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Advocacy under pressure: the challenges associated with advocacy during the second stage

Updated: Aug 23, 2022

Birth support
Image by Tia Biggs Doula & Photographer

Getting on the same page. The Birth Atelier strives to use education to improve birth experiences and outcomes. To achieve this goal, we must narrow in on change. Change can be brilliant, but it can also be ambiguous, uncomfortable, and imperfect. With this in mind, what we are sharing is ideas, rooted in empirical, physiological, and evidence-based information, not medical advice. We provide a perspective to consider, not a substitute for medical expertise. It is critically important that all readers continue to consult their healthcare provider when making medical decisions. No medical advice is provided by the Birth Atelier at any time.

The "5 minute rule" is a brilliant tool... for labour (i.e the first stage). For those who are unfamiliar with it, the 5 minute rule is both a temperature check and a pause. The idea being that when an intervention is suggested, the birthing person or birth partner will ask "can we have 5 minutes to discuss it?" If a care provider cautions against a short pause, chances are that the situation is emergent and the intervention is almost always urgent and medically necessary. If there are no issues with taking a pause, this then opens the door to exploring the BRAIN acronym & formulating any additional questions that will facilitate a fully informed choice. However, this tool becomes nearly impossible to lean on during the second stage of labour (i.e. pushing),

In fact, many would suggest that the second stage of labour presents the most number of challenges with respect to making truly informed choices. There are several reasons for this, some of which can be mitigated and others that cannot. There are a variety of factors that contribute to this additional difficulty including, but not limited to: the intensity of pushing (typically making it more difficult to communicate), exhaustion, shortened decision making times, the constant presence of other people in the room, ambiguity around best practices (such as recommended pushing times or optimal timing for delayed cord clamping (1)), inconsistent application of evolving best practices & more. More generally, things tend to happen quickly and under pressure, making it difficult to pause and think.

As a result, the second stage of labour typically requires a very different approach to advocacy than the hours that precede it. There are several ways to work towards greater informed choice in the second stage that families may wish to incorporate, however, it is incredibly important that we also acknowledge that this complexity cannot be ever fully mitigated or avoided. There will be times where the suggestions below will promote informed choice, but also situations where a care provider must adapt care incredibly quickly in order to ensure the health of both the birthing person & baby.

Seek first to understand, then to be understood

Prenatal education, whether through independent learning or structured classes, lays a foundation for faster and more informative conversations. Families who fully understand their preferences are not only better able to share these preferences with a care provider but also to understand their healthcare provider's explanation of why or why not they are supportive of those preferences. Take for example the following example of a conversation that could take place between a birthing person (B) and a healthcare provider (HCP):

Potential Scenario

B: "Could you please apply warm compresses to my perineum during pushing"

HCP: "Tearing is essentially inevitable. You are likely to tear with or without warm compresses."

Someone who has truly come to understand their preferences may reply by saying "I understand that tearing is likely, but wish to pursue this option if safe to do so after reading recommendations from Health Canada that support this practice (1)" whereas those who do not fully understand the reasoning behind their preferences may struggle to respond to this reply. That being said, if a healthcare provider could also respond "I typically would but I am currently concerned about how baby is responding to pushing and so will need both of my hands free." Someone who is informed about the benefits of warm compresses would be better able to differentiate between the quality of reasoning behind these two different responses ultimately supporting their ability to make a safe and informed choice.

That being said, while many birthing people may come prepared to have these conversations, very few actually take place once pushing begins. Not only are the physical sensations associated with pushing incredibly overwhelming, but most birthing people are truly exhausted by the time we reach the second stage. It is for this reason that the following two tools are particularly helpful.

Try to speak with the healthcare providers who will actually be in attendance about your pushing preferences before pushing begins

While prenatal discussions with a healthcare provider are just as important, they are typically not a substitute for discussions with those who will actually be attending the birth. The likelihood that the healthcare provider who has provided prenatal care will also be the one in attendance at the birth will depend on the side and operation of each specific unit/practice. For most obstetrical units in Edmonton, there is only a small probability that a birthing person's obstetrician will be the one on call at the time of the birth. While prenatal discussions provide an opportunity to go home and continue thinking about and/or researching a topic upon discussing it with your healthcare provider, they do not take into account the context of a birth as it unfolds nor variation amongst healthcare providers and their recommendations.

In practice, this suggestion could take shape as a quick discussion with each healthcare provider you meet as they come on shift. This will not only help you to get to know each healthcare provider better, but also allows you to digest as many new pieces of information or recommendations in advance as possible (knowing that things may continue to change with time/new developments). For example, a conversation about pushing positions could resemble the following:

B: Thank you for coming to say hello. If you have a moment, I would love to touch base about a few of our preferences around pushing in advance.

HCP: Absolutely!

B: My usual OB and I had discussed pushing positions in advance and I had shared that I really do not wish to push on my back if at all possible. We are eager to give hands and knees a go!

