Artwork by Amanda Greavette
This article was published in The Practising Midwife journal in June 2015 along with ‘practice challenge’ questions for midwives (not included here).
Introduction
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).
Related posts: perineal protectors; pushing: leave it to the experts; the anterior cervical lip: how to ruin a perfectly good birth.
References
Aasheim V, Nilsen ABV, Lukasse M et al (2011). ‘Perineal techniques during the second stage of labour for reducing perineal trauma’. Coch Data Sys Rev, 12: CD006672. DOI: 10.1002/14651858.CD006672.pub2.
Aderhold K and Roberts JE (1991). ‘Phases of second stage labor: four descriptive case studies’. Jour Nurse- Midwif, 36(5): 267-275.
Aldrich C, D’Antona D, Spencer JAD et al (1995). ‘The effect of maternal pushing on fetal cerebral oxygenation and blood volume during the second stage of labour’. Brit Jour Obs Gyn, 102(6): 448-458.
Bergström L (1997). ‘”I gotta push. Please let me push”: social interactions during the change from the first to second stage of labour’. Birth, 24(3): 173-180.
Borrelli SE, Locatelli A and Nespoli A (2013). ‘Early pushing urge in labour and midwifery practice: a prospective observational study at an Italian maternity hospital’. Midwif, 29(8): 871-875.
Bosomworth A and Bettany-Saltikov J (2006). ‘Just take a deep breath: a review to compare the effects of spontaneous versus directed Valsalva pushing in the second stage of labour on maternal and fetal well- being’. MIDIRS Midwif Dig, 16(2): 157-165.
Downe S, Trent Midwives Research Group, Young C et al (2008). ‘The early pushing urge: practice and discourse’. In: Downe S (ed.). Normal childbirth: evidence and debate, 2nd edition. London: Churchill Livingstone: Elsevier.
Kopas LM (2014). ‘A review of evidence-based practices for management of the second stage of labour’. Jour Midwif Wom Health, 59(3): 264-276.
NICE (2014). Intrapartum care: care of healthy women and their babies during childbirth. NICE clinical guideline 190, London: NICE.
Prins M, Boxem J, Lucas C et al (2011). ‘Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trails’. BJOG, 118(6): 662-670.
Roberts J, Goldstein S, Gruener JS et al (1987). ‘A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor’. Jour Obs, Gyn Neon Nursing, 16(1): 48-55.
Tieks FP, Lam AM, Matta BF et al (1995). ‘Effects of valsalva maneuver on cerebral circultation in healthy adults: a transcranial doppler study’. Stroke, 26(8): 1386-1392.
Yildirim G and Beji NK (2008). ‘Effects of pushing techniques in birth on mother and fetus: a randomized study’. Birth, 35(1): 25-30.
Fantastic overview of the benefits of leaving woman alone to push. thank you
Love this, thank you Rachel. I was told to ‘stop pushing’ with my first baby as I was 9 1/2 cm’s with an anterior lip.. I then had to try to not push for 30 minutes, it was the most exhausting, disempowering and painful part of my labour. Nothing changed in that 30mins and then they said “ok try pushing now anyway and see how we go” my baby was born with breathing distress.. I wonder how that 30mins was for him.. he’d probably have been born in that time if I’d continued with the urge of my body. I was so exhausted when I was “allowed” to push, it took a long time.. Thanks for all you do.. love x x x
🙂 x
Thank you for this gentle reminder as to how to empower women during their labours. How you would recommend ensuring a woman pushes effectively or guiding a woman who looks to her midwife for instruction? What phrases would you use?
This is a difficult situation and not uncommon. Women have been taught and reinforced that they need ‘external expertise’ to birth. They often then turn to the ‘external expert’ to give them instructions about pushing. When women ask me to tell them how to push I see it as an opportunity to reinforce their expertise rather than my own. If this is a woman I don’t know ie. on birth suite – not continuity of care then this approach needs to ‘set up’ in that first introductory time at handover or admission. I usually tell women that they are doing an amazing job of birthing their baby so I will not be saying anything (unless necessary) so they can focus on what their body is doing – I don’t want to interrupt them. If they then ask while they are pushing I would say something along the lines of “I can’t tell you how to push – your baby is inside you and your body knows how to do this. Don’t ‘try’ – just follow. You are doing great.” Of course the exact phrase will depend on the woman and situation.
