What You Wish Someone Told You About the "Pushing Phase" of Birth!
“It’s time to push!”
“Do you want to try Pushing?”
“You are at a 10, so you should start pushing.”
Did you hear any of these during your labor? Was there a rush of adrenaline that entered the room when they saw you were at 10 cm? or when the medical team started to gown up and adjust the hospital bed? Maybe you just had a midwife whisper in your ear, "can you give me a push?”
If you’ve ever given birth vaginally or gotten to this phase during your labor then you probably can relate. It’s both an exciting and overwhelming part of birth. It can be coached and managed, it can also come on so suddenly that only you know the baby is coming and have the time to catch them. I’ve seen moms give birth suddenly in their closet after hours of trying and I’ve seen them reach down feel the head and then gracefully push their babies into the water. I’ve seen moms stand up to try a new position just to immediately be overcome by gravity and baby almost hit the floor and I’ve seen moms try pushing for hours with slow progress.
There is a lot about the pushing phase we just don’t talk about though. It’s left in mystery land along with most things in birth. It’s something we consciously know we will have to go through but rarely are given any truth or facts to prepare ourselves. Sadly leaving the pushing phase clouded in mystery doesn’t serve us as educated and empowered birthing people. Hospitals are known for having some pretty counterintuitive policies that conflict with the physiological nature of “pushing” a baby out. Policies that can cause harm more than they help.
This is why we can’t let the pushing phase stay a secret, we have to talk about it openly!
So today I thought I’d share a few important thoughts and facts for preparing yourself for the realities of pushing.
The truth about the magical 10 cm
Just because you are measuring 10 cm dilated doesn’t automatically mean you are ready to push. Baby needs to be engaged in the pelvis atleast station 0 though you may benefit from waiting for baby to descend even more before actively pushing. Laboring down or resting are great options for giving baby time to descend even when you are fully dilated.
You also don’t actually have to be 10cm dilated to start pushing. Baby heads come in many different sizes and oftentimes baby knows better than a cervical check which can be heavily dependent on the hands measuring. In the same vein though baby may also need a little more than 10cm. This is why following your body actually can be the best guide to know when it’s time and to avoid tearing.
You can also dilate within seconds so if a provider measures you at an 8 but you feel pushy, you may have just dilated to a 10 that fast!
How long is pushing supposed to take?
Just because someone says “it’s time to push” or “let’s try pushing” doesn’t mean they fully know your body and baby are ready. Of course, with an epidural or some other forms of pain relief you may need someone to direct you to know “when” but for those choosing unmedicated birth, you will be the person most knowledgeable about when to start. In some situations, progressive pushing can last up to 3 hours but often times this is due to a premature start or overly managed pushing phase. If you are seeing gradual progress then oftentimes the best choice is to keep pushing and bearing down because baby is already engaged. But if after an hour or so things are not progressing it may be better to rest and wait.
Just a reminder here, your pushing taking a while is not and should not feel like an imposition to your care provider. Rushing you without an indication of risk or problem -Should Not Happen- just because they are all gowned up and don’t want to be inconvenienced or they have been waiting a while does not equal an emergency. The length of pushing can be very dependent on the care provider, midwife or OBGYN, which tells us a lot about the risks of overly managed pushing. Some providers have a certain cut-off in their minds before they reach for a vacuum, forceps, or episiotomy. Some are more patient and will suggest rest or pain relief to help the birthing person to relax and let the baby engage a bit more.
When pushing is left to the discretion of the birthing person completely we see very short pushing phases. When mothers are able to push in positions that use gravity and aren’t just laying on their backs/ legs in stirrups (also called the Supine position) we also see a decrease in pushing lengths. Following your body to birth is incredibly important especially when you are birthing in a place that may have policies on time limits for labor or that may force you into a more agreeable position for their convenience.
The history behind the “Supine” (laying on your back with legs spread) pushing position.
