Posts Tagged ‘second stage’

The Red/Purple Line: An Alternate Method For Assessing Cervical Dilation Using Visual Cues

October 9th, 2012 by avatar

By Mindy Cockeram, LCCE

Today’s blog post is written by Mindy Cockeram, LCCE.  Mindy explores the “mystical” red/purple line that has been observed to provide information about cervical dilation without the need for a vaginal exam. – SM

When couples in my classes are learning techniques for coping in labor, such as the Sacral Rub (sacrum counterpressure), Double Hip Squeeze and Bladder32 accupressure points,  I always talk about the great position the partner is in for spotting the red, purple or dark line (depending on skin color) that creeps up between the laboring woman’s buttocks and how – by ‘reading’ that line – he or she may be able to assess more accurately the woman’s cervical progress than the health care providers!  This empowering thought is often met with smiles and laughter especially when I translate ‘natal cleft’ into more recognizable words like ‘butt cleavage’.  Strangely, I’ve never had anyone in class mention having heard of this ‘thermometer’ for accessing cervical dilation by sight and I find this interesting considering the number of medical professionals that come through my classes.

Photo CC http://www.flickr.com/photos/alexyra/214829536/

I first came across this body of research as an Antenatal Student Teacher with the National Childbirth Trust in London.  The article I was reading was in Practising Midwife and was a ‘look back’ at the original article (Hobbs, 1998) published in the same magazine.  The original Practising Midwife article was based on a letter referencing a small study by Byrne DL & Edmonds DK published in The Lancet in 1990.

In the 1990 letter to The Lancet, Byrne and Edmonds outlined and graphed 102 observations from eighteen midwifes on 48 laboring women. It states “The red line was seen on 91 (89%) occasions, and was completely absent in five (10.4%) women and initially absent in three (6.25%).”  The report then goes on to talk about the “significant correlation between the station of the fetal head and the red line length.”  Later the authors write: “To our knowledge, this is the first report of this red line.  We believe that it represents a clinical sign which is easy to recognize and which may offer valuable information in obstetric management.”

So how does this line work?  And why does this it appear?  Practising Midwife Magazine presented a graphic which I have attempted to recreate here.  Basically as the baby descends, a red/purplish (or perhaps brown depending on skin color) line creeps up from the anus to the top of the natal cleft in between the bottom cheeks.  When the line reaches the top of the natal cleft, 2nd stage is probably a matter of minutes away.  A line sitting an inch below the natal cleft is probably in transition.  A line just above the anus probably signifies early labor.

Byrne DL & Edmonds DK, the authors of the original study, surmise that the cause of the line is “vasocongestion at the base of the sacrum.” Furthermore, the authors reason that “this congestion possibly occurs because of increasing intrapelvic pressure as the fetal head descends, which would account for the correlation between station of the fetal head and red line length.”  Fascinating and logical!

Interestingly, I came across a 2nd Scottish study from 2010 published by BMC Pregnancy & Childbirth: (Shepherd A, Cheyne H, Kennedy S, McIntosh C, Styles M & Niven C) which aimed to assess the  percentage of women in which a line appeared (76%. ) The study cited only 48-56% accuracy of vaginal examinations to determine cervix diameter and fetal station.  So why aren’t clinicians using this less invasive visual measure – especially considering how much some women may dread vaginal exams in labor??  Wouldn’t the thought of using a methodology to lower infection rate after rupture of membranes has occurred enthuse Health Care Providers instead of using higher risk techniques?  Or how about using the accuracy of the line at the natal cleft to know when a women using epidural should really be coached to push?

My educated guess is that this information has not yet reached Medical Textbooks and non-standard practices can take years to become mainstream (for example. delayed cord clamping) – and then only if or when women request them or media sensation activates them.  In addition, since laboring women are only intermittently attended by Labor & Delivery staff during early and active labor and often encouraged to “stay in bed,” Health Care Providers aren’t necessarily faced with a woman’s buttocks in labor.  Also vaginal examinations are considered “accurate” so staff have no need to peek between a woman’s natal cleft.   However both these studies, paired with the roughly 50% accuracy rate of manual vaginal exams, show that there is potentially a more accurate and less invasive way ahead.

