Labor has been exhausting but with your birth team you're almost through the hardest part. The lights have been low, you brought your favorite essential oils, you've used the tub, birth ball, and shower for pain relief, and NOW THE TIME HAS COME. You start feeling "pushy". Finally you know what that means. The sharp pull at the peak of contractions begins to be replaced by a totally different, nearly unexplainable feeling. You have to get that baby OUT.
The nurse rushes in, pages the doctor, the lights come on (ESPECIALLY the big one pointed at your vagina), the bed is broken down, and you are instructed to 'HOLD YOUR BREATH AND PUUUUUUSH. COUNT TO 10 WITH US!' And now you start to understand why they call it "purple pushing". It isn't pretty or fun. The whole energy of the room has changed, and you're not sure that you like it. (DISCLAIMER- this doesn't happen at ALL hospital births. But it is VERY COMMON due to how most doctors and hospital staff have learned to manage the pushing stage. Listen to women tell their birth stories...you'll see the trend).
I love to discuss the benefits of physiological pushing. What does that mean exactly? It's letting the birthing mother decide when and how to push her baby out. It doesn't mean:
I always bring a copy of this lovely blog post by Rachel Reed of MidwifeThinking with me to prenatal visits with families that I'm working with, because it really emphasizes how the mother is the expert in pushing out her baby. Risks of "purple pushing" or directed pushing include:
Even though study after study has documented the risks of directed or purple pushing, the physiological pushing has been slow to take hold in most hospitals. This survey from 2005 documented that only 21% of women pushed when they felt like pushing. Over 90% gave birth on their back or semi-reclining. Some reasons for this likely include the fact that upwards of 60% of women in most areas choose an epidural, which leads to more management of pushing, but also it's just a fact that most birth professionals are taught directed pushing in their trainings, and they rarely see or experience anything else. Humans are creatures of habit, and we tend to fall back on what we know.
This study review has a great overview of the differences between physiological and directed pushing. Women who are pushing instinctively often push only for 3-5 seconds and then take a short breath, before pushing again. They tend not to close their mouths or clench their jaws. The mother often will chose a position such as kneeling or hands and knees. She might not put her chin to her chest and push "down" to the baby. I very often see women wanting to arch back and do just the opposite! There really are no "rules", and a position that works for all women. Remember: a woman's body knows how to give birth! Listen to it.
Now that you know that it's evidence-based and healthy for a mother to push when she feels like it, and in positions of her choosing, what can you do to maintain your physiological birth even if you are being encouraged to do something different? I love this article about saying "no" to purple pushing, but I've found that it's really not that simple when that moment comes. So here are my tips for saying 'no' and being successful at mother-directed pushing no matter where you are.
Strategies for Physiological (Mother-Directed) Pushing in the Hospital
The bottom line is that mother-directed pushing is safe for the mother and her baby. If you discuss this with your care provider and they are unwilling to consider this option, you might want to think about finding a care provider who will work with you, and the birth that you would most like to have. Or, you can share some of the linked studies with him or her and ask them to reconsider.
I've said it before, and I'll say it again. You can have a great birth no matter where you choose to be! Hospital, home, birth center...but it never hurts to know what you want, to communicate those wishes clearly, and to bring a supportive team who knows you well to help you achieve that goal.
A supportive birth partner, and a doula, can help to remind you of the plans that you made before you reached a point in labor where it's easy to think that 'those details weren't important, so let's just get this over with.' But you might feel differently once the hormones wear off. (I speak from personal experience when I say this, can you tell?) It's normal to feel like you need reassurance and guidance during this phase of labor, but remember that YOU are the only one giving birth to your baby, and your body knows what to do! Have your birth partner remind you of that! It's not the last time that you'll need to lean on your instincts as a mother to do what's best for your child.
What was your experience with pushing your baby (or babies!) out? Do you have any other suggestions for supporting mother-directed pushing? And thanks to the mothers who shared their beautiful birth pictures to show the various positions that women can choose for pushing!
'What? What is she talking about? Pregnant women should never ever drink alcohol!' (I might be exaggerating a bit there).
No, I'm not talking about alcohol. Who is going to get that into a hospital? I'm talking about water.
'Water?! Oh, water is great. Did you know that if you feel thirsty, you're already dehydrated, and pregnant women ESPECIALLY need to be drinking at least 100 ounces of water a day! And labor is just like a marathon, so keep your water and laboraid close and make sure that you're getting plenty of fluids!!'
Here's the thing though. EVERYTHING in life is about moderation. For some reason, this doesn't seem to apply to water. As I've written about before, this is likely due to misinformation and exaggeration, first on the part of bottled water companies, and then picked up and disseminated by the health industry. Statements like "drink 8, 8 ounce glasses of water a day", or, "drink one half of your body weight in ounces of water a day" may seem harmless even if they aren't based on science, but are they? Can this type of advice be particularly dangerous for pregnant and laboring women? Yes, there is evidence that it can be.
Our cells require a certain balance of nutrients and salts. What happens in hyponatraemia (overhydration/low sodium levels) is that the extracellular fluid becomes too diluted with water and rushes into the body's cells, which causes them to swell and triggers the sympathetic nervous system, or a stress response. That is of course a very simple version; the actual mechanism is way more complicated and also involves the interplay of potassium, calcium, and other minerals in the cells and cell membranes. However along with the stress response comes many symptoms which probably many of us who have taken the mainstream advice on water consumption have experienced:
….sound familiar? Yeah, I thought so. Yet many pregnant women who complain of any of these symptoms during pregnancy will be told…what?
