Pushing: leave it to the experts

Edited and updated: April 2014

A birthing woman is the expert regarding when and how she pushes. Providing directions implies she needs our guidance and we are the experts. Of course each woman and birth situation is different and in some circumstances guidance may be helpful for a woman. This post will examine the implications of telling women when to push, how to push and not to push during birth.

This post is based on part of a literature review I carried out for my PhD. You can find more information and the reference list in my Phd thesis (p.19 to 24) or on a research poster you can download here.

Telling women to push

There is overwhelming evidence that directed pushing results in increased morbidity for both mother and baby, and amongst other things is associated with: Mother – altering body fluid pH resulting in inefficient uterine contractions; maternal fatigue; and metabolic acidosis. Babyinterferes with the gradual descent and rotation and increases risk of hypoxia.

In addition directed pushing does not reduce the duration of the ‘second stage’. However it does result in the common scenario of: Woman is directed to push = baby becomes hypoxic and fetal heart rate abnormalities are heard… woman is shouted at to push harder to get her stressed baby out quickly… woman pushes harder… baby becomes more hypoxic and stressed… obstetrician is called in to rescue the baby and pull it out.

Telling women not to push

The cervical lip

The most common reason for telling a women not to push is that her cervix is not fully dilated. Often when a baby is in an occipito posterior position the woman will feel the urge to push before the cervix is completely open. She is then told not to push because the lip will swell up (and/or tear) and prevent the baby from descending. Not pushing is an almost impossible task and many women in this situation opt for, or are encouraged to have an epidural so they can stop pushing. The baby is then less likely to rotate into an anterior position because the pelvic floor tone is reduced and the woman is unable to move.

There is no evidence to support his notion of a swelling cervix and I am yet to encounter the situation as a result of  ‘premature pushing’. In some cultures it is tradition for the woman to push with each and every contraction from the beginning of labour. Surely these cultures would have died out if the outcome had been swollen/torn cervices and stuck babies. Studies (Borrelli, Locatelli & Nespoli 2013Downe et al. 2008) have found that the incidence of ‘early pushing urge’ EPU (as it is referred to in the literature) is between 20% to 40% and is not associated with complications.

When we tell a woman not to push the message is ‘your body is not working correctly and is sending you the wrong messages – you need to fight against it’. Fighting her body until she is ‘allowed’ to push may result in difficulty switching into trusting and following her body once given the ‘go ahead’ (Bergstrom 1997). For more information about pushing and cervical lips see this post.

Breathe don’t push

I need to breathe before I write this next bit as I am sure it will offend many – some of them my friends. So please feel free to comment and share your alternative views. Here goes… there seems to be a growing trend of telling women to resist their instinctive urge to push. The idea is to ‘breathe’ the baby down gently, and it does sound lovely. However, I have spoken to a number of women whose birth stories conveyed a sense of failure because they were unable to achieve this gentle ‘birth breathing’. I have also seen women attempting this during birth – struggling to breath upwards lightly to avoid the guttural downward pull of their body.

Hypnobirthing – the Mongan method seems to be one of the key advocates of this no-push technique and I recently read the book in an attempt to understand the approach. Overall the book has many positive messages for women about their innate ability to birth. However, I have concerns regarding some of the concepts (which I will blog about in the future) in particular ‘birth breathing’ . I agree that staff directed pushing is not good (see above) but I disagree with the following quote: “Often women speak of an overwhelming urge to push taking over. If this is felt it is also because of conditioning… our animal sisters elect to gently expel their babies” (Mongan 2005, p.129)

Pushing is physiological and instinctive, and a feature of all mammalian births. To tell a woman that if she pushes she has given in to external programming and her baby will not enjoy a gentle birth is disempowering – especially for those who fail to override their ‘conditioning’. A powerful, primal, loud and ‘out of control’ birth is just as amazing and valid as a gentle, quiet ‘in control’ birth.

Suggestions

Antenatally

  • Find out what the woman’s expectations are about this part of labour.
  • Reinforce her belief in her own innate ability to birth and explain that this is the reason you will not be telling her how and when to push. This is important as some women will interpret a lack of instructions as a lack of support if they are expecting to be told what to do (Anderson 2010; Parnell et al. 1993).
  • Encourage first time mothers to talk to other women and read birth stories written by birthing women. This will give her some idea about what it may feel like, and how different it is for each woman.
  • Show her ways to connect with her body and relax her pelvic tissues so that she can use this in labour if needed. Jenny Blyth and Fiona Hallinen run fantastic workshops about this.
  • If the woman is planning a hospital birth she will need to be prepared for hospital practices including directed pushing – a Doula and a birth plan can help. The Maternity Coalition have a good info sheet aimed at parents.

During birth

  • Avoid interfering with the physiological process ie. only do or say something if it is really necessary.
  • If the woman tells you she feels the urge to push, reassure her that this is good. Don’t tell her to push. There will come a point when she is pushing rather than feeling an urge to. Gloria Lemay has recorded an audio ‘pushing for first time mothers’ explaining why this is so important, especially for first time mothers.
  • If she is extremely tense and the baby is not descending encourage her to use the techniques she learned antenatally to relax her pelvic tissues and open.

In essence – telling women when to push, how to push or not to push contradicts the notion that women are the experts in their own births.

Pushing with an epidural

The information above is about physiological birth ie. a woman birthing without intervention. An epidural can alter the ‘urge to push’ and prolong the descent of the baby once the cervix is open. An evidence based approach to pushing with an epidural is to wait until the baby’s head is visible ie. is almost birthed. Then, if required, actively push to birth the baby… it should only take a few pushes. This approach reduces the chance of an instrumental delivery and decreases pushing time (Brancato et al. 2008). I have worked in a hospital where this was the standard approach and there was a lot less fetal distress and perineal trauma for women with epidurals.

