Episode 167 - Pushing out your baby
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host,
[0:03] Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:24] Welcome to today's episode of the great birth rebellion podcast and today i'm talking about pushing out your baby what happens you've done the whole labor and now you've come to the part where you need to push your baby out now this will be of interest to you if you're having your first baby or if you're having your first vaginal birth after previous birth was a cesarean and also if You've had an epidural for your previous birth and you didn't actually feel your first baby emerging or perhaps maybe you needed some coaching through your last birth and you think maybe I want to do it differently this time. So this is for you if you want to know what it's like to push your baby out and I'm going to give you some strategies to make it a more enjoyable and possibly better experience than the previous ones you've had. And I've heard lots of women, including myself, refer to this pushing phase of labor and birth as the most enjoyable part of the whole birthing experience.
[1:30] Your oxytocin levels are high. You feel powerful and strong because you've got a little bit of adrenaline in there as well in the mix. And you can feel the end of labor drawing near. And then there is this satisfaction of your baby emerging, like doing the best poo of your life. And if you heard our podcast episode a few weeks ago with Abby Cidery, and she just refers to her baby emerging like an octopus, like a blah, blah, blah.
[1:59] That's how she described it. Oh, it's a good feeling. How I would love for all of you to experience your birth as the best feeling ever. So it is possible to be in love with labor and in particular this part of labor where your baby's emerging. Lots of people talk about this being the most horrific experience of their life, their baby emerging, painful. But I think that's just society talking. If you really sink into it, this final phase of labor where you're pushing out your baby can be and is designed to be one of the peak human experiences that you can have. and that's what I'm going to talk to you about today.
[2:40] Now, if you're listening as a midwife, a care provider, doula, or support person in a birth space, this episode will also help give you some strategies to help women during this expulsive phase of labor where they're pushing out their babies. There are do's and don'ts in this arena, and I'll talk you through those in this episode too. All right, let's get started, Rebels, as we talk about pushing out your baby.
[3:06] And before we start, it would be remiss of me not to quickly mention the stages of labour and do a quick refresh of these because this becomes relevant in the discussion about pushing out your baby. So if we're going to follow the textbooks, the medical textbooks, the ones that give you this standardised information about how women's bodies work, they will tell you that when it's time to push out your baby, you're in what they would call the second stage of labour. The first being dilation phase from one till 10 centimeters dilated. If your cervix is dilating, that's the first stage of labor, according to a textbook. Then you would enter into the second stage of labor, which is the pushing phase of labor. You're fully dilated and you're ready to push your baby out. Now the textbooks will tell you that the second stage of labor is when the woman's cervix is fully out of the way and it's time for the baby to move down and out. But if you've been listening to the Great Birth Rebellion for a while now, You already know that the textbook definitions of labor are fairly inaccurate and women's bodies don't normally follow the textbook definitions of labor. The delineation of labor into stages is reductionist and it closes women and their care providers off to other possibilities. So I like to think of the part of labor where the woman is pushing out her baby as just births.
[4:30] The expulsive phase of labor where the baby's coming out. And I can't be sure of where this expulsive phase starts, where the line occurs between labor and birth, because it's fuzzy. And as a private midwife myself, I very rarely do vaginal examinations. So if you haven't heard before, this is your very first Great Birth Rebellion podcast episode.
[4:56] I am a private midwife and I've been attending home births for about 18 years. And as a private midwife, I very rarely see a reason to do a vaginal examination. In hospitals, they tend to do them every two to four hours, depending on the clinician, depending on the scenario. There seems to be this routine practice of repeated vaginal examinations. That is not the case when you are a midwife working in a home setting or potentially in a birth center setting. So it's tricky to describe where the line is between labour and birth, particularly if we're not doing vaginal examinations. So midwives around the world may be familiar with the practice of doing vaginal examination. When the woman starts to feel an urge to push, sometimes their employer will require that they check that she's fully dilated.
[5:51] And then give the woman permission to push once you've confirmed as her care provider that her cervix is fully dilated. And I've got a lot I could say about that, but not really on topic. But I find vaginal exams to diagnose the start of the expulsive phase to be unnecessary most of the time. There's sometimes a place for them when the woman wants one or where you're trying to diagnose an issue. But as part of routine care they have no place. We know from research that routine vaginal examination and even the ones that you give to the woman to confirm whether or not confirm in inverted commas whether or not it's time for her to push to give her permission they don't improve outcomes and it's unbelievable that it's become part of routine practice. In fact every time I say this, every time I say there's no reason to do a vaginal exam to diagnose fully dilated so the woman gets permission to push, I get emails and messages from midwives saying, oh, well, Mel, what about if her cervix isn't fully out of the way? Or what about if she pushes on her cervix and she's not fully dilated? Won't that give her a swollen cervix? What about that? What if there's an anterior lip? That could happen.
[7:11] And if that's the case, the baby won't come out. You'll have signs that the woman's not fully dilated. Even if you don't do a vaginal exam, it will be obvious that she's not fully dilated if you're looking for it. So yes, it's possible that a woman's cervix could be swollen, but we actually don't know if that's because she's been pushing on a non-fully dilated cervix or not. I'm just saying from my experience I personally don't need and many home birth midwives don't need a vaginal examination to tell you that a woman's fully dilated.
[7:45] Before she starts pushing. And there's a whole Cochrane article about this. They've looked at the research on vaginal examinations and they've actually said they cannot believe that it's been integrated into maternity care considering how little evidence there is to support the use of routine vaginal examinations. And they concluded that it doesn't improve outcomes for women or babies. So that research paper is in the resource folder. If you're on the podcast mailing list, then every week I send an email out to give you the resources for each individual episode. So you can join that mailing list. You'll get the resources for all previous
[8:21] episodes as well, but that research paper is in there. So next time you feel like you want to send me a message to tell me that, oh, actually that's dangerous to not do vaginal examinations on women to be able to diagnose that they're fully dilated and give her permission to push as if she has no idea what to do, consider reading that paper before coming at me with your judgments about that.
[8:44] So if you're a woman out there listening and you're having mainstream maternity care, just know that your care provider may be required to or may want to check if your cervix is fully dilated before you start going with the instinctive urge to push your baby out. So this is considered part of diagnosing whether or not you've entered into the textbook phase of the second stage which is defined as the point in which your cervix is fully dilated and it ends with the birth of your baby and without a vaginal examination we can't truly know if you're in the birthing stage of labor or in the expulsive stage of labor until we see the top of your baby's head And then we can be very sure that your cervix is dilated and the baby has descended down into your pelvis and into your vagina. So for me, that's a sure sign that the second stage or the expulsive stage of labor has started and you're birthing your baby. And the urge to push itself is not an indication of the expulsive phase and neither is being fully dilated. So each individual element in itself can't be used to diagnose a second stage of labour. Having an urge isn't the complete diagnostic picture of being fully dilated and ready to push your baby out, and neither is being 10 centimetres dilated.
[10:10] Individual elements themselves cannot be used to diagnose a second stage of labour.
[10:15] You know, an early urge to push can be caused by things like malposition of the baby, a breech position, babysitting low in the pelvis, but it doesn't mean that the woman's ready to birth her baby because maybe the cervix isn't out of the way. Just being fully dilated doesn't start the clock on birth because maybe the woman's body yet has not transitioned hormonally or physically or emotionally.
