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:
- interferes with the gradual descent and rotation
- hypoxia (lack of oxygen)
- need for resuscitation
- admission to special care nursery
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.
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’ : )
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.
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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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.
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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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.
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?…
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.
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=rSsaJ0Zno9s
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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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.
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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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.
Hi Rachel, could you post a link to your post on supporting epiduralised women with minimal valsalva? I’ve had a good search for it but can’t find it!
Hi Louise – here is a meta-analysis: http://www.ncbi.nlm.nih.gov/pubmed/18226152 🙂
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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
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.
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.
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!!
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. 🙂
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.
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.
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….
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.
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.
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!
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.
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.
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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.
Hi, I did not feel the urge to push. In fact I haven’t come across anyone else in my peer group who didn’t have the urge to push. Which is what directed me to your fabulous site as I wanted to know why. My daughter descending down through my cervix and through the birth canal happened all due to my amazing uterus and was very quick. It did seem that I just literally breathed her out. Luckily I ignored the helpful advice to get on all fours and instead did what my body wanted – which was to lay on my left hand side. I am positive that this stopped me tearing more than I did as she came out superman style. Your article is absolutely spot on… We need to relearn to trust that women’s bodies will do what they need to and everything else is pretty much white noise.
Thanks for sharing your experience. It is amazing how different our bodies are – this is why it important not to impose general rules on individual women. Your body knew exactly what to do 🙂
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 .
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!
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)?
Hi Jo
I don’t make recommendations or give advice… only information 🙂
It is impossible to know what was happening without having been there.
You might find this post helpful: http://midwifethinking.com/2011/01/22/the-anterior-cervical-lip-how-to-ruin-a-perfectly-good-birth/
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.
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.
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. 😛 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.
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.
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.
Congratulations! Enjoy your new daughter 🙂
Kegel ( not level)
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.
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 🙂
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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.
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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.
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 🙂
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.
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!
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 .
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I love this! I flirted with the ‘breathe the baby out’ idea…but I found I wanted to push, I needed to, it felt good. I worked with my body. When it did not feel good, I did not bear down (for example when I felt the ring of fire). I was IN my body, listening to it, feeling it. So intensely aware of the birth that the world around me disappeared. I had no external awareness. It felt amazing.
are there any affects from holding the baby in once he is crowning?
Do you mean if the mother holds her baby in? No – and the baby will come out as contractions continue to push the baby downwards. The baby will just be born more slowly with is not a bad thing and may protect her perineum: http://midwifethinking.com/2010/08/07/perineal-protectors/
Hi Rachel,
I can’t describe how much this article has reassured me of what I experienced with my VBAC in 2012. My labour and delivery was fairly straight forward, however I had a cervical lip at about 7cm that just wouldn’t budge and was manually moved by the midwife. This was by far the most painful time of my labour. I recall the midwife explaining to another midwife that walked into the room that my cervix “was just one of those ones that won’t budge”. Hearing this was super frustrating because prior to this at 7cm or so I’d been bearing down/pushing involuntary. I was told not to which as you know is easier said then done. I can’t remember how long it dragged on after that, but by the time I was actually told I could push I no longer had the urge. I hadn’t had an epidural only gas for pain relief, but I distinctly remember her saying “ok you can do what you’ve been wanting to do the whole time, now you can push.” I felt like I wanted to 2 hours prior to that and it actually felt amazing and a relief when my body was pushing on it’s own, but I was disheartened to hear that I wasn’t allowed. I literally had absolutely no control over it my body was almost convulsing into each push on it’s own.
Well, fast forward to now I’m due with baby #3 26th December and hoping for another vaginal birth, but partly dreading the same scenario with EPU and another cervical lip.
Is there anything you can suggest I can do to help myself mentally or physically (positions etc) whilst in labor to avoid this again or help it pass? I keep wondering what would have happened if I’d just kept pushing instead of tensing up every time my body automatically pushed down like it knew what it was doing.
Obviously it didn’t help with the midwife going against my body’s determination to push before full dilation so I was getting dishesrtned. I do give her credit thought she obviously helped things along with what ever she did reaching up to my cervix but by golly it hurt.
Thank you in advance!
