Stage II: The Pushing Stage

CORRECT PROCEDURE To Push

Forget everything you think you know about the pushing stage.  Erase all images of panting women flat on their backs, legs in stirrups, holding their breath and turning purple as they push with all their might from your mind. It's time to learn the correct way to push out a baby: let the uterus do the work.

Here's the list of don'ts for this phase:

• DON'T HOLD YOUR BREATH
• DON'T LAY ON YOUR BACK
• DON'T LET SOMEONE HOLD BACK YOUR LEGS
• DON'T COUNT THE LENGTH OF A PUSH
• DON'T PUSH WHEN YOU DON'T FEEL THE URGE

Even a woman in a coma can birth a baby:  her body will do the work.  Women truly don't need to add much extra pushing stage effort when the muscles of her body are allowed to work in harmony as they were designed. The key components of a comfortable, speedy pushing stage are birth position, breathing patterns and perineal support measures.

1.  USE AN EFFECTIVE BIRTH POSITION

2.  LEARN HOW TO CORRECTLY PUSH & BREATHE

When you feel the "urge to push", the sensation you feel is really your uterus telling you that it is already pushing the baby out.  Your response to this sensation is the critical factor.  Despite common perception, the pushing stage does not use the same muscle relationship as when having a bowel movement.  You don't have to "bear down" and you most definitely don't want to hold your breath.  If you aren't getting oxygen, then neither is your baby. The best scenario is letting the baby drift down in a slow, controlled fashion.  This is the best case for several reasons:

• It allows tissues to slowly stretch.
• It is easier on the baby.
• You conserve energy.
• You minimize risks of tearing.
• It's more comfortable.
  
• Recovery time is decreased.
• You can avoid the "ring of fire" that some women describe when the baby crowns.

Breathing the Baby Down Procedure

KEEP YOUR MOUTH OPEN AND THROAT/JAW RELAXED.

• When your jaw is tense, so is your perineum.  It's an involuntary reaction called the Sphincter Law and is something you most definitely want to avoid.

PLACE A HAND ON TOP OF YOUR ABDOMEN, JUST UNDER YOUR BUST.

• As you feel the urge, tighten just the top of your abdomen under your hand. This will ensure that your perineum stays relaxed.

EXHALE THROUGH YOUR BODY, SENDING BREATH DOWN TOWARD THE BABY

• This step can be very confusing.  You are not trying to blow the breath out your mouth but instead let it flow down through your body.  It can help to say a whispered "o" or "ah" sound as you exhale. This will in turn help keep your head/neck/jaw relaxed which in turn will help relax your perineum as well. Daily practice with a relaxation script is advisable to develop this skill until it becomes an automatic conditioned response.

WHAT & HOW YOU MAY FEEL

• Very Comfortable but Strong Pushing Contractions
• Urge to Push
• Sense of Intensity
• Pressure
• Invigorated

BEHAVIOR & ATTITUDE

• Sense of Relief
• More Comfortable
• Focused 
• Excited

MANAGEMENT STRATEGIES

The key to pushing is coordinated breathing and effective positioning to help your uterus work as efficiently as possible.  In some cases, the pushing stage can be a long process.  This usually occurs when pushing began before the true urge to push started.  To prevent this, wait for your body to signal that it is ready to push, not the reverse.  Being dilated to 10 centimeters alone doesn't mean you have to begin pushing.  You can let the baby drift on its own for as long as it feels right.  Remember, your birthing instinct knows best.

WHAT YOU MIGHT DO

• Change Positions Frequently
• Use Your Breath
• Request a Mirror to Watch (Great Motivator!)
• Touch Your Baby's Head as it Crowns

WHAT YOUR Birth COMPANION MIGHT DO

• Stay with You
• Prevent the Staff from Using Ineffective Positions
• Be on Episiotomy Alert
• Suggest Perineal Support
• Advocate for You
• Place a Hand Under Your Bust to Remind You Where to Build Tension
• Catch the Baby

Minimize the Risk of Tearing

Second to choosing effective birth positions, perineal support is the key to reducing or eliminating the risk of tearing.  Good perineal preparation starts in pregnancy with daily perineal massage and kegel exercises.  However, there are other techniques you can use when pushing to keep the perineum intact.