It is also beneficial to help women with epidurals to get off their sacrum to increase pelvic space. So, semi-supine is perhaps the worst possible position. Many women can move and kneel or squat with an epidural - if not a side lying position allows the sacrum and coccyx to shift backwards.

About midwifethinking

independent midwife, lecturer and student of all things birthy
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75 Responses to Pushing: leave it to the experts

  1. Sarah says:

    Thanks for the post. Particularly the topic of gently “breathing the baby out”. I was a loud moany women during pushing and it felt amazing. But- afterwards when people were
    Congratulating me they add and songlad you had “the birth you wanted/planned”. I dont believe birth can be planned and was kinda insulted that theyd think I thought everyhig wrnt ideally- thats notthw point of birth to me. Ots mwant ro be unconteollable and i wish i would have gicen up the idea of breathing the baby out so i didnt feel so bummed foe not “gently birthing”. It’s only been 15 days since my VBAC and while it was powerful and beautiful I had a hard time telling my story to friends because I had this Bit of Regrets over pieces of my Labor and birth. I think I’m ready to accept that my body kept Telling me to push and I should have just relied on it.

    • Thanks for sharing your experience and thoughts Sarah. You can’t plan or judge birth. It’s such a shame that women are made to feel their experience should fit other people’s expectations. Whilst it is amazing to watch a woman quietly and ‘gently’ birthing. It is just as amazing to watch the raw power of a woman releasing her control and embracing her primitive birthing instincts (and noise). My own birth was the latter and I am proud to say I sounded like a crazy roaring cow and was completely ‘out of control’ : )

      • sarah says:

        Yep, me too! Three weeks ago. The midwifes were rolling their eyes… but I didn’t care, I aarhed my way loudly through the whole 3 1/2 hour labour, going from 5cm dilated to 10cm in just one hour! I believe there is a connection between your mouth and opening it wide and letting your voice be heard and your cervix – opening wide too. I did however need to be reminded to hold my breath for the pushing. Partly I was waiting for my doctor to arrive. I was delirious by that stage and needed to stop doing the breathing out thing. So for me I appreciated a little pushing encouragement. Also Sarah.

  2. Bettie says:

    For me pushing was not optional. With the women I help I pretty much do the talking before birth. My explanation is pretty much in line with Gloria Lemay’s, to push with your body when it becomes an uncontrollable urge. If you can ignore it, then go ahead and wait.

    Nice post!

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  5. How very irritating to read this now. At maybe 8 to 9 cm dilated I got the urge to push. I had an op baby and an anterior lip, apparently, and I was told to fight the urge to push for 10 hours to allow further dilation, after which I gave in and asked for an epidural. (Try panting for a minute, every other minute, whilst running a marathon – it is tough!) It is practically impossible to stop this push once it has started. I wish I had ignored them now and just got on with it.
    (Don’t comment if you don’t want to. You weren’t there, not in possession of all the facts etc. I’m sure my lovely midwives were doing what they thought best)

    • Helen – thanks for your comment. Your ‘lovely midwives’ were doing what they thought best. Midwives are taught (still) that pushing on an unopened cervix will cause problems. I stopped women pushing based on this assumption myself (sorry to those women). Until we question the practice and experience what happens when we don’t interfere, we will never know. We need to get this information out there to avoid women experiencing what you did.

      • Leanne says:

        I am a student midwife surently being tought the “not to push on an unopened cervix” method so it’s great to clarify to read this and listen to Gloria Lemay’s audio. Whilst it will be hard going into work and going against the grain of everyone else telling the student what to do, when i finish and start on my own i will very much keep what you are teaching in mind.

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  8. enjoybirth says:

    In Hypnobabies Childbirth Hypnosis classes, we teach about Mother Directed Pushing. We talk about breathing your baby out, grunting your baby out, holding your breath and pushing…. and all the variants in between and how they all can work. The key is to do what feels right to MOM!

    I love this post because it really supports that.

  9. Kate says:

    Almost 4 months ago I gave birth to my second daughter at home. I didn’t have a vaginal check (didn’t want one) and was in the tub when I felt the urge to push. My midwife reassured me it was ok, but when I pushed it hurt, it felt wrong. I finally asked her to check me, and I was only 6 cm. (In my first birth, I had exactly the same problem, but chalked it up to the fact I was on Pitocin because of PROM) So I panted through the contractions and ended up getting out of the tub and walking around. Just like in my first birth, I went from 6-10 very quickly, I had a cervical lip which the midwife pushed back for me. I actually regret not having a vaginal check (And I hate checks!) when the midwives first arrived; if I’d known I was less than 6 cm, I would have continued walking outside. What would you say to someone like me? I do feel like I bruised my cervix pushing before it was fully dilated.

    • Thanks for sharing your story Kate. What would I say to someone like you?…

      “My midwife reassured me it was ok, but when I pushed it hurt, it felt wrong.”

      You listened to your body and asked for a vaginal check – every intervention/assessment has it’s place and for you that was a good use of this assessment. You were able to stop pushing but many women are unable to deny this strong urge. To tell them they have failed or will damage themselves is not helpful. Instead if they can not actively push (ie. add extra force) then great. If they can’t stop themselves then great. Also the urge to push is not necessary the time to push. I never suggest pushing or ask about pushing until the woman is actually pushing uncontrollably. An urge can happen hours before physiological pushing begins.

