(#9) Push it, Girl, Push It Real Good: 2nd Stage of Labor

Okay, so I totally just revealed that I was product of the 80s and cheese out on that era of music (she says, referring to the post title's nod to the 1987 Salt n Pepa song)! We're up to #9 on our 11 Ways to Prepare for Your Best Birth series:

#9 Avoid giving birth on your back, and follow your body’s urges to push

Today we'll talk about the 2nd stage of labor, in which our uterus is pushing the baby down and out and we get to meet our sweet baby.

Avoid giving birth on your back

First: Avoid giving birth on your back (also known as "dorsal lithotomy"). I've never worked with nor heard of a laboring woman who, if left to follow her body's instincts, would choose to lie down on her back. Isn't it kind of bogus that we tell women in pregnancy to stay off their backs for so many weeks and then in labor we order them to get on their backs to push a baby out? A woman should be allowed to have full freedom of movement and choose whatever positions she finds most instinctive and least uncomfortable throughout her labor, including the pushing stage. This will virtually never mean lying on her back.

Here are a few reasons lithotomy (either flat on your back or semi-reclined) doesn't feel right to a laboring woman at any point in labor—especially during pushing:

  • In labor, we often have discomfort in our backs, and lying on our back only increases that uncomfortable sensation
  • Lying on the back is the most closed position for the pelvis; our wise instincts lead us more often to sit, squat, or get on all fours -- significantly more open positions for the pelvis.
  • The vast majority of us, at least in our adult lives, have never passed a bowel movement while lying on our backs in bed. A laboring woman often pushes with the contractions very effectively while upright or sitting on the toilet because that's where she's used to coordinating her abdominal muscles and releasing the pelvic floor ones. Then if a care provider comes in and disrupts that process by ordering her patient on the bed, suddenly when she's out of the familiar territory she feels totally disoriented. This is normal and to be expected, so I'd say, "just say no!"

Actually, that's a little late for the communication. I would recommend doing that if you must, but it would be better for you to have conversations with your care provider now, prenatally, about this point in labor and get a sense of how flexible your care provider is for the moments of baby's head crowning and for baby's birth. In a hospital setting, most OBs/midwives aren't there with the laboring woman for the earlier stages of pushing until the baby is very close to crowning, at which time they'd come to stay with you until an hour or so after the baby's birth. For the early stages of pushing, one or more nurses would be the continuous support, monitoring the descent of baby through the birth canal and getting your care provider when it's time. So, in an unmedicated birth there's usually a good deal of freedom of movement until the OB/midwife comes. This is assuming, of course, that you get a natural-friendly nurse (tip: request this if you're hoping for an unmedicated birth upon arrival at the hospital in labor).

Follow your body's urges to push

When a woman's labor progresses to the degree that her cervix reaches 10 cm dilation (=openness of the cervix) and 100% effaced (no lip/edge of the cervix in the way of the baby's head), which we also call "complete", it signifies the end of Labor Stage 1 and entering Labor Stage 2 (Pushing).

For many unmedicated women, around the same time she'll get an uncontrollable, overwhelmingly strong urge to bear down and push. This urge can be hugely helpful for women, particularly when it's our first time to experience labor. It takes the insecure feeling of, "how in the world do I do this?" out of the equation entirely because the urge is SO strong and helpful.

It's equally normal for other unmedicated women's urge to take a while to be triggered. If you find yourself in this latter camp, here are my tips for you:

  1. If hospital staff are pressuring you to push immediately, ask if there's any reason you can't wait to actively push until the urge is triggered. (In the mean time, your uterus will continue to do lots of that work for you.) That is, there's no rush to start actively pushing just because you are "complete"—contrary to what hospital staff might make you think due to their being stuck in their ways of regular all-too-impatient protocols.
  2. Change positions. Often the simple act of changing position can trigger the urge. (It's a good general rule of thumb in labor, in fact: When in doubt, change positions to encourage progress.)

In a hospital setting, the nurses are accustomed to the majority of women getting the epidural and therefore not feeling this natural, instinctive urge to push. Therefore, they are trained to default to a highly coached, loud method of the "valsalva maneuver", aka "purple pushing" because women are encouraged to bear down vigorously and hold their breaths for unnaturally long periods of time. With this method, nurses loudly and slowly count to 10 while yelling, "harder, harder!...that's good!...go, go, go!" and often scold the laboring woman if she lets her breath go before they reach 10. For most women, this coached method will really only be needed if a) we're rushing things and not waiting for the natural urge to push comes (as is standard in most hospital settings), or b) a woman has the epidural and most likely won't feel the urge and therefore may welcome some guidance (particularly if it's her first time to give birth). It is far from the most likely non-breath-holding method you'd use with the physiologically organic urge to push and tends to lead to greater likelihood of fetal distress due to oxygen deprivation.

I would add that, in the 2014 ACOG report on things hospitals can do to reduce the unnecessarily high cesarean rate in the U.S., they ask hospitals, "Why are you putting women on a deadline in this stage of labor?" -- that is, most hospitals have set a fairly arbitrary time limit on the 2nd/pushing stage of labor. Usually it's a generous 3-4 hours, but there's really no reason to move to a c-section solely because "time's up" if a mom and baby are doing fine and are up for pushing longer. With this, keep in mind here that studies have revealed that hospitals take 15-17 years to adopt new recommendations, no matter how evidence-based, wise, or urgent they are to incorporate.

Here is the BEST article I've ever read on the topic of instinctive pushing.

If you've given birth before, or if you are a birth professional, I invite you to chime in with your experiences and insights! What worked for you? What didn't work?

Further reading