A couple of weeks ago I went on a quest to find out just what pushing was like for other women.  As an educator and doula it is probably one of the more challenging concepts to address.  Why?  Well some of the imagery can be quite vulgar.  “Push like you are pooping.” Do women REALLY want the image of pooping out their babies?! “The urge will overwhelm you and you cannot help it.” That also is not quite right some women never get the urge until the baby is very low and engages the nerves and some women will have the urge when baby is high and dilation isn’t complete (I did not say premature because I believe when the urge comes pushing “gruntily” with the peaks is alright as perhaps that will facilitate complete dilation and rotation of babe).  Some women feel great rectal pressure, some feel it in their abdominal muscles, and some don’t feel much at all going into it. Hey I do not believe we need to be fixed in this area.  I think whatever a woman’s body does is right for her body.

Below are many quotes that I frankly trolled for to edify women everywhere on the spectrum of what pushing is like. I could bore you to tears with the physiologic nature of the process but that isn’t what you really want to know now is it?! If you have questions on the new perineal massage, please refer to my previous entry https://prepforbirth.com/2009/08/25/new-episiotomy.html.

Quotes from real women

“My babies #1-4 practically fell out. #5 I was in what looked like early labor for 4 days. Midwife assistant came over, checked me, I was at 7 cm but ‘not in active labor’. I got into it quickly! Long story short I pushed, painfully, for 3.5 hours, baby had 11″ cord with a true knot. She needed to be pinked up but is almost 3 and is doing well.”

“When I was coached to push (w/ no 3..first natural birth) I was in agony. When I was left alone and did not push (w/ no 4), life was good.”

“I feel like if I can just get to the pushing phase, it will be a breeze from there.” (and it was. The whole “surrender/dilate” phase is much more challenging to me than the whole “take control/pushing” phase.)”

“Pushing was fantastic with my 2nd baby and awful with my 3rd! It was really surprising because after my 2nd birth I thought “Okay so pushing is the really fun and satisfying part! That’s when it gets EASY.” Then my third birth totally shocked me. Pushing was the most painful and difficult part of the birth. I had stayed so calm and collected… until then. Every pregnancy and birth is so different!”

“I love the way it feels to have a baby move through me and into my waiting hands.”

“I *loved* pushing. I didn’t do it for very long (two contractions), but it was so great to finally get there. I was told to purple push (not in those terms – the nurse told me to hold my breath), and intellectually I knew I shouldn’t, but I tried it and it really did feel like I was more productive that way. I felt like a warrior. It was awesome.”

“Before anyone hates me for only pushing through two contractions, you should know that I’d been in labor for three days – so it all comes out in the wash ;-)”

“Pushing with my 2nd was horrible. 3+ hours of the worst pain I had experienced at that point in my life. Turns out her little fist was up by her cheek (um ouch) and her head did not mold much. My 3rd I did not push because she was precipitous and we were trying to get to the hospital. I felt like all the energy in the world was gathering and swirling at my fundus and then suddenly flowed through me carrying her with it. It was the best physical experience of my life.”

“I have heard some say that pushing feels good.. um, I personally have not experienced that and I have had clients remark the same … :p”

“Hmm…Definitely the best part of labor and delivery. For me though – never had any “urge” to push but still had baby out in 20 mins…I think I was feeling determined being a VBAC mom…still, would have been easier if I felt the need to and not just contractions. “

“Heard lots of clients say it feels good after hours of labor”

“Ahhh, I’m not so fond of the pushing. Did it for 2 1/2 hours with my daughter (LOA) and though it was only about 20 minutes with my boys, they were both OP. That was, shall we say, unpleasant. I cannot relate to those who’ve told me it was such a relief!”

“My labor was surprisingly short, only 6 hours and she’s my first baby so far. I woke up in active labor and at 4 cm and I wanted to push THE WHOLE TIME! It was horrible having the nurse say I couldn’t push yet when I wanted to so badly, but once I did get to push, oh my goodness, it felt incredible. So much control and power, it felt so good to finally work to end. 3 big pushes and there she was. :)”

“Sheer, immeasurable power. Unbelievable!”

“Babies actually come out of your butt. Don’t let anyone tell you otherwise.” One of my clients recently said that. :)”

“Birth is shockingly rectal” – Gretchen Humphries. She was totally right.”

“Pushing with my first felt like I was satisfying an urge, an uncontrollable urge. It felt almost desperate I couldn’t stop it. (kinda like having that rectal urge when you REALLY have to poop). Pushing with my second was no big deal, I followed my urges again and pushed 3x and out she came in her 10# glory. It was extremely satisfying and powerful I felt like I had just finished exercising. Amazing!”

“The ring of fire OH MY it is indeed! Though as soon as the burn started the whole are went numb almost like too hot or too cold numb and the power of the urge to push my son out was almost beyond description.  Pushing was never easy for me as I have an unusual pelvic shape.  But my last son WOW no molding and quite a large head to birth him was incredible really.  No tearing, just some abrasion.  Recovery was a snap.”

“I had at the point of delivery what was the best orgasm of my life!”