Not sure if you read this post: http://midwifethinking.com/2011/01/22/the-anterior-cervical-lip-how-to-ruin-a-perfectly-good-birth/
Perhaps if no one puts their fingers into you and determines what your cervix is doing you will be left to follow your own body and birth instincts. There is no evidence to support vaginal examinations during an uncomplicated labour and a Cochrane review to support not having them. You might find this post interesting too: http://midwifethinking.com/2010/12/22/stages-of-labour-and-collusion/
Thanks for this! I was looking up premature pushing. It happens to me each time I labor once I get around 7cm! My last baby was OP and asynclitic. I had pushing urges and couldn’t stop pushing at around 7cm or so. My cervix actually did swell up really badly and thicken like “a thick ring of calamari” from my pushing. I did transfer to a hospital and got an epidural to slow the pushing urge and was rotated like a roasting chicken to get baby in the right position. I think that if I’d have been able to handle breathing through the pushing urges or something that I may have been able to do things differently, but it’s practically impossible to fight that. I felt like I needed to post a bit of my story to give an example of when the cervix does swell up from pushing before it’s open. It does happen, sadly. I still wonder why.
Thanks Jessica
I wonder if you cervix would have been swollen regardless of your pushing. I have ‘seen’ swollen cervixes in the absence of ‘early pushing’ and non-swollen cervixes with ‘early pushing’. Sometimes we put 2 and 2 together when they may be incidental rather than causal.
Agree totally with the above. My mission as a midwife has been to eradicate the nonsense that has pervaded over the fear of an OP baby, especially that compounded by well meaning ‘professionals’. I’ve often encouraged women to trust their bodies when pushing with a cervix at 6 or 7 cm dilated. I believe that nature rarely makes mistakes and has ensured that the cervix can take the place of the pelvic floor to encourage rotation, thus minimising the risk of lengthening an OP labour with instructions to ‘breathe through it’ for 6 or 7 hours. I teach hypnobirthing and use the KG method and I too have had to alter the way I teach the pushing phase; as for blaming the primal urge to push on ‘conditioning’ it is no different than the overwhelming urge to push upwards when vomiting and I’m fairly sure I’ve not been conditioned to do that. (Hope you’re all well) x
three weeks ago my niece gave birth to a little girl. at midnight she was told she was fully dilated and pushed for 2 hours. With no sign of the baby a consultant was called in to examine her and she was told she was not fully dilated. She is on her way to hospital now suffering terrible internal pain and feeling as if her insides are about to fall out. What damage could this have caused. Extremely worried about her. Her baby was eventually born at 9.15 am.
I’m not sure how long ago she gave birth. This is why it is important that the woman is not told when to push. She is unlikely to have done any serious damage. The pain could be a number of things – a tear, bruising, an infection.
This is ironic, but my instincts are telling me that the discussion around instincts is oversimplified here! I think it highlights many key issues well (don’t idolise a quiet ‘gentle’ birth) etc, and I love that the research undertaken helps question practices about ‘holding back’ from pushing against a theoretical lip, as well as forcing pushing. Practices are improved as we question, examine, and reconsider. However, the key concept of instincts and trusting the body’s messages is one that I think is more complex than laid out in this blog. As both a childbirth educator for nearly 20 years, and a mother who has experienced loud and empowering and quiet births, I affirm this author that one of our key tasks in empowering women that they can birth positively, is to encourage them to simply trust that they can do it!
However, I think it is fair to say that the body does not always give accurate instincts as some complications cause an array of conflicting physical responses. Janet Balaskas gives a good description of ‘good pain’ and ‘warning pain’ in birth, but sometimes we cannot know what to do with the warning pain. And, of course, I have a ‘one-off’ personal experience that runs completely contrary to what you have written about pushing. My first child had her arm wrapped up under her chin causing an enormous diameter to push out. This was not palpable. My baby was in the tightest part of the birth canal and close to crowning for over 90 minutes. I certainly had warning pain. Ultimately, despite the mix of conflicting information from my body, increasing pushing effort ended up with the safest result for my baby and my body. It avoided forceps which would have added damage to my already super-stretched pelvic ligaments, and it avoided a last minute caesarean which is one of the safest surgical procedures but is still a less optimal option for baby and mother compared to vaginal birth. Interestingly, the midwives were being very ‘hands off’ and it was only when a registrar wanted to intervene that I increased pushing effort. Their concern that we were entering a danger zone for the baby was actually accurate, though none of us could have ‘felt’ what was the best course of action. It was my bloody minded desire to have an intervention free birth that motivated the extra pushing. Not instinct.
