Understanding And Assessing Labor Progress

The current framework for understanding and assessing labor progress is inaccurate, not supported by evidence, and fails to incorporate women’s experience of birth. Given those realities, how best can we assess labor progress without vaginal examinations or palpating contractions?

The elements required to assess labor progress are:

An understanding of physiology—knowing what is going on inside
Facilitating and supporting (not disturbing) physiology
Being focused on the woman and engaging all of your senses: sight, hearing, smell, touch, and intuition to read the signs (this requires you to be quiet and receptive rather than busy and “doing”)
Ideally knowing the woman beforehand, which helps you assess her individual behaviors and better understand her experience
Accepting that any assessment can be inaccurate, and that individual women may not display the “usual” signals of progress

The following is a general guide only, for physiological, undisturbed birth. It does not apply to women who have altered physiology, for example through induction or an epidural. Women who are being medically managed require medical assessment.

In this article I am using “childbirth as a rite of passage” as a framework to understand what is going on during the birth process. The physiology discussed herein is really an overview and does not delve deeply into the complex hormonal interplay during birth which includes the baby.

Here’s a brief overview of key hormones at play in birth.

Oxytocin (OT): facilitates love, bonding, reduction of stress; healing; uterine contractions
Beta-endorphins (BE): facilitates pain relief; activates reward centers in the brain, altered state of consciousness—”transcendence”
Epinephrine and Norepinephrine (E-NE), aka adrenaline and noradrenaline: stress hormones (shorter-term activation)
Cortisol: stress hormone (longer-term activation)
Prolactin (PRL): mothering hormone; lactation

Separation

“…the first phase of separation comprises symbolic behavior signifying the detachment of the individual or group either from an earlier fixed point in the social structure or a set of cultural conditions (a ‘state’).” –Victor Turner, “Betwixt and between: the liminal period in rites of passage.

Liminality

“The attributes of liminality or a liminal personae (‘threshold people’) are necessarily ambiguous, since this condition and these persons elude or slip through the network of classifications that normally locate states and positions in cultural space. Liminal entities are neither here nor there; they are betwixt and between the positions assigned and arrayed by law, custom, convention, and ceremonial.” —Victor Turner, “The ritual process: structure and anti-structure”

Incorporation

“Undoing, dissolution, decomposition are accompanied by the processes of growth, transformation, and the reformulation of old elements in new patterns.” –Victor Turner, “Betwixt and between: the liminal period in rites of passage”

The first phase of the childbirth rite of passage involves the mother separating from the outside world and focusing within. Toward the end of pregnancy, women begin to focus inward in preparation for the birth. Physical separation occurs particularly in early labor when the mother secludes herself in her birth space and seeks to minimize distractions (external stimulation). Ritual separation from society during pregnancy and birth is common throughout history, and across cultures.

Physiology (what is happening inside)

Levels of PRL, progesterone, and BE rise during pregnancy, reaching high levels at the beginning of labor. In addition, the maternal stress response decreases. This supports feelings of calm, and a focus on herself and her family.

It appears that the baby initiates labor, and the mother’s body responds. OT levels rise and the uterus contracts, with contractions becoming stronger and noticeable to the mother (the uterus contracts during pregnancy before labor). Initially the contractions can be irregular in length, strength, and interval. The cervix is softening and opening, and the baby may begin to rotate and settle into the pelvis. BE increases further in response to the pain of contractions.

The excitement/anxiety/anticipation (eustress— a beneficial/physiological stress, as opposed to pathological stress) of early labor increases the release of E-NE. The balance between inward focus (OT + BE) and alertness (E-NE) allows the woman to remain aware of her surroundings and keeps her neocortex active. This facilitates her ability to do what is needed to “separate”—for example, to organize her other children, call her midwife, travel to the hospital, etc. If her OT + BE / E-NE balance tips toward E-NE, her contractions may stop altogether until the balance is restored. This mechanism enables women in early labor to stop contracting in response to danger, much like other mammals do. It can take many hours, or even days, for this early labor phase to tip over into established labor.

