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Thread: Pushing for First Time Mothers

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    Default Pushing for First Time Mothers

    Hi everyone, the thread on positions for birth reminded me of this, it's one of my favourite articles from an experienced Canadian Birth Attendant/Midwife. I've included the link below if you would like to read the entire article.
    Pushing for First-Time Mothers
    by Gloria Lemay
    2000 Midwifery Today, Inc. All rights reserved.

    "The expulsion of a first baby from a woman's body is a space in time for much mischief and mishap to occur. It is also a space in time where her obstetrical future often gets decided and where she can be well served by a patient, rested midwife. Why do I make the distinction between primip pushing and multip pushing? The multiparous uterus is faster and more efficient at pushing babies out and the multiparous woman can often bypass obstetrical mismanagement simply because she is too quick to get any.

    It actually amazes me to see multips being shouted at to "Push, push, push" on the televised births on A Baby Story. My experience is that midwives must do everything they can to slow down the pushing in multips because the body is so good at expelling those second, third and fourth babies. In most cases with multips, having the mother do the minimum pushing possible will result in a nice intact perineum. As far as direction from the midwife goes, first babies are a different matter. I am not saying they need to be pushed out forcefully or worked hard on. Rather, I say they require more time and patience on the part of the midwife, and a smooth birth requires a dance to a different tune.



    Let's take a typical scenario with an unmedicated first birth at home. The mother has been in the birth process for about twelve hours. The attendants have spelled each other off through the night. Membranes ruptured spontaneously with clear fluid after eight hours in active phase and mother and baby have normal vitals. There is dark red show (about two tablespoons per sensation) and mother says, "I have to push!" This declaration on the part of the mother brings renewed life to the room. The attendants rally and think, Finally, we're going to see the baby. The long wait will be done. We'll be relieved to see baby breathe spontaneously. We can start the clean up and be home to our families. Typically, the midwife does a pelvic exam at this point to see if the woman is fully dilated and can get on with the pushing now. It is common to find the woman eight centimeters with this scenario. The mood of the room then turns to disappointment.

    My recommendation with this scenario: Don't do that pelvic exam. A European-trained midwife that I know told me she was trained to manage birth without doing pelvic exams. For her first two years of clinic, she had to do everything by external observation of "signs." When a first-time mother says, "I have to push!" begin to observe her for external signs rather than do an internal exam. Reassure her that gentle, easy pushing is fine and she can "Listen to her body." No one ever swelled her own cervix by gently pushing as directed by her own body messages. The way swollen cervices happen is with directed pushing (that is, being instructed by a midwife or physician) that goes beyond the mother's own cues. It has become the paranoia of North American midwifery that someone will push on an undilated cervix. Relax, this is not a big deal, and an uncomfortable pelvic exam at this point can set the birth back several hours. The external signs you will be looking for are as follows:

    When she "pushes" spontaneously, does it begin at the very beginning of the sensation or is it just at the peak? If it is just at the peak, it is an indication that there is still some dilating to do. The woman will usually enter a deep trance state at this time (we call this "going to Mars"). She is accessing her most rudimentary brain stem where the ancient knowledge of giving birth is stored. She must have quiet and dark to get to this essential place in the brain. She usually will close her eyes and should not be told to open them.

    Does she "push" (that is, grunt and bear down) with each sensation or with every other one? If some sensations don't have a pushing urge, there is still some dilating to do. Keep the room dark and quiet as above.

    Are you continuing to see "show"? Red show is a sign that the cervix is still dilating. Once dilation is complete the "show of blood" usually ceases while the head molding takes place. Then you can get another gush of blood from vaginal wall tears at the point that the head distends the perineum.

    Watch her rectum. The rectum will tell you a good deal about where the baby's forehead is located and how the dilation is going. If there is no rectal flaring or distention with the grunting, there is still more dilating to do. A dark red line extends straight up from the rectum between the bum cheeks when full dilation happens. To observe all this, of course, the mother must be in hands and knees or sidelying position.