[10:41] Into the expulsive phase. So even though the cervix is out of the way in the event of being 10 centimeters or fully dilated, the baby's only going to be pushed out if it descends through the pelvis under the pressure of the woman's own uterus pushing it out. So without an urge to push, I don't believe you can properly diagnose the second stage of labor or the pushing expulsive phase of labor. Just being 10 centimeters doesn't mean anything. Doesn't mean you're ready to birth. Even for me personally, I was fully dilated for hours and hours and hours before I had an urge to push. My waters had not yet broken. And even though I was fully dilated after a long labor, I had no contractions and no urge to push my baby out. I was definitely fully dilated because we'd checked, but really, I don't even think I was in labor anymore. I was just fully dilated with no contractions, waiting for something to happen. We tried so many things. We went walking. Eventually we called an acupuncturist who helped elicit, ushered in my expulsive phase of labor and I gave birth to my baby soon after.
[11:51] But part of the issue was that the baby hadn't descended into my pelvis. So even though I was fully dilated, was not in the second stage, was not close to even birthing my baby. So you might wonder why I'm going on a little bit about the line between the second stage or the pushing phase of labor and where it begins.
[12:11] And it's because the maternity care system is obsessed with time and measuring. And if your body doesn't comply with the set measurements and set time expectations of your care provider or of the place that you're giving birth at, you are going to be invited to accept interventions that will make sure that your body comply with the rules of the facility in which you're birthing at all with your care provider's expectations. And that will force your body and baby to act in a way that is restricted to the amount of time, whether you're ready or not. So for example, many facilities will set the clock, one or two hours from being fully dilated before they expect to see your baby fully born or at least progressing towards that. And if you've been pushing for longer than one or two hours without a change, someone is measuring that and they're planning to do something to speed up the birth of your baby after a nominated amount of time that's in their head. So the clear diagnosis of the pushing phase becomes important in bigger birthing facilities or where systematic birth practices dominate because it marks the point from which your next intervention will be planned. And I'm not saying this is right. I'm just saying how it is. It runs on time.
[13:30] So there's this overarching belief that your baby should be born within one or two hours after you get the urge to push and where your cervix is fully dilated. Or even worse than that, and this is what I saw in my training all those years ago, I would do a vaginal examination and they go, oh, your cervix is fully dilated.
[13:52] And you can start pushing now even if you don't have an urge to push. And to me, this is such a shame. It's a complete corruption of the woman's opportunity to push her baby out in an enjoyable way. It makes the process really unenjoyable and actually quite unproductive,
[14:07] which we will hear as we go. So I'll start by explaining how the birth of your baby happens if you're just left to be and do your own thing.
[14:17] So here you are, you're labored, labored, labored. Maybe you're fully dilated or your cervix is out of the way. Or the other option is that it's not fully out of the way but it's stretchy enough and of a consistency that it can freely move out of the way under the pressure of your baby moving down. That's another option that you said is just super stretchy and just as the baby gets pushed down, it moves out of the way. The next thing your body is going to do is redirect the activity of your uterine muscles to start pushing your baby out because the uterus has three layers of muscles and they all function differently at different stages of your labor. So the initial contractions that you have are not interested in pushing your baby out. They're interested in pulling your cervix up and integrating it into your uterus. So the initial contractions are interested in shortening, opening your cervix and drawing it up into the uterus. And this gets your cervix out of the way so that when you reach the part of your labor where your baby is ready to be born, the function of your uterus is different and the activity of your uterus changes from trying to draw up your cervix to trying to push down your baby. So the pressure starts coming down from the top.
[15:37] And this stage can be governed by increased levels of adrenaline in order to give you the energy and the power that you're going to need to be part of that process, to be alert and ready for your baby. And this adrenaline and oxytocin combination puts you into one of the most blissful and powerful stages of your life, one that you may never experience again. This feeling is indescribable. I've never taken drugs, so I can't compare it with that. But a birth that is uninterrupted by interventions or medical management or people just like invading your birth space has got this unique hormonal cocktail that makes you feel incredible. It's, I can't describe it. It's actually so addictive and probably the reason why I uncontrollably laughed my baby out as she was emerging and why some women just after they've had their babies think to themselves, oh my gosh, I would love to do that again. It felt so good. It's a feeling of complete elation and awe at what your body is capable of, but it's a product of this unique hormonal cocktail that's designed to make you feel like a superwoman.
[16:48] So let me talk you through this pushing phase where you're going to push out your baby. And I'm going to start by talking about women who don't have an epidural because it's a really different situation if you have got an epidural but at the end I'm going to offer some pushing out your baby tips if you've chosen to have an epidural. We're going to talk all about that later. So there's two techniques I guess techniques in speech marks about how to push out your baby what's going to happen. So the first technique is what you would do if you were just going to go with your body. So if you were just trusted to do whatever your body wanted to do to push out your baby this is what we call spontaneous or physiological pushing just going with your natural inclination and doing what feels right and so this is spontaneous or physiological pushing you just follow your body wait for it to do its thing this is where you start to feel an urge to bear down and just go with whatever your body's doing.
[17:49] And in this phase, all the practitioner does is give words of encouragement or reassurance. You know, you're doing great. This is perfect. Wonderful. If that's what you need. Not all women need this kind of encouragement, but some women do look to their care provider. So what's going on? And the care provider can, you know, this is normal. You're doing great. There's no direction on how or when to push or how long to push or when to start pushing or anything like that. It's all directed by the woman's body, by your body, and you're encouraged to just go with your natural urges. Better still, the practitioner just doesn't say anything and doesn't distract the woman. This kind of requires a little bit of focus. And if you're allowed to go completely into body, closing your eyes, blocking out everything that's going on on the outside, you'd be amazed at what you feel and know about what to do next and what your body is capable of. So this does require you, the woman, to be fully confident in yourself and not in need of this external encouragement.
[18:59] You know some women are looking to their care provider for feedback or encouragement if they're not fully confident in what they're doing or if something doesn't feel right and then so that's just physiological pushing just letting your body do it I mean that's what we're made for that's what our body's capable of birth is an involuntary process so if your mind is not in the way and you just allow your body to do its thing it can do that similarly if no one's distracting you and interrupting that space. You've got capabilities that you're unaware of and that we as women have not been allowed to fully express because of the interruption that happens during this phase.
[19:39] So then there's the second option, this coached pushing option, this process where whoever's with you believes that whatever they know about your birth is more authoritative than what you know and that what your body is trying to do.
[19:56] So this is what I saw when I was a baby midwife. And even still today, I see this from midwives. But it's pretty much all I saw when I was working in a hospital as a student. And it can happen in a few ways. Sometimes it happens, the midwives done a vaginal examination and discovered that the woman's fully dilated and she'll go, great, you're fully dilated. It's time for you to push. With the next contraction, I'm going to get you to hold your breath, chill on your chest, knees up to your nipples. Usually women are lying on their back in the stranded beetle position. And then with the next contraction, you're going to go, push, push, push, push, push, push, push, push, push, push. And they'll go, one, two, three, four, five, six, seven, eight, nine, ten. And they'll try and get the woman to hold her breath for as long as possible and the woman's not making any sound. She's got a mouth shut and her eyes are popping out of her head and then the woman pushes and pushes and pushes and pushes and they just encourage her to go longer and longer and longer, not make a sound. And then when it appears as though the woman's about to pass out from lack of oxygen, they go, okay, take a big breath.
[20:58] And then they repeat the whole process again. Push, push, push, push, push, push, push, push. And then they encourage them not to let any sound out, to put all the energy and pressure down. And this is called coached pushing. When the woman is not encouraged to wait for a natural urge or a natural push, they're just encouraged to follow the instruction of their care provider. And that's kind of the worst of what I've seen, where midwives or doctors just assume fully dilated means that it's time to push.