  10. melissa says:

    your article is very helpful to women, and i agree with your logic on all but one thing. hypnobirthing as i understand it is not about resisting urges or breathing “up” (away from the action!), but directing breathing DOWN towards the baby in parallel with the natural expulsive reflex that causes the urge to push.

    we refrain from using the word “push” because of the negative conditioning it is associated with. my own hypnobirthing was not the best example of birth breathing as my midwives, who were otherwise brilliant, got excited and forgot the “rules”, and started telling me to push- so i did- and i tore. i hadn’t practised birth breathing as i taught myself from the book, but having seen lots of videos and spoken to many other hb mothers, i can assure you it is more than possible, and very effective.

    when taught the technique properly by a practitioner, the birth partner is able to give useful guidance for the woman to commence “j-breathing” as her body surges. there is no struggling against herself at all. she will also have conditioned herself to achieve deep relaxation in birth and can focus easily on this breathing even without encouragement. interesting point: if you watch any hypnowaterbirths you’ll notice how clean the water is- very very little bleeding due to the efficient nature of our birth breathing.

    here are two youtube examples of great birth breathing:

    http://www.youtube.com/watch?v=j3g1DcNWfvg

    • Thanks Melissa
      I was hoping a hypnobirther would comment as I am no expert in this area. Lovely movie too.
      I have cared for women who have birthed like this using hypnobirthing techniques or just that is how they birthed. I can totally see the benefit of these techniques for many women. I disagree with the quote from the book – for the reasons I state. I have also had to ‘counsel’ women who felt they failed because they were unable to attain the birth they practised for and ‘lost control’ of their pushing, or their breathing, or their calmness. I have even spoken to women who are convinced this somehow damaged their baby. I don’t think anyone should tell a woman how birth should be or will be. Share techniques that may help ie. hypnobirthing… but make sure she knows they may not work for her during her individual birth. Also make sure she knows that there is no ‘better birth’ – a wild, loud and out of control birth is just as amazing as a calm, controlled one.

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  12. Anonymous says:

    I’ve been a HypnoBirthing practitioner of the Mongan Method for 5 years, and you’re right. The book’s wording is very confusing and causes disappointment among mothers. I don’t teach it. I say it just the way you did–MY HypnoBirthing class encourages mothers to do EXACTLY what their body tells them, and if it’s pushing, so be it (just remember to breathe!!). Birth is the ultimate surrendering of control, it is primal and loud and all kinds of other things. Just like nature, it is not always gentle. You said it beautifully. Thank you.

  13. katie says:

    I had home births with both my children using Hypnobirthing each time and had really enjoyable births. Our HB instructor encouraged us to go with whatever your body is telling you- which is exactly what we did. Our midwives were great, and pretty much left us to it until the actual birth- as requested. I also didn’t want any vaginal examinations and specifically asked them not to tell me when to push. My experience (both times) was that I felt completely relaxed, trusted my body knew what to do, and just let the birth unfold naturally. I had practised the birth breathing a lot during my pregnancies so it just came naturally, without having to think to much about it. At no point did I think “I need to push”, but was aware that my body was doing just that when it was required. I think the most important thing was just having trust in my body; too often women are programmed to expect their body will malfuntion, or they are destined to failure. Hypnobirthing gave me confidence in my own body’s birthing abilities, but also to listen to my body- which I think made all the difference.

    • Hypnobirthing is fantastic when used as a method to encourage trust in the body. Unfortunately I think some teach it prescriptively. All a woman needs for birth is Trust, Patience and Acceptance. If Hypnobirthing helps them to develop this – that’s great.

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  16. iloveginger says:

    I need your help!
    I am a labor RN, yes in the (gasp) labor/delivery in hospital world.
    I really want to make the in-hospital birthing experience better!
    I do not tell my patients or instruct them to push, at least until the MD walks into the room–i am so sad about the games i have to play with docs. these women need empowerment and its heartbreaking what many of them go through …medicinalized-fear-based high intervention care..i am starting midwifery school next fall i cant be part of this anymore.
    what is the best care for second stage with a woman who has an epidural?

    • It is so hard to provide a space for women to hold onto their power in the hospital world. Good on you for trying to make a difference. I really think I achieved more for women as a midwife in the hospital than I do at homebirths. Women who birth at home already hold their power and my job is easy because I don’t have to follow prescriptive policies that make birth impossible.
      As for epidurals. Have a look at my latest post about working hard for these women. You can also access the NICE (UK) research based guidelines here: http://guidance.nice.org.uk/CG55/Guidance/pdf/English. Chapter 6 is about epidural management and p.21 has recommendations for position and pushing during the second stage. Based on my experience the best way to end up with a ‘normal’ birth is to wait until the baby’s head is visible at the introitus (without digging!) until pushing. Once directed valsalva pushing begins the clock starts because the baby can only cope so long with the hypoxia it causes. If the woman is upright and the head is visible – pushing with breaths in-between can be encouraged. There is no rush while the baby is good. Lots of position changes.

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  18. For me there was no urge to push, my body literally just took over and did it, quite a bizarre experience but a wonderful one. When my midwife said don’t push just as babies head crowned I said “I’m not, my body is!”

    Enjoyed your post. x

  19. Anisa says:

    I love that you said in a previous comment: “a wild, loud and out of control birth is just as amazing as a calm, controlled one.” I have actually had the privilege to experience both. And they were BOTH amazing – in some ways the wild one more so.
    My first son’s birth was calm and controlled… Except for that darn lip at 9.5 cm. when I was told not to push. The only part of his birth that actually hurt was trying to stop my body from pushing (which is impossible anyway) until that lip cleared. I was told verbatim what you said about swelling, etc. There have been a few times since then, where I wish I would have pushed anyway… might have saved me a transfer to the hospital while he was crowning!
    My second birth was fast – 1 hour and 4 minutes total for active labor and pushing. This was the out of control birth. I pushed for seven minutes. Right before I consciously started pushing, my midwife asked me if I wanted to (as she had been listening to me push unconsciously for a few contractions already). Because my labor was so fast, though I felt the need to push, I resisted a bit because I was afraid and thought there was no way I should want to push so soon. She gave me the gentle nudge of telling me (without any vaginal checks) that it was ok to have such a fast labor and that if I wanted to push, I should.
    I so appreciate this post, and especially the comments about “breathing your baby down.” I’m now a childbirth educator, and I recently read the Hypnobirthing book. I too was alarmed by the exact quote you mentioned. I think it’s dangerous to tell women that following their body’s cues during birth is just conditioned. Fear can be conditioned (though it’s not always), but the urge to push is natural -and normal!- when it hits.

