An Old Paradigm of Birth
If you were to ask ten people at random what giving birth looks like, many would describe a woman in a hospital, lying on her back with legs in stirrups, straining, holding her breath or screaming at her partner. Essentially a scene depicting a woman who feels out of control, scared or possibly even angry. For many decades mainstream media and Hollywood have portrayed birth in this way, so it’s no wonder why this picture may come to mind.
While there are numerous aspects to question within this image, here we will focus on the pushing in particular.
The Truth about Pushing
The idea that women push their babies out is not entirely in line with nature’s design. Let me explain…
What if I told you that both paraplegic as well as comatose women, birth their babies without intervention and in no less time than a fully conscious, fully mobile woman?
It’s true!
This is because a woman does not necessarily need to “push” her baby out.
Babies are born through a combination of uterine contractions and fetal movements working together in a symphony. The uterus is the powerhouse that creates all the force needed to birth the baby, around 25 lbs of pressure to be exact! These contractions are almost completely autonomic. Similar to your heart beating or breathing, you don’t have to think about it or control it, they occur automatically as directed by your body. In fact, Women with cardiac disease are specifically instructed never to push under any circumstances, as it would pose a risk to their own life. What happens to these women? Their babies not only come out, but often with greater ease and a lot less tearing.
When it comes time for birthing contractions, women naturally push around five seconds into the contraction. This is the body’s way of protecting the walls of the vaginal canal. The beginning of each contraction tightens and pulls up the walls of the vagina before the mother feels the urge to push.
You may be asking why would a woman push when she doesn’t feel the urge to?
Enter “coached pushing”, when someone tells a woman when and how to push in labor.
Often times caregivers will tell a woman to push because they believe she is fully dilated or they see a contraction starting on a fetal monitor (common in hospital settings). If she were to push without feeling the urge to, the vaginal walls would not be taught from contraction, thus would be pushed down and out of place in front of the babies head. This displacement and over stretching of the vaginal wall, causes damage and weakness internally, often resulting in rectocele or cystocele after birth. Cystocele is caused by the anterior wall weakening preventing it from doing its job of supporting the bladder. As such, the bladder falls down into the vaginal canal. A rectocele is caused by the posterior vaginal wall being weakened, causing the bowels to fall forward into the vaginal canal. There are no great options offered by MDs once this occurs, the best practice seems to be to prevention.
Understanding Contractions
Contractions naturally come in sets just like waves in the ocean. There will be milder contractions mixed in with the larger, stronger ones. The time in-between contractions, as well as the milder contractions, give the baby and mom the much needed rest, while the stronger contractions cause more movement or progression. In this way the baby as well as the mothers perineum are protected.
Uterine contractions occur automatically in the uterus and pelvis. This allows the mother to breathe through them and optimally oxygenate the baby. On the other hand Valsalva, or forced, strained pushing involves the mother holding her breath, clenching and bearing down from the thorax in a downward push. This reduces oxygen for both mother and baby. It also closes up the pelvic floor muscles, as she is essentially bracing against the natural downward movement.
A Study by Constance Beynon
This study included 100 vertex presentation births of first time moms with the intention to see how they would birth their babies without being coached to push. The birth attendants purposely did not mention pushing, no coaching or encouraging pushing at all. The results? 83% of the women birthed their babies spontaneously. The average 2nd stage was 1 hr and 3 min. Infrequent, short pains. She believed that they intervened too soon for 6 of them, using forceps, that left 11 who needed some suggestion to push while, mind you, on their backs in stirrups. This position is extremely unnatural to birthing because it closes the coccyx down into the pelvis, reducing the space for the baby to fit as well as forcing the baby to work against gravity to extend their heads up towards the ceiling to birth.
Study Conclusions
-Spontaneous second stage (birth of the baby) is the ideal mode of birth when we support it with practical and theoretical consideration.
Theoretical considerations:
-Slow distention is less traumatic than rapid stretching, so one would expect less tearing at the perineum.
-The amount of pressure needed to push a baby through a collapsed vaginal wall is more than a tight, smooth vaginal wall.
-When the uterine force is acting alone, the babies head will pass through the transcervical ligament in a way that does not stretch or pull it down. However when mother is pushing against the transcervical ligament, it can be the cause of prolapse after delivery. In other words, if you can see the head, you know it has passed the transcervical ligament. If not, she should not be encouraged to push.
When it comes to pushing, minimal is optimal. A mother will naturally push if and when she needs to. If the mother is straining because it is what she thinks she is “supposed to” do in labor, remind her there is no rush, to be gentle and to listen to her body. Not all contractions move the baby. In fact, more often they do not, they instead are slowly, naturally stretching the tissues. When caregivers refrain from coaching mothers to push, we see reduced tearing, reduced need for interventions and less distress to the baby.
Remember that over 80% of first time moms are able to birth instinctively with zero instructions and no more straining than is needed for passing a bowel movement. Coached pushing results in increased maternal exhaustion, increased fetal distress and as a result, a rising rate of c-sections. Constance made a plea in the 1950s for birth workers to eliminate the hurry and unnecessary pushing during labor. This plea stands just as relevant now as it was then. We can do better for our mothers, sisters and friends.
Birth does not ask to be managed, it asks to be witnessed, respected and allowed to unfold instinctually.