Assessment (what you might see)

Eyes open between and during contractions
Evidence of neocortex functioning—the ability to hold a conversation and answer questions, and to engage with external activities (such as using a cell phone to time contractions)
Excitement and anxiety
She may be keen to get settled into her birth space
Contractions slow or stop in response to a journey to hospital or other stressful/distracting situations
A bloody-mucousy show may occur as cervix opens
Posture remains the same as in late pregnancy (pelvis still stable). She should be able to easily walk upright between contractions

After the separation phase, a person undergoing a rite of passage enters the liminal (or transitional) phase, where they are often said to “be in another place.” The intense experience of labor requires mothers to “undo” their usual state of consciousness, behaviors, and their connections to the external world. They often describe being “in their own world,” in an altered state of consciousness. This space is located within the laboring mother. As mothers progressively move deeper into this internal world, they shut out the external world further, maintaining and increasing separation. The physiological processes involved in birth create a naturally liminal state— the rhythmic contractions and birthing hormones. Both mother and baby are journeying in this “in-between” world.

During the liminal phase, Turner suggests that a person is unstructured, at once both de-structured and prestructured. Women in labor act in ways that reflect their unstructured nature. The extreme physical process of birth involves the body functioning in a way that is unlike the everyday functioning of the body. In addition, behaviors are often inconsistent with everyday cultural norms. For example, making animalistic noises, being naked in front of strangers, lying down in hospital corridors, etc.

As the liminal phase peaks there is an undoing, dissolution, and decomposition of self. This point in labor is traditionally known as “transition.”

Physiology (what is happening inside)

As OT increases, contractions become stronger and more powerful. In response, cortisol and BE increase to very high levels to relieve pain and reduced stress. The natural BEs (opiates) help to create a trancelike state where the woman’s focus is within, and she becomes drowsy and less aware of her surroundings. Her neocortical functioning is reduced and her limbic system (instincts) are heightened. Her labor is now established. The baby is rotating around and moving down through her pelvis. The Rhombus of Michaelis moves up and backward to increase capacity in the pelvic mid cavity and outlet. As the pelvis opens up, it becomes unstable— and the woman moves instinctively to accommodate the movement of her pelvis and baby. The waters may break as the cervix opens enough for the forewaters to bulge into the vagina.

As labor progresses and reaches its powerful peak, there is a surge of E-EN to counteract some of the BE effects. This prepares the mother to be alert enough to protect her baby immediately after birth. The body’s response may be the fetal ejection reflex, resulting in very powerful contractions and a quick birth. However, for most women this surge of E-EN is experienced as “transition”—a feeling of fear, overwhelm, and general freak-out.

Once the cervix is fully open, there may be a lull in contractions as the uterus reorganizes itself around the baby as he or she moves down. As the baby descends, further pressure is applied to nerves deep in the pelvis, resulting in spontaneous pushing. Contractions become increasingly expulsive as soft tissue stretches, increasing the release of OT. The pain generated from the stretching of the perineal tissues initiates instinctive behaviors that protect the perineum. PRL, OT, and E-EN levels increase further as the birth approaches, to assist the initial bonding process.

Once the baby’s head emerges, there is likely to be a pause, allowing the baby time to rotate or change position to get the shoulders through the pelvis. The baby is usually born with the next contraction.

Once labor has established a strong pattern, expect the baby to be born within 18 hours (depending on contraction pattern and the individual situation).

Assessment (what you might see)