    I use a plastic mirror and flashlight to make these observations. The mother should be touched or spoken to only if it is very helpful and she requests it. Involuntarily passing stool is another sign of descent and full dilation. Simply put, where there is maternal poop there is usually a little head not far behind.

    Why avoid that eight-centimeter dilation check? First, because it is excruciating for the mother. Second, because it disturbs a delicate point in the birth where the body is doing many fine adjustments to prepare to expel the baby and the woman is accessing the very primitive part of her ancient brain. Third, because it eliminates the performance anxiety/disappointment atmosphere that can muddy the primip birth waters. Birth attendants must extend their patience beyond their known limits in order to be with this delicate time between dilating and pushing.

    Often when the primiparous woman says, "I have to push," she is feeling a downward surge in her belly but no rectal pressure at all. The rectal pressure comes much later when she is fully dilated, but in some women there is a downward, pushy, abdominal feeling. I have seen so many hospital scenarios where this abdominal feeling has been treated like a premature pushing urge and the mother instructed to blow, puff, inhale gas and so forth to resist the abdominal pushing. Such instruction is not only ridiculous but also harmful. A feeling of the baby moving down in the abdomen should be encouraged and the woman gently directed to "go with your body."

    When I first started coaching births in the hospital I would run and get the nurse when the mother said, "I have to push." I soon learned not to do this because of the exams, the frustration and the eventual scenario of having to witness a perfectly healthy mother and baby operated on to get the baby out with forceps, vacuum or c-section. I have learned to downplay this declaration from first-time moms as much as possible, both at home and in the hospital. Especially if you have had a long first stage, you will have plenty of time in second stage to get people into the room when the scalp is showing at the perineum.

    Feeling stuck
    I recommend that midwives change their notion of what is happening in the pushing phase with a primip from "descent of the head" to "shaping of the head." Each expulsive sensation shapes the head of the baby to conform to the contours of the mother's pelvis. This can take time and lots of patience especially if the baby is large. This shaping of the baby's skull must be done with the same gentleness and care as that taken by Michelangelo applying plaster and shaping a statue. This shaping work often takes place over time in the midpelvis and is erroneously interpreted as "lack of descent," "arrest" or "failure to progress" by those who do not appreciate art. I tell mothers at this time, "It's normal to feel like the baby is stuck. The baby's head is elongating and getting shaped a little more with each sensation. It will suddenly feel like it has come down." This is exactly what happens.

    Given time to mold, the head of the baby suddenly appears. This progression is not linear and does not happen in stations of descent. All those textbook diagrams of a pelvis with little one-centimeter gradations up and down from the ischial spines could only have been put forth by someone who has never felt a baby's forehead passing over his/her rectum!


    For anyone who has taken workshops with Dr. Michel Odent, you will have heard him repeat over and over, "Ze most important thing is do not disturb ze birthing woman." We think we know what this means. The more births I attend, the more I realize how much I disturb the birthing woman. Disturbing often comes disguised in the form of "helping." Asking the mother questions, constant verbal coaching, side conversations in the room, clicking cameras?there are so many ways to draw the mother from her ancient brain trance (necessary for a smooth expulsion of the baby) into the present-time world (using the neo-cortex which interferes with smooth birth). This must be avoided.

    We spend so much money in North America on labor, delivery and recovery (LDR) rooms and now, adding postpartum, LDRP rooms. Yes, it is an advancement that women are not moved from room to room in the birth process, but there is so much more that can disturb the process: lighting, changing staff, monitoring, beeping alarms, exams, questions, bracelets, tidying, assessing, chattering, touching, checking, charting, changing positions and so on.