In terms of women not pushing ‘effectively’ – this is very rare during undisturbed physiological birth. I have only really seen it when women are attempting to ‘breath their baby out’ ie. hypnobirthing style… or with an epidural. In the case of hypnobirthing – a gentle reminder that they can follow that downward guttural push… and I’ll demonstrate 😉 With an epidural – it is best left until the head is visible then you sometimes do need to provide direction – but not for long as the head is already close.
During my labour the thing that I really loved to hear was “go with it”. When I was starting to push I was really confused, I kept feeling a bit lost (I had a similar don’t push you aren’t fully dilated thing) once I was meant to be pushing I felt like I wasn’t quite sure what I was doing. A lovely midwife kept saying to me “That’s it, go with it” and that felt like what was happening – I was along for the ride and I just had to let it happen.
I am wondering if you can comment on ‘cervical swelling’ which is often cited as a possible side effect of early pushing? As a doula, I am not doing cervical exams, but I have had many clients told that their cervix had become swollen because of pushing without full dilation.
You can read more about his here http://midwifethinking.com/2011/01/22/the-anterior-cervical-lip-how-to-ruin-a-perfectly-good-birth/
Basically there is no evidence that spontaneous pushing will swell a cervix.
Yes!!! Directing women in birth is like directing women in having an orgasm!
Thanks for such a fab article. I find this a really tough issue as a student midwife, when all I see is directed pushing with Valsalva, and I’m seen as “not participating” or “lacking confidence” for not directing the woman’s pushing and ‘cheerleading’ the baby out. In a busy labour ward it’s hard to find the opportunity (and words) to discuss this with mentors, especially with a different mentor every shift. It’s a tough choice between evidence-based belief in the woman’s body, and following the directed pushing culture in order to pass placements. Got any advice for students in this situation?
I directed pushing when I was a student… I even got a written compliment in my clinical assessment book about what a great coach I was! I didn’t know then what I know now. It can be really difficult to experience instinctive birth if you are in a setting that does not support it. A few tips: It is likely there are midwives secretly practising in a supportive way – if you can find one, ask to partner with her. If you have a friendly mentor for a shift explain what you have been learning about the evidence for management of the ‘second stage’ and ask if you can try it with the next woman you care for. And/or you could say to the woman – “you are doing a great job of birthing so I am going to keep quiet and let you focus on your body” – this may dissuade your mentor from launching into cheerleading or encouraging you to. Or, worst case scenario – do what fits the culture and pass, learn how not to do it… then when you are qualified do differently. You don’t have a lot of power as a student – it is frustrating – but you will be a midwife soon 🙂
I hear you Anna! I have this issue all the time. I had a midwife yell at me “well, aren’t you going to coach her through pushing?!” – this particular woman was on all fours, leaning on her husband, they were totally in the moment and she was doing brilliantly. I was stunned and said, well no, I wasn’t going to, she seems to be doing well don’t you think? We need to stick to our guns! It’s one thing if a woman has had an epidural, but if she is birthing and there is no need to say anything, I just let them know I am there if needed, they are doing an amazing job, listen to your body etc. Hopefully the cultural shift will happen on our watch. 😉
As a midwife I encourage self directed pushing as much as possible but the problem arises with hospital policies and guidelines which have time limits on length of second stage. I never do vaginal exams to confirm full dilatation and don’t always give the correct time at the onset of involuntary pushing. However if the doctor comes in, sees a few contractions with ‘no progress’ they are very likely to take over and start directed pushing. Anything over an hour of pushing requires constant fetal monitoring. It’s very difficult in a hospital situation to ‘allow’ a woman to follow her instincts.
