Pushing

Once your cervix is fully dilated, you may or may not feel the urge to push. Often, once your cervix is dilated, you will be directed to push whether you feel the urge or not. According to the WHO guidelines for safe motherhood, this is “a practice which is frequently used inappropriately.” It mentioned that women are typically checked for full dilation once they feel the urge to push, but it is not known how long they were fully dilated (which means that they could have had a long “latent” period in which they were fully dilated but not yet pushing). This means that when women are checked and found to be fully dilated and told to start pushing, they may also be in this “latent” period. I consider this to be nature’s way of giving women a break. The contractions slow down or are less intense than transition contractions, and allow women to rest and regroup before the work of pushing the baby out.

In the hospital, the typical pushing is “directed pushing” or “Valsalva maneuver” or “purple pushing.” This is what you see in all of those awful birthing shows in which a team of people surround a poor woman on her back, and count to ten telling her not to take a breath. The WHO guidelines (see my post here) says that this practice is “clearly harmful or ineffective and should be eliminated.”

The alternative to directed pushing is spontaneous pushing. When women are allowed to push naturally, they will usually bear down for 5-6 seconds and do this several times a contraction. A small study of 39 first-time moms showed “women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations.” When women hold their breath for 10 seconds, taking only a couple of quick breaths in between pushing, they are more likely to feel faint and weak, or need oxygen. (You can try this yourself–just hold your breath for 10 seconds, take a quick breath, hold your breath for 10 more seconds, take another quick breath, and then hold your breath for 10 more seconds–and see how you feel.)

This link to lamaze.org cites many studies that show the multiple benefits to spontaneous pushing, and the risks of “purple pushing.” When you follow the link, you can see all the studies they cite, in the footnotes. The only benefit of directed pushing was a slightly shorter second stage (13 minutes–discussed more fully below), but this did not have any improved maternal or fetal/neonatal benefit. In fact, sustained pushing was associated with a higher incidence of pelvic floor trauma (leading to greater urinary and fecal incontinence), and reduced fetal oxygenation. This only makes sense–if you’re feeling light-headed from lack of oxygen, your baby is also being deprived of oxygen.

This study reached the following conclusion: “These studies indicate that the only apparent advantage of Valsalva pushing is a shorter second stage, which, on occasion, may be desirable. However, expediting delivery by forceful, directed pushing is achieved at the expense of three negative outcomes: reduced oxygenation of the fetus, more frequent trauma to the birth canal, and potential injury to future pelvic floor function.”

The study that determined a shorter second stage of 13 minutes when using directed pushing looked only at women who had an epidural. Typically, women are directed to start pushing once they reach full dilation, whether they feel the urge or not. Since women who have had an epidural sometimes don’t feel an urge to push because of the medication, they are much more likely to be subjected to directed pushing than non-drugged women. The two groups this study divided women into immediate pushing once full dilation was determined, or delayed pushing of an hour or until they got the urge to push, whichever came first. Another study (this one appearing in ACOG’s Green Journal) had the following results: “When a period of rest was used before pushing, we found a longer second stage, decreased pushing time, fewer decelerations, and, in primiparous women, less fatigue compared with control patients. Apgar scores, arterial cord pH values, rates of perineal injury, instrument delivery, and endometritis were similar in both groups.” It concluded, “Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit.” While the authors stressed the need for close monitoring of the women to make sure that the labors were not obstructed (in other words, that the delay in pushing was not due to a problem, but was indeed normal), they said, “Our data suggest that in appropriately selected and managed women, extension of these time periods is safe, and may be beneficial for mother and fetus using a policy of rest and descend.”

This research demonstrates that it is reasonable to delay pushing until you feel the urge, and to push spontaneously instead of to a count of ten. While there are certain circumstances in which this may not be best for your baby, in the absence of these occasional problems, there is no reason to put your perineum or the baby’s oxygen at risk.

Updated to add this link with a discussion (and citations) of “purple pushing” and this link on waiting until there is an urge to push.

3 Responses

  1. Hi Kathy,

    Unsure if this is the right area to raise a question in, but am interested in intentionally delayed pushing.

    As a paramedic I have a great deal of respect for midwives, and recognise that while childbirth is a wholly natural process, things can go very wrong very quickly. As a result, the general approach myself and all the medics I have worked with take in labouring Moms is to assess if they are literally about to give birth (i.e., presenting part on view), and if so assist the birth as best we can. Otherwise, if it seems we can get her out of the house, to the truck and quickly on to the hospital this then we will move out, and fast. As a result, I have had Moms say they feel the need to push, but have encouraged resting, relaxing and panting but no pushing until we get to the safety of the birthing unit. This encouragement is always given in warm, calm manner.

    Aside from inexperience and thus fear that we will have an uncontrolled birth, I do have rationale for wanting to delay pushing. As medics we never perform vaginal exams, meaning we cannot be sure if the cervix is fully dilated and effaced. Also I was of the belief that if the baby was coming, no amount of requesting that the Mom not push would make any difference, as nature would simply take over!

    What I would therefore like to know is, can delayed pushing (even when the urge to push is present) harm mother or baby?

    Delivering babies in the back of ambulances is scary, but we’ll do it if requesting the Mom wait is in any way unsafe!

    Thank-you

    • Ask a natural-minded midwife, L&D nurse and/or an OB just to make sure. The reason I suggest a “natural-minded” caregiver is that I’ve heard stories of nurses physically holding a crowning baby’s head inside the woman, so the doctor can make it to the birth in time. Obviously, they thought it couldn’t harm the baby! [I’m not so sure, but don’t have anything concrete, nor even if it’s been studied.] Your way sounds pretty typical — you catch the baby if s/he’s crowning, and encourage the mom not to push if s/he’s not.

      There are numerous care providers (including home-birthing midwives, who would typically have a low intervention rate) who will for one reason or another suggest the mom not push even if she feels the urge, and there is no suggestion in these stories that it will be bad for the baby to wait. Some of the reasons include the cord being around the neck, and unlooping it after the baby’s head has been born — not exactly what you have in mind; or more commonly, allowing the perineum to slowly stretch around the baby’s head to give the best chance of an intact perineum.

      You are right that in many cases, the moms cannot refrain from pushing, or if they do not actively push, the uterus still will!

      The book Emergency Childbirth by Gregory White is the book I’ve consistently seen recommended that people get, if they think they may be in a situation of attending a precipitous birth. Perhaps that will help you in your situation. Also, would it be possible for you to spend some time on the L&D floor of your hospital, either just talking to the nurses about birth and postpartum, or even viewing or attending births as a medical observer? Then you will have more experience under your belt, and maybe won’t be so nervous.

      Also, if it makes you feel any better — my second birth was an unplanned unassisted birth, and my sister caught the baby, and she had zero experience, except for having given birth three times. The most important thing is, don’t drop the baby!

  2. Hi Kathy,

    Thank-you very much for your fast reply! Years ago when I was quite new to the job I had a week observing in a L&D ward but it was all so new then I didn’t know what questions to ask! I am planning to request some refresher time in an attempt to allay some of my fears.

    In 9 years in the job I have been involved with countless labouring Moms, and approx 6 deliveries, all ending with healthy Moms and bubs (thankfully). I was discussing birth with my colleagues today and we all agreed that huge car accidents or machinery accidents are less stressful!

    Thank-you for taking the time to help me out, I plan to follow up on your suggestions!

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