[21:28] We heard earlier in the episode that fully dilated does not mean the woman's in the second stage or the pushing phase of her labor because she can't be there yet because she's got no urge to push. So she's not in the birthing phase. She's not in the pushing phase yet. She's got to have an urge to push and be fully dilated to even be considered starting the clock on the pushing phase of labor. And the reason she doesn't have an urge is probably her baby is not in the right position yet. Part of having a baby and giving birth is, yes, your cervix being fully dilated and out of the way. But secondly, that your baby's in an ideal position to come low into your pelvis and be born out. If one of those elements is not yet achieved, you are not ready to push your baby out. And the other part of that is cervix fully dilated, urge to push, but has the woman's internal hormonal cocktail transitioned into the pushing phase? Has she entered into power mode, superpower mode, superwoman power birthing mode, whatever I'm trying to say. We have to wait for that if the woman's going to have a joyful and enjoyable birthing and pushing experience. The whole combination of the ideal hormonal cocktail for pushing, cervix is out of the way and baby's in a position that's creating a natural urge to push the baby out.
[22:47] So what's happening there when you're coached to push is that you're bearing down. So what you're trying to do is increase your intra-abdominal pressure. So the pressure in your core unit to push the baby out. But the uterus is designed to push the baby out and it completely surrounds the baby. And when your uterus enters into its pushing phase, it's pushing the baby from all around and down from behind it sort of like a plunger movement whereas when you're doing coached pushing you're straining you're increasing the abdominal pressure and there's more pressure on your pelvic floor so coached pushing is the equivalent of straining and pushing a poo out rather than sort of or forcing a wee out rather than just allowing them to flow and come out as you know as they would and that extra pressure not only does it build up through your eyeballs it builds up all into your intra-abdominal space and puts pressure on your pelvic floor more than if you were just going with what the power that your uterus was offering, and there's been some research on this in this coach pushing technique uh they've had a look at the outcomes and the impact it can have on both the mom and the baby but before i go on to talk to you about the impacts of coach pushing.
[24:08] Midwives who don't practice this sort of prescriptive type of pushing, some of them still pride themselves on being involved in this pushing phase. So.
[24:20] There's great midwives out there who acknowledge that pushing the baby out is the woman's job. She's got some innate wisdom in her body and she's capable of doing that under her own urges. But then we can fall into the slump of not properly reflecting on what we're doing and saying to women during their pushing phase and that somehow our input is going to help.
[24:42] And even though we're not coaching them to push, we're still often coaching the women about what to do during the pushing phase, even if it's not about pushing. We're still compelled to offer this advice and instruction, including things like just go with your body. But there's a difference between instructing the woman and offering encouragement. So things like, yep, that's great. Everything you're doing is great. You know, if the woman needs reassurance.
[25:11] And it's a bit of a nuanced conversation and I suppose what I'm encouraging midwives to do is to be always reflective on your practice and I know even when I'm with a woman during physiological birth at home sometimes I fall into this instruction trap where I'm telling the woman what to do rather than just encouraging her and it's usually just based on my own assumptions like oh if I get her to breathe through this maybe I can help prevent a perineal tear sometimes the words come out of my mouth because I want to say them, not because the woman needs to hear it. So it really all depends on the needs of the women. And something that I get to work out with women ahead of time because I'm their care provider through their whole pregnancy, then you can talk to the women about what strategy they want to use when pushing out their baby. The best strategy for helping a woman to push out her baby is to understand what her expectations are ahead of time if you can this is can be really tricky if you've only just met the woman and basically your job as a midwife is to meet her expectations so I've had clients who've said you know when it's time to push the baby out I want you to just sit down don't say anything you know I don't I don't need I just want to push this baby out on my own I want I want to catch the baby I want my partner to catch the baby whatever the instruction is and others have said that they're going to need constant feedback. They want me right there.
[26:35] Lots of verbal reassurance, lots of instruction. And that's for their own reasons. Sometimes they've had big previous perineal tears and they think, right, this time I want the midwife to give me some instruction. Totally fine. But it's about giving the instruction that the woman needs, not giving the instruction that you want her to have or that you need or that you think she needs. So it's not as simple as coach versus physiological pushing.
[27:02] But consider that if we're in the mindset of physiological birth and trusting women to birth their babies how they feel they need to, then perhaps we should consider toning down the coaching or instructing during physiological birth because it's still a coached second stage, even if you're not coaching her to push. So for example, I've heard people say to women, just breathe your baby out, like resist the urge to bear down, you know, instructing the woman to go against
[27:32] that urge to bear down, to somehow override it and breathe. And the midwife or support people are doing this thinking, oh, I'm helping the woman have a physiological pushing phase. But in fact, by offering this coaching, you're positioning yourself as the expert in the room and you're dishonoring the woman's own wisdom by coaching and instructing her to birth in the way that you think she should birth. You're coaching her not to push, but it's not, you know, it's the same as somebody coaching a woman to push when they're not ready. Encouraging them not to push and not to listen to their body is just as big an intervention as trying to coach a woman to push her baby out when she's not ready. Physiological pushing phase is about trusting the woman to know what she needs to do. She's got an inner wisdom that we can't possibly understand.
[28:30] And that's just a bit of food for thought for those of us, me included, who think that we aren't coaching women through their pushing phase because we're not coached pushing, but we're still giving instruction and that still interrupts the woman's own experience. So we just have to ask ourselves, does the woman need my wisdom right now? Does she have enough of her own? Probably. If she doesn't want it or need it, leave her to rely on her own wisdom. There's so much power in that for them. There's such a deep experience. When you don't interrupt someone and don't try and speak to them and let their brain fully sink into that, you'd be amazed at what women can do. Even that instruction to just breathe through or resist the urge is coaching the woman in her pushing phase. So you're not coaching her to push, but you're coaching her not to push, coaching her to breathe. This is all coaching in the birth process. So if you're putting your instruction above the woman's own experience, is she truly experiencing her own physiological pushing phase?
[29:38] So let's talk about what you might expect, the birthing woman,
[29:42] to happen when it's time to push out your baby. So if everything's progressing normally and no one's giving you any instruction on what to do next, no one's telling you to breathe differently or push or stop or go or whatever your well-meaning midwife is trying to do. So now I'm not tapping into the textbooks. Now I'm going to tell you what I know about physiological pushing phase and what it looks like and what happens to women when they go with their own body to push their baby out. So this is based on 18 years of observing physiological birth at home and it's usually associated with some kind of noise. Women do not hold their breath during the pushing.
[30:27] They look like they're intensely trying to concentrate, so much so that if you interrupt them, you can see them snap out of something. They're trying to concentrate. Some women will thrash about. Some women will put their hand between their legs so they can feel what's going on. Some will cry out. Some clench their faces and bodies. Some are completely chill and zen. And some need physical attention and encouragement from those around them. They'll look to people wide-eyed and some of them look terrified. And some of them are calm and confident. And the role of the people in the space are to help the woman sink into a sense of calm, to know that everything is okay and that she can trust what her body is doing.
[31:14] So what is happening is that your cervix, if fully dilated, you've reached the end of the part of the labor where oxytocin and endorphins are governing the labor process to pull your cervix open. And imagine now your uterus is looking more like a gum nut, you know, with this big opening and less like a balloon that's cinched together at the bottom. The result is of your cervix coming up into your uterus is that the uterus is thicker and the multiple layers of the uterus start to transition into a new function. The function of pulling the cervix open is over and now it's time for your uterus to gather its strength and its power and start the downward motion to push your baby out through your pelvis. And the uterus is not this weak passive organ that's all flaccid like a balloon.
