One of the most important healthy birth pratices Lamaze promotes is: Avoid giving birth on your back and follow your body’s urges to push.
In today’s world of modern obstetrics, women are conditioned to give birth on their backs. At the hospital, they are admitted to a labor room where everything is arranged around a birthing bed as the focal point. Other than a rocking chair, there often is no other furniture or equipment that encourages the laboring woman to be out of bed and utilizing various positions for giving birth.
The media reinforces the idea that birth happens while lying on one’s back. Try to recall the “births” you’ve watched on television dramas and sitcoms. How many times have you seen a woman portrayed as being anywhere but in bed, reclining on her back, during labor and birth? Most young women who will give birth in 2010 have never seen birth in an upright position. Childbirth educators, rather than being able to correct the misconception that birth is best on one’s back, are often constrained by having to teach methods and procedures with which the obstetricians and hospital policy makers want their patients to comply.
What difference does it make, though, if a woman gives birth on her back? It’s pretty much the way we’ve done it–at least in hospitals–for the last 100 years or so. And why follow your body’s urges when it comes to pushing? Wouldn’t most women rather start pushing as soon as they are completely dilated, and labor over with sooner?
There are many disadvantages to giving birth on your back. Among them are:
- Increased risk of perineal tearing and trauma (1)
- Increased vulvar edema (swelling of the genitals after birth, which is painful and makes it difficult to urinate, sometimes necessitating a urinary catheter) (1)
- Increased risk of fetal intolerance of contractions(2)
- The laboring woman is pushing “uphill” against gravity. as the birth canal angles upward from the small of the back to the vaginal opening
Some providers pride themselves on “allowing” the laboring woman to push while in a semi-sitting position. While this position does utilize gravity, there are still disadvantages. One study showed that, compared to women who were in a kneeling or hands-and-knees position during labor, women who were sitting experienced increased pain, feelings of exposure, and vulnerability.(3)
Another study found that there was a higher rate of severe lacerations when the woman gave birth in a sitting position. While the rates were not statistically significant, this result makes sense to me. The tailbone is normally flexible. When a woman sits on her buttocks to give birth, the tailbone’s flexibility is limited. Rather than the tailbone being able to flex and expand the pelvic opening, the baby’s head is pushed directly into the perineum and upward toward the clitoris. While I am not aware of research that specifies the location of lacerations that occur with various birth positions, it has been my personal experience that clients giving birth in a sitting position experience more tears around the urethra, clitoris, and inside the labia. These tears are often more difficult and painful to repair than a perineal laceration.
What are the advantages of spontaneous pushing, rather than directed pushing? Although many providers firmly believe that the “take a deep breath, hold it, and push as hard as you can to the count of ten” style of pushing is essential to a shorter second stage of labor, research does not support this belief.(4) On the contrary, women who are not coached regarding how and when to push will spontaneously begin to bear down with short pushes, exhaling as they push, rather than holding the breath. As the baby’s head moves down, women’s pushing efforts often become stronger and more prolonged, but typically will include several short pushes per contraction rather than three long pushes. Finally, as the head begins to crown, most women feel the “ring of fire”, the burning sensation in the perineum, and instinctively hold back. This instinctive reaction has the benefit of allowing the skin of the perineum to stretch slowly, avoiding tears. Modern obstetrics coaches women at this point to do exactly the opposite of what their instincts tell them: “push through the pain!” “get mad at the pain and push it out!” “take a deep breath and push as hard as you can!” These instructions cause more rapid delivery of the baby’s head, increasing the risk of lacerations.
Rather than checking a woman’s cervix and telling her she can or can’t push yet, I prefer to simply offer support and encourage the laboring woman to follow her body’s cues. The old belief that allowing the woman to push before she’s fully dilated will cause swelling of the cervix is out of date. When a woman says she has the urge to push, I tell her to go ahead and push if she feels like it. I’ve noticed that when the cervix is not ready for pushing, the woman will not consistently push with the contractions, or will hold back because it is more painful. However, when the cervix is ready for pushing, even if it is not fully dilated, the woman will push spontaneously with her contractions, and will usually report that pushing is a relief. This method is so easy to use, and doesn’t require a woman with a strong urge to push to pant and blow for a long period of time before she is allowed to follow her natural intincts. Following this method, I’ve never had a problem with cervical swelling.
Woman who are supported in pushing when they choose, in the position of their choice, seem much calmer during the second stage of labor. I think of Carolina, a young woman having her second baby. She had had a rapid labor with her first child, and despite the fact that the baby was descending down the birth canal quickly, Carolina was urged to “push harder! push! push! push!” She felt frantic and out of control, and did not want to repeat the experience. During her second labor, she shared with me her desire to try to breathe normally through her contractions, until her body took over–and that’s exactly what she did. When she experienced the first urge to push, I noticed a very slight change in the rhythm of Carolina’s breathing at the peak of a contraction. The room was quiet, except for the soothing music she had chosen, and the soft sound of her breaths. Carolina was bearing down gently with her contractions for several minutes, then made eye contact with me and said, “The baby’s coming”. I couldn’t see anything, as she had her hand covering her perineum, but moments later, the baby’s head was out. One more push, and the rest of the baby was born into Carolina’s waiting hands. She smiled at me, “That was so much better than being yelled at to push!”
Birth doesn’t have to be a panicked, pressured event. It can be calm and peaceful, especially when women are supported in spontaneous pushing and choosing their own birth position.
1. Terry RR, Westcott J, O’Shea L, Kelly F. Postpartum outcomes in supine delivery by physicians vs nonsupine delivery by midwives. Journal fo the American Osteopathic Association. 2006 Apr;106(4):199-202.
