Birth Plan Options for Pushing
The options available to a mother for pushing will be dependent on several factors. First, the attendant with her may have strong opinions about pushing positions and styles limiting her to only a few options. Secondly, the place a mother gives birth may have policies or other limitations, such as equipment available. Finally, decisions made during the labor may limit options, such as using an epidural will make it difficult for a mother to be upright.
Directed pushing is the most difficult and tiring for the mother. It involves being told to push while someone counts (usually to 10), then being told to take a breath and push again. Using directed pushing will require pushing through the entire contraction, regardless of desire or urge to push.
This style of pushing can be helpful it there is concern for the baby's health because directed pushing does decrease the amount of time spent in second stage labor. However directed pushing also increases the risk of a tear, increases the mother's fatigue and can decrease oxygen levels for both mother and baby.
Spontaneous pushing refers to the pushing efforts that a mother makes on her own as she feels the urge from her body. Using this style of pushing is generally easier on the mother and reduces the risk of tearing. Spontaneous pushing takes longer to get the baby out than directed pushing. Many women feel the benefits of not wasting energy, ability to breathe when necessary and allowing the perineum to stretch make the longer pushing time worth the wait.
Exhale pushing can be used to decrease the strength of a push, or to release some of the tension the mother feels. Using this style of pushing promotes the gentlest, slowest pushing phase which may be easier on the mother and baby. To exhale push, the mother will slowly let the air out of her mouth while she pushes instead of holding the air in. Some women find this this pushing style helps them stay relaxed and focused during second stage. Other women find that it is difficult to coordinate exhaling with pushing when their urge to push is overwhelming.
Laboring down is the term given to the process of letting the body push without the mother adding extra effort. It can be helpful when a woman is using an epidural for pain relief, especially if she is unable to feel when she is having contractions. The body slowly moves the baby lower without the mother actively pushing. When the mother begins to feel pressure of the baby's head on the perineum, she begins to push with the contractions (pressure). This decreases the amount of time the mother needs to actively push, allows the mother to maintain an epidural during pushing and has not been shown to increase risk to mother or baby. Because this process is slow, it may not always be appropriate.
This is the classic hospital pushing position. Some women find that this position is helpful because it allows them to use their arms to hold their legs. Other women like the way this position allows support persons to assist them. Many women use this position because it is the position they are most familiar with from TV and movies.
Some experts feel that a reclining position increases the length of the second stage by causing the woman to push "uphill." Others are concerned that reclining positions may cause unnecessary pressure on a mother's back.
Squatting is the position the body is designed to use to eliminate and give birth. It opens the outlet of the pelvis to allow for an easier passage of the baby. It also helps to prevent perineal tears. Some women find that using an upright squatting position helps them focus their efforts to push with the right muscles. Other women feel that being upright makes them more in control of their pushing.
Some mothers find that a squatting position is uncomfortable because their bodies are not familiar with it. In that case, tools or props can be used to help the mother maintain a squatting position, such as a squat bar on a hospital bed, a birth stool or a handle or counter that the mother can hold onto for support while she squats.
Hands and Knees
For mothers who are experiencing back pain during labor, a hands and knees position can help to relieve some of the back pressure. It also uses gravity to help encourage the baby to turn to an easier position. Some care givers are uncomfortable with the hands and knees position because the "upside down" view is unfamiliar to them, and that makes it difficult for them to assess progress.
Some mothers find it difficult to isolate the muscles necessary to push effectively. Other mothers are embarrassed by the sensations of pushing, concerned that body fluids may be excreted. In these case, sitting on the toilet to push may allow the mother to feel more free with her pushing efforts. By imitating the pushing she does for a bowel movement, a mother can improve her pushing technique. Having the toilet to catch body fluids can make the mother feel more comfortable with the effects of her pushes.
Side lying may be equally helpful for a mother experiencing a fast labor as for a mother experiencing a long labor. During a fast labor, the side lying position may help to slow down the expulsive phase. This may help to prevent perineal tearing. During a long labor, side lying may allow the mother to rest completely between pushing contractions.
Studies have found episiotomy is not an effective way to prevent a tear, and may increase the likelihood of a deeper tear. Despite this, there may be instances where a midwife feels an episiotomy is the best choice. For example, if the skin looks as if it is tearing up towards urethra, an episiotomy may be performed to ensure the tear happens toward the rectum where it is easier to repair and heal. On average an episiotomy takes 3 months to heal.
There are two types of perineal massage. One type, done during the month before labor, helps the mother to learn to keep her pelvic floor relaxed during the stretching of crowning. The other type is done by a health care provider during pushing to gently stretch the perineal skin around the baby's head. This may be done with an oil or other lubricant to help the baby slip through the stretching skin. Some health care practitioners will provide perineal support, a type of counter pressure to the stretching from the baby's head, to help prevent a tear. Other's feel having a "hands off" approach is a better way to keep the perineal skin intact. To have perineal massage during your labor will require hiring a health care provider who is familiar with this technique.
Hot compresses soften the perineal skin allowing for more stretch in the tissue. This is what all the hot water was boiled for in the old books and movies. Some experts have expressed concern that hot compresses can "over stretch" the perineal tissues. Many women find the compresses to be valuable for comfort as well as to promote stretching of the perineum.
Second Stage Labor Research
Length of Pushing
Moon, J.M, (1990). Perinatal outcome after a prolonged second stage of labor. Journal of Reproductive Medicine, 35(3), 229-31.
Infants born after a prolonged second stage did not have an increased incidence of umbilical artery pH less than 7.20 or of five-minute Apgar scores less than 7, nor did they need intensive care nursery admission. A prolonged second stage of labor appears not to impose an increased hazard on the fetus but does require close fetal monitoring and increases the possibility of operative delivery.
Hansen, S. L, Clark, S. L., & Foster, J. C. (2002). Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Obstetrics & Gynecology, 99( 1), 29-34.
Delaying pushing for women with an epidural was not associated with any adverse outcomes, even when the delay was up to 4.9 hours.
Hanson, L., (1998). Second-stage positioning in nurse-midwifery practices: Part 2: factors affecting use
Journal of Nurse-Midwifery, Volume 43( 5), 326-330.
Midwives who reported less autonomy were more likely to report using the lithotomy position . Midiwves who reported more autonomy were more liekly to report using non-lithotomy positons.
Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D, & Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194( 1), 10-13.
Coached pushing was associated with a shorter pushing time, but had no other advantages. Withholding coaching during pushing is not harmful.
Roberts, J. & Hanson, L. (2007). Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning. Journal of Midwifery & Women's Health, 52( 3), 238-245.
Due to the evidence of adverse fetal and maternal outcomes with sustained bearing down efforts, best practice is to support women's involuntary bearing down sensations.