There are many ways in which a labouring woman and those providing care for her can either work with the natural process, or interfere. Whether to follow the instinctive urge of bearing down, or to have another person direct the pushing efforts, is a decision that each mother needs to consider in planning for spontaneous birth
It is normal for a labouring woman whose baby is ready to be born to feel a strong urge to bear down and push her baby out, without anyone telling her what to do.
For many years in Western cultures, midwives, doctors and nurses have practised directed or coached pushing, or the ‘Valsalva manoeuvre’, in which the attendant instructs the labouring
woman to “Take a deep breath, hold your breath, and push…”
Directed pushing is frequently a feature of managed births, in which the labouring woman is lying on a bed, with her legs drawn up to her chest, rather than being in an upright position.
The rationale for directed pushing is usually to speed the labour up, and get the baby born.
Spontaneous bearing down usually occurs in response to the leading part of your baby’s head descending deeply into the birth canal, beyond the ischial spines.
Questions to consider when making an informed decision:
This information is only a guide — the decisions you make in labour will depend on your individual situation, the skill of the midwife or doctor who is with you, and the trust you have in that person as your leading professional care provider. Here are a few questions to consider.
Q1: Will directed pushing result in my baby being born sooner than if I wait for the urge to bear down?
A: Possibly. Some studies have shown a reduced duration of second stage of labour.
Q2: Is there a problem with waiting for the urge to bear down?
A: No. Bearing down spontaneously is less likely than directed pushing to result in non-reassuring changes in your baby’s heart rate pattern, which indicate that your baby may be distressed.
Q3: Are there any differences in the way babies are born when the mother is either directed to push or waits for the spontaneous urge to bear down?
A: No significant differences have been shown. However you would be wise to discuss with your midwife or doctor whether they apply time limits to the stages of labour, and what actions they
usually take if these time limits are exceeded.
Q4: Is there a greater likelihood of perineal tearing or episiotomy with one method over the other?
A: A mother who experiences directed pushing is more likely to have an episiotomy or a tear than a mother who waits for the urge to bear down.
Overall, women who are in active labour may experience a shorter second stage with directed pushing rather than waiting for the natural urge to bear down. However, as there are no clear
advantages to speeding second stage of labour, and there are increased risks to both the mother, in perineal damage, and the baby, in increased likelihood of fetal distress, the practice of directed pushing should be discouraged.
This review refers to women in active labour, without epidural anaesthesia.
Bosomworth A and Bettany-Saltikov J 2006. Just take a deep breath. A review to compare the effects of spontaneous versus directed Valsalva pushing in the second stage of labour on
maternal and fetal wellbeing. MIDIRS Midwifery Digest, vol16, No2, June 2006 pp157-165