Is the art of midwifery the art of creating the conditions for a fetus ejection reflex? The phrase "fetus ejection reflex" was originally introduced by Niles Newton in the 1960s, when she was studying the effect of environment on the birth of the mice(1). I found it relevant in the 1980s to rescue the term from oblivion and to use it for humans as well(2). Today I consider this "reflex" as the necessary physiological reference from which one should try not to deviate too much. During the powerful and irresistible contractions of an authentic ejection reflex there is no room for voluntary movements. A cultural misunderstanding of birth physiology is the main reason why the birth of the baby is usually preceded by a second stage, which may be presented as a disruption of the fetus ejection reflex.(3) All events that are dependent on the release of oxytocin (particularly childbirth, intercourse and lactation) are highly influenced by environmental factors.
The passage towards the fetus ejection reflex is inhibited by any interference with the state of privacy. It does not occur if there is a birth attendant who behaves like a "coach", or an observer, or a helper, or a guide, or a "support person"(4). It can be inhibited by vaginal exams, by an eye-to-eye contact, or by the imposition of a change of environment. It does not occur if the intellect of the laboring woman is stimulated by a rational language ("Now you are at complete dilation; you must push"). It does not occur if the room is not warm enough or if there are bright lights.
A typical fetus ejection reflex is easy to recognize. It can be preceded by a sudden and transitory fear expressed in an irrational way ( “kill me”, “let me die”, etc.). In such a situation the worst attitude would be to reassure with words(5). This short and transitory expression of fear can be interpreted as a good sign of a spectacular increase of hormonal release, including adrenaline. It should be immediately followed by a series of irresistible contractions. During the powerful last contractions the mother-to-be seems to be suddenly full of energy, with the need to grasp something. The maternal body has a sudden tendency to be upright. For example, if the woman was previously on hands and knees, her chest tends to be vertical. Other women stand up to give birth, more often than not leaning on the edge of a piece of furniture. A fetus ejection reflex is usually associated with a bending forward posture. When a woman is bending, the mechanism of the opening of the vulva is different from what it is in other positions. The risk of dangerous tears is eliminated. After a typical ejection reflex, the placenta is often separated within some minutes.
There are circumstances when it is more imperative than ever to deviate from the physiological model as little as possible. This is the case of a breech birth. A breech birth is not dangerous when the first stage has been easy and is followed by a powerful fetus ejection reflex. Although I have a personal experience of about 300 breech births by the vaginal route I back up the attitude of the obstetricians who prefer to routinely offer a cesarean section. We must take into account the widespread misunderstanding of birth physiology. A breech birth is dangerous in the presence of a scared obstetrician (or midwife, or father, etc.). A breech birth is dangerous when voluntary efforts are necessary to push the baby out.
These considerations about ejection reflex versus second stage are opportunities to suggest that the true role of the midwife is to protect an environment that makes the ejection reflex possible. The point is to keep in mind the basic needs of labouring women. The point is to reconcile the need for privacy and the need to feel secure. This means the importance of the midwife as a mother figure. A mother is first a protective person. Furthermore one does not feel observed and judged by one’s mother.
The vocabulary I use is inspired by the pioneering works of Niles Newton. It helps understanding that sexuality is a whole. Today it is artificial to study the episodes that are essential for the survival of the species in isolation(6). The same hormones are involved. Similar scenarios are reproduced, so that there is always a final ejection reflex: milk ejection reflex(7), sperm ejection reflex, fetus ejection reflex…