[32:02] It's muscular, it's strong, it's got the contraction ability that's strong enough to push the baby out of your body. But before it does, your hormonal cocktail changes and your body starts to receive some adrenaline, which you're going to need to have this newfound alertness and strength to push out your baby. But you're also going to need that to parent your new baby that you're about to have. So there's this transitional point that your body has to traverse before pushing. All of this transition, the hormonal one, the uterine one, are all necessary if your body's efforts are going to be effective and enjoyable.
[32:39] Because the joy often comes from the hormonal element. So my suggestion here is to bother.
[32:46] Allow your body to make this transition to give yourself the best chance of pushing your baby out with your own power. And during this transition stage, you would do good to protect yourself from unnecessary interruptions, unnecessary conversations, and ride this transitional moment in a space where it won't be interrupted. This means that people around you need to be quiet. Stay warm. Immersing in water can help at this point, induce some relaxation and accentuate your focus.
[33:21] Have a rest if you need to, stay hydrated, drink if you're thirsty. I'm going to suggest here that you listen to the previous episode, episode 166, which was an ode to Audant. If you need to fully understand the needs of yourself and women in labor, he gives a beautiful explanation of how to help women transition into this phase but basically if you want to have a physiological pushing phase you have to optimize the function of your body and optimizing it means not interrupting the physiological process staying warm quiet safe dark and an unobtrusive environment so that's the first job so the first job is to block out anything that's going to distract you give your body time to transition into this pushing phase then just submit to your body slowly as your contractions peak you'll start to feel your body doing something different at the peak of contraction whereas before when you had a contraction you wouldn't have felt the urge to bear down it could they kind of start to feel a little bit all the same then when you're fully dilated and your baby's starting to move out and you're transitioning into this part where you're about to give birth, the contractions do start to feel different. Sometimes some will feel different, some won't.
[34:41] Then maybe at the peak of a contraction you feel something different, but they're not. And you can just notice it. Just notice what's changing and do what feels right. Just let it pass. But just noticing, what is my body doing? Ooh, that's new and different. How exciting. Maybe I'm transitioning to birth. You might notice your voice and sound changing and doing something different. And certainly midwives who work with women in physiological birth and who are prone to just sit back and listen, midwives recognize the unique sounds of a woman who is feeling the urge to push or who's transitioning into feeling the urge to push. This happens to me all the time. And me and the second midwife are making eyes at each other like, we know what's happening here. she's transitioning into a pushing phase. So gradually that urge to bear down will strengthen and.
[35:34] And in the situation where you start to feel an irresistible urge to do something, it might be an irresistible urge to bear down or scream out or vomit, whatever you feel like you need to do, it's going to be involuntary. Your body is going to want to do that. So try and keep your thinking brain out of this moment and just submit to whatever your body is asking you to do. It's designed to do this. We don't have to instruct our body as to what to do to push our babies out. In fact, if you let your brain take over this process, you're probably going to complicate the whole thing. So your body is in communication with your baby and it knows how many contractions are needed, what strength they're needed, and when to give you an urge to bear down and when to bring your baby out. This is the same as labor. So submit to the process, do what feels good and right in the moment. Don't overthink it. There's no room for our cognitive capacity in this process
[36:32] of labor that's largely involuntary. Of course, ask for help and advice if you need it. If your mind's taking over and you're feeling doubts, you can ask around to the people around you that you trust, whatever you need to ask. But it's okay to sink into this process and you don't have to ask people around. You've got an expertise that you can tap into, but you've just got to be allowed to.
[36:58] So then as this urge to push builds, your pushing efforts will feel stronger and bigger, and you'll feel your baby moving down into your pelvis and filling up your vagina. And at this point, you may instinctively try and slow down the birth of your baby by trying to hold it in internally. Some women sort of like, you can see them there. They've tightened up their whole body and you think, oh gosh, she is really trying to hold her baby in and sometimes women will hold their breath and just breathe really shallowly like oh my gosh if I let this breath out maybe I'll be letting my whole baby out but I do think women do something instinctively to try and slow down the birth of their baby and sometimes they're doing it because they're scared and they get this tense feeling about the stretching that's about to happen and they feel frightened and they almost harden up to hold their baby in because they're fearful.
[37:56] So in this moment, if you're feeling fear because of the pressure of the baby in your vagina and you can feel that you're getting really close, that if you just allowed your body to have this baby, that it was going to come out, but that is frightening you, now it's time to remind yourself that your body is capable of opening and softening and the less that you fight the process of birth and the process of your baby emerging, the softer you can make your vagina and your vulva and the tissues around and your pelvic floor.
[38:31] They're all very flexible and movable. And as the baby moves through, if you're surrendering rather than fighting, you actually might reduce the chance of your perineum and vulva tearing as your baby comes out. Because your baby is coming. Your body's got the strength to push your baby out. But if you're fighting that emergence with fear, then you could end up causing your perineum to just be firm and hard and your pelvic floor to be firm and hard around the baby. And your baby's got to fight through that. And overcoming this mental barrier can become easier with some control of your breath. And so here's where at times I'll give women instruction about their breath. If they've said to me, oh, I'm really scared and oh gosh, I don't want the baby to come out and I'm really worried I'm going to tear or whatever their fear is about the baby emerging. It's the time where I might just give some instruction on how to breathe to soften and to reduce the fear. And this breathing is just a remedy. If you can feel fear creeping in and the fear is causing you to feel tight and unable to submit to the birth process. In these circumstances, you can try some big, deep, slow breaths. Just in and out. Soften your jaw and your throat.
[39:53] In a way, if you let out a sound, like a low moan, like a...
[40:02] Rather than like a high-pitched screech, like a, you know, when you're holding everything in and tight with a tight, clenched jaw. This kind of activity can just help you to override those feelings of fear and just tell your body it's okay to surrender. So soft jaw, soft throat, low breath sounds out, deep breaths instead of shallow ones. This breathing can be a way of calming and relaxing yourself. And this is where I see midwives, myself included, if I sense that the woman is feeling this fear, here's where the coaching of a midwife or a support person or a doula can help the woman find her zone again by reminding her of techniques to add calm to the situation. It's not coaching her on how to push her baby, but more about how to stay soft and calm so that she can just surrender to this really new and sometimes alarming feeling of the baby coming out of you. It doesn't happen very often for us. And so the new sensation can fill women with fear and concern.
[41:12] So some reassuring words, this is normal. This is how it is. This is how it feels. Let's do some deep, calm breaths so you can surrender and open your body up to allow your baby out.
[41:25] And as you're breathing, you can try and tap into the experience of the baby moving through you. Close your eyes, notice what's happening and pay attention to what your body's asking you to do and what it's capable of doing. Like, whoa, I am at full stretch. How amazing. So you have this internal wisdom and this internal instruction that no one else has. So that's your wisdom and that's your power on how to birth your baby. It's different for every woman and every baby. So you can just tap in and listen to that. Close your eyes. Slow deep breaths. What's my body asking me to do? Is it asking me to move? Is it making me bear down? What do you need?