    Linguistics and concepts
    Midwives have lots of research support encouraging them to be patient with the second stage and wait for physiological expulsion of the baby. Recognizing ways in which we can support the mother to enter that deep trance brain wave state that leads to smooth birth is imperative. I find it very helpful to have new language and concepts for explaining the process to practitioners. Dr. Odent has taught me to wait for the "fetus ejection reflex." This is a reflex like a sneeze. Once it is there you can't stop it, but if you don't have it, you can't force it. While waiting for the "fetus ejection reflex," I imagine the mother dilating to "eleven centimeters." This concept reminds me there may be dilation out of the reach of gloved fingers that we don't know about, but that some women have to do in order to begin the ejection of the baby. I also find it valuable to view birth as an "elimination process" like other elimination processes-coughing, pooping, peeing, crying and sweating. All are valuable (like giving birth is) for maintaining the health of the body. They all require removing the thinking mind and changing one's "state." My friend Leilah is fond of saying, "Birth is a no brainer." After all "elimination processes" are finished, we feel a lot better until the next time. Each individual is competent to handle her bodily elimination functions without a lot of input from others. Birth complications, especially in the first-time mother, are often the result of helpful tampering with something that simply needs time and privacy to unfold as intended.

    Gloria Lemay is a Private Birth Attendant in Vancouver, British Columbia, Canada and a frequent contributor to Midwifery Today and The Birthkit.
    Pushing for First-Time Moms - by Gloria Lemay
    Last edited by Julie Doula; October 3rd, 2009 at 07:28 PM.

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    Wow, what a brilliant article. I wish I had've read it before I gave birth!
    I felt the urge to push about 4 hours before reaching second stage. I couldn't control it, and it wasn't with every contraction. Fortunately, my SIL was there to tell me that it was ok, the baby was moving down and just go with my feelings but don't force it.
    Then, in second stage, I honestly did feel like my baby was stuck! It took about 1.5 hours of pushing to get her out and in that time I kept thinking, they're going to need to cut me open! Had I have heard this beautiful analogy:
    This shaping of the baby's skull must be done with the same gentleness and care as that taken by Michelangelo applying plaster and shaping a statue. This shaping work often takes place over time in the midpelvis and is erroneously interpreted as "lack of descent," "arrest" or "failure to progress" by those who do not appreciate art. I tell mothers at this time, "It's normal to feel like the baby is stuck. The baby's head is elongating and getting shaped a little more with each sensation. It will suddenly feel like it has come down." This is exactly what happens.
    I'm sure I would've felt more relaxed during this stage (I'm sure I still would've been in a fair bit of pain and desperate to see my baby, but not thinking about c-sections at least!).
    Thanks for sharing this one, Julie

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    What a great read. I hope midwifes & maternity depts across Australia read this and learn from it. Thank you Julie for sharing it.

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    Excellent article Julie! I think I'll print it off and take it to my midwives. (not that they had any issues with my birth!) Thanks!

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    Very interesting (and as I haven't given much thought to what happens at that end of this pregnancy yet, scary!!) for a first timer. Thanks for sharing

  6. #6
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    I have seen so many hospital scenarios where this abdominal feeling has been treated like a premature pushing urge and the mother instructed to blow, puff, inhale gas and so forth to resist the abdominal pushing.
    This happened to me at home and i continued to blow, then moo, then roar, for 3 hours until my daughter's head was crowning. I was finally allowed to give in to the "premature" pushing urge when her ears were already born. Luckily i suffered only a small tear from that one whole-hearted push which delivered the rest of her in one go.

    I'm kind of sad to read that the same will happen (i'll be encouraged to "slow it down") in my subsequent labours as that bit of my birth was by far the hardest and i've been actively looking forward to being able to push when i feel that urge next time.

    Thanks for posting this Julie. Since the forums at Midwifery Today went down i've been really missing Gloria and the other wise birthing ladies. I hope they rebuild soon!

    Bx

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    Thanks for that article Julie. It sure was well written. Now if only we could share that story elsewhere.