In The Practising Midwife (Jan 2007, Vol 10 no 1, pg 27), Lesley Hobbs writes “Accurate reading would seem to the key to this practice.  I sometimes notice in myself a wish to see the line progressing more quickly than it actually does; when I do this – and check with a vaginal exam – only to find the line is right, I get annoyed with myself and wish I’d trusted my observations.”  Later she goes on to say “I can now envisage a time when I shall feel confident enough to use this as my formal measurement mechanism and abandon intrusive and superfluous vaginal exams.”

Licensed Midwife Karen Baker from Yucaipa, CA commented “The purple line is a curious thing.  It’s definitely not present on everybody but is more prominent on some than others – especially right before pushing.  It tells us when she’s in full swing if we are in a good position to spot it!”

I often urge couples to send me a picture of the so called ‘purple line’ which I promise I will use only for educational purposes but so far a picture is as elusive as the Loch Ness Monster.  So, as I say in class, ‘show me your purple line’!

Are you a midwife, doctor, nurse or doula who has observed this in a client or patient? Partners, have you seen this when your partner was in labor? Has anyone heard of it or witnessed it?  If you are a childbirth educator, do you feel this is something that you might mention in your classes?  Do you think that the families in your classes might be likely to ask for this type of assessment if they knew about it? Please comment and share your experiences.


Byrne DL, Edmonds DK. 1990, Clinical method for evaluating progress in first stage labour.Lancet. 1990 Jan 13;335(8681):122.

Downe S, Gyte GML, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.

Hobbs 1998. Assessing cervical dilatation without Vaginal Exams. Watching the purple line. The Practising Midwife 1(11):34-5.

About Mindy Cockeram

Mindy Cockeram is a Lamaze Certified Childbirth Educator teaching for a large network of hospitals in Southern California.  She has a BA in Communications from Villanova University and qualified as an Antenatal Teacher through the United Kingdom’s National Childbirth Trust (NCT) in 2006.  A native of the Philadelphia area, she spent 20 years in London before relocating to Redlands, CA in 2010.





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Institute for Healthcare Improvement Takes on Maternity Care

April 28th, 2010 by avatar

The Institute for Healthcare Improvement (IHI), the leading nonprofit organization working to accelerate change in healthcare, has been in the news this month because its CEO, Donald Berwick, was recently nominated to head up the Centers for Medicare and Medicaid Services. (For those not familiar with Berwick, read his phenomenal article, “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist“). Berwick himself and IHI’s Managing Director, Sue Gullo, RN, were key players in the recent Transforming Maternity Care Project coordinated by Childbirth Connection. Now, the IHI is rolling out programs to help hospitals and health care systems implement some of the work put forth in the project’s Blueprint for Action. These initiatives also coincide with the new Joint Commission perinatal core measures which hospitals may implement as of this month. Here’s what is on offer so far:

  • Earlier this month, IHI recorded Momentum for Maternity of the Safest Kind, a podcast with the Transforming Maternity Care leadership about trends in health care for pregnant women, new mothers, and newborns and the work needed to reliably provide safe and effective care, reduce disparities, and rein in costs.
  • On Tuesday, May 4 from 3-4 PM ET, Sue Gullo will host a public call to discuss the IHI’s work on improving safety in second-stage labor. The call can be accessed through the IHI Webex System (Click on Improving Perinatal Care Collaborative Info Call) or via land line at 866-469-3239 (enter the session ID 354 952 217*. More information can be found on IHI’s Improving Perinatal Care page.
  • A series of seven web-based sessions for hospital staff involved in quality improvement efforts will focus on the safe use of oxytocin for induction, starting with avoiding all elective deliveries before 39 weeks. The series begins May 14.

To keep up with other IHI offerings, you can follow them on Facebook or Twitter

WebEx Log-in Instructions:
* Go to ihi.webex.com (Note: There is no “www”)
* From the top of the page, select the “Event center tab”
* ” Improving Perinatal Care Collaborative Info Call” will be a listed session. From the status column, select “Join Now” and follow instructions.
To join by telephone only (or if you are having trouble joining via web):
Call (866-469-3239; click here for global call-in numbers <https://ihi.webex.com/ihi/globalcallin.php?serviceType=TC&ED=106051772&tollFree=1> ) and enter the session ID # (354 952 217*).  If you experience any difficulties, please contact Lauren at lmusick@ihi.org.

