When and How to Push: Providing the Most Current Information About Second-Stage Labor

I really liked this. Very useful especially if you want to show that your birth plan preferences really are evidence-based. I'd love to see a copy of this in every maternity unit.

When and How to Push: Providing the Most Current Information About Second-Stage Labor to Women During Childbirth Education

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The “old way” of assisting women during second-stage labor typically involves pushing immediately at 10 cm regardless of whether the woman has an urge to push; telling the woman to take a deep breath and hold it while someone counts to 10 during at least four to five pushing efforts per contraction as the woman lies in the supine lithotomy position (often using stirrups); and a care provider forcing the woman's legs back against her abdomen. These techniques have the potential to cause harm to the mother and baby

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A better approach based on current evidence is to delay pushing until the woman feels the urge to push. With epidural anesthesia, pushing can be delayed up to 2 hours for nulliparous women and up to 1 hour for multiparous women ... The most stressful period of labor for the fetus is the active pushing phase; thus, shortening this phase minimizes fetal stress and promotes fetal well-being. When pushing is delayed until the woman's urge to push, there are fewer fetal heart rate (FHR) decelerations and less of a negative effect on fetal acid-base status and oxygenation.

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When the time is right for pushing, the best approach based on current evidence is to encourage the woman to do whatever comes naturally.

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wow! a published article actually says this! about time eh?

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Positioning is an important component of safe and effective pushing. An upright position or lateral position works better than supine positioning

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finally!

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If the fetus does not respond well to pushing, the best approach is to stop pushing temporarily and let the fetus recover.

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yeh, that!

I hope this is helpful for someone out there.

Very interesting Julie! Thanks for posting.

Apparently this is normal teaching in some places like Russia. Stage 2 includes Stage 2a) baby descending and 2b) pushing. Sometime baby needs time to descend.

I read that online on a Midwifery magazine site.

Great - Thanks Julie. A friend of mine has worked as a midwife in Africa and she said the women over there laugh at the prospect of us trying to push a baby out whilst lying on our back. To not utilise the force of gravity is absurd to them! Even more mad is the fact that the US has the highest infant mortality rate in the world with regards to birthing - above Africa, which is full of 'third world' countries, where surprise surprise, women are not put on an arbitrary timetable set by a peice of scanning equipment and are typically left alone to listen to their bodies and labour when mother nature deems baby and body are ready.

Crazy world eh? Who would've thought common sense could apply to humans as it does to all other mammilian species that birth?

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Great - Thanks Julie. A friend of mine has worked as a midwife in Africa and she said the women over there laugh at the prospect of us trying to push a baby out whilst lying on our back. To not utilise the force of gravity is absurd to them! Even more mad is the fact that the US has the highest infant mortality rate in the world with regards to birthing - above Africa, which is full of 'third world' countries, where surprise surprise, women are not put on an arbitrary timetable set by a peice of scanning equipment and are typically left alone to listen to their bodies and labour when mother nature deems baby and body are ready.

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I feel great relief when I read that, JellyBean. I live in dread that midwife-led, cultural birthing in other countries will be destroyed by the western obstetric juggernaut. This has occured in parts of Asia. China and Viet Nam have very high c/s rates now. Nations of women with a heritage of squatting - ON BEDS! It makes me weep. This is classic, I love it:

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the women over there laugh at the prospect of us trying to push a baby out whilst lying on our back. To not utilise the force of gravity is absurd to them!

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I saw a doco of a woman birthing in Africa once, she walked miles in labour and I thought 'good, good' - but when she reached the clinic, they lay her down on a narrow trolley-style bed and I was so sad to see that.

I still hold that my two best births (the last two) I didn't have to 'push' at all. I just 'relaxed' my muscles as much as possible and my body done the work without me.

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the best approach based on current evidence is to encourage the woman to do whatever comes naturally.

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and then we will see more women experiencing what you experienced, misty.

In four births I never had to push volitionally, it was all 'hang on for the ride' while my uterus and the foetal ejection reflex did their thing. The only time I pushed volitionally was during my third birth when I gave one slight deliberate push between contractions, just to ease things ever so gently.

love love love thanks for posting

Wow. I don't think much of this in "Figure 2":

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For women with epidural anesthesia who do not feel the urge to push when they are completely dilated, delay pushing until the urge to push is felt (up to 2 hours for nulliparous women and up to 1 hour for multiparous women).

or how about until however long it takes for her to feel the urge? I've seen women fully go our for a walk, come back, and have a baby. One mother went to bed, had a sleep, got up and had a baby! What's the rush?

• Use upright positioning with the woman's feet flat on the bed.

um, what about, 'let the birthing women assume whatever position she chooses'. It is HER that 'uses' any given position, not the staff!

Change to a lateral position or other positions of comfort as necessary.

Let the WOMAN change positions as she wishes, as her body compels her - again, it's not the careproviders who 'change the position' - it's the woman!

• Avoid forcing the woman's legs back against her abdomen.

how about, keep your hands off her, don't do ANYTHING to any part of her body - rather, let HER use YOUR body for support if she chooses.