I have two thoughts. What is the interplay with midwives instincts? Experienced midwives can have such a great ‘sense’ that works to help and empower mothers, and respond to a picture of ‘warning signs’. We need to be upfront about the degree of experience and how that affects decisions to influence mother’s choices in birth.
My other thought, is, do we need to place some weight on the sense of ‘growing instincts’ given the long journey for many western women? That each birth is a learning experience. That their instincts may sometimes, albeit rarely, be wrong but that will refine their instincts, and refine their relationships with caregivers that support them. I think this relates to parenting as well, where women need to grow their trust in their instincts, but I have seen women equally frustrated by the fact that they keep being told to trust their instincts and yet their ability to listen to instincts isn’t much developed yet. They need to hear that they will make mistakes and that’s okay. Making mistakes while surrounded with caring support is the safest place to make mistakes, it’s okay if they aren’t fabulous at listening to their instincts yet, they will grow to know their instincts, the place of their instincts and the limitations of their instincts.
I am not intending to imply that women will always be able to instinctively ‘fix’ a problem… but if undisturbed they do usually know instinctively that they need help. Eg. in your example: “though none of us could have ‘felt’ what was the best course of action” – no but you knew that something was not right… the pain was different – a ‘wrong pain’. I attended a birth with exactly that scenario (arm under chin). The mother knew something was not right but we didn’t know what. It is then the midwife’s job to help work out what exactly is ‘wrong’ and suggest ways to sort the problem. In our case we eventually used position and rebozzo to move baby backwards out of the pelvis to come back through in a better position.
Your questions…
“What is the interplay with midwives instincts? Experienced midwives can have such a great ‘sense’ that works to help and empower mothers, and respond to a picture of ‘warning signs’. We need to be upfront about the degree of experience and how that affects decisions to influence mother’s choices in birth.” – I agree, this is part of the mother-midwife relationship, being open about who we are an what experience/knowledge we have.
“My other thought, is, do we need to place some weight on the sense of ‘growing instincts’ ” – I love this concept. In my thesis I discuss how women and midwives work to build self trust (instincts). This can be difficult in culture that constantly undermines women’s innate instincts and body knowledge. In fact the birth journey can be a transformative experience in which women learn to trust their body and instincts. I might steal your ‘growing instincts’ quote 😉
I found that I had no problem listening to and being aware of my body and instincts. Unfortunately I was in a hospital with an insensitive nurse and midwife who thought they knew better than me and did not ask me what I wanted.
Medical culture needs to change and not treat the birth of a baby as a foreign object that must be expelled ASAP.
So look at the scant evidence about early urge to push and what it actually says. The Itialian midwifery article that you reference; Borrelli,Locatelli & Nespoli 2013, had only 8 women out of 60 with EUP who were left alone to push at will, the 52 other women the midwives used stop pushing techniques like change maternal position, blowing breath, vocalization, get in a bath. ( in this study 44 nullips and 16 multips) . Yes the summation was not outside normal outcomes for EUP, but more OB interventions did occur in the group as a whole.
So this is a thoughtful article you have written but the evidence so far supports delaying techniques, with some selective go with the urges.
Yes – this was a very small study and not ‘high quality’ evidence. But there is NO research evidence supporting the notion that EUP causes complications. It is about interpretation and the context in which it occurs. The current birth culture = continue carrying out an intervention (started without evidence) until good quality evidence is found to support not doing the intervention. How about not carrying out an intervention until we have good evidence to do so? I would also argue that if we look holistically at this ie. that outcomes also involve emotional and psychosocial aspects… then the interventions discussed are associated with poor outcomes… take a look at the comments and the upset caused by undermining a woman’s urges during birth.
I am so glad to read this article, directed pushing did not help me. I gave birth to my lovely son here in Canada almost 9 months ago and TBH I am just getting over the traumatic parts of his birth. When I was at home for the start of the labour, I was able to listen to my instincts and my body. I was free from distractions and able to move and change position as I needed. It was painful but good, I was able to BE at one with labour. I have done aikido and yoga and felt that I was able to tune into my body and be with every moment and let the pain go after each contraction.
