Push It Real Good
In addition to the pain of contractions, the act of pushing a baby out is frightening to many women. Other than the pain associated with pushing, there may be concerns of vaginal tearing as a result of the delivery. In addition, some women worry about pooing in front of their partner and feeling embarrassed in doing so. While all of these concerns are valid and may happen, they are not necessarily guaranteed to occur. Pulling from best practice guidelines, current research in obstetrics, and my own experience as a labour & delivery nurse, the aim of this blog post is to explain the realities of pushing in a hospital delivery.
Disclaimer: This post is meant for informational purposes only and should not replace information or medical advice provided by your primary health provider.
There’s a lot of information available on the best way to push out your baby. Our two main focuses today will be birthing positions and techniques.
Birthing Positions - A women’s position while pushing
There’s a couple of trains of thought regarding which positions are more optimal for pushing out your baby. The most common hospital birth position is called the lithotomy position. The lithotomy position means that you’re lying on your back with your legs bent and open. Your hands are placed under your knees pulling your knees back towards your ears. Some research states this position is not optimal for pushing because it takes longer to push your baby out, your pelvis is narrower, and you are not pushing in a position that allows gravity to help pull the baby down. This research is in favour of pushing in a hands and knees position or squatting which is more upright and lets gravity help you. There is nothing wrong with the squatting position to delivery your baby, and when you have no medication during your labour this might be the most comfortable for you. That being said, two thirds of women in Ontario get an epidural for contraction pain relief. Having an epidural restricts the positions you can labour in. With an epidural labouring completely upright/standing, kneeling or squatting is generally hard to accomplish. Epidurals cause numbness in the legs that makes them not steady to stand or kneel. Women who have an epidural typically push out their babies on their back and sometimes on their side. This is the position I’ve seen most women push out their babies, and it’s the one many healthcare teams in hospital have experience with. There is research out there that recommends the squatting or standing position, but if you feel that you want an epidural administered, the reality is that it may not be possible in a hospital setting.
Further, no matter what position you push in, many women have vaginal tearing with their first vaginal delivery and can poo during pushing. These are unpleasant and scary things to consider, but you must remember the health and safety of labouring women and their babies is what’s most important to your healthcare team. The hospital staff want mom and baby happy, healthy and safe and will do what they can to ensure the best possible outcome. Also, any poo is cleaned up quickly and from my experience is not the part that most people remember of the birth of their child. Further, dealing with poop is a substantial part of the responsibilities new parents have, and is really not as big of a deal as it sounds before having a child. You might be surprised at how small of an issue it would end up to you after experiencing it.
Pushing Technique – Specific ways of pushing which relate to timing and intensity
Pushing techniques can also be categorized into two main approaches:
1) Directed pushing (also called closed glottis pushing or Valsalva maneuver) involves taking a deep breath in, holding your breath and bearing down or pushing like you are constipated and having a bowel movement for 8-10 seconds. Many women are coached to push three to 4 times per contraction.
2) Spontaneous pushing or open glottis pushing involves pushing in a way that feels natural for the women. This can include pushing 3-5 times per contraction and breathing or making sounds while pushing.
There’s been research done for many years on which technique is the best for pushing. Studies have looked at length of time, vaginal tearing, baby’s health and mom’s health. Unfortunately, there isn’t a consensus to support one technique over the other that’s better for you and your baby. Both the Canadian and American associations for obstetrics and gynecology support women pushing how they want to push but recognize more research is needed to identify the best method. The technique most commonly used and coached in hospital is directed pushing.
There is a lot of research that encourages women to push how they feel (with emphasis on spontaneous pushing). Some research counsels against directed pushing because of an increased risk of vaginal tearing, damage to the pelvic floor and reduced oxygen to baby. An important thing to consider is that pushing based on how you feel is usually only possible without an epidural. Without an epidural, it’s easier for women to listen to their bodies and push how they feel is necessary. However, with an epidural it’s a different story. Epidurals affect every woman differently. Some women with epidurals are relatively mobile and have a lot of feeling and ability to move around. However, some women become so numb to the point where they have difficulty holding their own legs for pushing. If you are numb then you don’t generally have a lot of feeling and less urge to push. To put it bluntly, pushing how you feel is difficult if you can’t feel. In fact, the concept of how you feel is flipped on its head when you are given medication that purposefully reduces the feeling you’re supposed to have in the first place. Most women with epidurals feel some pressure or urge to poo when they get to the pushing stage but not all.
Limiting and preventing negative long term affects from childbirth for mom and baby is extremely important. And, pregnant women should be aware of what their options are for labour and birth at their delivery facility. At the same time, women need to understand the realities of what it looks like to deliver a baby in a hospital today and the limitations that it puts on them. Regardless of which method you’re considering, if you are delivering in a hospital please talk to your primary care provider about how they coach pushing and what pain management options are available during labour.
Summary
There is no consensus on the best pushing position or pushing technique
In a hospital birth, if you deliver on the hospital bed you will likely deliver in the lithotomy (lying down) position
Getting an epidural will reduce your pain in labour but limit your options regarding pushing positions and techniques
More research is needed on the most optimal techniques for pushing specifically in women who get an epidural
Many women but not all women poo when pushing
Many women but not all women have vaginal tearing with their first birth
References
Lee, L. RN. Dy, J. MD. Azzam ,H. MD. Management of Spontaneous Labour at Term in Healthy Women. Journal of Canadian Obstetrics and Gynecology. 2016
Joyce Roberts, CNM, PhD, and Lisa Hanson, CNM, PhD. Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning. American College of Nurse-Midwives. 2007
Approaches to Limit Intervention During Labor and Birth. Committee Opinion. American College of Obstetricians and Gynecologists. 2019
Managing Pregnancy and Delivery in Women With Sexual Pain Disorders Articles Talli Y Rosenbaum Anna Padoa. Journal of Sexual Medicine. 2012.