2. Simpson KR, James DC. Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: A randomized clinical trial. Nursing Research: May/June 2005 – Volume 54 – Issue 3 – p 149-157.
3. Ragnar I, Altman D, Tyden T, Olsson SE. Comparison of the maternal experience and duration of labour in two upright delivery positions–a randomised controlled trial. BJOG. 2006 Feb;113(2):165-70.
4. Sampselle CM, Miller JM, Luecha Y, Fischer K, Rosten L. Provider support of spontaneous pushing during the second stage of labor. Journal of Obstetric Gynecologic and Neonatal Nursing. 2005 Nov-Dec;34(6):695-702.
Not a comment on this post specifically but I just wanted to let you know that I just discovered your blog and read a ton of your posts. I think it’s great and I’ll definitely be back!
Thank you! I’m glad to have you as a reader.
Your statement on not waiting for exactly 10 cm dilation really intrigues me. Has anyone looked into this? It would be amazing to see how necessary it is to put women through trauma of fighting against the urge to push if it really isn’t necessary.
I have not seen studies done specifically on pushing prior to 10 cm. However, there are several good studies that support spontaneous pushing, which means allowing the mother to push to the degree she wants, when she wants. Some have argued that women may confuse the pelvic pressure that is often felt around six centimeters of dilation with the urge to push, but this has not been my experience. I have practiced this way for some time, and whenever I have had a mother with an uncontrollable urge to push, she has had a rapid delivery without any cervical problems. Those who mistake pressure for the urge to push will not bear down forcefully because it hurts. This helps differentiate those who are ready to push and those who are simply feeling pressure.
With my first child, a little girl, I was allowed to labor on my hands and knees. Things were going well until the doctor /insisted/ I was getting dehydrated and mandated an IV. I hate needles and IVs and nearly lost it. Luckily the phlabotomist was relatively quick but I found the line in my hand very annoying. After a bit, I had the urge to push. I was checked (another disturbing moment in my concentration) and told I had to turn over onto my back. Biggest mistake in the world!! She slipped backwards and then I was told I was not allowed to push as I went down from 10 to 9. This article would have been helpful.
All-in-all, my hospital birth was not bad and I stayed with the practice for my second birth.
I had a different doctor the second time around (that seemed to honor my birth plan more) but unfortunately, as I went to move into a differt hands-and-knees position, they seemed to think I was getting on my back and wouldn’t let me off it once I was there. It was too late anyway as I had given several really good pushes in a crouched position and my little guys head was crowning. The second birth did not result in an IV but that doctor did not like all my moving (they kept loosing the fetal belts) so she wanted an internal monitor which she placed after breaking my bags at nearly 8 cm. While not as ideal as a home birth, given the compromise I had to make (my hubby is an RN that faithfully trusts the “system” so I convinced him we should get a doula), both births did not go “badly”.
If I could get him to agree to a home birth (we are considering a third), how do I get guidance on doing that – insurance, midwife, emergency plan, etc??? We live in Orange County, NY.
This is the part that bothered me the most about my daughter’s birth- everything was fine until we got to the hospital and she was crowning. Since it was so rushed no one looked at my birth plan and of course the on call OB didn’t remember that I didn’t want to push in the bed. My husband tried to tell them, but no one was listening to me or him. Instead of being able to push when I wanted to (like I was at home) I was semi-sitting in bed with nurses holding my legs- just the way I didn’t want to be. I only had the “hospital ride” for 15 minutes before she was born but even that was enough to make me go for home birth next time. I might have avoided the small tear that I did have if I had been able to push upright like I had wanted to.
This is what happened to me! I had no desire to push despite being 10 cm dilated and was told to push. My daughter’s head had been resting on my cervix since the 32nd week so it wasn’t like she wasn’t like she had to be pushed down in order to birth. I pushed for 2 hours before I *finally* felt the urge to push but by then I was exhausted. She had to have internal monitoring and I had to have an episiotomy and with that she came out in one push. Next time I will be more knowledgeable and wait until the urge to push comes. Thank you for your posts!!!!
It is hard for both providers and laboring women to be patient and wait for that irresistible urge. It’s only natural to want the hard work to be over with. But in my experience, it really doesn’t speed anything up, and creates more problems for mom.
I wish I would have known that about pushing. I was 8 cm and having a strong urge to push with every contraction. This went on for over an hour and everyone (including my doula) was telling me NOT to push, I had a panic attack during labor and ended up in a c-section.
This is so true! I wish I could get more of my friends to understand this, but they all think, “Who am I to argue with a ‘Doctor’!” I’ve had four vaginal deliveries without any pain medication and I tell my friends that there is NO denying that urge to push when it comes! I couldn’t have NOT pushed if the doctor had told me to! My first three births were in hospitals, but because of increasing regulations and “control” issues, I opted to have a homebirth for my fourth, even though that is not easy in my part of the country. My baby is 7 weeks old now and I am SO GRATEFUL for the homebirth experience! Just allowing things to happen when my body and the baby are ready results in a beautiful miracle!
I am often asked, “How will I know how to push?” My standard reply is “Who taught you how to poop in your diaper on the day you were born? Who taught you how to vomit when you are sick to your stomach?” Your body knows how to do these things when it is ready.
I couldn’t agree more! I HATED the pushing part of labor with my first two babies and it was uncomfortably with my third. The fourth was absolutely wonderful because for the first time I actually had the urge to push myself, instead of my midwife telling me to push. It makes all the difference in the world.