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The Fifth Healthy Birth Blog Carnival: Push it real good!

April 11th, 2010 by avatar

I kicked off this blog carnival with a post titled, “Six Reasons I *Heart* Qualitative Research.”  I had been wanting to write a post about qualitative research for a while, and the topic of the second stage of labor was the perfect opportunity, since there’s so much great qualitative research on second stage.

After collecting the posts for this carnival, I have discovered why. Women want to tell their stories about pushing their babies out. With only a couple exceptions, everyone who contributed to this blog carnival wrote about their own personal experiences.

Just like good qualitative research, the stories show what spontaneous, upright pushing looks, feels, and sounds like.

  • Kristin at Birthing Beautiful Ideas posted three remarkable videos that show how a pushing urge develops, grows into strong bearing down efforts, and culminates in the baby’s birth.
  • Sheridan at the Enjoy Birth Blog prepared educational videos showing several women instinctively birthing at home and others using mother-directed pushing in the hospital.
  • Well-rounded Mama, who blogs about the maternity care needs and experiences of women of size, shares photos of women of all sizes pushing in upright positions.
  • The nurse blogging at At Your Cervix posted her thoughts on upright positions and shares a diagram of images of nearly every position imaginable.
  • Macondo Mama describes in detail how her care providers supported her in second stage (proving that care during a spontaneous birth need not mean the care provider or labor companions sit there doing nothing.) They helped her work with her voice, breath, and movements to birth her baby, provided feedback about the baby’s descent, and gave support to her partner.
  • Tiffany at Birth In Joy shares some of the encouraging words from her labor support team: “Way to go, you’re moving the baby down!” “I’m not in a hurry, rest if you want.” and so many other phrases of support and caring.
  • boheime at Living Peacefully with Children shares the words she herself said while birthing her baby. When her water broke just as she transitioned to second stage, she coped with the intensity by talking tenderly to her baby “Okay baby, let’s go slow. We will do a little bit and then take a little break. Mommy needs to take a break, and then we will go a little more. It won’t be long and then I can hold you. Just a little bit and then Mommy needs a break.”
  • The midwife blogger at Birth Sense recalls attending a birth of a mother who wanted a more calm and unrushed experience the second time around. “The room was quiet, except for the soothing music she had chosen, and the soft sound of her breaths. Carolina was bearing down gently with her contractions for several minutes, then made eye contact with me and said, ‘The baby’s coming.’ I couldn’t see anything, as she had her hand covering her perineum, but moments later, the baby’s head was out. One more push, and the rest of the baby was born into Carolina’s waiting hands. She smiled at me, ‘That was so much better than being yelled at to push!'”
  • Desirre at Preparing for Birth collected the comments of two dozen women sharing what it felt like to push and give birth.
  • Three bloggers offered analogies. Lori at Choices in Childbirth compares the shifting and wiggling that gets a baby born with the best way to get a stuck wedding ring off. “I’ll grab hold of my wedding band and pull forcefully toward the tip of my finger,” she writes. “Invariably, it moves a fraction and then gets stuck. The flesh between the band and my knuckle gets all bunched up, my finger starts to turn frighteningly red, and I begin to wonder if the ring will ever come off. On my second try, I tug on the ring while gently jiggling it back and forth. This time it moves right along without any trauma to my finger at all.” Doula, Annie Reeder suggests that the winning combination of upright posture and relaxed pelvic floor that helps get the baby out is something some women may already be familiar with – that is, if they have ever hovered over a public restroom toilet while urinating. The aspiring Lamaze educator at the Birthing Goddess Blog presents a common sense analogy many of us are already familiar with: “Who would ever think of having a bowel movement while lying down? No one, right? Same goes with a baby being born.”

Contrast these with the stories that document the opposite: our cultural norm of rushed and managed birth, and the emotional and physical toll this approach can take.