I know how hard it can be in a hospital setting… I worked for many years in hospitals. You can only do your best within the constraints you are given. In some settings the ‘institution’ is open to evaluating policies and implementing evidence. I was lucky to work in one hospital that – after the team (midwives, obstetricians, etc.) looked at the research – took away the arbitrary time limits for pushing. Decisions about when to intervene were made on an individual basis. This is why it is so important for midwives to get into research and understand evidence enough to argue their corner. Keep doing what you can 🙂
Finally some literature to support what we have known for centuries. Allow women to birth intuitively, with our support! I can’t wait to print this article & display in our staff room!
I appreciate your insight and research on this subject. I was wondering what your thoughts would be in cases where the mother has reached full dilation and is exhausted before she is experiencing the urge to push. As we know it could mean a few more hours of labor before she reaches the stage where she begins pushing involuntarily. In a case like this where there is maternal and possibly fetal exhaustion would you consider directed pushing to bring the baby down until the mother begins to feel the urge to push? Or would this be a situation where you would refer care to an obstetrician? Thank you again for sharing your research with the midwifery community.
It is common to have a lull in contractions at the end of labour before pushing starts – this is the ‘rest and be thankful’ stage. And most women are ‘exhausted’ at the end of labour – they have high levels of endorphins circulating which create a spaced out, sleepy state. However, I don’t think the concept of ‘active birth’ helps in some cases – women are encouraged to keep moving about in early labour rather than rest, and they end up physically tired by the time labour establishes. Luckily the birth of the baby is not reliant on energy – women can birth babies whilst in comas.
If a woman has reached an exhausted state and is fully dilated (not sure why you would do a VE on a woman having a physiological birth: http://midwifethinking.com/2015/05/02/vaginal-examinations-a-symptom-of-a-cervix-centric-birth-culture/) – then help her get comfortable and make the most of the rest between contractions (if they’ve spaced out). I don’t understand the rationale of getting a woman who is ‘exhausted’ to start doing something that is exhausting (directed pushing) and creates fetal hypoxia, and that doesn’t speed up the birth significantly. The uterus will bring the baby down as it continues to get smaller with contractions – once baby hits the right spot, mother will push regardless of ‘exhaustion’. Timeframes for the ‘second stage’ should take into consideration the station of the baby. A baby who is ‘on the perineum’ should be born fairly quickly (within approx an hour) – as spending a prolonged time in this place = increased pressure to baby’s head and mother’s perineal muscles. However, a baby who is not in the vagina at full dilatation ie. still up in the uterus = no different to a baby not in the vagina at 4cm. There is no rush. I think this highlights the need to stop evaluating labour progress by what the cervix is doing (see linked post) 🙂
Thank you for your point of view and expertise on this. You are right that we get too fixated on the cervix. When the labouring mother can be encouraged to continue to trust her body birth goes so much more smoothly. I wish all of the mothers who delivered with us could feel this confidence in themselves and the process.
The other day I was working with a group of parents, running their antenatal course. We were talking about pushing and all the images they see on TV of directed pushing. Some found it hard to believe me when I was explaining how and why it was helpful to listen to their bodies and instincts and to work with, not against, the messages from their bodies. They found it hard to accept that there is no evidence to support the routine use of directed pushing. When talking about the baby’s head crowning and how midwives often “instruct” women to open their legs, pant, maybe “guard the perineum”, etc to slow things down to reduce the risk of tearing I found myself saying that women do know what to do, even if it is their first baby. As an example I told them that if you were doing a poo that felt a bit big and wide for your bum, you don’t need anyone to instruct you how to release it with least damage. You instinctively “hold back”, do little pushes, change your breathing,etc. It may not be the best analogy, but it did resonate with everyone! I love your articles. They’re clear and sensible. Thank you.
Having had three very different births (the first was an ’emergency’ c/s after being messed about with and induced unnecessarily 🙁 my second was at home with some directed pushing, to my most recent where my daughter came so quickly at home that the Midwives hadn’t arrived yet, I found that my body was (unsurprisingly) highly adept at pushing when I needed to, and the only thing I had to consider was getting my husband to put the phone on speaker so he could use both hands to catch her. I had 2nd degree tears with both 2nd and third births, so I don’t think it made any difference to the tearing having the direction.