    • Anisa says:

      I just want to clarify that what happened in my second birth is different from directed pushing. My midwife asked me questions and reassured me that everything was normal and that I could try pushing if I wanted to – even just to see how it felt. :) She allowed me to give MYSELF permission to push, since in my fear of how out of control things felt, I was holding back.

  20. Christinq says:

    I’ve read the hypno birthing as well. I have also birthed 6 soon to be 7 babies. I have also witnessed and aided in (when needed) the birthing of many farm animals. In response to the statement that our animal friends do not push – Ummm They do. Very much so. While it is true that some gentle expell their offspring many many must push and push hard to get those little ones out. While the cervix and perinium are very stretchable sometimes they need a bit of pushing to stretch them to the suitable size. I love this blog! I have yet to read anything here written by the author of the blog that I don’t agree with, and much of what I didn’t know to begin with! Thank you!!

  21. Laura Innes says:

    Thanks so much for this great post.
    I had a wonderful Homebirth experience with my second daughter and the ONLY thing I feel I would do differently next time is the 2nd stage. I also was under the belief that pushing hard over the top of your bodies urges was the only way to get the baby out! After more research I am convinced that following your body’s urges, whether it be to push hard one contraction and just lightly the next, is the best and most logical way to birth our babies. Our bodies know how to gently guide our babies all the way through the first stage of labour, why then do we think we’d need to get all aggresive and force them out as soon as we feel 2nd stage urges??? It may have a lot to do with social conditing, this is the way it’s generally depicted in movies and stories about birthing, but when you really think about it, it just doesn’t make that much sense. I also had a cervical lip (suspected as blood was entering the water on pushing, no VE’s to confirm, I find them pointless) and was advised I should breathe through the next contractions and wait for the cervix to fully dilate, I never even questioned it until reading this post. As a result after a while I did start to question my ability to read my own body’s messages. Did I really need to push, or was my body just tricking me? Should I go with it or fight it incase the timing isn’t ‘right’? On reflection now when I did start to push, I was doubtful I was doing it right, and pushed really hard with only one thing in mind, to get the baby out fast. I think in the back of my mind I thought if I didn’t get her out quickly it would mean my body had been tricking me again and I had failed. Although my midwives didn’t direct pushing, these words were said and stuck with me through the 2nd stage “The way this works is the harder you push, the faster your baby is born”. I feel went over the top of my natural urges to ensure this would happen so I wouldn’t disappoint anyone.
    Sorry about the lengthy post, I’ve just had a series of revalations regarding my own birthing experience and this is the first time I have expressed those.

    • This is the problem with us humans. Other mammals don’t have a big neo-cortex (thinking brain) and just instinctively birth. We have thoughts, assumptions and expectations which make us question and doubt our body. It can be hard to shut of the neo-cortex and just birth. :)

  22. Dawn says:

    I have just recently discovered your blog, and as a maternity support worker who will begin midwifery training in September your approach to woman-centered care is so fresh and startling! I am yet to read a blog that I dont immediately think “wow!” to, especially this one. Only yesterday I assisted a midwife in delivering a woman’s first baby. She was 8cm when she arrived, and very quickly felt the urge to push and said over and over ‘I want to push/I think I want to push/I need to push’ and the midwife said to me “There’s no way she’s fully” and proceeded to tell this woman to ignore her urge for half an hour, explaining that “if we start pushing we then start the clock and if your baby isnt born within an hour I have to get the doctors in to help so hold back as long as you can” – after 30 mins she was reexamined, found to be fully dilated, vertex just visible and birthed her gorgeous baby 15 minutes later. The pushing was heavily directed “I need 4 pushes from every contraction, its a waste of a contraction if you only give me 1 or 2 good pushes” and as a witness felt heavily medicalised, depsite it being midwife led.

    Sorry for the lengthy post, I needed to share with you how upsetting thinking about that birth is after reading your blog. Perhaps the woman didnt feel let down, but I felt we’d let her down because her body wasnt trusted in.

    I do have one question – do you give any direction whilst the head is crowning (ie – pant/blow)?

    • If a woman is birthing undisturbed and following her instincts she doesn’t need directions, and directions will disturb the process. I’ve noticed that as the head crowns women naturally stop bearing down (if that is what they were doing) because of the sensations. They almost ‘hold back’ and the uterus does the rest without additional maternal force = gentle. Sometimes they put their hand down to hold themselves and their baby. Suddenly giving instruction such as pant/blow would interrupt this important moment and imply the mother needed me to tell her what to do.
      However, if she has an epidural and is already being instructed to push it would make sense to carry on giving directions. I hope that answers your question.

      • Dawn says:

        It very much does, thank you. Thinking about it, it makes perfect sense that if we truly let mothers instinct and body push and bring her baby out, then we also need to trust it to prevent perineal trauma – given that the latest research shows us hands on has no better outcome than hands off. Any advice for a student midwife when encountering practice that we may see or be encouraged to be a part off that goes against being woman centered?

        • Students have very little power in this situation. You will unfortunately see care that is not optimum. Best to use it as a learning experience (of what not to do). If you have a good relationship with your mentor you can raise the practice as a discussion and ask about why they do things a particular way. But, some people get very defensive when questioned so tread carefully. Find like minded people to support you and learn from your experiences – good and bad. One day you will be the one who is able to make a difference for women.