In hospital the midwife told me to get onto the horrible narrow hospital bed with a ball. I could still move but my range was limited and I think I felt controlled and inhibited by that bed. For some reason the labour and delivery nurse took over and decided that she would ‘help’ me by very forceful directed pushing. It was horrible, stressful and painful, she did not help me find a good position for me, in fact I was on my back for most of the process and when I was too tired to squat but in obvious pain on my back she just told me that, “I had to breathe for baby”. The directed pushing and holding my breath was painful and stressful. I could not tune into my body and I was not encouraged to listen to myself or move as I wanted. My baby kept crowning but I couldn’t relax, I wasn’t in the right position and I think that was why I couldn’t give birth to him. They then took him out with a vacuum and forceps. Even if I had had the same inventions, had I been left alone to move and labour as I needed, I would not have been in so much pain and fear during active labour.
I have written to the hospital to complain about the nurse, and I have spoken with the boss of the registered midwife that I had. I received a positive response from the hospital and it was good to talk the process through with the chief midwife from the midwifery clinic I attended.
In subsequent pregnancies (if I am low risk) I want to give birth at home with registered midwives. This has taught me to listen to myself and my body and that I must be clear and communicate when something does not work for me.
I am so pleased that you wrote to the hospital. It is important that hospital staff get feedback on women’s experience of what they often consider to be ‘normal’ practises.
I like that you addressed hypnobirthing. I have experience in this area and have seen mostly negative outcomes. To me it seems that womens minds are still in the wrong place. They are still not believing in their natural abilities, their bodys, natures design. Instead, they are seeking an altered state of mind as an alternative to having drugs, they do not believe they can do it themselves, they need this outside assistance, this outside source to control/manage their pain, save them from this horrible experience.
It is important not confuse the Mongan Method of hypnobirthing with all other hypnobirthing programs that are offered, as there are quite a few now being taught around the world, and although there are similarities they all differ to each other. I now teach the Hypnobirthing Australia model which advocates for “mother directed pushing” or “bearing down”, whenever the mother feels the urge to – and that was one of the reasons I stopped teaching the Mongan Method because of the breathing instructions (among other things) that just did not sit well with me. Let’s also remember that what works for one woman may not work for the next, we are all individuals, so go with your body and your instincts and do what feels right for you.
I agree there are lots of different versions of ‘hypnobirthing’ being taught. Often women don’t go to classes and instead read the book (Mongan Method). I know that hynobirthing is extremely helpful for some women but I do have some issues with how it presents the birth experience. One example from the Australian hypnobirthing website:
“When women understand that pain is caused by constrictor hormones (created by fear), they learn to release fear and create endorphins instead. Endorphins are the ‘feel good hormones’ that we naturally produce when we are calm and happy.”
This is incorrect. The release of endorphins happens in response to pain – not when we feel calm and happy. Endorphins are the body’s natural pain relieving hormones – when you are in pain (such as childbirth) they are released and reduce pain sensations and create the ‘stoned’ opiate induced feeling which facilitates calm. Pain is an important part of the process – not something that occurs if you are unable to relax. Loss of control is also part of birth. You might find these posts – and more importantly the comments – interesting.
http://midwifethinking.com/2013/03/27/feel-the-fear-and-birth-anyway/
http://midwifethinking.com/2011/04/09/judging-birth/
Thank you so much for this article. I read the Mongan Method & used the techniques for my labour 3 months ago and I think it rwalky helped me stay calm and relaxed and believe in my body and it’s natural processes to birth my baby. When I felt that urge to push though, my midwife had to tell me it was okay to push ‘go with your body’… I had no concept of what it would be like and I really couldn’t get my head around the ‘breathing your baby out gently’. When the time came I could not help but push, and make deep gutteral noises. But I felt like I ‘shouldn’t push even though the midwife told me to go with my body. My midwife at the birth centre supported my wanting to ‘breath the baby out’ for an hour in the birthing pool without directions and then on my hands and knees and then on the birthing stool until eventually she became concerned with me & my uterus getting fatigued (I was in labour about 24 hours at this point & pushing for well over an hour & I could feel My contractions weren’t as powerful anymore). She had to give me some directions towards the end, I guess she had to help me make the most of the contractions I was having. I never anticipated having to push so hard and I wonder now whether I was actually inefficiently pushing in that first hour because I was trying to breath my baby out rather then really going with those powerful contractions with all I had. I got my baby out after 2 hours or so of pushing and ever since, even though I had a natural birth and everything went well, I’ve felt I somehow I failed or did something wrong to have to actually push and be directed to push. I feel like I need to ask someone why this happened even though baby was in the optimal position for being born…
I think your article might have helped answer these questions and I feel a bit better about it.