Thanks so much for sharing your research, since my first birth cock up (with a beautiful result I hasten to add) I have got slightly militant in knowing my facts and the latest research to aid my own experience and help empower my friends, and your blog has helped a lot.
Fascinating reading and confirms what I imagine quite a few mums know looking back ( myself especially! I birthed my breech baby with far too much direction – this resonates greatly with my experience).
T hank you for sharing 🙂
thank you so much for all of your amazing articles they have changed my life, especially this one on pushing and also the one on cervical lips. I’ve recently had a baby (vba2c) and was frightened because I had crazy strong urges to push at 4cm. Tried as a may I could not stop pushing which really concerned my midwife and then me. My previous birth I had the urge to push at 4cm with a big anterior lip, which then resulted in another C-section. Although I achieved my dream of a vaginal birth and felt very supported, the possibility of having these urges at only 4cm again made me nervous to ever give birth again. These articles give me comfort, healing and so much hope.
Thanks again
Isnât it about time!! LOVE you!
Love,
Jan Tritten
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A respectful celebration of birth – thank you. What about with breech birth? Would that be the exception to make sure there is full dilation before pushing?
Opinion is divided about VEs during breech birth. Not being an expert in this area… I’d suggest yes with a premature baby who’s head can be bigger than his bottom ie. chance his bottom could be born before his head can get through the cervix. With a full term baby – if the pelvis can get through the cervix, the head can. So, what would be the point of a VE? If the woman is ‘pushing’ then what harm can she do? And if she can’t stop pushing why tell her to stop? The last thing you want to do during a breech birth is interfere with the woman’s instincts and physiology 🙂
That is helpful! Thank you.
One anecdote: I had one VE during my breech birth, to check for the presenting part. (Nothing to do with the VE, but) shortly afterwards I turned to the IMs to say that I could feel that the baby was no longer moving down, in fact it felt like she was moving back up. They moved me to a birthing stool (from all fours) and I immediately had a huge contraction – the only really painful one – and the baby soon made an appearance. She was bruised on one hip, so I took from that that she’d been moving down but not in a great position until I changed mine.
Ohh such wonderful reading!! When I gave birth to my third child, I screamed a lot during my pushing and I remember feeling surprised there and then, because the midwife never told me to “Be quiet in order to not let the power out through the mouth”, which had been the case during my two first labours.
When I asked her about it afterwards, she told me that she could tell I did exactly what my body needed, that my screams and letting a bit of the power out through them were letting my baby be born in a good pace.
Thank you for this article!
Mona, Sweden
My daughter, with her first baby refused to go to classes to learn about labour and how to cope with pain, she refused all except the bare minimum AN care, one scan to locate the placenta, one set of bloods because she couldn’t work out whether or not they were truly necessary and thought reassurance would be nice. When labour began she came over to my house and laboured serenely, just withdrawing into the growing contractions and resting between. We had cups of tea and watched pictures in the fire. Around dawn she felt happy that the labour was established, we called the midwife around seven and the baby arrived around ten am. She was totally in control and yet there was still some impulse for the midwives to direct her. After they had gone she said, “next time just tell them to drop off the gas and air and I’ll let them know when the baby’s out”. She found being talked to a nuisance, an irritation.
The interference continued with many PN visits, all offering quite impossible, bossy advice around feeding times and techniques. She disregarded all that too. Her baby is one of the most well grown, alert, happy, intelligent of children. He’s happy, and so she is happy. I am full of admiration.
I have also found that women who have no antenatal ‘education’ often find it easier to birth instinctively. The can just ‘let go’ of their neocortex and follow their body moment to moment rather than thinking about what they have learned or about coping techniques.
Many of us focus on this when working antenatally with parents. Sharing a little information so they have ticked the cognitive box they were expecting, but then concentrating on the value of ‘letting go’, and their innate ability to birth – in fact at NCT our training as antenatal practitioners requires us to believe in and share this 🙂 .
Having said all that, of course many women don’t feel the need for ‘education’, and that’s wonderful too. I look forward to a world where we are obsolete, as all women feel beautifully supported by their families and midwives.
