Pushing: leave it to the experts

Posted on April 16, 2014 by Dr Rachel Reed

Updated: July 2019

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 was initially 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. I have updated this post and included links to new research.

The following sections are about women birthing without epidural analgesia. I have dealt with epidural in a seperate section below – as it is a very different situation.

Telling women to push

There is overwhelming evidence that directed pushing is not good for either mother or baby. Telling women to push is associated with:

Mother:

  • alterations in body fluid pH resulting in inefficient uterine contractions
  • maternal fatigue/exhaustion
  • metabolic acidosis
  • longer duration of pushing phase
  • perineal trauma

Baby:

In summary, a recent study concluded that: “directed pushing is associated with an increased duration of second stage labour and risk of adverse neonatal outcomes.” Clinical guidelines reflect this evidence and recommend that women should be supported to follow their own pushing urges (WHO; NICE UK; Queensland Health)

However, despite the evidence and guidelines, directed pushing is still the norm in mainstream maternity care. Unfortunately the following scenario is very common: 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. Woman thanks care provider for saving her baby.

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’. Studies (Borrelli, Locatelli & Nespoli 2013; Downe 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”

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 approach 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, 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)

This reflects the belief that birth should be ‘calm and gentle’ rather than ‘out of control’ and wild. However, 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 for supporting instinctive pushing

I have written a journal article about this topic which you can find/read here. However, below is an overview of how to support women to push their own babies out their own way.

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.
  • 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.
  • 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.

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.

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.