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    This gets me a bit sad of the time limits imposed by so many places (including the hospital where my birth centre was)... I was only allowed 2 hours for this gentle pushing. My instincts were to go (relatively) gently and I was supported in that but in the end my 2 hours were up and everything had to change to crazy, intense pushing to get my baby out to avoid intervention. So, I think for this to work hospital policies on time limits need to change. My problem wasn't my midwife but the policies we were under pressure from.

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    Julie this article was so valuable, thank you so much for sharing.

    I love the section about art and the shaping of the head. I'm printing it out and taking it to my next birth.
    It describes so much of what i was unsure of when i was in labour. In fact it now makes me realise that I knew exactly what my body was doing, and that i was in complete control.
    It also makes me realise how damn thankful I am for who was such a wonderful midwife.
    I barely let her ever come near me, and i never once listened to her telling me to pant, etc because it didn't feel as though I was pushing to birth the baby.
    It turns out that I did my labour myself. In the end there was no directed pushing, it was just me, me birthing my baby.
    Obviously musn't happen too often as they seemed all too surprised that I had no injuries from my quick and "undirected" second stage (eighteen minutes - so they 'estimated' - i say no more than ten).


    Ahhhh...
    Typically, the midwife does a pelvic exam at this point to see if the woman is fully dilated and can get on with the pushing now. It is common to find the woman eight centimeters with this scenario. The mood of the room then turns to disappointment.
    That's when I asked for my epidural (10pm)... the anaesthetist didn't get there until 11pm and DS was born at 11:08. Next time i at least know what my body is doing when i "need to push".
    Because she did a pelvic exam and guess what, only 8 cm (only dilated 1cm in 3hrs at hospital). "First, because it is excruciating for the mother." Certainly is.

    The rectum will tell you a good deal about where the baby's forehead is located and how the dilation is going. If there is no rectal flaring or distention with the grunting, there is still more dilating to do.
    That's when the an. left the room. About 2 minutes after he walked in. It's also how my mid realised i was about to have the baby. 2 contractions on all fours, 2 on my back. Woohoo.


    ETA - Ren I didn't think to check out hospital policy. Is that something you knew beforehand or not until it was happening?
    Last edited by The[cookie]Doctor; April 19th, 2008 at 08:18 AM. Reason: ETA

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    Quote Originally Posted by ashnant View Post
    Ren I didn't think to check out hospital policy. Is that something you knew beforehand or not until it was happening?
    Funnily enough it came up when I was checking with- with the midwife I ended up birthing with! She told me about the 2 hour limit then when I was asking about reasons for transfer out of the birthing centre. I argued it then saying 'what if I am okay with going for longer than 2 hours?'. The impression I had throughout my pregnancy though was that women rarely take longer than 2 hours and you'd be so buggered by then if you had that intervention would be pretty much necessary.
    I was concerned about a few hospital policies and freaked out that I wasn't having a homebirth quite a few times... in the end my labour went well but I bet I wouldn't have torn if I'd birthed at home.

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    Quote Originally Posted by Cricket View Post
    Excellent article Julie! I think I'll print it off and take it to my midwives. (not that they had any issues with my birth!) Thanks!
    Hi Cricket, if you want to print it, you might like to click on the link and get the complete article - I only posted excerpts here.

    I offer this article to all my doula clients who are first time mamas. Gloria's "External and Observed signs of Labour Progress" is excellent too - how to observe for progress and dilation without vaginal exams to 'measure' the cervix. Much less intrusive for the mother.

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    Great article Julie thank you!
    What are the differences for a second time mother, or in my case going for a vbac?? Are there many??

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    Oh I wish I knew this when I was in labour at the hospital.

    The examinations were HELL. I only had two, but I hated them. First was when I arrived at the hospital and midwife wanted to see if I "really was in labour". (ok, so I was a first time mother, but I know my body and KNEW I was in labour).