Ohh such wonderful reading!! When I gave birth to my third child, I screamed a lot during my pushing and I remember feeling surprised there and then, because the midwife never told me to “Be quiet in order to not let the power out through the mouth”, which had been the case during my two first labours.
When I asked her about it afterwards, she told me that she could tell I did exactly what my body needed, that my screams and letting a bit of the power out through the mouth were letting my baby be born in a good pace.
Thank you for this article!
Mona, Sweden
Wonderful article! Can I ask what your advice would be regarding mums who have had an epidural and have lost a lot of their natural pushing sensation? I’m a student midwife in an extremely high risk and medicalised unit where they are very strict about duration of time to allow a woman to push. I recently had a nullip who was fully dilated with an epidural, we allowed 2 hours for descent of the head as per hospital protocol, had been doing directed pushing for 45 minutes as she couldn’t feel a thing (and actually very good pushing too), only for a doctor to come in and demand a trial forceps in theatre. In vain did I point out that hospital guidelines allowed up to an hour and a half pushing before seeking medical advice, or the beautiful CTG that showed that the baby was clearly not in hypoxia. We got taken to theatre, only for her to end up with a caesarean. I was so disappointed for her – she had such a clear idea of what she wanted and I feel like I failed her by not being able to halt the process. 🙁 The trouble is they rely so much on timings and stages at the hospital, and I understand in some high risk scenarios it i appropriate, but I do feel it constrains normal labour.
A woman with an epidural is not having a physiological birth. The evidence based approach – to improve the chance of a vaginal birth – is passive descent. The research regarding how ‘passive descent’ is defined varies – from 1 hour to 4 hours. I worked in a hospital that did not commence active pushing until the baby’s head was on view (monitoring for progress of descent hourly). This significantly reduced fetal distress, instrumental delivery and c-section. Even if in your case, the hospital had adhered to medical time frames for ‘active pushing’ – a primip is not considered to need intervention until 3 hours (if mother/baby is well). You as a student (and the woman) are powerless in the system. However, the woman’s midwife needs to make sure that she understands what is being suggested and why + is given adequate evidence-based information about her options and circumstances (ie. your baby is well, the policy/recommendation is not evidence based). And that she can decline recommendations… and the midwife will support her wishes. It really is not up to the doctor to demand anything. Midwives need to stand with women against bullying and poor practice.
http://www.ncbi.nlm.nih.gov/pubmed/18226152
http://www.ncbi.nlm.nih.gov/pubmed/24850283
This is an excellent article on something I’ve been thinking about. Having watched many births, I’ve always felt uncomfortable when I hear the midwife or doctor directing a mother to push or not to push. How would they know?? The mother and baby know best as to when to push and how to be most effective; I’m so glad that I didn’t have that kind of midwife and that I was trained well in the Bradley Method to trust in my body. Like someone else mentioned already, it is so important to get proper education regarding birth! It doesn’t really come naturally anymore because women don’t see normal births anymore. They really need to stop perpetuating the idea that women need to be told when and how hard to push. Do you have any good recommended videos that I could show my Bradley students without the doctor/midwife instructing the pushing stage?
~Lillian from yournaturalbirth.co.uk
I agree and disagree… birth does still come naturally – it is an instinctive and natural process. The problem is we try and do it in environments and with people that constantly disturb and interrupt our instincts. If we didn’t we wouldn’t have to learn anything – we could just birth regardless of whether we had seen a birth or not. I have looked after women who have had absolutely no education and refused to watch a birth. They birthed beautifully and just followed their body and instincts.
There are some good birth movies out there – I suggest you search for ‘unassisted birth’ or ‘freebirth’. Unfortunately most movies of births attended by care providers involve directed pushing and/or other interventions. Here are a couple: http://www.documentingdelight.com/2014/07/09/eddies-birth-homebirth/ (a birth I attended) and a freebirth https://www.youtube.com/watch?v=3payaTlwk-Y 🙂
Thank you so much!
