By Katie Hunter
“In the wild, mother and young have a better chance of survival if the mother can regulate labor so that the young are born in safe, quiet surroundings.”
–Niles Newton, behavioral scientist and professor at Northwestern University circa 1987
Before I explain what all of this means… let’s go over some of the facts.
In the Obstetric Care Consensus No. 1, The American Congress of Obstetricians and Gynecologists, along with the Society for Maternal Fetal Medicine, reaffirmed the following in 2016:
- One in three women who gave birth in the U.S. did so by C-section.
- The number one cause of cesarean delivery is “labor arrest” or “labor dystocia.”
- Recent data shows that labor progresses substantially slower than has been historically taught.
- Providing continuous labor support has been shown to reduce cesarean birth rates.
There are so many questions these days about what the “perfect” birth plan looks like. What is safest for the baby? What is safest for the mother? Does a vaginal delivery have more after-effects than a C-section? Does a C-section have more health risks and lead to a more difficult recovery? Should I push when I feel like I have to push? Should I push when the doctor tells me to push? Should I lie down? Stand? Squat? Take a bath? These are questions that not only mothers are asking but also doctors, nurses, midwives, and physical therapists. There is consistent research explaining the normal physiology of labor defined by three stages [stay tuned for a future blog on this] but, the literature is mixed on how the physical delivery should occur. Pelvic floor physical therapists are caught in the middle of this discussion because of how the pelvic floor muscles have to stretch so tremendously for the baby to pass. Not to mention how orthopedic and neurological conditions can impact the position in which the mother is able to deliver.
So, in my continuous search for answers, I perked up a little when I saw a Facebook discussion amongst clinicians pleading to end the “pushing” concept. Since I have been spending the last few years helping women understand the “proper” way to push and the best position for them to push, I then began scrounging for information on why we should NOT be pushing the “push.”
Returning to my list of facts above, labor dystocia is simply a “slow or difficult labor or delivery,”1 and is the cause for 34% of cesarean deliveries.2-3 There are reports of significant increase in rates of C-sections since 1996,2 and much controversy has developed over the “business” of birth with confused mothers looking for answers on the best method for them. Since there is no substantial evidence (even after my exhaustive efforts to find them) that pushing is not necessary, I encourage expectant mothers to become informed on the different types of pushing as explained in Malinda’s blog as well as this useful handout provided by the American College of Nurse-Midwives. The American College of Nurse-Midwives and National Association of Certified Professional Midwives have been promoting normal, healthy births through physiologic birth where they encourage a calm environment and allow the birth to start and progress without disruption.3 Physiologic childbirth (which you can read in detail here) appears to mirror the early works of French obstetrician, Michel Odent, in which he developed and defined the “fetus ejection reflex.”
I know you might be asking yourselves… is labor a reflex!? When you really think about how our bodies work to evacuate everything else that comes out of us (i.e. pee, poop, etc.), do we really have to think about it or work all that hard? I advised you read the rest of this post with reservation and keep in mind that I am simply sharing these facts and do not endorse them at this time.
The fetus ejection reflex was first proposed in 1966 after an experimental study of the inhibition of labor of mice through environmental disturbances. Basically, the authors hypothesized that the environment can impact how labor progresses, or does not progress. Michel Odent went on to publish a roundtable discussion on his clinical observation of a similar reflex in humans that scientist Niles Newton coined as the “Odent fetus ejection reflex.”4
Odent describes this reflex as follows.5-6
- First stage of labor occurs in a quiet, calm environment.
- The mother then has a sudden and transitory fear expressed in an irrational way (i.e. by saying “kill me” or “let me die”).
- The mother is suddenly full of energy and wants to be upright.
- One last contraction is seen as a “sudden, strong, muscular energy, grasping something or somebody, hanging on to something or somebody, or needing to have her shoulder supported.”
- Baby is born and Odent reports “I have never had to repair a tear after a fetus ejection reflex.”
That last statement is bold considering there are reports that nearly 50% of women experience perineal trauma during delivery.7 So what really drives this reflex? Odent reports that this reflex is induced by “physiologic fear.” Anecdotally, he writes signs of fear in women prior to seeing the reflex: sudden thirst, dilated pupils, and a period of panic. He believes that adrenaline and catecholamines (our “fight or flight” hormones) are released in the body, which induces the final stage of labor.
Odent explains that if these hormones are stimulated in the early stages of labor, labor will be slowed in order to allow us to “fight or flight.” If the hormones are released in the late stages of labor, then the baby is quickly evacuated in order to “fight or flight.” Sounds like that makes perfect sense to me.
So, how does our environment promote or inhibit these feelings of stress to help the laboring process?
According to Odent, we want a calm, private environment in the early stages of labor; best seen in a dark room without interruption and only the presence of a doula to act as a nurturing “mother-figure” for the woman in labor. Environmental disturbances in his experience include:5
- Interruption of privacy.
- Vaginal exams.
- Eye-to-eye contact.
- Change of environment (i.e. labor room to delivery room).
- Use of rational language (i.e. “you are dilated ‘x’ number of centimeters”).
- If the room is not warm enough or lights are too bright.
The ideal environment includes:8
- Small, dark room with nobody around.
- Presence of an experienced, low-profile and silent midwife.
- Avoid verbal communication until sudden feeling of fear.
- Verbal communication from the mother prior to reflex, includes words like “kill me”, “do anything”, “my bowels are going out… do a cesarean.”
Finally, a true fetus ejection reflex will eliminate the need for a second stage of labor altogether.8 Meaning, pushing is not a necessity and all that is required is positioning and relaxation of the pelvic floor muscles.
My main questions, after doing this research, are: does it really exist? And, if so, how can I assist my patients in achieving the benefits of such a reflex?
The benefits I see from recreating this environment to produce a reflex are this:
- Eliminating the second stage of labor.
- Eliminating the need to push.
- Reducing chance of perineal trauma.
- Decreasing need for medical interventions.
If you imagine the environment Odent is describing, do we believe that this environment is possible to reproduce? Can the medical profession shift from the standard labor and delivery room?
The final words of Odent that resonated with me are this:
“The fetus ejection reflex can happen only when the attendants are conscious that the process of parturition is an involuntary process and that one cannot help an involuntary process. The point is not to disturb it.”
In short, this is a process that we cannot control, nor should we try to control. Probably something every expectant mother has heard time and time again. But, expecting labor to be out of our control may be the best thing for us. Perhaps the next step is to consider planning the environment in which we labor and less time on how we labor.
- Merriam-Webster. (2017, February 27). Retrieved from https://www.merriam-webster.com/dictionary/dystocia.
- American College of Obstetricians and Gynecologists, SMFM consensus. (2016). Safe prevention of the primary cesarian delivery. Obstet Gynecol. 123(3). 693-711.
- American Congress of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. (2012). Supporting Healthy and Normal Physiologic Childbirth: A consensus statement by the ACNM, MANA, and the NACPM. J Midwifery Womens Health. 57(5). 529-532.
- Newton, N. (1987). The Fetus Ejection Reflex Revisited. Birth. 14(2). 106-108.
- Odent, M. (2000). Insights into pushing. The second stage as a disruption of the fetus ejection reflex. Midwifery Today. 55. 12.
- Odent, M. (1987). The fetus ejection reflex. Birth. 14(2). 104-105.
- Ventolini, G. Yaklic, J. Galloway, M. Hampton, M. Maher, J. Obstetric vulvar lacerations and postpartum dyspareunia. J Reprod Med. 59 (11-12). 560-565.
- Odent, M. (2010). First stage: preparing the fetus ejection reflex. 95. 35.