Second Stage of Labor - What Happens When You're 10 cm Dilated

Today, we are joined by Dr. Kirstin Leitner, an Ob/Gyn, who answers our questions about what happens when we are 10 cm dilated, or what we call "the second stage of labor." 

1. What is the second stage of labor and how long does it take?

   • Before we talk about the second stage of labor, let’s go back and talk about how labor is divided up. The first stage of labor is when someone is contracting, and the cervix is changing, from 0 to 10 cm. This, I think, is what people traditionally think of as “labor.”

     The second stage of labor starts when the person is 10 cm dilated, and ends when they give birth to their baby. And finally, the third stage of labor is after the baby is born, up until the placenta, or the afterbirth, is delivered.

2. What can patients expect as they are giving birth?

   • People’s experience of second stage sometimes depends on if they are a first time mom or if they have had babies before. I want to highlight that pushing during the second stage is a hard process. It’s lots of work, just like exercising! Also, for a first time mom with an epidural, it can be normal to push for up to four hours, as long as they are making progress and pushing the baby’s head down in the pelvis. Not everyone needs four hours, of course! But most first time moms need maybe one or two hours of pushing, especially with an epidural, before they give birth.

   • With people who have had babies before, this is usually a shorter process. It can still be normal to push for up to 3 hours with an epidural, but many times, for people who have had babies before, it can even be just a few pushes before birth.

     This time is also shorter for people who don’t have epidurals, simply because sometimes with an epidural, it may be difficult to feel exactly where to push. But without an epidural, you can’t mistake it!

     What is key here is that we want you to listen to the guidance of your nurse, midwife, or doctor during this part of labor.

   • Pushing can be different for everyone. If something is working for that person, and the baby’s head is coming down through the birth canal, then that is the correct way for them! But, I also understand that for first time moms, this may be a challenge and they may need some more guidance.

     We usually tell people to wait for a contraction to push, so that they are working with their bodies to give birth. We usually ask people to take in a big deep breath, hold the breath in their lungs, curl up around their belly, and push downward, into their bottom, almost as if they have to poop.  

     The most effective way to push is to hold the push for as long as possible, usually about 10 seconds is what most people can manage. Then, because most contractions last anywhere between 30 seconds to 1.5 minutes, we ask our patient to try and push three times with each contraction. That means three times taking a big deep breath and pushing down, for a total of 30 seconds of pushing with each contraction.

3. What are episiotomies, and do we still cut them?

   • So first, what is an episiotomy? An episiotomy is when your midwife or doctor uses scissors to cut a small portion of the skin or muscle on the perineum, which is the area between the vagina and the anus. This is usually done to allow for the baby’s head to deliver more quickly or to allow for other necessary procedures to be performed. Also, the thought used to be that if we cut an episiotomy, mom will have less tearing from the baby’s head coming out.

     That being said, we don’t normally cut episiotomies anymore if everything is going well. We have many studies that now show that it is better for mom if we allow there to be natural tearing of the area from the baby’s head instead of cutting an episiotomy. If you do need to have an episiotomy, your doctor or midwife will tell you and explain why. But again, this is not something that we routinely do anymore.

4. Why do mom and baby need to be monitored during second stage of labor?

   • Sometimes, pushing can be a very easy process, but sometimes, even though birth is natural, there are some things that can go wrong. That is why we always keep monitors on the baby.  In the Induction of Labor podcast, we talked about different types of monitors, including the contraction monitor and the fetal heart rate monitor.

     Both of these monitors can be placed either inside the uterus or on mom’s belly, whichever is best to keep track of the contractions or the baby’s heartbeat.

     If we compare labor to a marathon, the second stage of labor, or when mom is pushing, is very much like that last leg of the marathon. We know that both mom and baby are tired. This can be a very vulnerable time for the baby, and we always want to make sure by looking at the heart rate monitor, that the baby is not becoming too stressed out. We want to make sure that the baby is still getting good oxygen from the placenta.

     Any time that we are afraid a baby is not getting enough oxygen from the placenta during labor, we have to think about 1) how do we correct that so baby can get the oxygen it needs or 2) if we can’t correct it, how do we deliver the baby soon so that the baby can start to breathe and get oxygen on its own.

     Inside the uterus, the baby will get oxygen from the blood flow from the placenta, so sometimes, the problem is as simple as the baby is laying on its umbilical cord. That can certainly decrease blood flow to the baby! If this happens, we may ask someone to move to a certain position, like on their side, when they are pushing so that the baby rolls off of the umbilical cord. Other times, we may give a person more fluid through the IV so that there is more blood flow to the uterus.

     But sometimes, if we try all of those things, and they don’t work, we need to think about delivering the baby very quickly because we want to prevent the baby from being deprived of oxygen for too long. As we said before, a baby that is deprived from oxygen for a long time can have brain damage or even pass away.