[42:14] So then you'll get to the point where your body's pushing efforts will result in your baby crowning. And basically, that's where you're feeling the most pressure on your perineum and on your vulva. Your vulva is at full stretch. Your vaginal opening is at full stretch. Because before that, the baby was coming down and pushing on your vulva. And it was stretching during the contraction. And then when your uterus relaxes for the rest between contractions, the baby goes back up a little bit. That's normal. This kind of swinging back and forth. So with the pressure of a contraction, the baby moves down and applies pressure and you're feeling that stretch and you're thinking, oh, okay, there's the stretch. And then the contraction goes away and you feel the baby move up back again and the stretching reduces. This is normal. This is appropriate descent of the baby. Sometimes with coach pushing, they'll say, oh, hold your baby there. Hold your baby there. What they're asking you to do is increase the pressure in your abdomen, increase the interabdominal pressure with this unnatural pushing effort to try and keep the pressure on the baby to keep it there and to resist this back and forth swinging. The back and forth is normal. That's how babies come out. It's okay if it goes back again.
[43:37] They'll go little by little back and forth. And it's only right at the end of your pushing efforts that the baby will stay applied and fully stretching the opening of your vulva. And this is what we call crowning. We can see a lot of the baby's head now, like about the size of a little saucer, like a tea saucer. That's how much of the head we can see when your baby's fully crowning.
[44:01] And you just have to become comfortable with that full stretch sensation. But it can feel really surprising because your vagina will only have stretched this far during any previous births. It's a sensation that we only really feel during childbirth. So it can feel scary because it's new. But in this moment, if you feel scared, remind yourself, my body is made to stretch this far. It's just a stretch. I'm not in any danger. This is how babies are born. This is how babies come out. I'm designed to stretch.
[44:39] Sometimes we're designed to tear, but also repair. And Ina May Gaskin speaks about this idea of our vagina's getting big. My vagina is capable of getting big, just as yours is capable of getting big. Big enough to allow an entire baby out. That's how our bodies work. But we've been taught to fear this part of what our bodies can do. You know, Ina May says, we never once considered, is a penis capable of getting really big and then shrinking back down? We don't ever ask, oh my gosh, is that dangerous? Does it hurt?
[45:16] Of course, we're frightened of the stretch of labor. We're told so many different things about it, about the stretch of birth. But this is what we're designed to do. This is how babies come out. Of course, we can do it. So just talk yourself around about this. If you're feeling fear of your baby coming out, what are we scared of? This is how our bodies work. So you can consciously take the fear out of this moment by boosting your mental game with some positive words. It's just a stretch. For me, I felt the stretch and I thought, oh, it's not that bad at all. Because when I was having my first baby, I was waiting for what people had described. Many people said to me, oh, it's like a ring of fire. And I expected to feel burning and pain only because of what other people had said. But in the moment of full crowning for both my babies, I remember feeling that, nope, it did not feel like burning at all. It felt like stretching, but not painful stretching. It just felt like functional stretching. And in fact, I was actually thinking to myself, no, this actually feels good.
[46:25] Actually like this feeling of being fully stretched with a baby in my vagina.
[46:31] It was incredibly satisfying. It just felt so good. And imagine if all women spoke to other women about that, about the exceptional sensations that we can get when pushing out a baby. Imagine if that was the social dialogue about childbirth, how different it would be. So if I was going to revisit and re-experience any part of both my labours, it would be this moment of full stretch. It was definitely my favourite part. Feeling the full stretch of your baby's head coming out is exquisite.
[47:09] So, you'll get this stretch and you may feel one of two things. Firstly, you may just want it to be over and done with and you'll push with the next contraction, making every effort to have your baby born as fast as possible. Some women just want it to be over. Or number two, you will instinctively want to slow down the birth of the baby's head. As a midwife, if I was going to pick an option, I would say that the gradual, slow, but consistent birth of the baby's head is a nice idea. It may reduce the chance of you tearing. So just when you're pushing the baby's head out.
[47:48] Try gradual pushing if you feel like it or you can breathe and allow the power of your body to push your baby out i mean do whatever you want to do but if you're floundering and you're not sure what to do next just remember slow gradual birth of the baby's head and this can be aided by slow consistent breaths or you can put your hand on your baby's head if you want some feedback about how fast the baby's being born and you know if I was if I was going to give any instruction to women if women were like oh my gosh what do I do now you know your baby's fully crowning and then you feel the build-up of that contraction I would say slow gradual breaths let your body push the baby out. And one technique is the ha, ha, ha, ha, ha, breathing. So that's when you feel the peak of the contraction. You can feel your uterus bearing down and pushing out your baby. And you're thinking, how do I just surrender to this process? Ha, ha, ha. So big, deep breaths out, a bit of a ha, ha, ha breath. There'll be a moment where you think, oh, I just want to push as well. Totally fine. Go with it. You know what you're doing. Okay. Your body knows what it's doing.
[49:05] So, okay, your baby's crowning and then it will take some time to go from crowning to fully birthing the head. So some women will do it in like one or two pushes, one or two contractions, or you might need like five or 10 from the point where the baby's crowning to giving birth. But once the baby's crowning, you're close to giving birth. It's happening. Don't go anywhere. So there can be reasons that prevent the baby being born from this point, but it's the job of your midwife to recognize that. You just focus on what your body's doing, but your body might be telling you something's not right. And it's good to vocalize this. That's what the people around you are for, to help you deal with any complications. So I've been with women before and they've told me what maybe I was already thinking. So I was thinking, oh, why is this taking so long? Something doesn't seem right.
[49:56] And then the women will look at you and say, I think the baby's stuck. This doesn't feel right something's not right and you think right that's kind of what I was just thinking I didn't want to say anything at this point but when you tap into your own experience that you're having you'll be amazed what you can know and what your body's telling you and it can be good to share that with the people around you because maybe they're also thinking it and so at that point I'm like right if that's what you think and that's what I'm thinking let's see what we can do about this and that's the time where you can brainstorm some options for what to do next but if there's no delay so soon after crowning you'll be birthing your baby's head and that depends on how hard you push to get the baby out so either the head will be born and there might be a contraction or two between the birth of the body and the baby's head so just be prepared for this not all partners or women are prepared for the fact that you push the baby's head out and then there could be a gap of, minutes, long minutes, which feel like ages, the gap between contractions, where just the baby's head is out and you're waiting for the next contraction to push the body out. This can be a little bit startling if you've not experienced birth before. In fact, I used to go into schools and educate the senior kids about birth.
[51:15] And I would show them this particular birth and I could guarantee every time, so much so that I had to warn them ahead of time, that we'd get to the point where the baby's head was out and they would all start screaming at the screen to the woman to like, push the baby out, push the baby out. Because they hadn't realized that there was this gap between, okay, the head's born, but then we've got to wait for the next contraction for the rest of the baby. That's not always the case. Sometimes the head comes out and so follows the rest of the baby. No drama but just know it's very normal for the head to be born and then wait for the body for the next contraction and what's happening in this break the head's born but then the shoulders have to navigate the pelvis in the same way as the baby's head did so the baby's shoulders and body needs to navigate the pelvis in the same way that the head did so give the baby some time and space to do that head is out what will happen in the gap is that the shoulders just need a minute to get in the right position.
[52:15] And sometimes women will move in interesting and instinctive ways in response to the baby's movements through their pelvis. And in order to be able to do this, you do kind of need to be in a more upright position. So up on your knees, somewhere where you can move in water, standing, squatting, whatever it is. For this pushing phase of labor, just as you breathe and push as you feel like you need to, you also need to move and change positions in ways that feel comfortable. So if you're lying on your back on the bed and if that doesn't feel good, go anywhere else. There's no rules for positioning. It's just whatever feels most comfortable.
