Directed pushing is a common practice without evidence to support its continued use. As a midwife today, I rarely see hospital staff who support spontaneous pushing, despite knowledge of the evidence for allowing a woman to push how and when she feels the urge. Even when staff agree that the onset of pushing should occur when the woman feels the urge, once the woman begins pushing, staff almost universally will start coaching the woman in prolonged, breath-holding pushing (dubbed “purple pushing” because the woman pushes so hard her face turns purple).
In a study of spontaneous pushing, Hanson stated that “imposing specific directions for Valsalva pushing does not result in optimal outcomes but continues to be widely used, particularly when labor progress is less than optimal.”¹
Let’s take the common-sense approach to this problem. What makes a woman have the urge to push? Generally, a true urge to push occurs when the baby descends low enough in the birth canal to cause rectal pressure, which is then felt as an urge to push, similar to a bowel movement. Sometimes women will say they want to push prior to this time, but I have found that when I them encourage to do what their bodies are telling them, usually they find pushing is uncomfortable and they will not have very sustained or forceful pushing efforts.
So if labor is prolonged, and the woman does not have an urge to push, it’s most likely because the baby is still too high to be creating an urge to push. As the baby descends through the birth canal, its head ideally rotates into the proper position for birth. Pushing before the baby is low enough to create a pushing urge can force the baby down into the birth canal in a less than optimal position.
Another situation we find is the woman who has an incredible urge to push (think of having to have a bowel movement RIGHT NOW and how difficult it is to hold it back), yet staff are yelling at her not to push because she’ll tear her cervix! I have not had once incidence of a woman spontaneously pushing and damaging her cervix in any way. Simply put, if the cervix is not easily moving out of the way when a woman bears down, it is very painful to put more pressure on it, and the woman will hold back.
What are the risks of sustained, forceful bearing-down efforts? One study found “Directed pushing might slightly shorten the duration of second stage labor, but can also contribute to deoxygenation of the fetus; cause damage to urinary, pelvic, and perineal structures; and challenge a woman’s confidence in her body.”²
With evidence strongly supporting spontaneous pushing, why do so many providers still use directed pushing, instructing the woman to hold her breath and push to the count of 10? Researchers in one study³ concluded that the most common reasons for directed pushing were:
- helping the woman push effectively (when was the last time you needed instructions in how to have a bowel movement?), despite the fact that woman have given birth for thousands of years without anyone to teach them how to push
- expediting the labor process because of maternal distress, fear, fatigue, and pain. This makes no sense, because if a woman is having pain and is not ready to push, her pain will be increased. Fear and fatigue call for support and rest, not shouting orders to push harder.
- routine pratice (why are the providers not evaluating their routines based on current evidence?)
- lack of urge to push (how about waiting until the mother feels the urge, and then you won’t have to coach her). Even a woman who has epidural anesthesia can feel the pressure of the fetal head when the baby is low enough in the birth canal, and can generally push effectively at that time.
- fetal distress. This one only makes sense in the case of a woman who’s given birth before, and can push the baby out very quickly in the event of distress. Otherwise, you are likely only increasing the fetal distress. More benefit would likely be gained by position changes, rest, and breathing through contractions so as to decrease stress on the fetus.
Perhaps the most ridiculous statement I’ve ever heard a health care provider make is, “Your baby will never come out if you don’t push!” Babies do come out. Our bodies are perfectly designed to gently ease the baby out the birth canal with the least amount of stress. The common-sense tip for today:
No one had to teach you how to have a bowel movement. No one needs to teach you how to push. Listen to your body, and you will know what to do.
1. Hanson, L. Second-stage labor care: challenges in spontaneous bearing down. J Perinat Neonatal Nurs. 2009 Jan-Mar;23(1):31-9; quiz 40-1. Retrieved 12/20/09 from http://www.ncbi.nlm.nih.gov/pubmed/19209057?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=2
2. Roberts J, Hanson L. J Midwifery Womens Health. 2007 May-Jun;52(3):238-45. Best practices in second stage labor care: maternal bearing down and positioning. Retrieved 12/20/09 from http://www.ncbi.nlm.nih.gov/pubmed/17467590?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=1&log$=relatedreviews&logdbfrom=pubmed
3. Roberts JM, Gonzalez CB, Sampselle C. J Midwifery Womens Health. 2007 Mar-Apr;52(2):134-41. Why do supportive birth attendants become directive of maternal bearing-down efforts in second-stage labor? Retrieved 12/20/09 from http://www.ncbi.nlm.nih.gov/pubmed/17336819?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=13
Guess that doctor has never heard stories about women giving birth in their sleep or even in comas?
I guess not!
I have had six children, and have had directed pushing a few times. The urge to push with me means baby is out in less than 5 minutes, but last time I had an OP baby that the OB didn’t realize. The nurse had me push at 9 cm (I was stupid in labor and just did what she said). I pushed for an hour and 1/2. I now struggle with my bowels 2 years later. I had a sore stomach and chest for a few weeks after, and felt so worn out. When I finally did get the urge to push (felt baby turn right before) she came out in the full bag of waters within a few seconds.
Thank you for sharing this classic example of how women push spontaneously. Studies have shown that the pushing phase is not any longer (and some studies showed it was shorter) when women wait until they have the urge to push. The same research also shows that babies tolerate pushing much better when the mom pushes spontaneously.
What really gets me right along with this is when the head is born, and the care providers start pulling on it to deliver the body, yelling at the woman to push even when she isn’t having a contraction.
Do you know if there is any data for or against this? My gut tells me this is a bad idea–I wouldn’t want my head pulled on in that way! And also I see that these babies don’t get to do the rotation that occurs when the body is allowed to deliver spontanously.
The maneuvers for vaginal delivery as taught to midwives and obstetricians call for delivery of the head, then allowing for spontaneous rotation and the next contraction before continuing with the birth. Pulling on the head is strictly forbidden, but practitioners are instructed to put downward traction on the fetal head to release the anterior (top) shoulder from behind the pubic bone. In practice, I see more and more providers completing the delivery immediately, by having the mother continue to push while traction is applied to the head. There is some speculation whether by doing this right away, shoulder dystocia can be avoided by not allowing the anterior shoulder to rotate behind the pubic bone, which occurs when the head spontaneously rotates (restitution) after delivery. Common-sense tells me that babies have been born for centuries without the help of midwives or doctors. When would the woman push if she was not instructed to push? Obviously, she would push when she felt the next urge to push. As the textbooks state that it is OK to wait for the next contraction, and this seems to be the common-sense time when a woman would spontaneously push the rest of her baby out, it is hard to justify the panicked yelling “push! push!” that typically occurs once the head is delivered.
I love this post! Thank you. I was shocked during my home birth (VBAC) when my midwife just noted nonchalantly when I started pushing. I was the one that told her what was going on. Never did a cervix check or anything. Just let me push away at my own pace, with encouraging words like “good work.” I describe it as taking the biggest BM of my life! But sooooooooooooooo much better than the heaving and counting during my induction-turned-cesarean first birth.
I believe that is the essence of midwifery–mostly just standing by, observing quietly, not interfering unless needed. I’m glad you found such a wonderful midwife!