When the vast majority of our society thinks of a birth scene, the subsequent images they have may look something like this…
…but more than likely, you are probably imagining a distressing scenario of a woman that looks sweaty and terrible, with her legs high in stirrups, exposing her dignity to the world. She has an expression of pain and terror on her miserable face, while a doctor under a drape chimes in with the chorus shouting “PUSH!!” in between exasperated gasps of “hee-hee-hoo.” (see video below…)
To the surprise of many, birth does not have to be an event of misery. Most mothers would agree that the happiest day of their lives is the day their children were born. Aside from the joy of finally meeting your baby, giving birth should be as enjoyable an experience as the outcome. A crucial mission of midwives is the intent to change the way modern society (women, men, and even medical professionals) perceive how child birth “should be.” One of the significant issues concerning most people is how to deal with the pain. While I will be making another post in the future discussing the many different strategies midwives use to manage discomfort in labor, this post aims to explore a timeless factor of childbirth, pushing, and the many mistakes and misconceptions we have developed about such a primitive force.
Pushing, or bearing down, together with the downward force of the uterine contractions, creates a strong positive pressure in the abdomen that allows the baby to move through the birth canal. While these forces are no doubt crucial for delivery, pushing requires an immense exertion of energy. Unfortunately, many women fail to realize that there is a right and wrong way to push, and if not done correctly, all their hard work can leave them with nothing but mere exhaustion. One way to push might be described as puffing out your cheeks, holding a deep breath, and forcing your belly out as far as it will go. The other method of pushing can be thought of as similar to taking a massive….. Full force effort down towards your butt, and releasing loud, guttural grunts and moans. I will leave you to guess which method of pushing is more effective; hang your vanity at the door baby, this is childbirth.
This may come as a shock to many, but our bodies were designed to know how to give birth. While many women in labor benefit from the emotional support and coaching from their loved ones and providers, they generally are able to commandeer the birth on their own (epidurals labors not included). What we don’t realize is that as birth starts to take that crucial turn (where the fetal head exerts strong downward pressure on the nerves in pelvic floor and rectum), women experience an automatic reflex to bear down. I have heard it described as “feeling good to push.” Women in labor begin to develop their own natural rhythm and technique in response to the events taking place in their body. When implementing what is known as a supportive approach, providers take a more passive role, and “encourage women to push in response to the involuntary, physiologic urges that normally occur during second-stage labor” (Osborne & Hanson, 2011). Using this method, research has found a significant increase in birth outcomes and overall maternal satisfaction with the birthing process. On the contrary, however, modern obstetrics takes a more aggressive approach to labor management in what is known as a directive approach. Early OBGYN practitioner Constance Beynon summed it up perfectly when she described her colleagues approach as “seeming to consider it their function to aid and abet and even coerce the mother into forcing the fetus as fast as she can through her birth canal,” (Beynon, 1957). This approach utilizes direct instruction for the woman to perform sustained, strenuous bearing down efforts starting from the time they are fully dilated until birth. While this method undoubtedly would seem like the more effective route to giving birth, one must question the pathophysiology behind these aforementioned actions.
First, pushing that involves holding of the breath is known as closed-glottis pushing. This also utilizes a physiological phenomenon known as the Valsalva maneuver, by which holding of the breath and bearing down creates increased intrathoracic and abdominal pressure (much like the force used to pop you ears), and stimulates the vagus nerve, and the increased pressure inhibits blood return to the heart, resulting in reduced cardiac output, and decreased heart rate and blood perfusion. This is why many people have fainting spells while on the toilet—decreased blood supply and oxygenation to the brain. Considering that the fetus depends on maternal blood perfusion of the placenta, it is not surprising that we see evidence of fetal decelerations during continuous prolonged pushing episodes. On the other hand, open-glottis pushing, quite the opposite, using groans, grunts and animalistic vocals is just as effective, and allows for controlled respiratory exchanges that decrease the risk of acidosis and hypoxemia.
Another point to consider cautiously with this method of pushing is one of the reasons it is so frequently used—its effectiveness. We all know that giving birth is like pushing a watermelon through a hole the size of a lemon. When women push and push with a closed glottis, the fetal head gains speed and momentum, occasionally shortening the length of time of labor, and very frequently resulting in major vaginal tears and lacerations. Think about it. When that watermelon pops through that tiny hole, the poor vagina could hardly stand a chance. Conversely, patience is always rewarded, and alternating between controlled pushing and breathing can make all the difference by allowing the pelvic floor to stretch and accommodate the baby’s head and thus less tearing of the tissue.
A final point to make is the unnecessary insistence for a speedy second stage, whereby women are instructed to start the pushing process as soon as they reach 10 cm. Just because you have become fully dilated does not mean its time to cut the cord. Even when dilation is complete, there is still a good chance that the baby is still relatively high in the pelvis. Consider the anatomy the baby must travel before it is born. It must come down first then out. Using our advanced human brains, we know that gravity is most likely not going to help bring the baby out, but it most certainly can pull the baby down until it is low enough to be pushed out. This is a concept known as “laboring down.” Using gravity together with the continuous force of the contractions is a great way to conserve energy (birth can be Green too!), and still keep labor progressing. By starting to push unnecessarily at the moment you learn you are completely dilated, you are putting yourself at risk for exhaustion (not that you haven’t already been up for days), as well as other issues (see points #1 and # 2 above).
A found a couple tips on how to really enhance pushing efforts the other day in the “midwife bible,” also known as Varney’s Midwifery (2004).
1. Breath control: implementing a variety of breathing techniques during pushing can ensure that you are generating plenty of intrabdominal pressure, as well as allowing for adequate gas exchange and oxygenation of the tissues.
2. Body control: while the lithotomy position (laying on back, legs in stirrups) is a less than optimal way for humans to deliver, many women choosing epidural pain relief are left with very few other options. The best practice for body positioning generally involves legs apart (duh.), and knees to chest or elbows, allowing you body to essentially curl around your belly (and your baby). Also, it is beneficial to keep the chin tucked to the chest (emphasizing that belly curl).
3. Applying a counterforce of resistance with the arms: a very common tool we use in labor and delivery is the “tug-o-war” technique, which really helps when women are not pushing the right way (see above paragraphs for more info). This technique utilizes the counterforce motion the arms provide when simultaneously bearing down (pushing) and pulling (elbows bent) on a towel or sheet with your midwife.
4. Vaginal stimulation: another very common finding on the L&D unit is the nurse or midwife inserting two fingers into the vagina and exerting downward pressure to the rectum. This can be helpful especially in women with epidurals or those who don’t know how to push right. By pressing down on the posterior vaginal walls, we are stimulating the nerves of the pelvic floor to elicit a reflexive pushing response, very much in the same way the baby’s head does as it descends into the forward curvature as the pelvis (this event is often described as the unbearable urge to push or have a bowel movement).
So, in effort to sum things up: do yourself and your baby a favor and be patient, take things slow, and let your body do the talking.
Beynon, C. (1957). The normal second stage of labour: a plea for reform in its conduct. Journal of Obstetrics & Gynaecology, 64:815-820
Varney, H., Kriebs, & Gegor (2004). Varney’s Midwifery, (4th ed.), Jones and Bartlett Publishers: Ontario, Canada