“Pushing was totally primal.  I had an incredible urge and it took over.”

Questions and Answers

1. I have had a previous episiotomy, do I need another one automatically? No you don’t.  Depending on how your scar has set and the position you push in the scar can re-open or it adhesions in the scar will need to be broken up.  I would suggest perineal massage prenatally if there are any adhesions to break them up and soften the area prior and to choose a pushing position that doesn’t put all the tension on that exact area.
2. Is is wrong to push when I am not fully dilated? Not necessarily.  Now I think grunty smaller pushes with those contractions can be effective to complete dilation if you are in transition.  Prior to that change the position you are laboring in to change where baby is placing pressure.  Knee chest can be very effective to abate very early pushing desire.
3. What if I poop during pushing? Some women will pass some stool and some won’t. You may here that when pushing the right way you may pass some.  Hey open bottom is vital to pushing, so hey it is a normal but not always occurence.  A fantastic nurse, MW or doc will not actually wipe it away but simply cover as to not cause constriction of the sphincter muscles which can disturb pushing progess. If it is possible to discard the stool without disrupting you, it will be done very quietly and discreetly.
   
4. I am very modest, do I have to have all my “glory” showing? Absolutely not.  You can maintain good modesty all the way up to delivery.  Even then you do not need to be fully exposed.  Truthfully a home birth or birth center birth with a midwife if likely going to help you have your modesty concerns respected and honored. Really no one needs to put hands in you during pushing, or needs to stretch anything, or needs to see everything either.  A midwife is trained to see by taking a quick peek or simply to know when she needs to have hands ready to receive baby and to offer external positive pressure if mom wants.

Check back later more Q and A to come as more questions are sent to me.

“Pushing felt good.” “The urge to push was unstoppable.” “I loved when I got the urge to push!”. “I felt like I was going to split apart.” “It hurt so much more than I thought it would.” “I didn’t want to push.” “Why did I have to hold my breath and tuck my chin?” “I grunted and threw back my chin.” “Why were people yelling at me?” “All I wanted to do was breathe and not push.” “What is the deal? I was told I couldn’t get a baby out on my side, squatting, hand and knees or when I arched my back and threw my head back.” “It felt so good to put support at the top of vagina.” “If I would have pushed in another position would I have torn so much?” “Why did the nurse and doc keep putting their hands in me while I pushed?” “Would I have avoided a cesarean pushing in another position?”

The myths surrounding pushing in our culture are widespread. Over and over women are told unless they push in the “C-position” or reclined position with tucking chin and holding breath “purple pushing” there is no way they can effectively push out a baby. Women are told that spontaneous or limited bearing down will take much longer. When in fact that is untrue.

Interestingly, when not coached, women spontaneously know how to push, how to breathe properly and how to help baby descend. As a matter of fact, most women choose to squat, stand and lean or use a variation on hand and knees to deliver their babies and even nap in between pushing cycles.

By the comments above pushing can be wonderful, challenging, or even both.  Outside influence can hinder or encourage a woman. She is very vulnerable and usually tired, but then the second wind comes.  She knows her baby will be here soon.  She knows that after the hours of getting out of her own way and letting her body do the job it was designed for, she can now DO something. Second stage can last minutes or hours, though it is like early and active labor more rest than work. Women may even sleep in between contractions.

So why are women continually told there is only one way to effectively deliver a baby and expected only to do that?

Here are a few thoughts to chew on:

• 98% of babies in USA are born in the hospital versus at home  with or without a midwife or at birth center with midwives in attendance.
• Most OB’s are not trained to receive a baby in any other position. They are trained to see with their eyes for one orientation and have not learned to “see” with their hands.
• Most OB’s are trained to sit in front of the mother on a stool like a catcher.
• Staff and OB’s want something to do when really the woman pushing is the only one who needs to be doing anything.
• In hospitals, nearly ALL women – in some areas close to 100% are medicated with narcotics or more likely with epidural anesthesia disallowing freedom of mobility and body presence.
• Beds are used virtually 100% for hospital deliveries versus a birth chair, birth stool, toileting, squat bar, standing or leaning.
• Women are programmed to be in one particular position because it is virtually all we hear about from others and see in the media.
• Women are not taught to trust their instincts and to listen to their body and baby during birth so instead they look outside to gain understanding of what to do.
• Nurses are trained only is “pushing” women in the new classic C position with vigorous perineal and vaginal “massage”.
• Women are limited to a specific pushing time and often in the one position before a cesarean is performed even when mom and baby are doing well.

When a woman chooses a variety of positions for pushing without hindrance (this can include the C position) it can:

• Reduce trauma to the perineum, labia, clitoris, and urethra
• Shorten pushing time
• Allow for movement of the tail bone thus opening the pelvis more
• Can lessen stress on the baby
• Give mom more sense of control over the birth
• Changes the pelvic shape to aide baby in molding and adjusting
• Allow for fetal ejection reflex to occur
• Allow for a euphoric and natural state to occur

Using alternative breathing techniques other than holding the breath as in directed pushing to a count of ten or more can allow for baby to get more adequate oxygenation as well as,  be a more gentle process for both parties. A laboring woman may breathe in several different ways during pushing.