[52:52] So most women will only give birth on the bed because this is the instruction or preference of their care provider. But physiological pushing is all about listening to and responding to your body for breath, for the pressure that you need to exert to bear down and for the type of movement that you need to do to help your baby navigate your pelvis. And there's a lot of work that can be done by a woman who's tapped into her body after the birth of the baby's head, some movements that she might be instinctively doing in order to help the rest of the baby navigate the pelvis. So you want your baby to move through your pelvis, you've got to move in the way that your body's instructing you. And I'm recalling a birth that I was at a few years ago where the woman had quite a long labor, longer than she was expecting and she was in the birthing phase of her labor but really felt like nothing was working to bring the baby down you know we've tried all kinds of things she was in the pool and then hands and knees and then we tried the toilet and all these different positions didn't feel right to her they kind of felt she described as just like unproductive you know she's feeling the urge to bed down she's feeling the contractions but she just feels like nothing's happening the baby's not moving down.
[54:07] So we tried a deep squat, which we know anatomically can open up the pelvis quite a way. And she felt this immediate change in progress. And then when she moved back to her hands and knees, again, she felt like the pushing was unproductive. And so the only way that worked for her and the only way that I could see, you know, I could see actual changes when she was in the deep squat. And then when she was on hands and knees, I couldn't see anything. The only thing that worked for her was this deep squat, which is not something I usually use except in these rare circumstances where the woman notices a helpful change. And because of the deep squat, it actually is kind of a, it does elicit a bit of an artificial sort of Valsalva experience within the woman's body, a bit of extra pressure, like you were exerting a big push.
[55:00] And so the baby can come out quite fast and I usually if we're going to use this to help the baby reposition we'll just get the baby to a point of say crowning and then change into a position that's less impactful on the speed of the birth but for this I just had this feeling I was like no I think we're going to stay in the squatting position for the whole birth and we saw the head crowning and my other colleague said are we going to get her on her hands and knees and I said Absolutely not, because we've just witnessed how this is not working for her. The baby's head is nearly out. There's no way I'm about to change the mechanics of what's going on right now mid-birth, where you might be in a situation where the head is out, but then because you've changed position, the shoulders are no longer capable of navigating the pelvis. So we left her in the squatting position, which is what she wanted as well. We sort of said look I think this is the best position to push in and she said yep I agree and she was happy to stay in that position and so you know my initial habit was to only be in the deep squat until we saw progress but in this scenario we read the room we listened to the woman she felt like it was a more productive way to push and so we stayed there and did it like that A lot of birth is just reading individual circumstances and learning on the fly, doing what feels good.
[56:27] Okay, so this is your birth now. The head's out and we're waiting for the body. And so for the next push should come the rest of the baby if they're positioned ideally. Then up to your chest for uninterrupted skin to skin. Both of you wrapped in warm towels and blankets in this big warm nest, meeting each other's gaze and keeping the cord attached for optimal transition to life. and just keeping the oxytocin levels high. This is where the joy is in birth. The transitional hormones that happen when you're pushing your baby out, absolute bliss. The moment where the baby's fully stretching to be born, oh my gosh, amazing. And then the oxytocin peak the minute your baby's born, peak human experience.
[57:22] Where do we get off interrupting this moment for women and babies if it doesn't need anything, leave it be oh my gosh it's the best feeling in the world so what do we know for sure we know for sure that there's no need to prematurely push if you don't feel like it also not to hold back on pushing if you do feel like it and I think that's a good basic rule so if you're confronted with a practitioner who's like, right, it's time to start pushing, but you're not feeling it, it's okay to say, look, I'm going to wait until I feel like pushing before I even start. And then again, if the midwife's saying, oh, don't push, don't go with those urges, you can just say, look, I'm just going to do whatever my body asks me to do. I feel like I want to go with my body. You do not have to submit to the coaching of somebody who's outside of your body if you don't want it. Now, there's some research about this. This is not just me like saying what I think. So if we have a look at the research on this, there was a study done by Nigel Lee, Yu Gao and Sue Kilday and Lauren Lultz. So shout out to you guys.
[58:37] These guys did some research and the title of the paper is Maternal and Neonatal Outcomes from a Comparison of Spontaneous and Directed Pushing in the Second Stage. So they compared this coach pushing, that push, push, push, push, push, push, hold your breath type, like eye-popping pushing. They compared that to what happens if you just like let a woman do what she wants and only give encouragement, not instruction. The research paper is in the resource folder. So you can read this in full, just, you don't have to take my word for it, read it if you want to. And so Nigel and his team compared the outcomes for both the mom and the baby who just spontaneously pushed, went with their urges, weren't directed to do anything. So they compared those to the ones that were directed to push or that were coached to pushing. And in the article, this is how they describe the two options. So directed pushing or coach pushing involves a response from the woman to the instructions given by the midwife or support people. And it usually consists of the valsalva maneuver. So valsalva is where you're holding your breath and your throat is closed tight and there's no noise coming out and you're pushing. And they'll usually tell you to push for 10 seconds or more. And it could be two or three of these in a single contraction. So big, long pushing in one's equal contraction, two or three of those.
[1:00:04] Whereas spontaneous pushing or physiological pushing is characterized as self-directed breathing pattern. So a self-directed breathing pattern, not a clinician-directed breathing pattern. And self-directed pushing. So self-directed were the important words here. And the researchers acknowledge what we've known for a long time, that women's bodies have innate wisdom that they can tap into if everyone around them would just stop imposing themselves in the woman's headspace. And then she can fully experience what it means to immerse into this pushing phase and immerse into the sensation of her baby emerging. So stop robbing women of this powerful moment where they can meet their full capacity. and when they get an opportunity to trust themselves. But they won't get to do that if we as well-meaning midwives or doulas or support people or obstetricians are in their ear giving them guidance as to what to do next. Oh, breathe now, don't breathe now, push now, don't push now. Anyway, rant over. So let me continue with the research.
[1:01:12] So what Nigel and his team did is they gathered up a huge number of women. There were 69,000 over a six-year period, and they gradually whittled them down to a group of women that they could easily compare each other against. So they eliminated women who didn't match their inclusion criteria, which is the usual way that we do things when you're trying to compare two groups, because you want to make them as similar as possible.
[1:01:36] So women who had assisted vaginal births with vacuum or forceps or epidurals were excluded and women who didn't have the baby come out without assistance weren't included either. So nor were women who had epidurals. All the babies were full term and head down. They weren't breech. So they excluded all those women and only included the ones who progressed to an unassisted vaginal birth without a vacuum or forceps. And so when they took everybody out, they had 19,000 women to include in their study. And then they went about matching them in terms of age, health, ethnicity, and all these other factors. So they ended up getting 5,000 women in each group who were as evenly matched as possible so that they could properly compare the outcomes to make sure there was sort of no other explanation for why some women would have different outcomes to the other groups. So pretty good quality study if you look at it. Big enough numbers because previous research done And I didn't include the paper in the resource folder, but Cochrane did have a look at the, they compared coached versus physiological pushing and they said they really couldn't make a good clinical decision based on the research that was currently existing back in the day. So, yeah.
[1:02:54] This study by Nigel Lee and his team was kind of responding to the Cochrane research. We'd said we don't have enough information and they're like, mic drop, here's all the information.
[1:03:07] So they answered the call and basically went, we're going to do a really good study that has enough statistical power to answer this question. And I think we can rely on this research to help answer the question about the benefits or not of coached pushing versus physiological pushing. So when they assessed the two, they found that women who were directed to push.