• Discourage prolonged breath-holding. Instead, instruct the woman to bear down and allow her to choose whether or not to hold her breath while pushing.

how about, do NOT instruct her, other than to tell her to go with her body?

• Discourage more than three to four pushing efforts with each contraction and more than 6 to 8 seconds of each pushing effort (avoid counting to 10 with each pushing effort).

Amazingly, if you don't presume to instruct her, this will never happen!!

• Take steps to maintain a reassuring fetal heart rate (FHR) pattern while pushing. Push with every other or every third contraction if necessary to avoid recurrent FHR decelerations. Reposition as necessary to treat FHR decelerations. Use the fetal response to pushing as a guide for second-stage care.

Once again, the language implies the careproviders are in control and are active, and the mother is passive. No - careproviders should not "reposition", it's the MOTHER who 'changes position'. Even to say, "encourage the mother to change position" is more honouring of her autonomy.

• Avoid uterine hyperstimulation during the second stage of labor. Make sure that contractions are no closer than every 2 to 3 minutes while pushing. Titrate oxytocin accordingly, use an intravenous fluid bolus of lactated Ringer's solution, and reposition to decrease contraction frequency.

How about just don't use syntocinon but practice unhindered birth principles so her own birth hormones are at peak levels? Not to say that there is *never* a time to use syntocinon - but this reads as if it's normal practice for a woman to be on a bed, with an IV in, and synto running!

• Allow the woman's perineum to stretch naturally rather than using manual massage or stretching.

[I]I repeat: keep your hands off her! And yes, there is evidence to show that manual stretching and the use of oils, lubricants etc actually increases tearing and does not decrease it - amazing, letting the body do its job naturally turns out to be best!

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I think this is a useful article, especially for people planning in-hospital births, but the wording of this appendix is rather disappointing.

sorry i tried to have my comments in italics to differentiate from the actual text in the quote, but it turned out all in italics ??

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I still hold that my two best births (the last two) I didn't have to 'push' at all. I just 'relaxed' my muscles as much as possible and my body done the work without me.

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I just gave birth to a big baby, and like Misty i didn't push at all. I was breathing through it, to slow things down, and baby and my body did what they needed to.

I call it pushing, but like HotI I didn't actually push as such, I breathed and my body pushed DD out on it's own. I found that near when she crowned, the surges changed and she would descend and then slip back up for a few minutes, softening and stretching the area. DD wasn't huge (8lb 9oz) but I had no tears or grazes whatsoever :)

Yay for more births like that, PZ & HotI. Given half a chance, the female body works well! Can you share what positions you were in while your body was pushing? All four time, it was some variation of kneeling for me.

I was on all fours leaning over a fit ball (on the bathroom floor, with the lights out lol!) I spent probably 4 and a half hours out of my 6 hour labour in that position, I was drawn to the floor and it was where I felt in control. I only moved to shower briefly, transfer to hospital, or near the end I moved to squatting on the toilet to help DD around the bend. My knees were sore after haha!

I was upright or leaning forward in the pool. My body was already pushing for a couple of contractions before I realized what was happening! I worked hard for about 50 mins until she was born in that position, but there was no need to count to anything. I also let my baby and body bring her out at the end, gradually and with no assistance (or tearing).

As for 10cm dilated, at home I had no VEs (and no need for them) so how would we have known? My labour progressed quickly this way - at a guess I would have gone from about half dilated to fully in less than two hours. Not sure how 'measuring' me would have improved anything!

I had the works with Amelia - gas, epidural, something in a drip I'm not even sure of... Forced supine position, legs pushed back into me, continuous bloody monitoring... The only control I felt I had was when I was pushing. They were "coaching" me, but I wasn't paying a great deal of attention to them anyway and just pushed when I felt the urge (luckily for me, the epi didn't work 100% and I still felt some contraction pain - in my leg :o)

Next time will be better. I won't lose sight of what I want!


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Good on you TB, you go girl! And this article backs you up.

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As for 10cm dilated, at home I had no VEs (and no need for them) so how would we have known? My labour progressed quickly this way - at a guess I would have gone from about half dilated to fully in less than two hours. Not sure how 'measuring' me would have improved anything!

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Absolutely Jennifer - this puts me in mind of Gloria Lemay's article about Pushing for First Time Mothers - she strongly discourages doing a VE to confirm a woman in 10cm.

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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.

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http://www.havingababytoday.com/articles/pushing.asp

Great article, Julie! Interestingly I'd had a big show on the toilet (I refused to get off until it was finished) and apparently exhibited a couple of transition signs on the toilet too (I didn't notice). So my m/w and doula both weren't surprised that the sounds I was making changed when I got back in the pool. Do women usually make different sounds when fully dilated and pushing?

Of course, the only issue with all of this is that following this would mean being with a woman throughout her labour and what hospital does that?

I had one VE upon arriving at hospital (planned HB, transfer for meconium). My doula and midwife had not yet arrived and although I didn't want one I agreed. 6cm after an hour labour. After that, I had no further intervention bar a Doppler check every now and then. I too transitioned on the toilet, my show came away and my pitch rose which was a telltale sign. I have no idea when I was at 10, just that when my body started to surge I felt the change and let it happen.

