Will I Be Coached to Start Pushing?

Pushing: Physiological or Directive?

Knowing when and how your care provider will expect you to start pushing can give you an idea of whether you will be able to birth as normally and physiologically as possible.   Ask your care provider  if they know the difference between physiological and directive pushing, and be sure to ask which one they recommend and why. 


Will I be expected and coached to start pushing as soon as I am fully dilated, even if I have no urge to push yet?


There is a normal, physiological plateau phase that can occur once a woman reaches 10 cms (fully dilated), and the contractions may space out.  The physiological model of birth recognizes this phase, the normality of it, and the important role it plays to achieve a natural birth. This phase may last about 20-30 minutes. Midwives call this the “rest and be thankful stage,” when the contractions space out more, and allows for her to regroup, ambulate, empty her bladder, eat, drink, shower or rest and gather strength for when the contractions resume a more frequent pattern again to begin the next pushing phase. This phase also allows for the baby to find the optimal position to realign his/her head to fit easily out of the pelvis.  When this phase is normally completed, usually the baby will have assumed an optimal position for entering the pelvis, and as it descends it presses on the pelvic floor and produces a natural urge to push. If a woman is forced to push during the plateau phase, the baby’s head may be forced deeper into the pelvis in a misaligned or tipped (asynclitic) position and may make it more difficult to proceed normally with descent, sometimes necessitating a C/S for “failure to descend.”  She may even be given Pitocin to “strengthen the contractions” because they have naturally spaced out during this plateau phase, and this normal physiological stage is not appreciated. The medical model may diagnose this normal plateau as “inadequate contractions,” and may put a woman on Pitocin to enhance the power and frequency of her contractions artificially, which requires CFM, restriction of mobility, confinement to the bed, inability to allow the coccyx bone to naturally flare out, increasing the need for an episiotomy to enlarge the pelvic outlet.  If you doctor is unaware of this physiological plateau phase of labor, and starts intervening with requiring forced pushing without an urge to push and/or administering Pitocin, your chances of a vaginal birth are diminished.


For the active pushing stage, will I be able to use physiological pushing? or will I be "expected" and coached to use directive pushing?


Physiological pushing is when you push when you feel the urge to push, holding the push for as long as feels comfortable, (even if it seems shorter than what the nurses want), taking breaths when you need to instead of holding your breath for longer than feels right, and listening to your own body to tell you when and how to push (if no epidural). Directive pushing is counting to 10 during each push, and being expected to do 3 pushes per contraction, chin to your chest—“purple pushing” as they call it.  Physiological pushing leads to better oxygenated babies (less acidosis in babies), less fetal distress, less perineal tearing, and only a 7 and ½ minute longer pushing stage, compared to directive pushing.  Directive pushing should only be used if there is fetal distress and the baby’s birth needs to be expedited, or 2 hours of physiological pushing that has not brought the baby down.   

Sources:

  • J Perinat Educ. 2006 Fall; 15(4): 6–9. When and How to Push: Providing the Most Current Information About Second-Stage Labor to Women During Childbirth Education; Kathleen Rice Simpson, PhD, RNC, FAAN.
  • Piquard F, Schaefer A, Hsiung R, Dellenbach P, Haberey P. Are there two biological parts in the second stage of labor? Acta Obstetricia et Gynecologica Scandinavica. 1989;68(8):713–718.
  • Roberts J. E. The push” for evidence: Management of the second stage. Journal of Midwifery and Women's Health2002;47(1)2–15
  • Roemer V. M, Harms K, Buess H, Horvath T. J. Response of fetal acid-base balance to duration of the second stage of labour. International Journal of Gynaecology and Obstetrics. 1976;14(5):455–471.
  • Sampselle C, Hines S. Spontaneous pushing during birth—Relationship to perineal outcomes. Journal of Nurse Midwifery. 1999;44(1):36–39
  • Simpson K. R, James D. C. Effects of immediate versus delayed pushing during second-stage labor on fetal well-being. Nursing Research. 2005;54(3):149–157.
  • Thomson A. M. Pushing techniques in the second stage of labour. Journal of Advanced Nursing. 1993;18(2):171–177