Thank you for sharing your experience. You did not fail! The Mongan Method of ‘breathing’ your baby out was not what your body needed to do. You had been persuaded to ignore your instinctive bodily functions in favour of a method. I have been the midwife in this scenario – it is frustrating to watch, and particularly for first time mothers it makes the birthing process longer than necessary. I am pleased you have given others the opportunity to read about how this method altered your birth experience.
Thanks Rachel. So in a situation like mine where I could feel my contractions not being as powerful after nearly two hours of the pushing phase and baby’s head not coming down – is that a situation where directed pushing is appropriate? My midwife never directed me to push between contraction only encouraged me to give it all I had and hold it longer and to do the opposite of breathing the baby out and actually hold my breath during the push. This is how I made progress & was able to deliver my baby. It was very hard work especially because those contractions were not powerful anymore. It was a bit scary, I kept believing I would get him out with the next one but it took ages. Afterwards when she was stitching me up she told me there was a point where she thought I might have needed ‘help’ (forceps) because the head just wasn’t descending past a certain point. I know directed pushing isn’t ok in other circumstances where Mum is going with her body but do you think there is a place for it such as in my situation?
If only I had listened to my instincts about that ‘breathing and gently expelling your baby out’ crap.
There are always exceptions to the rule. And yes, it seems that in your situation you had missed your ‘window’ for instinctive pushing behaviour and your contractions were reducing. Your midwife probably realised that if she didn’t direct you to strongly push you would end up with intervention ie. forceps. We learn lessons from every birth experience – that is why there is no failure. You have learned how important your instincts are – you can take that lesson into mothering 🙂 – And watch this space I’ll be publishing another post about pushing behaviours next week.
I completely agree. I even agree with the whole “breathe vs push” and that a woman should listen to her body, to be gentle, yes, to breathe, yes, to not forcefully push, yes, but to hold back and try to control any urge, no! Your body knows what to do, listen to that and your instincs, birth as your body impels you to!
I gave birth recently. The first stage of labour was very long (26 hours), I think because the baby rotated the “wrong way”. I was at a birthing centre and things were pretty chilled, but by the end I think they just wanted to get the baby out (although her heart was fine). When I was fully dilated I was in the pool. I didn’t get an urge to push initially. In retrospect I think this may have been the “rest and be thankful” phase that kitzinger talks about. The midwives decided (I discovered from my husband later) that I needed to get the baby out faster because it had been so long. They led me to a birthing stool and i squatted on that and hung from a rope on the ceiling while my husband held my back. They encouraged me to bear down hard with each contraction. I should say at this point that I’d had a real fear of tearing, and my birth plan actually asked midwives to take precautions against it, including guiding me into an all fours position and using warm compresses. I was scared by their hurried tone and scared to push as hard as they wanted me to, but I did it because I figured they knew what they were doing. At no point was i told to slow down, only to push harder, which went against my (terrified) instincts. Well. The pushing stage lasted only 40 mins (my first labour). All 8lbs of baby shot out in one go and I got a third degree tear and hematoma requiring surgery, losing 1.5 ltrs of blood. I was in so much pain for weeks and my husband and I are traumatised. A few days after the birth the midwife who had delivered called me. She told me she’d thought about it and there was nothing she could have done to prevent a tear, and that the problem was that I was too anxious. But I was anxious because they were telling me to do something that I was scared would cause a tear! I spent weeks crying and having flashbacks and blaming myself. I still have ongoing problems from my injuries.