What a great article. DS was an induction with the works - epi, pushing when told to on my back and a nice second degree tear on a bub who was 6lb 14oz......DD was a water birth with a midwife who did one VE on my request and after an hour of labour I was 7cms. In the next 15 mins I hit transition and I assume got to 10cms - when I asked her if it was "safe" to push she said "your body won't tell you to do something it isn't ready for". So I got on my knees and gave birth to my 7lb 6oz DD without even a graze!

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Do women usually make different sounds when fully dilated and pushing?

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Yes, absolutely. There are so many external signs of progress that it is not necessary for VEs to be routine in any normal labour, let alone every 4 hours - beware those words, "and then we'll assess you".

I'm not saying that there is never a time to do a VE (as long as the mother has consented - and has the right to withold her consent, otherwise it's not an unbounded choice!), but research shows that many maternity units & obstetric policies are not allowing long enough for primip labours, and many primip labours unfold over a much longer period of time than many obstetric staff are trained to believe - according to this study.

New study shows normal labour takes more time than OBs are allowing for

So there's a good case for waiting longer and reducing or avoiding VEs, and instead - waiting and observing for external signs of progress such as:

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• Location of FHT (foetal heart tones) with pinard or fetoscope; good for gauging descent. FHT early deceleration pattern will indicate resistance onto pelvic floor and therefore descent.

• 6cm = contraction pattern shifts, flushing over cheekbones.

• 8cm = hot/cold/trembly/irritable/nauseous. Contractions seem to not give her a break.

• Near full = increased pressure, vomits, breathing more ragged, ‘catch’ in breath, deeper, guttural moaning. FHT’s midline and low. Sacrum seems flat and full. Her energy will be acutely aware during contractions but she will retreat just as intensely between them. More show, spotting of fresh blood. Feels like pooing, membranes release

• Purple line that creeps up like a mercury thermometer from anus to top of bum crease. When it reaches the top, the woman is fully (increase in intrapelvic pressure affects veins in the sacrum).

• Vomiting and ROM (release of membranes) at the same time = 7 cm stretch

• Look at bottom of foot with the toes pointing up. The spot above the heel and in the center will tighten and release as the uterus contracts IF she is at least 5 cm.

• Fully = passing stool involuntarily, pouting of anus, instinctive bearing down begins at the beginning of the contraction and not at the height of it.

• The contracting uterus swells upwards as it pulls in the dilating cervix. Before a woman begins to dilate and is about at term, you can get about 5 fingerbreadths of measurement between the fundus and the tip of the breastbone (xyphoid). As she dilates, this measurement decreases at about 2 cms per fingerbreadth. I.e., 1 1/2 fingerbreadths between these two points would be equal to 7-8 cms. dilation. It's an old trick I learned several years ago. This really works but, like vaginal exams, it takes practice. Unlike vaginal exams, it's not out of the scope of practice as a doula to do this type of exam because it's not done internally and not "really" considered a clinical test.

• Abdominal signs: thin line or crease above/parallel to Symphysis Pubis. As baby descends and cervix opens, the line/crease becomes wider from side to side. Near transition = ¾ across. All the way across indicates that pushing is most likely imminent (bulk of baby’s shoulders closer to SP?)

• 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. 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, instinctively 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. Don’t mistake another gush of blood which may be 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.

External & Observed signs of dilation, descent and progress

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I had no VEs this time- and the baby still came out!

My first labour was augmented/induced with syntocinon, multiple VEs, over 2 hours of coached pushing - because i was 10cm, and i never felt the urge to push. The environment was so wrong that i don't think i was able to listen to my body, and resulted in ventouse, episiotomy...

My 2nd labour was at home, i felt supported during my pregnancy, i was mobile during labour, i didn't feel i had to push, more just support my body & baby as baby entered the world. I was standing with one leg on the couch, and then entered the birth pool and was kneeling when my baby was born. My professional support people (student midwife & then midwife) didn't need VEs to know that bub was on its way.

Was this just a few weeks ago, HotI? I see on your sig your DS was born Jan 2012? Congratulations! It sounds just wonderful. Is there a link to your birth story? (If you have written it yet - it took me like 9 months to get mine written!)

only 5 days ago! no birth story yet but i will write it.

Wow, congratulations HotI! Babymoon blessings to you, enjoy those milky snuggles and baby-gazing *bliss*

I was the same as most of these girls. I never made a decision to push. My body just pushed as it wanted to. The pushing contractions were spontaneous and erratic because I probably had an anterior lip. My MW did a very basic VE when I was in a forward leaning position and suggested that I float on my back for awhile, just so that the lip wasn't crushed between the babies head and my sp. when I did float on my back the contractions intensified but actually decreased the lower abdo pain I was experiencing. But it was amazing the way my body just curled up and pushed on its own. I really was a bystander to my body at that point.

I too only pushed when my body pushed. The midwife would be saying push, but I just ignored it and only pushed when my body was. I actually wonder if my body would have pushed DD out on it's own if I hadn't have helped it, it was pushing pretty strongly lol