  23. Felicity says:

    Hi, i have thoroughly enjoyed reading all the above comments as this is a topic that confuses and frustrates me enormously. I teach calmbirth in Australia (a childbirth education course) and have taken to rethinking the word “push” and replacing it with “pressure”. Many women experience intense pressure as the cervix is nearly completely open and the baby starts to descend, which when thought of as such, they can manage instinctively by doing whatever their body tells them to do. Similarly to hypnobirthing, we encourage a birth breathing, visualisation,moving your body among other things. If mothers start thinking of the sensations in terms of “push” or “don’t push” rather than pressure, it can become very confusing – especially for first time mothers where these really strong sensations are all completely new. If they think in terms of “pressure” – they respond in whatever way feels right without question, often groaning into it, grunting into it – importantly, not resisting it. ” Push” has strong connotations and for many of the clients i work with (inner city), and brings to mind all the depictions of birth they have seen in the movies or tv – where a woman is holding her breath and being directed by the medical team around her, rendering her listening only to them, not their own urges. Allowing a woman to go with the pressure and then instinctively birthing her baby in the way that she feels is right (bearing down when that powerful urge actually comes) seems a better way. I think the problem with the term “breathing your baby out” is that it implies that focus and effort are not required – which it sometimes is… I would love to see the word “push” banned from birthing rooms – especially being chanted to a birthing mother. For so many, a beautiful, calm, positive and empowered labour journey can become very frightening, circus like and dis-empowering very quickly when directed pushing takes over….

  24. RobynHeud says:

    All I know is that the one person I wanted out of the delivery room more than anybody else was that nurse who was counting as I pushed. I pushed for four minutes without contractions, vacuum assisted. I took one deep breath right after another and she kept counting. She even told me to stop when she hit 10, but I can hold my breath a lot longer than 10 seconds. Looking back, there are a lot of things I want done differently with my current pregnancy and one of them is that the first person to start counting or telling me when to push or not to (or to not scream) is getting booted out of the room.

  25. Ely says:

    My first child was born in a private hospital in Brisbane. We were admitted at 3am and at 9am they decided to administer syntocin as labour had “stalled”. The midwife shift changed at 7am, so I’m wondering if that was part of the “stalling”. The Ob & midwife very much directed pushing and I remember reading my records in preparation for baby #2 and being so angry that they had noted that I “felt the urge to push” when I quite clearly recall NEVER feeling the urge to push and thinking that I should have felt it since they were coaching me to push (and everyone says you’ll know when it’s time to push). My baby was 6p 8o and I tore slightly but also had terrible anal tears and haemmoroids for many weeks afterwards that was extremely painful, which I attribute to the directed pushing. My baby also came out with her arm up next to her head, which in hindsight makes me think that could have been a reason for my labour slowing – to give her a chance to rearrange herself before birth. We had an extremely difficult breastfeeding experience which I think was because of the way she came out.
    With baby #2 we planned a homebirth but my blood pressure was elevated at 39 weeks so I ended up being induced. I had provided my previous hospital records, and the doctor told me that it was not normal for labour to have stalled at the point that it did. I was so angry that he completely discounted any other possible reason for labour slowing. Ended up having a completely natural birth with my homebirth midwife attending, which was fantastic, and the hospital dr didn’t make it in time. And I KNEW when it was time to push.

  26. Sally says:

    Wow, I’ve wondered why I wanted to push so early on, it was like a physically unstoppable reflex, like the powerful contraction you get when vomiting (nice analogy, ugh sorry!) and I found it SO hard not to push it was the worst bit! Will try to listen to my body more next time. Great blog, thanks!

  27. Kim says:

    I too was directed not to push, or to push with each of my first 3 babies. With my first I had my GP attend at a hospital. I wasn’t sure if I had to go to the bathroom or push. At one point I did have uncontrollable urges to push – like a gag reflex, no stopping it. But they told me not to push, so I fought it. The Dr. was not there and they hadn’t checked me. Once the nurses decide I was ready to push (gee thanks, I could have told you that) I no longer had the urge/reflex. They told me to push with contractions. I had to ask them to tell me when I was having them since I couldn’t feel them anymore, didn’t know when to push. I don’t recall the pushing process being particulalry painful, though I did end up with tearing that they stitched, and horrible swelling on one side (I was on my side). The worst part of the birth was the stitches! And the resulting keloid scar, pain and “heavy” feeling for 6 months after birth. I also ended up with prolapse, which a physiotherapist wondered out loud if it had to do with waiting to push. Now I wonder if it was the directed pushing when I felt no urge.

    With my second baby I had a home birth with midwives. After having a few “out of control” intense contractions on the toilet after bloody show, we headed to my room to get ready to push. Feeling a gush I thought my water broke and I sat down on the commode temporarily set up in my 2nd floor bedroom. I made a joke, then had a contraction during which I said, “I need to push!” The midwives following me up told me to wait until I got to the bed but as I said, “I can’t!” my water broke and out he came! He landed in the (empty) bucket! No one was prepared. He had a nuchal cord as long as a skipping rope. At the time I was disappointed to miss out on the pushing and felt like I “cheated”, and was kind of in shock for an hour or so. I did tear, but did not require stitches and healed much better second time around. Now I wish I could have another similar birth!

    With my third, I had another home birth. I had GBS so I had an IV for the antibiotics and spent much of the labour in bed. I felt lost. Didn’t know what to do with myself. Kept saying, “Ow, ow, ow” during contractions on my hands and knees. I think I may have had an anterior lip, and I’m fairly certain she was OP. I needed direction, so I know the midwives were trying to help. I fear pushing because I have prolapses and because I did poop with my first birth. I don’t want my husband to see that!

