This article was published in The Practising Midwife journal in June 2015 along with ‘practice challenge’ questions for midwives (not included here).
Clinical guidelines recommend that women should be guided by their own pushing urges during birth (National Institute for Health and Care Excellence (NICE) 2014). However, directing women’s pushing behaviour has become a cultural norm within maternity care. Women are still told when to push, when not to push and how to push. In order to promote and support physiological birth we need to reconsider the assumptions underpinning this practice. In addition, we need to reflect on how this practice influences women’s experience of birth. This article discusses supporting instinctive pushing behaviour during uncomplicated, physiological birth.
The current discourse around pushing and cervical dilatation is underpinned by a mechanistic understanding of the birth process: that the cervix opens first, then the baby is pushed through the vagina. However, this does not reflect the multidimensional and individual nature of birth physiology. Descent, rotation and cervical dilatation happen at varying rates, and are not necessarily related.
The urge to push is initiated by the position of the baby’s head within the pelvis (Roberts et al 1987). Therefore, the cervix can be fully dilated without the baby descending deep enough to initiate an urge to push. Alternatively, spontaneous pushing can begin before the cervix is fully dilated. Directing a woman to push or not to push fails to support the individual physiology of her body and birth process. In addition, it contradicts the notion that women are the experts in their own births.
Directing women to push
Once full dilatation of the cervix is identified or suspected, it is common practice to direct women’s pushing behaviour in an attempt to aid descent of the baby. Pushing directions usually involve instructions to use Valsalva pushing, or a variation of this method which includes: taking a deep breath as a contraction begins; holding the breath by closing the glottis; bearing down forcefully for eight to ten seconds (into the bottom); quickly releasing the breath; taking another deep breath and repeating this sequence until the contraction has ended (Yildirim and Beji 2008). Directed pushing was introduced in an attempt to shorten the duration of the ‘second stage of labour’ in the belief that this would improve outcomes for women and babies (Bosomworth and Bettany-Saltikov 2006). This type of pushing has been found to have a number of detrimental consequences for women including alterations to circulation (Tieks et al 1995), and increased perineal trauma and long-term effects on bladder function and pelvic floor health (Bosomworth and Bettany- Saltikov 2006; Kopas 2014).
Valsalva pushing may also reduce oxygen circulating via the placenta to the baby (Aldrich et al 1995). Current research reviews do not identify a significant impact of directed pushing on fetal wellbeing, but further research is needed (Kopas 2014; Prins et al 2011).
In addition, Valsalva pushing does not reflect how women push instinctively (Kopas 2014). Instinctive pushing does not commence at the start of contractions, and women do not take a deep breath before pushing: women alter their pushing behaviours, and use a mixture of closed glottis and open glottis pushing. The number of pushes per contraction also varies, with women not pushing at all during some contractions. Women also instinctively alter pushes according to their contraction pattern. For example, if contractions are infrequent women tend to use more pushes per contraction, and if contractions are frequent they push less often. This individual and instinctive pattern of pushing helps to oxygenate the baby more effectively than Valsalva pushing.
Directing women not to push
Some women will instinctively push before their cervix is fully dilated. This is often treated as a complication, and a common approach is to encourage the woman to stop pushing due to fear that cervical damage will occur. However, there is no evidence to support this concern. Two studies examined pushing before full dilatation and found that between 20-40 per cent of women experienced an ‘early urge to push’ (Borrelli et al 2013; Downe et al 2008). Borrelli et al (2013) found that the sooner the midwife performed a vaginal examination in response to a woman’s urge to push, the more likely they were to find an undilated cervix. They also found that ‘early pushing’ was much more common for primiparous women, and occurred in 41 per cent of women with babies in an occipito posterior position. Both studies conclude that an ‘early urge to push’ is a normal variation and is not associated with complications. Perhaps there is a physiological advantage for ‘early’ pushing in some circumstances? For example, additional downward pressure may assist the baby to rotate into an anterior position, or assist with cervical dilatation.
The impact of telling a woman not to push when her body is pushing also needs to be considered. Once the baby is applying pressure to the nerves in the pelvis that initiate pushing, the woman is unable to control the urge. Attempting not to push at this point is like trying not to blink or breathe. In addition, telling a woman not to push when her body is instinctively pushing suggests that her body is wrong, and that she needs to resist her urges. After resisting her body’s urges, she may find it difficult to switch into trusting and following her body once given the ‘go ahead’ (Bergstrom et al 1997). Encouraging a woman not to push when she is instinctively pushing can be distressing and disempowering for her.
Another situation in which women are encouraged not to push is during crowning. The rationale is to minimise the chance of perineal trauma by slowing down the birth of the baby’s head. A slow birth of the head reduces the chance of tearing as it allows the perineal tissues to gently stretch over time (Aasheim et al 2012). A number of techniques have emerged aimed at slowing down the birth of the baby’s head, including instructions and hands-on approaches. However, these approaches fail to acknowledge instinctive birthing behaviour. There is one study examining what women do during birth when following their instincts (Aderhold and Roberts 1991). This very small study of four women birthing without instructions found that they altered their own breathing and stopped pushing as the baby’s head crowned. This is consistent with my own observations of undisturbed birth. The intense sensations experienced during crowning usually result in the woman ‘holding back’ while the uterus continues to push the baby out slowly and gently. In addition, women will often hold their baby’s head and/or their vulva during crowning. Some women will bring their legs closer together, not only slowing the birth but also providing more ‘give’ in the perineal tissues. Telling a woman to ‘stop pushing’, to ‘pant’ or to ‘give little pushes’ distracts her at a crucial moment and suggests that you are the expert in her birth. Instructing her to open her legs to ‘give the baby room’ contradicts her instinct to protect her own perineum by closing them.
Conclusion and suggestions for practice
Evidence supports the notion that women instinctively push in the most effective and safe way for themselves and their babies during birth. A birthing woman is the expert regarding when and how she pushes. Providing directions implies she needs our guidance and that we are the experts. Facilitating women’s instinctive birthing behaviours rather than directing them is evidence based and reinforces women’s innate ability to birth.
Suggestions for practice:
- Include information about the physiology of birth in antenatal education/preparation. Reinforce the message that women have an innate ability to birth without direction.
- Provide an environment that facilitates physiological birth and instinctive behaviour – low lighting, minimal disturbance, comfortable furniture that supports mobility and movement (floor mats, beanbags, birth pool, shower).
- Avoid asking the woman if she needs to push, or feels ‘pushy’ as this may suggest that she should and could interfere with her inward focus and instinctive behaviour.
- If the woman tells you she feels the urge to push, reassure her that this is good, but don’t encourage her to push. There will come a point when she is spontaneously pushing rather than feeling an urge to.
- Avoid vaginal examinations to ‘diagnose’ full dilatation. If you are not going to provide instructions about pushing based on cervical dilatation, there is no benefit in knowing this information.
- Do not disturb the woman’s instinctive pattern of pushing and breathing. Avoid directions and, if you must speak, gently reinforce her ability to birth.
- Avoid directions or distractions as the baby’s head is emerging to facilitate the woman’s instinctive perineal protecting behaviours (such as gasping, screaming, closing her legs, holding her baby and perineum).
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