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