  • Dionna at Code Name: Mama recently helped her sister have a natural birth and describes her as calm and coping well until the hospital staff forced her into bed to give birth. She writes, “She was uncomfortable on the bed, and when the nurses forced her to lie down, she began to cry from the pain and pressure – not from the fact that the baby’s head was crowning – but because she had felt more comfortable and in control in the position she chose for herself previously.”
  • Mamapoekie at Authentic Parenting had an urge to push that stopped her in her tracks as she walked across her room. “When the contraction subsided,” she writes “they led me to the birthing bed, positioned me on my back and had my legs in the stirrups before I knew what happened.Everything was kind of a blur, but I remember wondering where everybody came from, because all of a sudden, there were three midwifes, two OB’s and my husband miraculously reappeared. I had not the strength to fight the position I was in and my husband was shaking like a leaf in a thunderstorm.”
  • Rebecca at Public Health Doula laments the many great labors she has attended that take a turn for the paternalistic, medicalized worse once the woman is 10 centimeters dilated. She writes, “The second a woman is judged to be ‘complete’, everyone in the room suddenly gets license to, quite frankly, be a total jerk to her. Before she has pushed even once, there is the presumption that she is going to push ‘wrong.’ She is never even given a chance to try pushing in different positions or for a few contractions to get the hang of it. Instead, the nurse spells out the position she should assume (chin to chest, pulling back on her thighs, on her back? but of course!), support people are given her legs to hold, and she gets the 3-pushes-per-contraction speech. Then from the first push she is loudly coached, counted off, and urged on MORE MORE MORE KEEP GOING PUSH HARDER HARDER HARDER and that’s about when I start grinding my teeth.”

Women who prepared carefully for birth were not necessarily immune to repression and coercion in second stage.

  • Simone Snyder, blogging at ICEA.org, had prepared a birth plan that clearly laid out her wishes for a spontaneous, upright second stage. Instead, she got “doctor’s high pitched, screeching voice-‘Push Push Push’-the nurse counting in my face-the confusion and fear as I lay there on my back in the hospital bed”. In her post, she writes, “There is a point [in my birth video] where you can hear me say ‘I don’t understand what to do-do I push-what do I do?’ All the direction, all the shouting and commotion-I was not encouraged to listen to my own body and therefore I was lost.”
  • Karen Angstadt at Intentional Birth went on the hospital tour, heard all the right answers and even saw the squatting bar she hoped to use, only to find out when it was time to push that none of the doctors would agree to use one. In her birth story she recalls that with persistence she was “allowed” to try a few squats, “before being told, ‘This isn’t working’, and put on my back for the remainder of the birth.”
  • Hilary at Moms Tinfoil Hat had been careful to do her homework, and thought hiring a nurse-midwife would ensure that she could have a natural birth. “I ended up flat on my back…pushing against a cervical lip for three hours, while being barked at and blamed by my CNM,” she writes. “I remember begging her to stop, and feeling defeated while I was forced to push, and push, and push, as my mother, husband, and even the labor nurse looked on with dread. I was unprepared for pushing the first time around, and terrified of it the second.”
  • Melodie at Breastfeeding Moms Unite planned a home birth and wrote a birth plan and still got told what to do. In her birth story, she recalls, “I remember when transition was finally over. A sudden peace washed over me. A calm in the storm. I was 10 cms. They told me I was ready to push. Except I wasn’t. My body wasn’t. I didn’t feel the urge. My midwife decided that this would then be the perfect time to instruct me ‘how’ to push.”

On the other hand, several bloggers’ stories show that it is possible, healthy, and feels amazing to push a baby out with one’s own immense power in all sorts of unexpected circumstances.