This position for birth has only been used in the last 200 years and is very popular mostly in the USA as the most convenient way for care providers to support a mother in pushing. Prior to this a birthing stool was much more common. The supine position has been often credited to King Louis XIV in France who had 22 children and "enjoyed watching women giving birth, he became frustrated by the obscured view of birth when it occurred on a birthing stool," (1) But more accurately the French Dr. François Mariceau should be given the credit for changing the “go-to” birthing position in the 17th century. “reclining bed birthing was both comfortable for the women and accessible for the midwives and surgeons.” (2)
So while this position can’t be directly linked to the french king who liked to watch, it can be seen as the reason for its growth in popularity. “Louis XIV's purported demand for change did coincide with the changing of the position and may well have been a contributing influence,"(1)
What is crazy is that over the centuries this position has only grown in popularity around the world. Mostly due to its convenient view/accessibility for the care provider rather than for it being a helpful position for the birthing person.
Could it be a Cervical Lip or Swollen Cervix
Now there are things called cervical lips and a swollen cervix that may limit your ability to push baby out while still feeling pushy. This is when knowledge of physiological birth is SO important and the freedom to change positions or relax/ stimulate the body in a different way can make all the difference. This can be hard when on an epidural but not impossible. You may be able to facilitate a squatting or sitting position in bed while numb. If you are unmedicated getting into a new position or asking for rest may be needed.
Having a provider hold back the cervical lip may be offered but does increase risk of tearing and can be much more uncomfortable for you. As a birth worker I have seen this done in a consenting and unconsenting way at home and in hospital and it may speed things up if that is needed or your priority but if this manual assistance is not moving things forward significantly with a few pushes it may be time to try resting and laboring down instead.
Is FER real?
FER (Fetal ejection reflex) is real but can also be rare. It’s basically the involuntary and natural pushing our body goes through without you having to try at all. When completely left to our own intuition or on our own, I have seen it happen suddenly but even in the most hands-off scenarios, I’ve also seen where it does help to “try” pushing, getting used to listening to our body’s impulses and sending energy and force down into our bottom intentionally. So do not be discouraged if you have to mentally push your baby out the most important thing to remember is that you are listening to your body’s impulses.
So now baby is crowning…
Once you reach crowning during the pushing phase babies head may appear and then go back in. -YOU WANT THIS TO HAPPEN! -Many moms think they are losing progress but in reality, the more you allow this to happen the less likely you will tear. With each stretch, it allows more blood flow and strength to your perineum so that the next push can continue to gradually open for babies head to emerge. You are not going backward you are following your body! This can also be an important part of the process for baby as they may need to change positions during these final stages of pushing. So don’t rush them.
Don’t be afraid to reach down and touch your own perineum. Often when a tear is imminent you can actually prevent it by placing your own hand/finger over the stretching part until the next contraction. Stimulating blood flow and controlling the stretching on your own terms. This may feel impossible in the moment if the pain, position, chaos, or surroundings are overwhelming but at least something to consider.
We often forget that we still own our bodies when we are giving birth or surrounded by “professionals” we may not feel authorized to touch ourselves during pushing or bring our own knowledge into the hospital room. This is not true, you truly are the best guide for your body during pushing, trust yourself! One mom I worked with many years ago was pushing on a hospital bed. The Dr. was using his gloved hand to stretch and “support” her perineum during the early parts of pushing. She reached down and placed her full hand there and said “if anyone is going to touch me there, it’s me.” She took complete control and within a few pushes she birthed her babi’s head into the palm of her own hand!
I was told my body couldn’t do it…
Like I said above, pushing is often put on the clock in a hospital when In reality you may have not been ready to push in the first place. I’ve seen many a mom try for 2,3,4+ hours actively pushing just to be told her pelvis is too narrow or a cesarean is required because her body just can’t do it… it’s traumatic and false in almost every instance. I have also seen moms push for hours and even once the baby is born, they feel defeated about how long it took their bodies to get the baby out. BUT There are many factors that limit our ability to push freely that aren’t about your body’s inability to birth or your body lacking in any way.