Her contraction pattern becomes increasingly strong. Note that contractions may not necessarily become closer, but they will become increasingly powerful. In general, there should be a shift in the pattern/power every 2 hours
She will be in “her own world.” She may have her eyes closed and doze off between contractions, or look stoned. She may cover her eyes with a cloth or bury her head in a pillow
She is less able to respond to questions or anything else that requires her neocortex to function. Her communication, if any, will be short and to the point (for example, “water!” rather than “Can you please pass me the water?”). If you ask a question (best not to), it might take a while for her to answer, and she will not speak during a contraction
Her movements and sounds will be instinctive and rhythmical. She is likely to vocalize during contractions— often the making same noises or movements with each contraction
Reduced inhibitions. It is during this phase that a previously shy woman might rip all her clothes off and crawl about naked
At this point the hormonal symphony is in full swing and it is very, very difficult to stop or slow contractions. A significant stress at this point may generate a fetal ejection reflex, but it is unlikely to stop contractions
As the baby moves downward and the mother’s pelvis becomes less stable (opening), her posture will change. She will want to hold onto things (and people) when standing or walking. She will not be able to sit directly on her bottom. She will walk leaning slightly with a waddle, as the pelvis tips
If she is in an upright/forward-leaning position, you might be able to see or feel the “opening of her back” as the Rhombus of Michaelis moves
A purple line might be visible between the woman’s buttocks as the baby’s head descends
During transition, you may see fear as she reaches out for reassurance and support. However, some women do not, and instead feel this on the inside, without their care provider being aware of it
During transition E-EN can cause a dry mouth, and the mother might suddenly be very thirsty. High levels can also cause vomiting, as the stomach empties in the fight-or-flight response
As the cervix opens to its full capacity, you might see a bloody/mucous show, and the waters might break
There may be a “rest and be thankful” phase after transition, where contractions slow and the woman rests as the baby descends into her pelvis
She might mention pressure in her bottom, or that she needs to poo. And you may see poo as the baby compresses the rectum and squeezes it out
Contractions become expulsive and the pattern will change. The mother’s noises and behavior will also change
If you are able to visualize the mother’s perineum (and you really don’t need to) you will see signs of the baby’s head descending through the vagina—gaping anus and vulva, flattened perineum, bulging bag of waters (if still intact), the baby’s hair/head, etc.
As the baby’s head stretches her perineal tissue she will hold back her pushes, gasp, scream, close her legs, and/or hold her baby’s head in—protecting her perineum
Once the baby’s head has emerged, you may see the baby rotate or wriggle, and then be born with the next contraction (there should be some movement or change with the next contraction)

In all rites of passage, the third phase involves re-assimilation or incorporation of the person back into society in their new state. The state of motherhood and personhood (for the baby) happens immediately following birth. However, the reintegration of mother and baby back into society occurs progressively. In some cultures, women have extended periods of separation from society following birth before being reintegrated. However the transformative nature of birth is not limited to a change of status to “mother.” Turner also identified the power of the liminal phase as a process for inner growth and transformation. Mothers incorporate the birth experience into their sense of self, resulting in empowerment—and for some, healing.

Physiology (what is happening inside)

At the moment of birth, both mother and baby have high levels of BEs, OT, and E-NE. Along with PRL, this combination provides the perfect recipe for mother-baby bonding and connection—BEs (pleasure, reward, dependency) + OT (love and bonding) + PRL (mothering behaviors) + E-NE (alertness). Skin-to-skin contact and mother-baby interactions enhance the production of OT and PRL, priming the breasts for milk production. High BEs contribute to the euphoria that many women experience following birth.

The placenta transfers the baby’s blood to the baby and the process of placental separation begins. The baby instinctively seeks his or her mother (looking into her face) and crawls to the breast—feet stimulating the uterus to contract. Skin-to-skin contact regulates the baby’s temperature, breathing, and heart rate, and provides a sense of safety, reducing stress hormones produced at the end of labor.

After birth, E-NE declines quickly but cortisol declines slowly. Cortisol may promote PRL’s effects on milk production (extreme stress levels inhibit milk production).

Assessment (what you might see)

Immediately following birth the mother may appear “stunned,” and there might be a moment or two before she picks up and cradles her baby
Baby is alert and instinctively interacts with mother, seeking the breast
Mother and baby interact
You may see a gush of blood as the placenta separates
After some time focusing on her baby, the mother may begin to shift her focus back to the outside world, often beginning with her partner and family, then other birth support (including midwives, etc.), before moving on to those outside the room

The above information is not rocket science, and anyone who has spent time with women during physiological birth will already know it (even if using the technocratic approaches to assessment). I think it is time to own women’s knowledge and start shifting the discourse of “stages of labor” and cervical measurements. This means changing how we talk about labor with women, other care providers, and students.