thank you Rachel, you are the first midwife who said that putting legs together during natural pushing is normal and we don’t need to interfere xx
I love this article and I love reading your posts. I had you for one of my subjects at USC in 2010-11 for nursing. You inspired me to become a midwife and installed my passion for midwifery. I loved attending your classes and hearing all your experiences and knowledge with labour and birth. I am now in my grad year as a midwife and I LOVE it. And I love being able to read your articles to help me know how I can provide better care for women in labour/birth. So thank you! 🙂
Thank you – it is so lovely to hear from an x-student and know that you have gone on to become a midwife. I often feel really demoralised about the maternity system. However, knowing that there is a new generation of midwives who are committed to woman centred care gives me the motivation to keep teaching and writing. Keep up the good work 🙂
Back again to my most favourite website. Having my second home birth I hope but I need help with something from my last birth.
I was dosed up on gas and air as I really was in pain. Probably more than normal. My labour was 12 hours in my eyes, almost half of that from when midwives arrived so failry quick for a ftm. However by my 10 hours I was so fed up with that stuck feeling (a huge pressure which I thought would not be able to pass). I guess my contractions were really close by then as I reached for the g&a frequently so the midwives at that time asked if they could check for dilation. I had refused several times with the other midwives but by this point I was fed up, probably impatient. They checked, worst feeling ever never ever want that again and said I was ready really, sort of like I don’t need to delay by letting my body do it, I can push. I knew full well not to do controlled pushing but I was so fed up I listened to them and baby birthed within an hour of be trying hard to push during contractions. I didn’t feel any urge to bear down and push or anything like that during this time.However when I talk to friends who had pitocin so had gone to sleep for a few hours, the way they describe their urge to push is the way I describe that stuck feeling but to me it was stuck, not wanting to come out. Is it because I had so much gas and air? Honestly when they describe it I think that’s how I felt but I didn’t think of it as a natural urge to push at all, I feel like that off the edge was taken away from the gas and air? How can I stop myself from giving up next time? I know I had a amazing birth but man I lost a lot of blood!
Even if I had a lot of g and a, I guess my body will still birth the baby whether I feel it’s coming out or not? Ah so hard to explain.
I’m not sure why you experienced this. Could have just been your version of a ‘pushing’ urge… might have been the G&A interfering with your perception of what your body was doing (usually it does not do this). Seems like it was quick for a ftm and I wouldn’t worry about next time. And yes – your body will birth your baby regardless, even if you are in a coma 😉
Great read! The urge to push is something we feel is incredibly important to guide the mother through. Please give our blog a read sometime and we look forward to your next post. http://www.confluencemidwifery.com/blog/
I loved this so much (as with most of your blog!) I was involuntarily “pushing” before my midwife arrived (she had left 2 hours earlier, thinking I was still in early labor.) When she did come back, 45 minutes before my daughter was born, she told me that there was still a bit of cervical lip, but that she suspected that I should keep pushing and it was “disappear on it’s own.” I found this extremely gratifying since, as stated, I’d already been pushing when no one had been around to tell me whether that was “good” or not.
Interestingly, I talked with another woman who had used the same midwife who told me that our same midwife had told her, also at 9.5cm, NOT to push. This worked for my friend seeing as she had no urge yet to push herself.
The key takeaway, for me, is to have a team of people who help you trust yourself. And who know what they’re doing too, of course. But ultimately, a team whose knowledge, study and experience serve to aid you in doing what you do naturally during your own birth.
This is so right 🙂
… and the faster midwives move away from using the cervix as a measurement (along with invasive VEs) the better. You either trust the birthing woman or you trust an arbitrary measurement!
Thanks so much for this article. The information given to pregnant women by health professionals is often misguided. I wish there were more people out there helping to promote the points you made in this post. I got some valuable information from this article and plan to use it as a reference. 🙂
I would love to implement more natural breathing and pushing techniques in my practice. However, with the high rate of epidurals and inductions at our hospital it seems as though this approach would be difficult. If the woman can’t feel much, being desensitized from an epidural, then directed pushing really seems to be the only option. What advice do you have?