Please don’t blame yourself. Your labour was a normal OP labour (baby back-to-back): http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/
Directed pushing and birthing in a squatting position (birth stool) increase the chance of a 3rd degree tear. Your midwives are responsible for both of these interventions. I am sorry that you experienced this and sorry that you have been unfairly blamed for the outcome. Here are some other posts you may find interesting/relevant:
http://midwifethinking.com/2015/09/09/supporting-womens-instinctive-pushing-behaviour-during-birth/
http://midwifethinking.com/2010/08/07/perineal-protectors/
Thank you, it means a lot to hear that.
Very interesting writings on the premature pushing.
I am currently in a big dilemma as i’m into 36th week of my 2nd pregnacy. The complication is i’ve pelvic prolapse and my OB has repeatedly told me to go for epidural. Her explanation being, to avoid premature pushing and resulting in swollen cervix. I told her in my 1st pregnancy (a different OB), i tried (and was sure) to not make premature pushing and she said “that’s what all mothers said and they would still subconsciously push”. Of course, she said how would I then now have this prolapse issue!
I am hoping to go for non-epidural vaginal birth this time (which I did for 1st pregnancy) but she’s advising otherwise. While I have a preference, I wouldn’t want to be overly stubborn if epidural really can be of help to current prolapse problem. I’ve sought opinions of 3 other OBs who said epidural has no effect to help reduce further pelvic prolapse. I’m at a loss as my OB is supposedly with 20+ yrs of experience, delivering more than 10,000 babies!
What is your advice?
An epidural will not stop your body from ‘bearing down’. Women push with epidurals – they just can’t feel it as much (some do). An epidural also relaxes the pelvic muscles. Pelvic tone helps the baby to get into a good birth position = epidurals increase the chance of mal-position. I’d imagine this lack of tone could also increase the chance of prolapse if anything, rather than reduce it.
I’m sure your OB has a lot of experience of ‘delivering’ babies. I wonder how much experience she has of being present whilst a woman births her own baby instinctively and physiologically? OBs tend to do what they are used to and comfortable with (as do most practitioners) – this may or may not be evidence based.
When I was having my first baby, I was scared, clueless, and under the influence of “experienced laborers”, three women who had delivered at least three babies. Plus the doctors and nurses. I was two weeks overdue, do they gave me pitocin to start labor. I was in so much pain and I didn’t know how to appease it; the doctors advised me to stay in bed, the ladies told me to lay on my side and rest because I needed strength for the pushing. I couldn’t handle it by the time I got 4 cm, so I asked for drugs. And that’s what they gave me. I was hallucinating, plus feeling all the pain but unable to respond to it. By the time that started wearing off I was dilated to 6 and they offered an epidural, which two of the women encouraged. I went for it and the rest of the first stage was a blur to me. I could finally breathe and relax, it was heaven. But then came that ” I think I’m going to poop” feeling, and next I know there are a half dozen people folding me in half and another half dozen starting between my legs, and all 12 are screaming “PUSH, PUSH” and I’m pushing and pushing and trying desperately to get that baby out. I was sliced from front to back and still ripped half my rectum, and it took three hours of bearing down and gaping and then bearing down again before my little girl was born with “angel kisses” and “stork bite” bruising.
During my second pregnancy, I watched videos and read books and educated myself more about delivery options and such. I opted again for an epidural, but no strong drugs beforehand, and until it was time to get the epidural I experimented with different methods of relief. I found that rocking and focused breathing worked well for me, sitting up on my knees and rocking forward and back in time with my breathing. After the epidural was administered I was again euphorically laying in the bed until I felt the urge to push. This time I had a dozen people yelling “PUSH, PUSH” but I didn’t bear down as hard, I only folded up and grunted and panted through an hour of labor, letting my body do most of the work. And with no cutting AND no tearing I delivered an eight pound baby with NO bruising on her face.
I did the sitting and rocking until time to get the epidural again the next time. The epidural on my third baby didn’t do its job, and by the time the anesthesiologist for it right I was fully dilated and it was time to decrease it so I could feel the urges. I was already exhausted and had no energy to push, so I ignored the choruses of “PUSH, PUSH” and just laid there panting and had the occasional grunting automatic response of pushing. After a little more than an hour, I again had a flawless baby with no tearing. If the cord hadn’t been wrapped around, it would have been less than an hour, but I had to resist the urge to push and they had to push him back up a little and untangle the cord before his neck and shoulders came out.
