One of the presentations that I most enjoy giving at conferences is called ‘Cervical Wisdom‘.
This is a session that I have developed over the years in which I analyse the things that textbooks and received wisdom would have us believe about the alleged behaviour of women’s cervixes in labour. I compare these to what we know from practice experience and research about the actual behaviour of woman’s cervixes in labour.
Which is not, of course, to imply that all cervixes behave in the same way. They really don’t. But it is the rare woman whose cervix behaves according to the rules set down in the textbooks. So my current conclusion is that existing textbook knowledge leaves out or ignores some important key knowledge and principles.
One of these principles is the phenomenon in which cervical dilation can decrease as well as increase in labour.
Because yes, that’s a thing.
A cervix which was seven centimeters dilated at one point can later be two or three centimetres. In fact, there are many possibilities as to when and how the numbers can change, but the exact numbers aren’t that important. We just mean a situation where the cervix is closing rather than opening. Or, to use the medical term, in which dilation goes backwards rather then forwards.
Why do cervixes recoil?
In my experience, cervical recoil tends to be the result of an interruption or disruption to labour. Here are the two examples that I have seen quite often and that I use to illustrate this idea.
One, a situation where someone with whom the woman does not feel completely safe enters the home or birthing space. This can be a stranger or sometimes a known family member, birth worker or care provider who disrupts the energy, often unintentionally.
And two, where the woman moves (or is moved) to a different environment in labour, such as from home to hospital or from one room to another.
I have seen many situations in which such an event can cause labour to temporarily stop. And, if vaginal examinations are being carried out, then it can become apparent that the cervix has either stopped dilating or that it is less dilated (open) than it was before.
The mammalian instinct
The explanation for cervical recoil is simple.
All mammals need to feel safe from predators in order to relax their bodies enough to give birth. Humans are no different. Cervical dilation is merely the measurable result of the women’s body making progress in labour. A woman’s cervix may close up a bit (or sometimes a lot) if she feels unsafe.
This is a normal, healthy protective mechanism. It’s not a problem. Any mammal who feels threatened would be wise to avoid giving birth until they feel safe again. Why would nature, evolution or whatever you believe in have us give birth in a situation in which we felt unsafe? It just doesn’t make sense. So cervical recoil is a safety mechanism. Just like pulling your hand away from a hot surface is a safety mechanism. It’s our body’s way of saying, “gosh no, not right now, thanks. Not a good place/space to birth at all. Better shut up shop and wait.”
And so the cervix closes a bit. To keep the baby safely inside until the coast is clear.
Given patience, understanding and willingness to follow the woman’s bodily instincts (which may be different from what her mind wants, but that’s another article), labour will almost always start up again on its own. The woman’s body will soften, and dilation will start to increase again. In my experience, it can sometime take just minutes for the woman to get back to the same point in labour. As long as we change the setting and situation so she feels that it’s safe to birth.
How do we do that?
How do we do that?
Well this is where it can get a bit tricky.
If it’s a person that’s the problem, we could suggest that they leave. That doesn’t always go down well, but it can make all the difference. Unfortunately, the person can sometimes be someone you’ve hired to help with your birth (or someone thay have sent to replace them, as they are busy), or a caregiver who is the only person available to help. Then it gets logistically tricky. Not to mention personally tricky, but that’s mostly because this phenomenon isn’t well understood. If it was, we would be having conversations and there would be more understanding and perhaps less taking it personally. It’s one thing if a caregiver is exhibiting bullying or coercive behaviour. That’s never okay. But if a midwife sounds too much like someone’s unsupportive mother-in-law, or the replacement doula reminds someone of a school bully? Maybe we could make space for it to be okay to talk about that.
When it’s the environment, that’s also tricky. Sadly, most hospitals aren’t set up to feel like safe spaces, and that’s a key problem. They look clinical and uninviting. Wards often smell weird. They may trigger memories of traumatic visits as a child, or of much-loved family members being sick or dying. No wonder our bodies ‘pull away’ and react as if we were unsafe.
Ideally, someone would say, “well, why don’t you go home again? We can send a lovely midwife with you.” Or, “how about the birth centre instead? That’s full of scented candles and oil burners, and the doctors have to knock before they enter rooms. They won’t come in unless you and your midwife say it’s OK to do so.”
The solutions are there. My colleagues and I have been writing about them for decades now. Frankly, it’s exhausting.
We need people to listen. And we need patience and understanding.
That’s not always easy in the system, though
In the reality of systems of modern maternity care, patience and understanding are sometimes in short supply.
Despite the best efforts of some practitioners, women experiencing this situation may be told that they have failed to make adequate progress and that they need syntocinon (pitocin) to speed things up.
Ironically, some of these women will go on to be very grateful that they were in the hospital. They will be happy that they ‘were in the right place’ when things went awry. We see the same gratitude in situations where a baby has become distressed after medical interventions were applied to labour. Ironically, the lack of progress and/or distress may well be the result of the drugs and interventions given to correct a physiologically normal and evolutionarily helpful behaviour.
These women and families may not realise that a woman’s body was reacting in a normal, protective and physiologically helpful way. Or that they likely would have had a far better outcome and no need to be rescued from anything if they had either been in a different environment in the first place. Or if they had received patience, understanding and holistic, woman-centred care once their body had responded in this way.
For more information
While midwives have long understood that the dilation of the cervix is not unidirectional, this hasn’t been written about extensively. It was noted and described in a research study by Betty-Anne Daviss and Ken Johnson (1998), further described by Ina May Gaskin, who discovered that it was called pasmo in parts of South America, and a few other midwives, including myself, have written up our own thoughts.
I am certain that it is a relatively common situation, though.
I have never presented my Cervical Wisdom session to a group of midwives or holistic birth practitioners without there being a buzz of recognition when I talk about this phenomenon.
A few people sometimes realise for the first time that they are not alone in a sea of cognitive dissonance. Perhaps even more reassuringly, they understand that their fingers are not deceiving them. They can correctly interpret what they are feeling during vaginal examinations. And it is the assumptions laid down by the gentlemen of the eighteenth century obstetric textbooks that are the problem, not women’s bodies or our midwifery skills.
Where midwives have found spaces to discuss this, we have tended to use the terms ‘cervical regression’ or ‘cervical reversal.’ When I presented this session at a conference in 2014, the very fabulous Canadian midwife and researcher Betty-Anne Daviss (who co-authored that study mentioned above) shared that she and her colleagues had decided to use the term cervical recoil to describe this phenomenon in English.
They use this term in order to reflect the fact that the cervix is generally closing because the woman’s body is recoiling from something that is disturbing her sense of safety. I had somehow missed this linguistic subtlety before and was really taken with the way in which a slight alteration in the terminology can help convey additional elements of the phenomenon, and have used this term ever since.
You can see all of my resources and articles relating to this topic here:
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Bowman L (2006). Cervical reversal/regression. Midwifery Matters, 108: 14.
Daviss BA and Johnson K (1998) Statistics and Research Committee. MANA Newsletter, 16(2): 16-17.
Gaskin IM (2003). Going backwards: the concept of `pasmo’. TPM 6(8): 34-37.
Wickham S (2009). Stepping stones and cervical wisdom. Birthspirit Midwifery Journal (1):39-42