     There are two ways of delivering baby quickly: 1) C-section, and 2) assisted vaginal delivery.

5. Why do some people need assisted vaginal delivery or cesarean section?

   • We all wish that everyone can deliver their babies vaginally. This is usually the best way for both the pregnant person and the baby. The pregnant person has a shorter recovery time, and the baby often has an easier time transitioning from living inside the womb to the outside world. However, as you can imagine, it may not always be the safest thing for baby if the baby is not getting enough oxygen from the placenta and we think it may be several hours before the pregnant person can push out the baby. That could lead to other very serious complications for the baby that we want to prevent.

     This is usually when we would talk to our patients about having a C-section. We will go more into details about what exactly happens during a C-section in our episode called, “Reason for Having a Cesarean Section,” so I won’t go into that too much here. However, you can imagine that if mom has been pushing for a long time, and the baby’s head is very low in the pelvis, trying to deliver the baby through a C-section may be harder because the doctor has to reach their hand into the pelvis to get to the baby’s head. Sometimes, it may also take more time for us to get the patient to the operating room, wash off their belly, give them antibiotics, and perform the surgery.

     If the baby’s head is low enough in the pelvis, and we think that the baby would otherwise fit through the pelvis, we can sometimes offer what’s called an “assisted vaginal delivery” or “operative vaginal delivery.” 

   • An assisted vaginal delivery is exactly what it sounds like: it is when a doctor helps someone to deliver the baby through the vagina, usually much more quickly than they would be able to on their own.

     That means that we would use a small suction cup called a “vacuum” that goes on top of the baby’s head, or some metal spoons called “forceps” that we place around the baby’s face, to help guide the baby out. A lot of people think that this means that we will do all the work and pull the baby out, but actually, we are only really guiding the baby’s head in the correct direction. Most of the force still has to come from pushing.

   • It is overall very safe in the hands of a trained physician. The biggest risk of both of these procedures is causing a bruise or mark on the baby’s head or face that usually goes away in a short time after birth. Very rarely are there other complications, like some weakening of a face nerve of the baby, but again, this usually goes away after a few weeks. Another rare complication is bleeding that occurs under the baby’s scalp. Permanent injury is very rare, and if we look at studies, the rate of permanent injury is about the same for patients in this situation who choose to have a C-section instead.

   • Remember, we do not perform these procedures if everything is going well. We only take on these risks because we think that if we do not deliver the baby quickly, there could be even worse outcomes for the baby from having low oxygen levels.

   • We only perform assisted vaginal deliveries for two reasons: one we already talked about, which is if the baby needs to come out very quickly and is low enough in the pelvis. The second is for the pregnant person. Some people have heart conditions where they cannot push for very long, and may need to be assisted in their vaginal deliveries so that they don’t put too much strain on their heart. Another reason would be if someone has been pushing for a long time and is too tired to continue pushing. Then, if the baby is low enough, we can also help.

     But overall, the chances of a patient needing an assisted vaginal delivery is very low. Right now, only 3% of all births in the United States are done through assisted vaginal delivery.

6. What can patients expect after the baby is delivered?

   • Like we talked about before, there are actually three stages of labor, and finally giving birth means that we are only done with two of the three stages. We usually will perform something called “delayed cord clamping,” meaning that we will allow for some more blood flow from the placenta to the baby so the baby can have a good buildup of blood.

     Once the baby’s cord has been cut, we will start to deliver the placenta. Luckily, this is a more passive act. Usually, your doctor or midwife will have you relax, and they will put one hand on your belly. With their other hand, they will put pressure on the remainder of the umbilical cord that is still attached to the placenta. The placenta will slowly start to detach, and you may feel some pressure as the placenta comes down the birth canal as well. We may ask you to push a little at the very end so that the placenta can come out.

     Then after, the nurse, midwife, or doctor will push very, very hard on the top of the belly over the womb to massage the womb and get it to contract down. This is uncomfortable, but we need to do it to prevent too much bleeding. We will give you more medicine through the IV, called Pitocin, which will help the uterus contract as well and prevent bleeding. Sometimes, if mom is having more bleeding than normal, we may need to do more exams and give more medications that are injections.

   • It is very normal for some people to get tears in the vagina or on the skin between the vagina and the anus, called the perineum. You can also have tears in the muscle of the vagina. Unfortunately, while we do all we can during the delivery to support this area, some tearing cannot be prevented.

     Most of the time, your midwife or doctor can repair these tears quickly, meaning in about fifteen to thirty minutes, after you give birth. If you have an epidural, you will already have numbing medicine going through the epidural to help you with the discomforts of the repair. If you don’t, your doctor or midwife can inject lidocaine, which is a numbing medication, into the area that they have to repair. For more information on this, please listen to the Complications of Labor and Birth Podcast!