How to Keep a Good Birth Going- Physiological Pushing in the Hospital Setting

This mother was supported in using "completely mother-directed pushing" during her hospital birth.

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).

TIME OUT

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:

• Telling her to push just because she's 10 centimeters
• Telling her to recline on the bed and lift her legs up
• Directing her to hold her breath and push as hard as she can
• Creating an environment that fosters stress and worry instead of safety

It DOES mean:

• Letting the mother push when she feels like it
• Assisting her in a position that she finds most comfortable
• Encourage her to breath when she feels like it to keep herself and baby oxygenated
• Remind her that she's doing wonderfully and her body knows how to push out the baby just as it grew the baby

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:

• Less oxygen (hypoxia) to mother AND baby, which can lead to unnecessary worry about the baby's well-being
• Higher risk of tearing for the mother, as well as possible negative effects on pelvic floor function months after birth.
• Baby is not able to make cardinal movements to 'spiral' out of the birth control as easily, leading to "sticky" shoulders
• Exhaustion for mother and baby if pushing lasts a while

Becky expresses that her labor was peaceful and filled with love, and that she was encouraged to walk around between pushes when other positions weren't as effective. All of this support and different positions helped her posterior baby to turn and to be born vaginally.

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. 
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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.

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Strategies for Physiological (Mother-Directed) Pushing in the Hospital

• First of all, take a deep breath. Stay calm. I know it's so exciting that you will be meeting your baby very soon, but there's no need to rush it if everyone is doing well. 
• Ask if the lights can be kept low. Oxytocin is just as important in pushing as it was in the rest of labor, and a calm, dark environment will keep oxytocin levels high, which also helps to reduce the chance of hemorrhage after the baby is born.
• Bring a short birth plan that specifies very clearly that you want to control your own pushing, and discuss it with your nurse and doctor before pushing (if possible). 
• Make sure that your birth partner(s) know your wishes, and give them the task of reminding you if you get so excited or in "labor-land" that you forget. 
• Side-lying is often the alternative position that I see accepted by hospital staff AND is comfortable for the mother. If you feel too tired for hands-and-knees or kneeling pushing positions, side-lying is a great option.
• If your care providers encourages purple pushing or a position that you aren't comfortable in, your birth partner should be willing to ask you or the doctor if you would like to try a different position or no counting, etc. 
• If you have an epidural, it's safe to wait until baby is almost crowning to push. This is called "laboring down". This reduces the chance of tearing. Contractions will push the baby down on their own with almost no maternal effort.

Bethany Bagnell is a Bradley Instructor who pushed instinctively during her hospital birth.

 ​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!

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