  • even with an epidural. Paige at The Baby Dust Diaries had complications that necessitated an epidural and confinement to bed. When the nurse began counting and coaching, she simply told her to stop. In her post, Paige shares the breathing technique she used to birth her baby gently.
  • even lying flat. Kiki at The Birth Junkie shows that it is the freedom to experiment with positions in second stage – not a certain position per se – that makes the difference. In her first birth, she knew instinctively to stay off her back, a knowledge that was confirmed when she tried it briefly. In her second birth, something deep down told her to try pushing on her back again, and this time it was just the thing to get her baby to come under the pubic bone . He was born with the next contraction.
  • even in the midst of grief. Molly Remer at Talk Birth, recalling her own three births, shares the story of birthing her third son too early for him to survive. (She was experiencing a second trimester miscarriage.) She writes, “I found myself kneeling on the floor in child’s pose. This position felt safe and protective to me, but I finally coached myself into awareness that the baby wasn’t going to come out with me crouched on the floor in that manner. I told myself that just like with any other birth, gravity would help. So, I pushed myself up into a kneeling position and my water broke right away.” Her baby was born moments later.
  • even when birthing twins. With the deck stacked against her (twins, one baby breech, an epidural, and stuck on her back) the mother of four blogging at Cream of Mommy Soup gave into the urge. She writes: “For a million reasons, I was impressed with my body. But pushing was the most surprising part of the whole adventure. I could not believe that my body had done that for me — had given birth to two children, in fairly rapid succession — without any assistance from my brain. It was awesomely primal, that experience.”
  • even when the baby is 11+ pounds.  Three (count’em – THREE) of our bloggers shared stories of pushing out 11+ lb. babies. In “How My Wife Had an 11+ lb. Baby At Home and Didn’t Die,” the nurse blogging at Man Nurse Diaries invites a guest post from said superhero wife, who uses gravity to birth her baby quickly when the umbilical cord begins to get squeezed during pushing. Born not breathing, their daughter resuscitates herself via an intact umbilical cord after birth, never needing the oxygen the midwives had handy. Things were a little less dramatic for our other two 11 pounders. Lauren at Hobo Mama reports having a really good time pushing out her baby, despite it being the culmination of a 42 hour home birth turned hospital transfer. As she pushed, Lauren overheard her midwife and nurse praising her pushing efforts. She writes, “Even in the distraction of pushing out an 11-pound, 13-ounce, baby, that exchange brought a smile to my face!” Finally, Jill at The Unnecesarean tried a bunch of positions until she found the sweet spot. In a post that started the “Captain Morgan maneuver” meme, Jill writes, “I put one leg on the edge of the tub and felt the baby spin out. It was freaking glorious feeling. I wouldn’t trade those twenty or thirty ridonkulous transition contractions for anything in the world if it meant that I would have had been unable to feel that.”

But we know that these stories are not the norm, at least in U.S. hospitals, where more than half of women with vaginal births give birth on their backs and 4 out of 5 are told how and when to push, according to the 2006 Listening to Mothers II Survey. Not surprisingly, many of the stories women shared were of births that took place at home, where women can more easily follow their own instincts to birth their babies, and are usually attended by midwives and labor companions who encourage and support those instincts.

  • Amy at 263-and-dna felt the urge to push before her midwife even arrived, then settled into the urge once she got there. She writes, “I started to push almost immediately – b/c we were READY. I didn’t need coaching or encouragment. I knew what to do and when to do it.”
  • Carol at Aliisa’s Letter has attended many births at home, learning something new from each one. She writes, “I saw the benefits of a variety of pushing positions: sitting (curled around the uterus), kneeling, hands/knees, squatting and side-lying. Each labor pattern and birth was unique and unfolded with its own revelation.”

The stories bloggers shared for this carnival are phenomenal and important. They call into question our cultural norms of what is safe, healthy, and appropriate care. Just as Robin at The Birth Activist learned in her childbirth class to reject the dominant cultural image of  laboring woman as stranded beetle and Michelle at The Parent Vortex likewise began to question cultural ideals of men telling women how to give birth after reading Janet Balaskas’ book, Active Birth, perhaps the posts in this carnival will be the spark the next woman needs to question unhealthy, unsafe obstetric routines.

To me, the posts in this collection suggest that what happens during the second stage of labor and how well the women is cared for may be the most important factor in how she sees herself and interprets her experience after giving birth. Not surprisingly, the care and support that helped women feel triumphant and strong are also supported by evidence of optimal safety. But reading through these posts, I’m also struck at how difficult it is to foresee the roadblocks to safe and healthy second stage care, and give women the tools to navigate around them. Having made her choice to have a hospital birth with a group of doctors she likes, pregnant blogger Jenn from Baby Makin’ Machine is sick of people telling her how to have her baby. Jenn has discovered what almost every mom has discovered before her: everyone wants to tell you what to do and how to do it, whether or not you ask for their advice, and it doesn’t stop once the baby is born. The best way to find a path through it all and parent with confidence? Follow your instincts, be patient with yourself, be assertive when something seems unsafe or uncomfortable (even if everyone else seems to be going along with it), and fall back on common sense. It’s good advice for second stage and for parenting.

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Are upright birthing positions harmful?