A few ways that this conversation could go from here include:

1) HCP: As long as you and baby are doing well I am happy to catch baby in whatever position is most comfortable for you!

2) HCP: Generally speaking I have no issue with hands and knees! Lets check to see how much mobility you have with your epidural right now... It looks like the epidural is quite strong and as a result I would not recommend trying hands and knees. (note the new information provided and how it may reshape recommendations)

3) HCP: I would like you to be on your back for delivery for ______ reason.

Regardless of the outcome of such a conversation, it is imperative to remember that recommendations may continue to change if circumstances change. These intrapartum conversations are not designed to guarantee an outcome but to build a stronger foundation for informed choice. Only time will tell how each birth unfolds, but because the door has been opened prior to pushing beginning, the birthing person is likely to be better able to digest their healthcare provider's response and will also have an opportunity to ask additional questions if further clarification is required to make an informed choice.

However, there is an additional complicating factor here that you may have noticed. Many people in labour are focused on labouring, not conversing. It is for this reason that having an prepared, supportive, and involved birth partner so beneficial.

The birth partner as the primary advocate

There is a fine line that emerges when advocating for someone in labour. On one hand, you do not wish to replace their voice, but on the other hand they may be depending on you to handle the conversations so that they can focus on labour. Discussing the birthing person's preferences and expectations with respect to their birth partner's involvement can be a brilliant way to address this prenatally, knowing that these too may change during the actual birth.

If the birthing person wishes for their partner to advocate on their behalf, a few things become incredibly important:

1. The birth partner needs to be as informed as the birthing person

Returning to our initial discussion about prenatal education, it is incredibly important that the birth partner is just as familiar with the reasoning behind a birthing person's preferences so that they too are ready to converse about it. Not only this, but it shows the birthing person that they can lean on their birth partner, trusting them to confidently support their preferences whenever safe to do so.

2. Ask yes or no questions

It is typically much easier for someone in labour to reply with a yes or no than it is for them to speak in full sentences. This is also a great way to ensure that the birthing person's wishes remain at the centre of the conversation even if they are not doing the talking. For example, as pushing is about to begin, a birth partner might say "I know you wanted to push on your side if you got the epidural. Is this still what you want?" All that is needed from a birthing person is a nod and the healthcare team has now been made aware that this is currently the birthing person's preference.

3. Be prepared for preferences to change

Even the "finest laid plans" may be thrown out the window once labour begins. Specific to pushing, it is not uncommon for someone who did not wish to push on their back prenatally to change their mind once pushing begins. It is hard to know what is exhaustion or even frustration speaking versus a true desire to change course. In these situations, it is often helpful to focus on comfort and diversity. According to Health Canada, the best position for birth is chosen by the person giving birth, ideally upright, and changed every 15 minutes or so (1). To support this while simultaneously respecting the birthing person's wishes the following two questions are incredibly helpful:

  1. Are you comfortable in this position?

  2. Do you feel ready to change positions? This might help baby make their way down.

By asking these questions, the birth partner is not only amplifying the birthing person's ability to choose how they give birth but also facilitating ideal positioning for birth.

The Lithotomy Position

When it comes to intervention in birth, what may be unnecessary in one case could be lifesaving in another. As previously discussed, informed choice discussions with healthcare providers are an excellent way to navigate a system with higher-than-recommended intervention rates. The discussion to follow aims to draw attention to a particular topic (pushing on the back/the lithotomy position) that has been identified as a source of misalignment between best practice recommendations and what is observed in practice. This is not to suggest that the lithotomy position is never necessary.

Health Canada has identified that lithotomy position (i.e. laying on your back with feet in the stirups) is routinely used not because it benefits the birthing person, but because it is more "convenient" for the healthcare provider (1). Routine use of the lithotomy position is included on the list of interventions that should be discarded unless medically necessary and they suggest that "providers need to develop the necessary skills and knowledge to comfortably assist women to give birth in different positions and encourage women to be upright as this is optimal for birth." Despite this, a large number of birthing people continue to be routinely directed to birth on their back.

While this requires systemic action to resolve on a broader scale, there is a window of opportunity that many birthing people and birth partners may wish to make note of. Often in a hospital setting a cervical exam is performed prior to pushing to assess whether the cervix is fully dilated. Typically this exam is done with the birthing person flat on their back. Once the exam is complete, pushing will usually begin soon after. If a birthing person does not wish to push on their back, it can be very helpful for the birth partner to ask the birthing person in what position they would like to begin pushing immediately after the exam is done but before pushing begins.

In Summary

Birth is unpredictable & the second stage is often a high-pressure environment. It is our hope that the information shared here strengthens your ability to advocate throughout the second stage by providing both realistic expectations and specific skills (including flexibility) to meet the needs of this unique and exciting moment in your birth.


If you have made it this far, we hope you are as excited about the information that we have collected as we are! More information about each of our courses can be found here. All of our classes are accessible online in a self-paced format and can be purchased at any time!


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