    The second one was when I was 10cm and I then got told to push whenever I wanted to. Probably about an hour and a half or so before that, I was in the shower and had so much pressure down there than I involuntarily did a poo (actually I did a few). Midwife didnt even ask me how I was feeling or if I felt I needed to push or anything like that. She just cleaned up the poo and went back out of the room. That second examination only happened because I told the midwife I couldnt do it anymore and give me some pethidine. It was so uncomfortable and painful that it made me so tense, I just couldnt relax. I had a massive urge to push and had been bearing down for quite some time before that. So I tell the midwife, yes I want to push. So what does she do? She starts telling me to do three big pushes for each contraction. When each contraction came she'd say "push...push...push" (it annoyed me ALOT). No wonder I had to push for more than 2 hours and ended up with constant monitoring, 2 obs and a few extra midwives to assist. They had me on my back and I dont even remember anyone encouraging me to try any different positions, or to push differently or breathe differently or anything. I ended up with 3 tears and so much swelling that I couldnt close my legs. It looked like I had a penis - thats how swollen I was.

    I want a homebirth next time. With a patient midwife who wont try to rush me.
    Last edited by Karina; April 19th, 2008 at 10:42 PM. Reason: silly typos!

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    I hear you, Karina. I'm so glad you're planning a homebirth for next time. A homebirth is light years apart from a standard hospital obstetric birth. Whereabouts are you? Let me know if you need any leads on good 'with woman' midwives in your area.

    I'm sorry about all that you went through. Everything you're saying is backed up by research. That VEs are unnecessary and intrusive. That the mother knows her body best and should be listened to. That Directed Pushing is counterproductive, and that instinctive pushing works. That making women push on their backs makes it harder, uphill against gravity, and causes more damage to the pelvic floor. That too many observers undermine her confidence and progress (because it inhibits her hormones).

    It's the standard approach - but nearly everything that is policy or routine in an obstetrically managed birth has a detrimental effect on normal, safe, physiological birthing, mostly because anything that interrupts, distracts or disrupts the birthing woman mucks up the flow of her birth hormones and trigger stress hormones instead - her birth hormones go down, her labour is more difficult and protracted, her stress hormones go up, she feels more pain and anxiety .... then they say or imply 'your body is not working, now we have to *help* you" when the problem was caused in the first place by the interference.

    If you would like any articles to add to your collection, please feel free to email me: [email protected].

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    Thanks for posting this article Julie! I was a victim of directed pushing first time (under epidural however, so no urge anyway). The second time, I had a gorgeous midwife who, when I felt the urge for the first time ever and looked at her scared, just calmly told me to go with my body.


    Cara
    Last edited by doulacara; April 19th, 2008 at 07:01 PM.

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    Quote Originally Posted by Tanstar View Post
    What are the differences for a second time mother, or in my case going for a vbac?? Are there many??
    Hi Tanstar, I think it would be very similar for a first vaginal birth. I attended my first VBAC as doula with a gorgeous woman from here at Bellybelly. The wise saying, "It's just a birth" kept going through my head. The idea being that a VBAC woman needs all the things that ANY woman needs to birth safely and effectively, the things that will promote her luscious birth hormones and not impede them, loads of TLC and freedom to move as her body impels her, to use gravity to her advantage, and to be able to go with the flow of her own unique rhythms. Therefore, it's important to choose and environment and careproviders who will be conducive to this.

    I think it would be quite similar for a first vaginal birth after c/s, because the sensations of being fully dilated, and the journey of the baby through the cervix, down into the vagina, past the bowel (creating that 'oh the baby is coming out the wrong hole!' kind of feeling) and the sensations of vaginal distention and eventually, crowning, would be new to most VBAC women. So, you need loads of support and encouragement to trust your body, listen to its signals, follow its cues and do what feels right - and celebrate your awesome birthing body.

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    Oh Julie - thanks so much for your reply. Just found this thread again! Such a great article!

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    What a brilliant article

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