    Now with my fourth due in 10 days, I am feeling very anxious again. My only option where I live now is a hospital birth with a Dr. He is very accommodating and basically told me I can do what I want. There is a shower in the L&D room, a birthing ball, I can use a tub (but not birth in it), and any position I feel like. He knows I don’t want interventions. But still, I am anxious. Anxious about interventions, about infection in hospital, about making my prolapses worse. While epidurals require a transfer to the city hospital, he does perform c-sections. I don’t want to refuse something that will put me or baby in danger, but I don’t want anything that isn’t absolutely necessary either. Any advice for how to trust my body and accept the situation for what it is?

    • Kim – this is a really difficult one. When you are in labour you need to be ‘in labour’ not outside negotiating what you want. You cannot think logically because the physiological changes going on in your brain. The only thing I can suggest is to take a Doula with you or at least someone who will stand up for you and negotiate if needed while you get on with birth. I hope it works out well for you. Come back and let us know.

      • Kim says:

        My husband is pretty good at knowing what I do and do not want. I don’t think my Dr. will push anything on me, but hard to say without being in the situation.

        What would you tell a woman who had anxiety about prolapses/pushing? When you talk with them before birth do you discuss it if they bring it up? Just what it means psychologically (fear), or are there positions, etc. that you would try to avoid in that situation. I have a rectocele, a cystocele and the vagina is prolapsed as well. I am very, very grateful not to have many symptoms associated with prolapse (no incontinence, more discomfort than pain). I don’t honestly know if I thought much about it during labour with my third, and I suppose that’s a good thing, but I am afraid to make it worse since it seems like it was due to labour with my first (back and side-lying for active labour).

        Do you have any posts about antibiotics for Group B Strep? My Dr. is leaving it up to me whether I do them or not since I am GBS+ again. I don’t want to be confined to the bed at all, but I wonder about the risks of not having them (and the risks of having them).

        • I really can’t evaluate your situation properly without knowing you and gathering so much more information. Pregnancy itself puts pressure on your pelvic floor as your hormones work to loosen everything up + pressure from the weight of baby. Birth may make your prolapse worse… or it may not. If you are going to birth vaginally and just let your body ‘push’ (ie. no direction or conscious additional effort) you will give your body the best chance of a gentle birth. Perhaps birth in a lateral position as this often slows birth and takes away the added effect of gravity which can take some pressure off the pelvic floor? Avoid squatting or a birth stool. As for Group B Strep… that is a whole post in itself. Gloria Lemay has written about it here: http://www.glorialemay.com/blog/?p=615 Even if you opt for antibiotics you don’t need to be confined to the bed. You can be given them via a cannula without needing a bag of fluids attached to you.

  28. Pingback: The Anterior Cervical Lip: how to ruin a perfectly good birth | Midwife Thinking « natural birth resource

  29. Fab article! I agree with everything you’ve said and am especially pleased by your birth breathing excerpt. I am unfortunately a Mongan Method teacher and enforced birth breathing is one of the many aspects of the course that I disagree with and refuse to teach, because it is just rubbish that the overwhelming urge to push is the result of social programming. (I am moving on from this antenatal course before too much longer!)

    A question for you as a midwife: Why do you think it is that some women in a normal birth really do not feel the urge to push alongside the many that do? Is there something physiologically different about these births?

    • Thanks Holly – I don’t know why some women do not feel an urge to push. My guess is that it is just their individual anatomy and physiology ie. the pressure on the nerves does not generate the spontaneous urge to push. We are all different. It doesn’t matter anyhow because the uterus continues to expel the baby regardless of whether the woman joins in with ‘pushing’. It may take a little longer but shouldn’t be a problem.

  30. Eleanor copp says:

    Great article . I do not tell anyone to push but I do get themto tune into their body , and I do use the toilet or birthing stool to get the baby visible and then encourage they change position .may sound interventionalist but on the birth centre after 2 hours of mother pushing , she needs some suggestions . And no one wants a transfer . I only do this when time is moving on . Not as a matter of routine . I am trained in hypno birthing and hypnotherapist and I quickly moved away from the second stage strategy although I think it has many fantastic elements to it as an approach . As I do not look after many women with an epidural I will benefit from reading your link thank you .

  31. Vicky says:

    I find that clients frequently ask me if it is time to push yet. I think it is due to the cultural images and scary birth stories so prevalent in our society. I usually tell them to push when they feel the urge and see how it feels. With a lip, I usually have my client get into a position that relieves the pressure on that part of the cervix or facilitates baby’s rotation and if her body says push, then push but don’t add any extra voluntary pushing. I recently had to reduce a lip for a client because it was causing her a lot of pain. Once the lip was out of the way she felt a stonger urge to push and she birthed her 3900 gm baby within a half hour! Telling a mother not to push when she feels the urge is just cruel and absurd. Anyone who has ever “labored down” a baby when mom has an epidural knows that the body will push without any voluntary effort!

  32. Jo says:

    Really interesting article! I’m gathering knowledge in preparation for my third birth. I was induced with my first, it lasted 50 hours until I had a lip (and an epidural) but never got to pushing and had a CS. I had a homebirth VBAC with my second, but stalled with a lip again, had no urge to push and really intense hip pain. The lip was heavily managed by my midwives, who did not direct me to push for the first couple of hours, but eventually did. Baby seemed to be stuck behind the pubic bone (my symphisis pubis is actually loose as a result and hurt for many months, I’m getting therapy for that) and all was finally resolved when I got in the butt up child pose and the MW was in the end able to push the lip behind the head and the baby passed the pubic bone. Then I got the urge and pushed him out in 20 minutes. He was 9lbs 8oz, his head was very moulded, but centered. I don’t want to go through that again! What would you recommend in a case like mine (though I know you would need more specific info to be sure)?