If a woman has an epidural and/or syntocinon she is not having a physiological birth. This is a totally different scenario to the focus of my post ie. supporting physiological and instinctive birth. With syntocinon the woman’s body will not be responding to the biofeedback of her stretching tissues by altering her contraction pattern and strength. With an epidural she is not getting the biofeedback that initiates instinctive behaviours. The best way to improve outcomes with an epidural (and synt) is to not direct pushing until the baby’s head is visible at the vagina – limiting the time spent doing direct pushing – and assist a slow birth with position (eg. left lateral) or guidance to breathe rather than push. Occasionally you may need to put your hand on the baby’s head to slow him/her down (with consent from the mother). Hope that helps 🙂
My question to this is that much UK guidance states that once a woman (with an epidural, which most have when on synto) is confirmed to be ‘fully’ by vaginal examination, she is ‘given’ one hour to allow for decent of the head and then active pushing is commenced. It would be extremely hard to provide a rationale for waiting until vertex is visible to commence directed pushing.
You need to provide a rationale for an intervention… not for doing nothing. This is a symptom of the back-to-front ‘evidence-based’ paradigm in maternity care.
There is plenty of research to demonstrate that passive descent improves outcomes. Some of these studies used a delay of 2 hours or more before pushing. There is lots of evidence re. the poor outcomes and complications associated with direct pushing. I worked in a hospital that had a policy of waiting until the vertex was visible (of course making sure progress was happening during that wait). So, this approach is possible and effective.
I would be asking for evidence to support pushing after only 1 hour.
If women and midwives started demanding evidence from those proposing interventions, rather than trying to find evidence to support not intervening…. we might get a shift in this paradigm 🙂
Another fantastic post. Thought provoking and evidence based. We, as midwives, need to stop telling women what to do in labour ward.
Have just shared this with my uni cohort. Fascinating read. Am writing about directed pushing and its relation to perineal trauma for my disseration so this is excellent.
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I’m writing my dissertation on midwifery care in the second stage with an epidural in situ. I feel uneasy telling women to push, however I recognise that some women want an epidural, therefore wanting to come up with evidence based way of supporting them. What are you thoughts on epidural and second stage midwifery? Thank you x
Check the comments in this thread… I’m pretty sure I’ve answered re. the evidence-based approach for epidural births.
Epidural alters birth physiology and removes instinctive pushing. It is an intervention that requires further intervention. Women need to be assisted to change position lots, techniques for creating space in the pelvis to assist with descent / rotation of baby (rebozzo etc.) It is hard work for care providers and should be.
In terms of ‘pushing’… the evidence = wait until you can see the baby’s head at the vaginal opening. Primips may birth quicker if they push with contractions at this point. Not Valsalva though. Alternatively you could wait until the uterus pushes the baby out. Up to the woman. 🙂
What would lead to someone not getting an urge to push when otherwise experiencing a physiological birth? I experienced a very long, beautiful private labour at home and I could feel the baby’s head with my index finger but an irresistible urge to push never came, eventually after 50 hours of active labour I decided to give pushing a try on the times when I felt a light urge, but after 5 hours I lost confidence that my body was going to be able to get the baby out and I went to hospital where I was give syntoconin and they used forceps to get baby out. I felt baby move and also intuitively felt baby was ok the whole time despite my water breaking just before active labour began. Between the light urges to push contractions, I felt some contractions that my were extremely painful and almost felt unsafe to push on if that makes sense. This was my fourth baby born alive, first baby I was induced and had epidural, second natural labour no drugs also urge not strong enough and given syntocinon and bub was born with directed pushing, third baby was cs due to grade 4 placenta previa. This fourth baby I felt confident and empowered and thought I had set myself up to experience a physiological birth but it didn’t happen. When I felt for baby myself, it felt as though baby was looking sideways and I could feel forehead but my understanding was that listening to my body’s natural impulses and contractions would rotate baby. I guess I’ve lost confidence that my body will ever have strong enough contractions to birth a baby naturally and the thought of subjecting any more babies to the hospital system is preventing me from thinking of having another baby. Thank you for any suggestions about this, I’m not sure where else to look.
Also one other thing I would say I went through transition ( or at least my previous symptoms of transition) three separate times, vomiting, shaking and then a small period of rest and I first checked to feel the baby’s head with my finger after the second time.