I was asked to pant for several minutes and rolled to my side with a nurse holding my legs together. The doctor was 10 minutes away I was told!! When she arrived I was rolled over and my baby literally fell out, I was asked to push one time for his shoulders. He weighed 8#3oz
This was my four child. I had vaginally delivered twins 1.5 years prior and delivered my first child in 2002. I was trying to deliver without an epideral because I knew that Thomas would be our last child. I was induced and was in a great deal of pain for over 8 hours and was not progressing. The dr painfully broke my water!!? And then I regretfully asked for an epideral. It didn’t take long after that and it still bothers me even after a year in half, that the dr almost missed the birth of my child. And even as I begged for a dr to help me, the nurse insisted I wait?
I would like to know…., when I had my three children (different times, different ages) I NEVER had the urge to push with any of them, nor have my water broken until the doctor did it.
The first child came through natural labor (very painful), the second through cesarean (not painful), and the third natural labor again (very painful).
I haven’t found articles about not having an urge to push; Is this uncommon?
It is uncommon but many women do not have an urge to push and this is normal – just a variation. The uterus will push the baby out without the mother having urges or following her urges. It just may take a little longer.
Would love to know your thoughts on this during a breech vaginal birth. With my second whrn the urge to push came there was no resisting and it felt good to go with that force. My midwife was not present at that birth so there obviously was no one directing or guiding me. With my third birth I found out late in the game that baby was breech and a good sized baby (he was born weighing 11.1) There was some talk with one of my midwives prior to me going into labor about no active pushing so when the urge came there was some talk about “breathing” baby down which honestly is bullshit sorry if I offend anyone but either I am really bad at this breathing babies down or the people that are suggesting this have never experienced the force of an 11 pound baby being expels from their uterus lol. It made me very frustrated at this stage and I felt a bit out of control. His birth went well and he was born vaginally and healthy but I have always wondered if my experience would have been different if I had followed my own instincts.
I can’t comment on whether anything would be different. Practitioners are often worried about you pushing the baby through the cervix before it has opened enough to let the head come through. This only really happen with premature or small babies who have large heads and small bottoms. I would imagine your baby’s bottom was as large as his head.
🙂
Yes, his rump was measured after birth and it was either equal to or bigger than his head. I joked that his head was the easiest part. It was a hands off breech birth and was a great birth but man did I want to go with the urge! 🙂
Hi Rachel,
Thank you for this post. I am a third year student midwife doing my dissertation on the ‘impact of pushing before full dilatation’. I find it interesting that you have wrote ‘ 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.’ I was wondering if you would be able to provide a reference for this or know anywhere I can find more information about this?
Many thanks!
Sarra
Hi Sarra – I couldn’t find any written references re. this practice. I have cared for women who have done this – encouraged by family members. When I asked I was told it was ‘what we do’. I have also heard other midwives and women talk about this. You may have more luck if you search for fundal pressure… this often goes hand in hand with ‘pushing’. Some cultures use fundal pressure throughout labour along with maternal pushing. WHO may have something on it?
Thank you for this article! I’m a student midwife & have always been absolutely horrified when the midwives told a woman with epidural to push (taking deep breath, holding it, no sound, head on chest, back round, holding their own legs. 3 times in one contraction). Sometimes for more than 2 hours (counting from complete dilation). Usually mum and baby are distressed / exhausted, so vacuum extraction follows. I work in big clinic with many pathologies. Our doctors say the pushing instruction is to both save the woman’s pelvic floor from being fully dilated too long and to save a baby with stressed heart beat.
But in this case I wish I had more guidance – how to instruct a woman with epidural, giving birth first time, on how to push? Are there cases where it’s even necessary or should it be avoided no matter the fetal heart rate? What are alternatives?
With an epidural it is best to wait until the baby’s head is visible in the vagina. Then work with the woman re. whether she has sensations/pressure that she can ‘add to’ if the baby isn’t moving. Generally multips don’t need any direction with an epidural. Primps don’t either but require more patience because it will take longer. I have written about epidurals and pushing in my book Reclaiming Childbirth in the chapter on Medical Birth.