  33. Lacey says:

    Great post! I felt an overwhelming urge to push after I was told I was STILL only 1.5 cm and needed to go back home. I called my midwife (who wasn’t at the birth center yet because she didn’t think I was anywhere near active labor) and told her I needed to push, and she told me to go ahead! I had my baby a little over an hour later — midwife showed up just in time to remind me to try to push gently because he was coming so fast. I tried to slow it down, but after a bit, I couldn’t hold back anymore and I pushed as hard as I wanted to, and baby torpedoed out into the water! I swear he hit his head on the tub.
    I have no idea how women can control this incredibly powerful urge, and I’m very grateful to have been surrounded by people who believed in my body and allowed me do what I needed to do.

  34. Tara says:

    This is a great article! I hated the directed pushing with my first baby (attended by an OB) and ended up with severe tearing because of it. With my other 4 births I made it very clear to my attendant that I didn’t want directed pushing and I never tore again. With my 4th though I had a strange very long labor and at one point my midwife checked my cervix and it was 8 cm but all mush. She advised me to maybe try pushing during a contraction to see what would happen and in one push babies head was bulging down on the perineum. So in my case pushing before full dilation didn’t swell my cervix but actually moved it the rest of the way and I was so happy to finally have that baby out! I completely agree that the notion that pushing before full dilation is not always a problem.

  35. T. Dole says:

    A powerful, primal, loud and ‘out of control’ birth is just as amazing and valid as a gentle, quiet ‘in control’ birth.
    Thank you for this! I have a friend who has wonderful, gentle births. I am a loud birther, and have always felt like I just don’t do birth well. =( And, I’ve given birth 11 times. What is frustrating is when the doctor or nurse says that the noise takes energy away from the pushing. I am at a point where I cannot birth at home anymore, and I am almost desperate thinking about an over-managed birth…I just want to give birth to my babies and be able to listen to my body. My last baby was positioned well before birth began, but because of ‘management’ during labor, I ended up pushing for 2 hours, and he was posterior upon arrival. :-P Definitely want to avoid that next time. Thanks for the article. It was good…although it made me a bit sad, because I think this is a pipe dream for me now.

  36. Brigitte says:

    Thanks for this article! I had an all-round good birth experience with my first (in a fairly progessive hospital, attended by a midwife & doula, no interventions or drugs), but the pushing stage lasted 3.5 hours and I’m looking to try things a little differently this time around!

    When I arrived at the hospital and got into the tub, I very soon had the urge to push (I had already dilated 7cm by the time I left home). However, only my doula and a student nurse were in the room at the time (my midwife was attending to someone else for a bit) and they told me they weren’t comfortable attending a water birth on their own so I would either have to move to the bed or not push. I didn’t particularly care one way or another about having a water birth, but at the moment I knew I did NOT want to move. I remember asking, “How do I NOT push?” and they said to just let the contraction pass without pushing.

    I began to visualize myself in a canoe (something I know well), and a power boat’s wake is coming at me parallel to the canoe. In this case you need to take the waves “rockabye” style, where you take your paddle out of the water, relax your body, and just let the canoe rock as the waves pass underneath you. You don’t fight the waves, you just let them pass. This is how I learned not to push.

    When the midwife returned, she said I could push if I liked. Now I had to re-learn to push! Apparently I wasn’t pushing effectively, so the midwife gave me a few tips, such as “push like you’re going to have a bowel movement”. So I did, and I did have a bowel movement. I still refused to leave the tub, so they drained it and re-filled it with clean water while I was sill in it! After an hour, the midwife said my pushing was still ineffective, and we should really move to the bed and try a few different positions.

    I think I tried every position possible while on the bed, many using the squatting bar in some fashion. The midwife began to direct my pushing. I was told to hold my breath during the push, told to take a quick breath and then push while holding my breath again. Two breaths per contraction. I was told not to make any noise, because that wasted energy that could have been directed toward pushing. This was all counter-intuitive to me, but I had never done this before and it was taking a long time, so I listened to the midwife. Eventually I ignored her “two breaths per contraction” rule and only breathed once, but that’s the only way I broke with her instructions.

    I pushed “effectively” for 2 more hours on the bed, and then was crowning for another 30 minutes before finally giving birth in one contraction: one push for the head, the next push for everything else. My baby girl was born in the caul, with her hand up beside her cheek and the cord around her neck. She was completely healthy and I only had two minor labial tears as well as a more serious tear inside thanks to that hand & elbow. (An OB was called to stitch me up inside.) But no perineal tearing!

    I think that with my second birth (coming up in a few months) I will be a bit more adamant about pushing in my own manner as long as everything is well. I’m a vocalizer by nature, and silently holding my breath was frustrating to me. However, I am grateful for a healthy, drug-free birth, and all that my midwife did to enable that.

  37. bm says:

    thank you for this article and the comments with it. i just gave birth to my second baby, a 4kg baby girl, drug-free over an intact perineum, and I think this article was one of the most helpful things I read in the leadup to the birth. when it came to the pushing stage, i basically howled down the birthing unit. it helped so much to express the sensations i was experiencing rather than feeling overcome by them or scared by them and to feel ok about doing that. i think the hospital midwives thought it was a bit weird – but i didn’t care at that stage. it was an exhilarating experience.

  38. Brady says:

    I don’t know how many “Animal Sisters” she knows, but I have personally witnessed animals pushing (without any coaching from me to push or not to push) in an effort to assist a contraction in getting the baby out.

  39. Michelle H says:

    Rachel, thank you for blogging about these topics and telling the truth about them! I’ve been reading your blog in bits and pieces, and have yet to find something based in fear. Have you written more about the Mongan Hypnobirthing method yet? If so, please direct me to it. I’m preparing for a freebirth in late Feb/early March, and trying to make sure my boyfriend is also prepared without being overwhelmed. Also, if there’s anything you’d specifically recommend reading or doing, please let me know. I already plan on a water birth & have decided to leave everything to happen as it will. The cord won’t be touched until it’s no longer pulsating. Breastfeeding will be at least attempted, & skin to skin is happening. Thank you!

