assessing labor progress without a cervical exam
Almost everybody is probably familiar with the concept of dilation as an indicator of labor progress. I put together a whole post about cervical changes during labor. But did you know that there are other less invasive signs that you can look for? Before we get into that, let’s take a quick look at how babies descend through the pelvis and into the birth canal during labor.
Now, there will always be variations. But the majority of babies enter the inlet of the pelvis turned to the side (you may hear ROA or LOA). As they descend, they rotate either back or front (anterior or posterior) into the birth canal. After your baby’s head emerges, their shoulders rotate and follow as their body is born. It is common for many providers to bypass this final movement, known as restitution, and pull your baby from your body. However, if there is no sign of distress from you or your baby, there is no reason to speed this process along.
Many of the signs discussed below indicate where your baby is in your pelvis, which is often a truer testament to progress than cervical dilation is.
Where is the sensation being felt? As labor progresses and your baby descends, there will likely be a shift in where you feel surges/contractions. If your baby is still high or “floating,” you will be more likely to feel pressure on your pubic bone, hips, and mid-upper back. When your baby reaches mid-pelvis, you will begin to feel increasing pressure on your cervix and sacrum. As your baby exits the pelvis and meets your pelvic floor as they enter the birth canal, you may start to feel rectal pressure. This is the classic feeling of “I have to poop.”
What are the intuitive movements? If you are unhindered in labor, you will likely find yourself moving intuitively based on where your baby is in your pelvis. While your baby is at the pelvic inlet, you may find positions that allow you to rock backward and forward or to tuck your tailbone to be most comforting. Think hands and knees; leaning over a chair or yoga ball; or deep squats. As your baby enters mid-pelvis, you may find yourself making side-to-side movements or shifting from one foot to the other. Anything asymmetrical, like lifting one foot onto a stool; laying with one leg over a pile of pillows; or a runner’s lunge. As your baby exits the pelvic outlet and enters the birth canal, you may once again find yourself rocking back and forth but this time untucking your tailbone. A common sign that someone is fully dilated is if they rise up on their tiptoes.
What’s the sacrum doing? Not only does your pelvis change during labor, but your tailbone moves too! When your baby is at the inlet of your pelvis, your tailbone will tip inward, which is called counternutation. As your baby exits your pelvis, their head will naturally push against your tailbone, pushing it back. This is called nutation. One of the reasons that pushing on your back or in a semi-reclining position is not ideal is because it inhibits the natural movement of your sacrum and can block your baby’s passage.
What sounds are being made? When your baby meets your pelvic floor at the outlet of your pelvis, you may find yourself making deep and guttural noises. Think animalistic grunting or even mooing. This is typically a good indication that your baby is entering the birth canal and could soon be born. Do what you can to release tension in your jaw and just let the noises flow.
What else? There are two other signs that often get mentioned as signs that labor is progressing. One is the rhombus of Michaelis, which appears during the pushing stage of labor. It consists of the sacrum, lower three lumbar vertebrae, and a ligament that runs from the base of the skull to the sacrum. If your back is free during labor (as in an upright or side-lying position), this kite-shaped area will open and allow space for your baby to rotate and descend. It is often a visible and tactile change. Another sign that is common but not always exhibited is the linea purpura, or purple line. It begins at the anus and grows upward as dilation increases. The length of the line roughly correlates to dilation. If the line is 5cm long, you are roughly 5cm dilated.
As mentioned above, there is always room for variation. These signs are not hard and fast rules, but many of them are common and easily observable. When you interview providers and birth attendants, consider asking how they might determine your labor progress without cervical exams. If they are unsure or don’t seem confident in their answers, consider if this would make them an asset or liability to your birth.
I am not a medical professional. The information in this post is not intended as medical advice. Please consult with your intuition and your healthcare provider about what is right for you and your family.