April 8th, 2010 by avatar

Just a few weeks before her death last year, Karen Kilson, a beloved local doula and childbirth educator, sent me this email:

Screen shot 2010-04-08 at 12.52.51 PM

She didn’t hear back from me, because it was one of too many emails I let sit in my inbox until I had the time to write a coherent response. And in the meantime she passed away.

Karen was a life-long learner and was in fact studying to sit for her Lamaze Certification Exam when she died. She shared information as voraciously as she collected it. So in her memory, I thought I would respond to her email here on the blog as part of the Fifth Healthy Birth Blog Carnival.

Karen hit on an important conundrum. Unlike practices that have benefits and no documented harms, such as movement and upright positions in the first stage of labor, continuous labor support, and skin-to-skin contact after birth, the Cochrane Systematic Review shows that upright positions are associated with a statistically significant increase in the likelihood of blood loss exceeding 500 milliliters, the clinical definition of postpartum hemorrhage. I have in fact personally heard care providers citing this finding as a rationale for keeping women in the traditional stranded beetle position.

So, are women trading an increased risk of postpartum hemorrhage for the benefits of being off their backs?

A critical look at the evidence in context suggests that the answer is “almost certainly not.”  Here’s why:

1. Some of the trials included in the Cochrane review used unreliable methods of estimating blood loss, such as simple visual estimation. This would probably bias against upright positions, since in addition to seeing blood loss, when the woman is upright you can hear it, too.  However, the result was statistically significant even after the Cochrane reviewers excluded the studies that used clearly unreliable estimation methods.

2. Blood loss greater than 500 milliliters may be the clinical definition of postpartum hemorrhage, but very few women losing that amount of blood would exhibit symptoms or need treatment. After all, a healthy non-pregnant person donates that much blood at a blood drive, and pregnant women have 50% more blood than non-pregnant people, which their bodies are designed to get rid of after birth. A much more meaningful definition for postpartum hemorrhage might be 1000ml or even 1500ml, significant postpartum anemia, or need for blood transfusion. The only one of these outcomes that the Cochrane review reports is blood transfusion, for which there was no significant difference between upright and supine positions.

3. One study with particularly rigorous methodology found increased blood loss in the sitting or semi-sitting positions compared with recumbent positions, however the difference was observed only when perineal trauma occurred. This suggests that it is not the position the woman assumes in second stage but the position she assumes after birth and before necessary perineal repairs that contributes to excess blood loss.

Restricting women to give birth on their backs poses significant risks, including an increased likelihood of perineal trauma, a small increase in the likelihood of an instrumental vaginal birth, more fetal heart rate decelerations, and more severe pain. Then there are the intangible benefits, which come out loud and clear in many of the phenomenal contributions to the second stage Blog Carnival (which I will post at the end of the weekend). The statistically significant excess in an arbitrary amount of blood loss does not outweigh those benefits, whether or not the excess is an artifact of measurement errors. The excess blood loss seen with the combination of upright positions and perineal trauma underscores the need to minimize perineal trauma during birth. Effective strategies for reducing trauma include avoiding episiotomy, instrumental vaginal birth, or the combination of the two, supporting spontaneous pushing, and birthing the baby’s head between contractions.

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Six Reasons I *Heart* Qualitative Research

March 29th, 2010 by avatar

First, a confession: I am no expert in qualitative research.

I read a lot of it, and I understand the basic principles, but I’ve never taken a course to learn the specific methodologies. I know enough to know when I’m looking at good quality qualitative research, to have a few favorite qualitative studies, and to have some things about qualitative research that I just adore.

I know that sounds a little nerdy, but maybe I can make you learn to love qualitative research, too. Here are some things I love about qualitative research, with some examples from the second stage qualitative lit, second stage being the theme of this month’s blog carnival, not to mention a well-researched topic among qualitative researchers.

Qualitative studies demonstrate undocumented harms of common obstetric practices.

In a qualitative analysis of videotaped births, researchers documented the number of vaginal exams each woman had in second stage, which ranged from 2 to 17. And although not a single study defines the circumstances, if any, under which second stage vaginal exams are beneficial and indicated, this study suggests that they may be associated with harm – namely, severe, pathological pain.