    • Hi Michelle
      I don’t advocate any particular methods, techniques or skills for birth. Birth is a bodily function and will happen whether the woman has prepared or learned about the physiology. However, women need to build trust in their body and different women will do this in different ways… from nothing at all to learning all they can, and finding out about various ‘methods’. Birthing From Within has a good philosophy and focuses on the journey rather than you having o do particular things or have a particular type of birth. It also acknowledges the unpredictably of birth and encourages women to reflect on the ‘what ifs’ and expectations vs reality.
      If you are free birthing you may want to learn/practice some neonatal resuscitation and have a plan for transfer if you want to or need to. Good luck :)

  40. Pingback: A Perfect Birth! Freebirth After Previous Induction & Epidural (Guest Post: Birth Story) | theperfectbirth

  41. Pingback: Pushing a baby out…or not | MamaCafe

  42. Emma Stewart says:

    Agree with everything in this article – I’ve being saying it all for years !! Women are the experts and even as a hypnobirthing practitioner I remind women that the birth breathe is only a tool and that women know how to get their babies out, whether that’s with a urgent expelling push, a nudge or baby is just coming. Even the birth breath can be interpreted differently by different women when they practice it when defecating. Some describe it as a visualisation, others as a coffee plunger, others as following their natural expulsions, others as a reverse level or pelvic floor exercise. I whole heartedly agree that women will know if she wants to push, breath or nudge. Excellent article.

  43. Pingback: Can I breathe my baby out? | MamaCafe

  44. Emma (Speech Language Pathologist/wannabe midwife) says:

    Does this apply even when someone has been induced? Asking on behalf of my sister inlaw.. She was induced with gel. Cervix completely closed and tight. Waters broke roughly 5 hours after 2nd application of the gel. Baby was posterior and she got the urge to push at 4cms.. Told not to push and given an epidural. Many hours later when she was fully dialated the epidural was weaned off and she was told to start pushing. She was made to push for 5 hours before being told labour was not progressing and then had to be assisted with forceps and ventouse. Quite traumatic for Mum and Dad (my brother).. Thankfully baby showed no signs of stress throughout. Thank you kindly for your opinion.

    • An induced labour is not physiological and an epidural changes the process further. Evidence based practice re. epidurals and pushing is to wait until ‘head is on view’ ie. baby is very close to being born before pushing:
      http://onlinelibrary.wiley.com/doi/10.1111/j.1552-6909.2007.00205.x/full
      http://www.sciencedirect.com/science/article/pii/S0002937800701815
      I have worked in a hospital where this was standard practice and the outcomes for baby and for women’s perineums were good. However, your sister in-law was also induced and it sounds like her body was no where near ready for labour so this may have impacted on the outcome too. Forceps and a ventouse… sounds like quite a difficult birth for all involved.

      • Emma (Speech Language Pathologist/wannabe midwife) says:

        Thank you for your quick reply :) yes I wasn’t sure if she would be one you feel should have been allowed to push when she got the urge or if that fact that she was induced changed everything and meant the epidural was necessary to stop the urge? Sounds like it was but she was gutted. It certainly was a difficult birth for all involved by the sounds things. My niece is 4 weeks now and amazing.. My sister in law is still recovering but very smitten with her new daughter :)

        • I’ve added a bit about epidurals to this post :)

          • Emma (Speech Language Pathologist/wannabe midwife) says:

            Thank you :) I’m still wondering though.. Was 4cm dialated post induction with unstopable urge to push (posterior baby) too early to push and therefore required an epidural? Would you have let someone in my sister in-law’s position go with her body (and not require an epidural) or does being induced change things entirely? Sorry for the million and 1 questions.. And I understand you may not be able to respond given you do not know the full history. I’m only looking for a hyperthetical answer :)

          • It is impossible to know without being there and knowing the full situation. Generally I would not tell a woman with an unstoppable urge to stop pushing or suggest an epidural. Having said that most women experiencing induced contractions for any length of time request an epidural due to the pain.

          • Emma (Speech Language Pathologist/wannabe midwife) says:

            Thank you :) I certainly understand and appreciate that she may have got to a point where she requested an epidural herself. However at the point at which she recieved one it was upon advice by her midwife because she could not stop pushing when she was told to. And her and I have wondered if the rest of her birthing experience and the intervention required as a result would have been different if she had been allowed to push when her body was telling her to. Your replies have been much appreciated :) Good night!

  45. Mary Croskery says:

    As a 19 year old having my first baby laboured quietly at home sleeping on and off through contractions . Went downstairs waters broke told my mother I needed to go have a bowel motion. Was rushed into car taken to hospital . Midwives took me to prep room ready to shave and give enema. Then I had overwhelming urge to push gosh did that cause chaos . Hurried along to theatre told I needed to wait Dr on his way . Ah no waiting the urge was so overwhelming within 15 minutes gave birth to a beautiful baby girl . At 24 had my 2nd baby. Under GP obstectiric care . Was told that when I went into labour that I needed to get to hospital quickly due to my previous quick labour and birth . So get there about 6 pm . Labour quietly with support of husband . At around 2 am get offered gas told by midwife no need to be hero . Earn myself a VE fully . Dr is called taken to Delivery room legs in stirrups lights up lots of people . No urges to push get an episiotomy after being instructed to push with no progress. At 3am we had another beautiful baby girl . I have now being a midwife for 15 years I always now wait for women to get that instinctive urge to push and encourage each women to go with what their bodies are telling them to do . one O and G told me sternly once women don’t know what to do they need instruction . Well sorry to say he is a he not a woman . And now my first beautiful baby is also a midwife .

  46. Pingback: What Should My Birth Plan Include? A Walkthrough For Natural Birth. - Trimester Talk | Trimester Talk

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