-time mother says, "I have to push!" begin to observe her for external signs rather than do an internal exam. Reassure her that gentle, easy pushing is fine and she can "Listen to her body." No one ever swelled her own cervix by gently pushing as directed by her own body messages. The way swollen cervices happen is with directed pushing (that is, being instructed by a midwife or physician) that goes beyond the mother's own cues. It has become the paranoia of North American midwifery that someone will push on an undilated cervix. Relax, this is not a big deal, and an uncomfortable pelvic exam at this point can set the birth back several hours. The external signs you will be looking for are as follows:
When she "pushes" spontaneously, does it begin at the very beginning of the sensation or is it just at the peak? If it is just at the peak, it is an indication that there is still some dilating to do. The woman will usually enter a deep trance state at this time (we call this "going to Mars"). She is accessing her most rudimentary brain stem where the ancient knowledge of giving birth is stored. She must have quiet and dark to get to this essential place in the brain. She usually will close her eyes and should not be told to open them.
Does she "push" (that is, grunt and bear down) with each sensation or with every other one? If some sensations don't have a pushing urge, there is still some dilating to do. Keep the room dark and quiet as above.
Are you continuing to see "show"? Red show is a sign that the cervix is still dilating. Once dilation is complete the "show of blood" usually ceases while the head molding takes place. Then you can get another gush of blood from vaginal wall tears at the point that the head distends the perineum.
Watch her rectum. The rectum will tell you a good deal about where the baby's forehead is located and how the dilation is going. If there is no rectal flaring or distention with the grunting, there is still more dilating to do. A dark red line extends straight up from the rectum between the bum cheeks when full dilation happens. To observe all this, of course, the mother must be in hands and knees or sidelying position.
I use a plastic mirror and flashlight to make these observations. The mother should be touched or spoken to only if it is very helpful and she requests it. Involuntarily passing stool is another sign of descent and full dilation. Simply put, where there is maternal poop there is usually a little head not far behind.
Why avoid that eight-centimeter dilation check? First, because it is excruciating for the mother. Second, because it disturbs a delicate point in the birth where the body is doing many fine adjustments to prepare to expel the baby and the woman is accessing the very primitive part of her ancient brain. Third, because it eliminates the performance anxiety/disappointment atmosphere that can muddy the primip birth waters. Birth attendants must extend their patience beyond their known limits in order to be with this delicate time between dilating and pushing.
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