As the baby is descending, your care provider can apply warm compresses directly to the perineum.  This will help you relax and let you work effectively at allowing the baby to drift down. Oils can also be applied directly to the tissues to help it slowly stretch.

As the baby's head is crowning, the care provider can also support the emerging head and perineal tissues to allow for a slow, controlled delivery. However, the discussion of perineal support should not take place at the birth.  You must be sure to discuss your wishes at prenatal appointments so that these supports are in place.  Most OBs are not trained in supporting the perineum.  Rather, they are trained to intervene by pulling out a scalpel for a quick episiotomy rather than understanding the need to wait the extra minutes and do the extra work to preserve the perineum.

The birth companion should remain on episiotomy alert through the entire pushing stage.  Research evidence does not support the routine practice of episiotomy and it is also against ACOG policy. It can cause complications and extended healing time that could otherwise be avoided.  Tears heal better than episiotomies in that tears typically involve only soft tissue whereas episiotomies slice through muscle and skin layers, often leading to painful scarring and incontinence later in life. Avoiding episiotomy when at all possible is advisable in the majority of births.

THE URGE TO PUSH

As the baby is moving down through the pelvis and pressure increases, some women may feel the desire or need to push, even when cervical dilation is not yet complete.

Different care providers have different philosophies on the subject.  Some say that whenever the pushing urge is felt, pushing should begin and the pushing will dilate the cervix the rest of the way.  Others say that pushing before complete dilation will cause the cervix to swell and interfere with birthing.  They also might contend that early pushing can cause the cervix to tear. However, there are no documented cases of cervical tearing from pushing before full dilation.

An effective solution instead of focusing on pushing, is to focus instead on breathing the baby down.  You want the baby to drift as far as possible so that you both have the gentlest birth experience possible.  It's preferable to let the baby drift into this world, rather than forcefully pushed into it.

There are three different types of urges that women report in the pushing stage:

OVERWHELMING URGE

This is the uncontrollable urge to push.  When you feel this, it is your body telling you that the baby is coming, no matter what.  It may be difficult or impossible to resist.  It may take every ounce of resolve to not let your body push.  In some cases, such as if a complication were to arise, you might be instructed to stop pushing, such as if cord compression was an issue.  A gravity neutral birthing position may help decrease this urge if the birth is happening quickly so that the cord can be safely manipulated.

SO-SO URGE

If you have the desire to push with every other contraction or only at the peak of the contraction, this may mean that the baby hasn't hit all the nerves to signal the overwhelming urge for pushing.  This may best be managed by breathing and changing positions until a strong urge is felt.  In some cases, the baby will just drift out with little effort, even without experiencing a strong pushing urge.

NO URGE

Positioning and time are the best solutions if this becomes problematic. This absent urge usually only occurs in medicated births, but can also be seen when the baby or mother aren't in effective positions.  If dilation has been complete for more than 30 minutes (without pushing yet), then perhaps consider a direct pushing style or "bearing down".  As long as mother and baby are fine, there's no need to rush.  The pushing stage will most likely unfold at its own pace.

In some cases, you may be advised not to push, even when you have the urge.  This may occur if there is evidence of cord compression or fetal distress.  It can be extremely difficult not to push. Focus on your breathing while the problem is remedied.  You might also consider changing into an all-fours position which can curb the pushing urge.

Just because a care provider hasn't arrived is not a reason to delay the pushing stage when an uncontrollable urge is present.  This frequently happens in a hospital birth because the actual care provider only spends mere minutes attending the birth.  They typically arrive just in time to catch the baby.  If they are not present when you feel the urge, you may need to follow your body's lead and push.  The instruction from the nurses not to push is to limit their liability alone, not for your comfort or to benefit your birth or baby in any way.

