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.