Factors like who is in the room, where you are pushing, if your body is in a comfortable or natural position for pushing or if you feel fueled and energized to push. These are just a few of the external factors that stall or prolong pushing
Mentally we are programmed to be incredibly shy about things occurring in or around our bottom. It is a vulnerable feeling one we often carry a deep amount of shame or embarrassment around. I mean pooping during birth is a topic that gets thrown around even in the most mainstream and comedic worlds doing the birthing mother zero justice by just reminding her of the “shame” that accompanies some realities of birth. Now take that deep feeling of vulnerability, shyness or shame and spread your legs to a group of medical strangers and you are bound to stall or take 2,3,4+ hours to push.
There is also a lot of professional but still foreign touching during pushing and unfamiliar commands being shouted at you, “push, push, push” “don’t stop breathing ” “go right back into another push” “feel my finger, push there” etc. it’s hard to feel fully comfortable and naturally “pushy” in most birthing situations.
And yet when the majority of births are supported this way babies still are born all over the world vaginally so we know these interruptions, and distractions can be overcome by the natural process of birth. Remember that the birthing body is truly powerful regardless of the things that try to stall it.
If you were ever told that your pelvis was “too small” for birthing a baby here are some real facts. CPD or Cephalopelvic disproportion is the term used for this but it’s actually VERY RARE. It is also NOT diagnosed by the length of the pushing phase or vaginal exams, it can only be seen through a specific ultrasound of the pelvis. It is almost always associated with genetic differences or injuries that the birthing person would already know about prior to pregnancy. Yet it’s thrown out as a way to control birth in many situations when the reality is more likely that all the other factors from atmosphere, to pushing to soon, and not waiting to be ready, to baby’s position are to blame for a long pushing phase NOT YOUR PELVIS SIZE.
Another huge factor that I want to emphasize is not being able to eat during labor. This is a huge policy problem in most US hospitals. Can you run a marathon without any fuel or energy? Yet we are expected to do the far more strenuous work of labor and birth on an empty stomach. Since I can’t go into detail about this specific issue you can Learn more about this problematic policy here.
the Danger of overly managed pushing
Have you ever been told to “stop pushing!” or “wait to push until the Dr is in” or had a medical hand literally set on your baby’s head to prevent them from naturally progressing? Those are all extreme cases but all I’ve seen in my years of birth work more than once. There is nothing safe about being told to stop pushing when you are following your body
Many policies that are created in US hospitals are based on liability and fear of risk. A baby being born without the presence of a DR or Midwife can add “avoidable” risk of liability so most nurses are told to prevent this from occurring. It is not based on any evidence for the birthing person though, the safest pushing phase is one that your body naturally progresses through no matter who is in the room.
We’ve mentioned these all above but in case you missed them,
Pushing too soon just because the care provider is ready can lead to longer pushing phases and potentially more tearing. Increasing your risk of cesarean or the use of forceps, vacuum, or episiotomy.
Too many hands on the perineum can cause pushing to occur faster than your stretching body and baby are prepared for. This can lead to more postpartum complications like tearing, fetal distress and hemorrhaging.
Care providers who aren’t patient or who are known for turning to forceps, episiotomy or vacuum soon into pushing are not evidence-based and should be avoided.
How can I prepare for pushing?
Just remember, “pushing” can be thought through and probably should be more!
You can assist your pushing phase with knowledge and choice by setting yourself up with your preferences and by listening to your body. You are always the authority on your body, how you are touched and how you push is your human right!Ask yourself,
Do you want several people in the room watching?Do you want to be able to move freely and into new positions mid-pushing?
Do you want perineal touching or massage during pushing? \
Do you want coached pushing at all?
Do you want to wait to push until you “feel pushy”?
You have a choice and a say in all of this, you aren’t destined for 4hour pushing phases forever simply because your first was long!
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Photographer, Mom, Birth Keeper, Blogger, and total Nerd when it comes to people giving Birth around the world!
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