[1:03:30] Experienced significantly longer pushing phases and a higher but not significantly higher rate of third and fourth degree tears. But they did have a higher use of episiotomy, significantly higher use of episiotomy, the episiotomy rate doubled. And some of the reasons why people do directed pushing, recommend that women do directed pushing is that they think that it shortens the pushing phase of labor. But what the study found was that it actually lengthened it. And I think we can pretty much understand why. It's because when you start directing someone to push when they're not actually ready, of course, you haven't got the power of the woman's own physiological function, that transition where the uterus is assisting with the downward pressure and pushing out of the baby. And also the hormonal changes that have to occur in order for a baby to be born, if you start directing a woman to push before she's actually ready, it makes sense that the pushing phase and the birth would take longer. And then if the pushing phase is longer, then that automatically puts the woman at more risk of interventions to speed up that birthing stage, including episiotomy. So that could explain why they found an increased number, doubling in the episiotomy rate for the women who were doing coached pushing.
[1:04:51] All right so let's have a look here the idea that a coached pushing can create a longer pushing phase. So what they found for first-time mothers, primips, women who are having their first baby, if they were not coached to push, two percent of the women in the study had what they would call a prolonged second stage, prolonged pushing phase, that was over two and a half hours was defined as a prolonged pushing phase. Only 2% if you're in the physiological pushing group. If you were in the directed pushing group, so if you were coached to push, 3.4% of women having their first babies had a prolonged second stage. So statistically significant difference in how many women had longer pushing phases. If you'd had a baby before, second or subsequent babies, 2.6% of the women in the undirected pushing group had a prolonged second stage.
[1:05:49] But now this was significant. If you've had a baby before and then you are directed to push, 7.2% of those women had a prolonged pushing phase compared to 2.6%. So if they're allowed to just push by themselves, 2.6%. So that's 5% more women, if you've had a baby before, having a prolonged pushing phase if you're coached. But it's the episiotomy rate that gets me. So, okay, if you're a first-time mum and you just do physiological, spontaneous pushing in hospital, this is hospital stats because it's not women having home births with private midwives in this hospital, you'd have a 13.6% chance of episiotomy, I mean, which is bloody high anyway.
[1:06:36] But the same kind of women so in the same group first time mums if you were directed to push you'd have a 23.5 percent chance of episiotomy so 10 percent more was 13.6 if you just pushed on your own 23.5 if you are part of the coach pushing group so that's some information they collected on the mums if you direct pushing you're going to increase the chances of them having a delayed second stage and also increase the chances of episiotomies but let's have a look at the babies that's what they looked at for the mums i won't go into all the stats but if you want to see the stats actually previous me before i was even doing the great birth rebellion podcast and i still have a youtube channel but on my youtube channel if you go to melanie the midwife on youtube there's a whole youtube channel there which gives you graphs and physical visual diagrams of this study of this particular research that I'm looking at. The video is called Pushing Out Your Baby and it was on Nigel Lee's study. So you can have a look. It goes for about eight or nine minutes, but in there is where I take you through all the baby stats.
[1:07:46] But basically, if I just glaze over it, if you were instructed and directed to push and you follow those instructions, then your baby has almost a double requirement to be resuscitated after birth. So about a 1% increase in the number of babies who needed to go to knee-natal intensive care unit and a slight increase in lower APGAS scores which is the score that they give your baby when it comes out in terms of its transitioning to life.
[1:08:15] So basically what we know from this research and good quality research is that directed pushing doesn't benefit the woman it increases the length of their pushing and makes them more at risk of episiotomy and it doesn't benefit the babies in anyway. There was no better outcomes. In fact, they were all worse from directed pushing.
[1:08:33] And so it's absolutely okay to stop diagnosing the pushing phase that women are fully dilated and just let women do what they need to do. It's okay to not do coach pushing under normal circumstances because it doesn't really do what we think it does. It doesn't shorten the pushing phase. It actually clinically lengthens it. And then there's the ramifications or happens to women after they've had a long pushing phase because I know this is what some midwives are doing.
[1:09:01] Midwives know that there is a consequence to pushing longer than two or two and a half hours. They know that the women are going to be exposed to more interventions. So in a well-meaning way, they try and help them get their babies out as fast as they possibly can. And many of them know that if it takes too long, then the list of interventions increases, episiotomy, vacuum, forceps, to help the women have their baby sooner, even if the baby's not suffering it's just like they want to comply with some arbitrary time limit but also there is a belief and there's some truth to this that if a woman pushes for too long they could damage their pelvic floor but that is way more likely with coach pushing versus physiological pushing our body's own functions aren't designed to damage us but when we start to interfere like giving women this unnatural way of pushing when you coach them that's what starts to damage their pelvic floor. Coach pushing for too long, yes, can damage pelvic floor. Physiological pushing, different story, but if you're doing physiological pushing, the pushing phase is shorter nonetheless.
[1:10:12] So perhaps one way of reducing the amount of time in the pushing phase of labor is to not start the women pushing prematurely. So let her body tell you when it's time to push and then you can start the clock on her pushing clock later in the piece when the baby's actually ready to come out because the woman is getting the urge to push her baby out and the research we just spoke about supports this idea. Shorter pushing phases are the result of waiting for the physiological urge to push and allowing women to push her baby out under her own instruction and not directing her in the way that you think she should be pushing. So we are making things worse for women and their babies by using these coached pushing efforts. They're not, it's not working.
[1:11:00] Some of you more astute listeners will be thinking about two things.
[1:11:05] The Ferguson reflex and the fetal ejection reflex. And some of you are like, Mel, no, we're not thinking about that at all. I just want to say that I did indulge in research on these two things as I was creating this episode. But after going down the rabbit hole, I realized that everything that I'd learned about the Ferguson reflex and the fetal ejection reflex as part of this pushing phase, it will not fit into this episode. It's already gone on for a while. So the Ferguson reflex versus the fetal ejection reflex is a discussion I'm going to have in the next episode. Episode 168 will be all about that. So hang tight for that episode. But what I do want to talk about now is pushing if you've got an epidural because some hospitals have got a 70%, 80% epidural rate where very few women are actually able to push their baby out under their own power because their capacity is reduced by having an epidural. There can be lots of reasons for why women choose to have an epidural and it's not always just for pain relief. Some women need them out of pure exhaustion after a long labor if they just need to sleep.
[1:12:18] Sometimes they're used to bring down high blood pressure. Often they're used for pain relief and some women use them as a solution to an early urge to push before they're fully dilated and anyway there's lots of reasons they use swollen cervix anxiety and not just the anxiety of the woman the anxiety of the care providers or support people but whatever the reason is.
[1:12:41] Epidurals significantly impact on the function of your body during your labor and birth, there's just no way around it massive impact on how your body is going to function and a full discussion of how and why epidurals disrupt the function of your body in labor.
[1:12:57] It's going to have to be a topic for another episode and I'm working on that too. But today I'll focus on a few strategies that you can use if you're going to try and push your baby out but you've got an epidural.
[1:13:09] And I'm just going to list these things out as possible options that you can use to make pushing out your baby easier and more likely to be successful without you needing a episiotomy or an instrumental birth if you've also got an epidural on board. So first, the first option is to plan ahead and ask for what people call a walking epidural. So this is an epidural that does ideally take the contraction pain away, which is what often you're getting an epidural for but it doesn't leave you completely immobilized so you can still move around a little bit and although it says walking epidural they call them walking epidurals the their name's a bit deceptive you often don't have enough movement in your legs to walk but you may be able to get your legs in a kneeling position on your hands and knees to sort of change positions on the bed or on the floor but not really walking around. The fact is that you can still move and it means your baby has a chance of being able to move through your pelvis and it can reduce the chance of malposition issues for the baby which is one of the side effects of an epidural.