"You're probably dehydrated, drink MORE WATER".
So it's a dangerous cycle. The authors of the study below note that "The maximum capacity of excreting a water load at rest is reported to be approximately 900 ml per hour in healthy women but is reduced by one-third in late pregnancy". So pregnant women are not able to get rid of extra fluid as quickly as a non-pregnant woman, which makes overhydration even more likely. They also note that "no physiologic warning system protects the body against overhydration". (See opening quote for a slightly different perspective on that). This means that once a person starts to become overhydrated, they can no longer trust what their body is telling them, because excessive thirst may not mean that the body needs fluid, but rather, salt. So avoiding that state is important!
Instead, here is what I tell pregnant women (and everyone, really). Drink when you're thirsty, and not a lot more than that. Animals and children know how to do this. Why do we, as adults, think that someone else has to tell us how much to drink to be sufficiently hydrated? And you don't even have to only drink water. There are many nutritious, tasty beverages that contain lots of water, but also minerals, salts, natural sugars, and probiotics. Some that you might consider are grass-fed whole milk, kombucha, water kefir, herbals teas, and even broth (homemade!).
Why This is Especially Important for the Laboring Mother
It's only been recently that hospitals have been "allowing" women to eat and drink during labor. Of course this is a basic human right, and a long time coming. However, it can also be a risk, because there are many women (especially those that are health conscious, who may already starting out labor slightly overhydrated) who have been told that labor is like a marathon, and that staying hydrated is vital to a healthy labor and baby. While part of this is true, and hydration is important, the truth is that labor is NOT like a marathon. Or rather, women's bodies in labor are not acting at all like the body of a marathon runner, or even someone exercising. A simple, crucial fact is missing.
Oxytocin, the "hormone of labor, love hormone", encourages the body to RETAIN water. So a woman that is drinking constantly throughout labor, especially a longer labor, may be in danger of drinking herself and her baby right into hyponatraemia. How can I say that? Not only have I heard of several instances from doulas where a client had a difficult, long labor and ended up with a cesarian birth, but there was enough awareness of it in the medical community to do several studies on it. The most recent is quite compelling.
In, Hyponatremia Complicating Labor: Uncommon or Unrecognized? The authors note that a high total fluid volume (2500 mL or approximately 85 ounces, by mouth and intravenously) taken in by a laboring woman was significantly correlated with overhydration, a longer second stage of labor, and other complications during the birth. Honestly you should really read the whole paper; it's not too long and really fascinating. But here are some key points:
Who are most at risk?
A woman who desires a natural birth and who is giving birth at home or a birth center should be encouraged to drink if she feels like it. Since the body retains more fluid during labor, she likely will need less fluids than normal. If she voluntarily is drinking more than 8 ounces of fluid an hour over the course of several hours, this could be worrisome and she might be encouraged to back off on the fluids. It's been noted before that the symptoms of overhydration often mimic dehydration, so keeping track of fluid intake can be very important.
I did some research on how much fluid a woman laboring in the hospital might be given if she requires an induction, antibiotics for Group B Strep, or an epidural. It's likely that if an IV of fluids is hooked up, the laboring mother will receive at least 1000 mL total, at 125 mL per hour (4.2 ounces) or sometimes even 250 mL (8.45 ounces) per hour. These women are likely most at risk, especially if they are also taking in oral fluids. Women who are continuously receiving IV fluids should be very careful with how much they add to that by drinking, and birth partners and doulas probably shouldn't be encouraging the mother to drink extra fluids. Remember, 26% of women who received more than 2500 mL (about 84 ounces), developed hyponatraemia, so it wasn't a rare occurrence by any means.
What is the Bottom Line?
Basically, all humans have the ability to tell when they're thirsty and when they need to drink. Sometimes we get so used to people telling us what to do, that we forget how to listen to our bodies, but pregnancy is a wonderful time to start really tuning in and trusting your body and instincts.
Despite the common advice to drink at least 64 ounces of water a day, and even more during pregnancy, there is no scientific proof to back this up. Each person is different and has varied fluid intake needs. During labor, a woman should be able to drink when she's thirsty, and not encouraged to keep hydrating unless there is clear indication of dehydration. However, thirst can't always be trusted as a sign of this, since excessive thirst is also a sign of being overhydrated. If a mother is receiving IV fluids AND oral hydration, especially over the course of a long labor, the care providers (or family and friends) should be especially careful to make a note of the total fluid volume, since these women are most at risk of overhydration.
To Be Continued....Implications for Baby
What do you think? Is overhydration more common or less common than the evidence suggests?
How Do You Eat This Stuff, Anyway?!
This one is kind of a quickie. I'm going to get back to the "pregnancy interventions" series later this week, but I thought that it might be helpful to give some tips on HOW to include some "sacred foods" from these traditional cultures into your preconception or pregnancy diet. Not all of us are ready to jump into liver and onions; I know that I wasn't!!
It's okay to go slow, but including at least some of these foods can only be helpful to your body and to your baby. And don't forget Dad! Cultures that prized these foods also included the father in the preconception period; he was also expected to eat liberally of whatever food was prized in fertility for his particular area. I'm going to start with homemade bone broth. Broth is incredibly nutritious and healing, and may even be palatable if you are coping with morning sickness in your pregnancy. Please keep in mind that the quality of bones is important; healthy animals will produce a more nutrient-rich, tasty broth. Buy local or pastured as much as possible, especially if you will be using the bones.
I look at birth from the perspective that our bodies are wonderfully made, and if we really believe that and work with the birth process and nourish our bodies properly, they will function optimally, most of the time!