This post is specific for a mother with an epidural. Laboring down is nearly impossible for an unmedicated mom. It requires denying the urge to push and that is like trying to stop a speeding train with a feather.
Look at this animation showing the different stages of presentation....
Note all of the movement of the baby. A baby descending through the pelvis is like a key having to fit in a lock. The baby is as much of a participant in the birth as the mother, s/he is not just conked out in the uterus. The baby needs to turn her head one way, her shoulders another, and then rotate back. This doesn't necessarily happen because the mom is pushing, it happens because it is how we are made. It happens because it must.
One mistake that I think a lot of nurses may make is that they start to push a patient as soon as she is completely dilated. I feel that as long as the mom is not uncomfortable/ feeling tons of pressure than waiting for the baby to start to descend in the birth canal is very helpful. It keeps the mom off of that "pushing clock" for a little longer and it shortens the total amount of time and effort needed for her to push the baby out.
I also have theory. When a mother is nearing complete dilation and the baby descends, there is a usually a slowing down and spacing out of the contractions (in natural labor). I believe that this happens because the fundus of the uterus is empty (as the baby's bottom is now lower). I think that waiting and giving time to labor down allows the muscles in that uterus to contract back down around the baby's bottom to allow the uterus to be more of a helper during pushing. A Boggy Uterus doesn't want to contract, but a nice tight uterus contracts much more efficiently. If you wait you will see contractions that have spaced out start coming closer together. This break is God's way of giving an unmedicated mom a rest before she has to push.
What should you do while waiting? Well, I believe that the epidural does not prevent a mother from being an active participant in the birth. Just because you have an epidural does not mean that you get to sleep throughout labor. I use a technique known as the "California Roll"- Google it and you just come up with sushi. It is sometimes called "Chicken Wing" (but that leaves an important step out). I am sure that other hospitals have different names for this, I am hoping that other nurses are already doing this. This is a great doula technique for you doulas who are attending a hospital birth.
I DO NOT like using high fowlers to labor a patient down. You do that and the baby's head is just slamming against that coccyx the whole time. You end up with a patient with terribly swollen labia, an increased risk for tearing, and a potentially swollen cervix.
1) I put the mom in a far left lateral position first- she is nearly laying on her stomach. The right leg is held up by the left stirrup, but the knee needs to be really flexed up as far as it can towards her stomach. I flip over the bottom left pad on my labor bed to support her left leg, but you can use a pillow here. This position allows her coccyx to be mobile. In a standard semi-fowlers, high-fowlers, or lithotomy position the coccyx is completely immobilized by her sitting on it! If you put a mom in this position, I want you to see how open her pelvis is, how much more room this gives the baby to descend. I leave her in this position for about 20-30 minutes.
2) I then sit her upright in a throne position in the bed. Essentially high-fowlers, but with a big twist. The bed essentially looks like a chair and I sit the father of the baby or another family member on the bottom of the bed in between mom's feet. She is leaning forward leaning on their shoulders with her belly falling between her knees. I then tell the Dad/family member to rock left to right and front to back. I leave them there for 20-30 minutes. This also works with her leaning over a birth ball, but with an epidural I prefer to have a person there to help stabilize mom.
3) I lay her back down in a far right lateral position. The exact opposite of step one. She is there for another 20-30 minutes.
Over and over I have had tremendous results with this. I have turned OP babies, I have fixed swollen cervixes, I have gotten a cervix to dilate that hasn't dilated in 5+ hours, I have caused a very tight pelvis to open and allow baby to descend from "sky high", I have fixed asynclitic babies, and I have saved moms many an hour pushing. I even had a brow presentation once with a G1 using this technique to help baby to descend. It gives both time and and the room for a baby to move down.
The goal here is to try and mimic what an unmedicated mom would do if possible. An unmedicated mom would NEVER choose to lay in bed in a semi-fowlers position if she wasn't hooked up to a monitor. She would be up rocking her pelvis and letting her belly fall forward.
An epidural labor will never be a "normal" birth, but a good nurse/doula can try to minimize a mother's chance of ending up with a surgical (vaginal or otherwise) delivery.