The researchers reported that both the woman’s experience of pain during vaginal exams and the providers’ response were markedly different from pain experienced during contractions. During vaginal exams, participants displayed pain with “unusual behaviors such as screaming, pleading, cursing, crying, arching back, pulling the head backward, and panting” (p. 15-16). Providers did not help women anticipate or cope with the pain associated with vaginal exams, and in fact did not even acknowledge it. In contrast, pain experienced during contractions was directly acknowledged and comfort measures or coping suggestions offered immediately.

Qualitative research finds new things to study:

In the same study documenting the practice of vaginal exams in second stage, the researchers discovered that, “The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.” The logical next step would be to design a study to determine the safety and effectiveness of vaginal exams to elicit better pushing effort.

Qualitative research tells you the words people actually say.

As someone who cares for women in labor, I always love to know the words other midwives and doulas actually say. We all have our go-to phrases for women who need reassurance or help coping. In a couple of the studies on coached versus spontaneous pushing, researchers looked at what care providers and support companions actually said to the laboring women, then categorized their words as supportive or directive. In a 2007 study in which the researchers watched the videotaped births of 10 women, we again we see that qualitative research documents undiscovered phenomena.

A category of “supportive direction” (20%) was identified. This care strategy has not been previously reported. It combined direction with support in a way that was supportive rather than overriding the woman’s involuntary efforts.

The researchers provided examples from the qualitative data of these “supportive direction” phrases:

  • “You’re doing so good, just push that baby down when you’re ready.”
  • “Take in another breath and get in another push, if you have it.”
  • “That’s great, if you feel the urge again, then try it again.”
  • “Try it like that and hold your legs.”
  • “Don’t forget to breathe.”
  • “Strong and steady.”
  • “Let’s try this…,” or “Do you wanna try…?”
  • “Keep it coming.”
  • “Just relax in between.”
  • “Concentrate on your breathing.”
  • “That’s it, push when you feel the urge.”
  • “Don’t push unless you feel a contraction, but go ahead if you feel it.” (p. 138)

Qualitative studies have titles that make you feel something.

“”You’ll feel me touching you, sweetie”: vaginal examinations during the second stage of labor


“I gotta push. Please let me push!” Social interactions during the change from first to second stage labor.

Qualitative research exposes the paternalism inherent in conventional medical model obstetrics

I gotta push… was the first study (to my knowledge) to document the ubiquitous practice of a doctor performing a vaginal exam to “certify” full dilation. The researchers analyzed videotape of women giving birth and present three cases that illustrate this phenomenon. In the most egregious case, transcripts revealed two nurses and a medical student insisting that the woman not push until a physician could perform the certifying exam, scolding and stalling her for 28 minutes despite her begging to push with her irresistible urge. Although nurses, students, and even women themselves can perform vaginal exams in labor, the official certification came only when the doctor performed the vaginal exam (in fact repeating an exam that had been conducted by the medical student 6 minutes earlier).

Upon certification of full dilation and despite clear evidence that the woman felt a strong spontaneous pushing urge, the nurse immediately “stated the new rules for the remainder of second stage, ‘Push three times on your next contraction, okay?’”

Um, no, not okay.

Qualitative research can expose trauma narratives

According to a Listening to Mothers national survey of women who gave birth in U.S. hospitals in 2005, 9 percent screened as meeting all of the criteria for childbirth-related post-traumatic stress disorder. But this condition – and the circumstances and environmental factors that contribute to it – scarcely exist in the quantitative literature. In the qualitative literature, however, such narratives are abundant. One women participating in a sociological study of prenatal counseling and consent recalled this about her birth:

So here I’d been up all this time, in all this pain, and he takes the baby out and what does he tell me? He said, “Your vagina exploded.” What a thing to tell a woman. “Your vagina exploded.” What a thing to say!

The study authors go on to tell the epilogue of her story (emphasis mine):

Without the benefit of examining Holly’s medical records, it seems as though she suffered extreme vaginal tearing, aggravated, or caused by, forceps, and went through vaginal repair surgery. As a result of this injury, Holly had difficulty post-partum: she suffered from depression, problems with breastfeeding because of her inability to sit and position herself properly, and difficulty with scarring and pain. She never had another child, and this experience left Holly with the sense that she could not risk childbirth again. Of note, the child was healthy, and this birth was considered a “good outcome [quantitatively speaking].”

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