[1:14:21] So one of the real downfalls of having an epidural used to be that women were completely immobile which meant that their baby was more likely to get into a posterior position or really any position that made it hard for the baby to navigate the woman's pelvis. So getting a walking epidural, it means you have a lower dose of the same medication that they would use for the more classical epidurals.
[1:14:46] And the old epidurals meant that the women just were completely immobile. They couldn't move their legs at all. So that's the first option. If you're planning an epidural, ask for one that will allow you to be able to move and change positions. And sometimes they call these walking epidurals.
[1:15:04] Number two, another strategy. After the initial dose of an epidural that creates the pain relief from the epidural, your epidural runs on an infusion where the medication continues to be administered into the epidural space in your spine. So it keeps dripping the medication in. It's not just like a bolus injection, one-off dose. It keeps dripping it in. and it's this continuous administration that creates the continuous effect.
[1:15:36] So an epidural isn't a single dose and the good thing about that is that if you want to stop the effects of an epidural you can turn off the infusion pump that the one that's administrating the medication and over an hour or two the effects of the epidural wear off and then gradually the sensation of labor returns and it does take longer than a few hours to fully wear off but a strategy that you could use to enhance your body's own capacity to push your baby out if you have an epidural is to turn off the epidural once your cervix is fully dilated and you can ask for it to be turned off and then while your baby waiting for your baby to move down into your pelvis into the right position to be born the epidural will wear off hopefully the baby's moving down and you'll be able to feel the sensation of what your body's trying to tell you to do when you're pushing. So you'll be able to receive instruction from your body on how to push. And this means that you can participate in the pushing because now you have some sensation back. But the real challenge with epidurals is if they're fully effective, that women can't always feel when it's time to push or even that they're having a contraction. They can't assist their body in any way. They can't move. They can't add or take away any of the pressure.
[1:16:55] You know, usually your body would be giving you feedback about what it needs you to do in order to help the baby be born. But these messages are dulled down if you have an epidural. So for the sake of improving your chances of being able to push your own baby out, perhaps consider turning off the epidural for the pushing part. Now, of course, you will feel a return in the labor sensations, which will gradually increase over the hours. But that's the point.
[1:17:23] But if you were planning on having an epidural to take away the pain completely, this might not be the option for you. But just know that you can ask for it to be turned off. You don't have to keep it on so that you can feel what you need to do in order to push your baby out. Now, even before you get to the pushing phase, and this is point number three, even before you get to the pushing part of your labor.
[1:17:42] One thing that can make it hard for you to push your baby out if you have an epidural is that epidurals make it harder for your baby to get in an ideal position to be born because you're not moving. So one part of the baby moving down into your pelvis is that you're moving to help the baby get down into your pelvis as well. So one thing that you can do to help avoid this pitfall is to ask your care team to help you turn from side to side about every 20 to 30 minutes. So laying on your left side and then laying on your right side and you can put one of those inflatable peanut balls or a stack of pillows between your legs and you want to slightly tilt the top leg over the bottom leg and most birth facilities will have these tools that you can use the peanut ball some extra pillows and so you want to ask your partner or birth supporters to flip you side to side throughout the duration of your labor and you can choose also to give birth on your side in a sideline position if you're unable to get into an upright position like with the walking epidural if you can't get on your hands and knees or up onto your knees in an upright position just ask them to lay you on your side to give birth and obviously someone's going to have to hold your leg up in a side lying position.
[1:19:00] So number four, the next thing you can do to help push your baby out if you have an epidural is not pushing right away once you discover that your cervix is fully dilated. And this can happen is that you're there with an epidural, you're getting regular vaginal examinations because there's not really lots of other ways to be able to tell the progress of your labor because all the external signs are clouded by the epidural. And so the midwife might check your cervix and go, oh, you're fully dilated. Hey you can start trying to push your baby out but you can wait so maybe once they've diagnosed yep fully dilated ask for time for what we call passive descent so as I spoke about earlier there's lots of elements that go together to determine when you're ready to push your baby out one of them is yes your cervix is fully out of the way but the second one is that your uterus has transition to a hormonal state in which it can actually create the power and adrenaline that it needs to push the baby out, but also that the baby's in a position lower in your pelvis.
[1:20:07] So that can take some time. So after your cervix is out of the way, you need to allow time for the baby to move lower into your pelvis before you start pushing. So, you know, basically there's a shorter distance to go when it is time to start pushing. So this is called waiting for passive descent. And so you don't start the clock on pushing yet because no one's pushing. She's just fully dilated. And there is a great paper on this in the resource folder about the idea of passive descent during an epidural. So if you're on the podcast mailing list, you'll have access to the resource folder. And the article is a combined research paper that looked, and I'm not going to go into the details, but it concluded that there are significant positive effects were found indicating that passive descent should be used during birth to safely and effectively increase spontaneous vaginal births, decrease instrument-assisted deliveries, and a shortened pushing time for women who have got an epidural. So you can read more about that if that article interests you. But fully dilated if you've got an epidural and then allow for what we call passive descent where they will start to sort of measure, again it'll be a vaginal exam, the movement of the baby down to the pelvis and not starting to push until the baby is further down in your pelvis.
[1:21:32] Okay, number five, my final suggestion to help you bring your baby out more effectively if you have an epidural is to pull in order to push. And what this means is that you can sit in a semi upright position on the bed. So the very big benefit of hospitals is that they've got these beds that move and do all kinds of things. You can sit the bed upright and be sitting a bit more upright, or you can even squat if you've got one of those walking epidurals. And if you've got some length of fabric so a birth sling or a non-stretchy fabric such as a rebozo or something you can rig that up in front of you and and play a kind of a tug of war with it during your contractions to help add a bit of oomph to your pushing efforts when you have the epidural. So you're pulling in order to push and this means you might need to get creative about where you're going to loop and anchor the other end of the sling. One end has to be fixed to something firm so that when you're pulling on it, it's not going to move. And that could be a part of the birth bed or if there's a bar over the bed, somewhere you can firmly anchor one end.
[1:22:46] I've actually seen a midwife loop it around her back. And when the woman pulled, she was almost pulling the midwife towards her, But the midwife was stopped from going completely forward by the edge of the bed. So the midwife was kind of being squished between the bed and the woman's pulling efforts. So we can get creative. But one end has to be fixed firm so that the woman, when it's time for her to push, then you pull in a tug of war type effort. And this can be a helpful strategy for effective pushing in circumstances where you're trying to push your baby out with an effective epidural that's in place.
[1:23:29] So unfortunately, when you have an epidural, you can't rely on your body to function physiologically because you've turned a lot of that off. A lot of the stuff that's necessary for your body to physiologically function is turned off. So you have to rely on the involvement of your care providers to assist and coach you through birth with an epidural. But if you don't have that, the evidence is clear enough for us to be confident that it's overall better for women and babies to be allowed to have control over the timing and process of pushing out their own babies. I can't even believe that I had to write that sentence and say it out loud, but there you go.
[1:24:14] It's clear from the research, I can't believe we've got research on it, that it's overall better for women and babies to be allowed to have control over the timing and process of pushing out their own babies okay stated a matter of fact so I can't actually believe that we needed to use evidence to prove that it's fine and better for women to push out their own babies using their own power in their own time but there you have it pushing out your baby all my thoughts and a bit of the research that has been this week's episode of the great Birth Rebellion podcast, and I will see you in the next episode. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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