THE BABY'S ROLE IN BEING BORN

The baby has an important role in how labour progresses.   During childbirth, the baby is twisting and turning trying to find the best possible position to be born.  This includes flexing its head to present the smallest possible diameter to pass through the birth canal.  When the head is flexed properly, the still-soft plates of the skull will overlap slightly to allow an easier delivery.

Sometimes, the baby is unable to achieve an optimal birthing position.  The most common scenario is an occiput-posterior ("posterior") baby.  This indicates the baby is facing the mother's abdomen rather than her spine.  In this position, the head cannot flex into the smallest diameter.  Sometimes, the baby's face will become wedged against or behind the pelvic bone, causing a longer pushing phase.  In most cases of back pain in labour, the source is a posterior baby.

TURNING A POSTERIOR BABY

The best way to avoid a posterior baby is prevention.  One of the main preventable causes of posterior babies is poor posture while pregnant.  Unsupportive sofas and couches are often to blame for malpositioning of the baby, as well as too much driving in the car.  Posterior babies are often seen in mothers with bicornate uteri or other such uterine abnormalities.

If you are experiencing chronic area-specific discomfort in your back during the pushing stage, a posterior baby may be the cause.  Fortunately, there are several techniques you can use during labour to encourage the baby to turn.  The Birth Positions section contains more specific information on posterior babies.

Sometimes, the baby is in the appropriate anterior position, but its head isn't planted squarely in the middle of the cervix as it should be.  In this case, the baby's head is said to be aysnclitic, or titled slightly to either side.  This is a common cause of irregular cervical dilation, or dilating with an anterior cervical lip, where the front portion of the cervix isn't dilated or thinned completely.  Sometimes an aysnclitic head is the cause of "failure to progress" in that the baby's head isn't putting pressure on the cervix in the correct manner to cause it to dilate and efface as expected.  The posterior techniques in the Birth Positions section are also effective in helping the baby's head to shift into the appropriate position.

During labor, you want to avoid having your water broken because artificial rupture of membranes will severely limit the baby's ability to maneuver into a better position.  The waters act as a cushion that facilitate the baby's movement.  Artificial and premature rupture of membranes is a leading cause of fetal malpositioning during birthing.  The former is completely avoidable.  

In addition, artificial rupture of membranes is a leading cause of "failure to progress" because it can cause a well positioned baby to become badly positioned.  The irony is that artificial rupture of membranes is usually performed to "speed things along" when it often has the opposite effect.

STIRRUPS,  FOOT PEDALS & "BREAKING DOWN THE BED"

Breaking the bed down, or the use of instruments in the pushing stage are usually completely unnecessary.  They're another arbitrary hospital procedure that has no basis in fact for the benefit of labour.  Those procedures were created as a result of the use of inappropriate birth positions.  Standard hospital positions are designed for the doctor's comfort and ease of use, not the birthing mother's, nor to the benefit of labor.  With the use of unnatural birth positions comes the use of unnatural pushing aids.

In a medicated birth, stirrups are the most commonly used "tool".  This is because when medications are chosen, it's quite common to lose all sensation and control in the legs which makes it impossible to freely move into optimal positions. Stirrups are sometimes used in a very long labor due to fatigue.  They hook on to the end of the bed and will support at least the calf area of the leg and sometimes the entire leg and foot.  They can only be used in the ineffective lithotomy position which research has shown to be the least effective of all birth positions.

Some providers forego stirrups in a medicated birth in favor of pulling the legs back toward the shoulders which also results in a very ineffective birth position. The drawbacks are that this can hyperextend the legs causing pain, does not use the benefit of gravity, and increases pressure on the perineum making the tissue more likely to tear. Foot pedals or heel cups are simply places to rest the feet while pushing. This can make the bed more like a birth chair. This can be used with or without medications.

The end of the pushing stage of labor is indescribable.  You will be holding your baby and your focus.

References

Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001063. DOI: 10.1002/14651858.CD001063.pub3.

Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia.  Golara M, Plaat F, Shennan AH Year: 2002

Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004457. DOI: 10.1002/14651858.CD004457.pub2.

Cluett E R, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub2.

Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2.

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Page Last Modified by Catherine Beier, MS, CBE