She may:

• throw her head back and open her neck with an open mouth while breathing to comfort and pushing
• spontaneously push while breathing non-specifically
• she may grunt and growl
• she may hold her breath for a moment and then exhale several times during a pushing episode
• she may do a slow-exhalation with mouth relaxed and slightly open (open-glottis) while pushing
• breathe slowly/rhythmically and not push actively allowing for passive descent of baby through contractions

Most un-medicated or lightly medicated women will choose a position and breathing style that works for her body allowing for the natural progress to occur, usually culminating in the fetal ejection reflex at the very end.  Instead of forcing a woman into a cookie cutter type position, she needs to be given the opportunity to trust her body, trust the process, feel the process and feel supported. Otherwise, we don’t really need to do anything.

I urge you to have deeper conversations about pushing and delivery with your care provider BEFORE you go into labor. The answers to the questions may be a green or red flag for you. Pay careful attention that your questions are really answered to your satisfaction.  It is your provider’s job to prove to you why he/she practices the way he/she does.

• Ask your provider what his or her philosophy about pushing and delivery is.
• Ask provider to describe what pushing normally looks like with his/her patients.
• Ask how many hands off deliveries your care provider has done.
• Find out what positions your provider is comfortable or willing to GENTLY receive your baby in.
• Ask if provider performs perineal massage? If so, have it described to you. GENTLENESS is the key here. No one needs to tug, pull and yank your vagina, labia, and perineum.
• Ask your provider if spontaneous pushing and delivery are supported.
• Tell your provider you will agree to coached pushing after you have tried everything you want to do
• Ask about percentage of women under provider care “require” an episiotomy
• Ask how long pushing will be tolerated before wanting you to have a cesarean or instrumental delivery.
• Ask for evidence to support practices. Actual studies not just verbal.
• If you are having a hospital or birth center birth upon arrival and admittance speak clearly to your nurse about what you plan on doing for pushing.

Here’s to pushing with confidence, using your instincts and following your body!  Here’s to finding the provider with a normal outlook on pushing and delivery.

“Pushing felt good.” “The urge to push was unstoppable.” “I felt like I was going to split apart.” “It hurt so much more than I thought it would.” “I didn’t want to push.” “Why did I have to hold my breath and tuck my chin?” “Why were people yelling at me?” “All I wanted to do was breathe and not push.” “What is the deal? I was told I couldn’t get a baby out on my side, squatting, hand and knees or when I arched my back and threw my head back.” “If I would have pushed in another position would I have torn so much?” “Would I have avoided a cesarean pushing in another position?”

The myths surrounding pushing in our culture are widespread. Over and over women are told unless they push in the “C-position” or reclined position with tucking chin and holding breath “purple pushing” there is no way they can effectively push out a baby. Interestingly, when not coached, most women choose to squat, stand and lean or use a variation on hand and knees to deliver their babies.

So why are we told there is only one way to effectively deliver a baby and expected only to do that?

Here a few reasons I have come up with:

• 98% of babies in USA are born in the hospital versus at home or birth centers with midwives.
• Most OB’s are not trained to catch in any other position, are trained to see with their eyes for one orientation, and do not know how to “see” with their hands.
• In hospitals, nearly ALL women – in some areas close to 100% are medicated with narcotics or more likely with epidural anesthesia.
• Beds are almost used 100% for hospital deliveries versus a birth chair, birth stool, toileting, squat bar, standing or leaning.

Using alternate positions in pushing (unless you are a small percentage of women who prefer the “C-position”), can reduce trauma to the perineum, shorten pushing time, allow for movement of tailbone thus opening the pelvis more, can lessen stress on the baby, and give mom more sense of control over the birth.

Using alternative breathing techniques other than holding the breath as in directed pushing to a count of ten or more can allow for baby to get more adequate oxygenation and be a more gentle process for both parties. A mom may spontaneously push while breathing non-specifically, she may grunt and growl, she may hold her breath for a moment and then exhale several times during a pushing episode, she may do a slow-exhalation with mouth relaxed and slightly open (open-glottis) while pushing, breath slowly/rhythmically and not push actively allowing for passive dissent of baby through contractions.

Most un-medicated or lightly medicated women will choose a position and breathing style that works for her in the event she is allowed to trust her body, trust the process and feels supported. We don’t really need to do anything.

I urge you to have deeper conversations about pushing and delivery with your care provider BEFORE you go into labor.

• Find out what positions your provider is comfortable or willing to catch in.
• Ask about use of compresses and perineal massage
• Ask about only using coached pushing if really needed
• Ask about percentage of women under provider care “require” an episiotomy
• Ask how long pushing will be tolerated
• Ask your provider what his or her philosophy about pushing and delivery is.
• Ask for evidence to support practices. Actual studies not just verbal.
• When you arrive at the hospital, speak to the nurse about what you want to do and the what you and your care provider have agreed upon.

Here’s to pushing with confidence, using your instincts and following your body!