This post is all about pushing... what works, what doesn't, and how to have the most rewarding pushing stage for your birthing time!

Pushing, or the 2nd stage of labor, is the active process of bringing your baby through the birth canal, past the perineum, and into the world!

There are a number of ways to push, generally broken down into two categories: coached pushing and spontaneous pushing. Coached (directed) pushing (aka purple pushing) is just what it implies - you are coached when and how to push. Spontaneous pushing includes grunt pushing, singing your baby down, and breathing your baby down. Many women find themselves doing a combination of these, with whatever feels and works best for them.

There is a great article by FitPregnancy called The Push Paradox.

"“Plain and simple, coached pushing, especially with the woman on her back, can harm mothers and babies,” says Amy Romano, C.N.M., a Connecticut nurse-midwife who contributed to the Lamaze International guidelines on care during the pushing stage of labor.

Several studies on coached pushing have been conducted in the past few years. Although not all reach the same conclusions, they suggest that the practice is more likely than spontaneous pushing to tire a laboring woman and make her less satisfied with her birth experience. The excess force of directed pushing may raise the risk of vaginal lacerations and episiotomies, as well as pelvic-floor weakness, which can lead to incontinence and sexual dysfunction. Pushing on command may also contribute to fetal heart rate abnormalities, lower blood oxygen levels in babies and an increased need for such medical interventions as instrument-assisted delivery. (It can be helpful if you’ve had an epidural, however.)"
Coached pushing is the most common hospital occurrence. This entails a woman pulling her knees back, tucking her chin, taking a deep breath in, holding it, and pushing for a count of 10.

This type of pushing shortens the time of pushing to birth by about 13 minutes. Which is not much in the grand scheme when you consider that a first-time mom will push for an average of 1-2 hours. On the other hand, it does have a greater incidence of trauma and intervention.

Grunt pushing is what occurs most often when a woman is allowed to listen to her bodies cues. This entails short bouts of breath holding and bearing down. If you have never heard a woman grunt pushing, this is a beautiful example that will give you a very good idea of what grunt pushing is.

Grunt pushing is the physiological response to a baby filling the birth canal, and as a result, compressing the colon, which is directly behind the Vaginal Barrel. This compression stimulates the Ferguson Reflex, the reflex that tells the body to bear down with a bowel movement, and results in the grunty pushing that you hear and see in the example above.

Singing your baby down entails simply keeping your glottis open and making noise to release air slowly and controlled. It can be a quiet aaah or a loud open yell. Not everyone differentiates between singing or breathing your baby down, but I have found that this is the second most common occurrence when a woman is not coached in 2nd stage and has not used a formal education program such as Hypnobabies.

Breathing your baby down is something that Hypnobabies brought to the forefront of the birthing community. It was something used previously (see singing your baby down), but is 'the way' of working through 2nd stage for a Hypnobabies birthing mother and is generally more controlled and quiet than singing a baby down. Here is a beautiful example of what this looks and sounds like, a light aaahh, and truly just breathing:

She does have a bit of involuntary bearing down, but it is the best example I can find on the web.

So, what about positions?

Here is a great video on positions for second stage:

There are a great number of positions that are physiologically more beneficial than lying on your back or semi-reclining for moving baby down.

These positions include: side-lying, standing, squatting, all-fours, frog squatting, and leaning.
  • Lithotomy - This position (also called supine) is the worst position for birthing. It is marked by being completely or nearly completely reclined (on your back with either your knees far apart or in stirrups. This position compresses the pelvis, making the outlet smaller, puts pressure on the vena cava (main artery supplying blood to the uterus) which can result in ineffective or stalled contractions, and works against gravity by providing an up- ward slope to push baby out of.
  • Classic - What is normally seen in hospital settings during a natural birth where the hospital staff directs a woman into a position for birth, this position allows mom to pull her legs back as far as possible and see the progress of pushing in a mirror. It also allows for a support person to get behind mom to support her legs or back. It involves sitting in a 45-90 degree angle—and allows mom to completely relax between contractions.
  • Squat - This position is considered the best for 2nd stage as it shortens the birth canal by 10-15% and opens the outlet of the pelvis by an average of 13%. This position is good for large babies, ‘stuck babies’, long 2nd stages, or mother’s interested in catching their own babies. Gravity is a great ally in this position.
  • Standing - Standing is a very uncommon position for birthing as it requires mom’s active participation in holding herself up, though gravity assists well in this position.
  • All Fours - All-Fours is a great position for posterior babies, large babies, or babies where shoulder dystocia is either present or expected. This position allows mom complete control over the strength and timing of her pushing contractions as it takes pressure off of the Ferguson Reflex.
  • Side Lying - A gravity-neutral position for birthing, it is considered one of the most gentle birthing positions as mom has the ability to lift her leg as much as needed, push to comfort, and gently stretch through contractions. It takes some pressure off of the Ferguson Reflex, allowing mom more control over pushing. If 2nd stage is drawn out, or if there is a large or stuck baby, this can be a detrimental position, though.
  • Variations- Sitting on a birthing stool, Frog position, asymmetrical position
To close, listening to your bodies needs, allowing your birth team to be an encouragement to you, and working with your bodies cues will ensure that you have the best, most rewarding 2nd stage as you welcome your baby into the world!


Kelli said...

Thanks for this post. It is very thorough. Again, it is putting the power back into mama's body where it was all along. :)

mommymichael said...

just in case you haven't seen it, here's Trillian's birth video. http://www.youtube.com/watch?v=ukPcRJWdDYA

definitely "breathing baby out".

Nicole D said...

Thanks Mommymicheal!

Nicole D said...

Mommymicheal - that was absolutely BEAUTIFUL! Great job mama!

Sheridan said...

Great pushing post! I would like to add that in Hypnobabies while we talk about breathing the baby down, we really emphasize "mother directed pushing" That mom should follow her body and the urges she feels.

So some moms might breathe/sing their baby out, some might grunt their baby out, some might more actively push. Most will do a combination of all three.

The key is to follow your body, it knows what to do!


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