Episode 228 - Pushing out a baby in 15 minutes
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson.
[0:05] 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. Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today I'm looking at one single study. It's from France, and it had 10,500 women in the study, and none of these women exceeded 15 minutes for pushing out their baby. That's why I wanted to have a look at this research paper. So today I'm going to walk you through the study, explain what they did, show you the findings, and give some discussion around how you can use this study, apply it to your own birth. But before we get into that, I'd like to thank today's podcast sponsor, Poppy Child. I would like to personally thank the sponsor of this podcast because that means that you get to listen for free. Poppy Child from Pop That Mama is a doula and hypnobirth practitioner, and she's a sponsor for today's podcast. Poppy has an online course, hypnobirthing course. It's called the Birth Box, and it's already helped thousands of women.
[1:23] I get behind the work that Poppy is doing in the birth box it's practical strategies to help you get ready for labor and birth but also the challenges of parenting and with my code if you type Melanie in at the cart you'll get 25% off so if you're preparing for birth go check it out you will be so glad you did the link is in the show notes type Melanie at the cart and get 25% off. Thank you Poppy for sponsoring this podcast so that everybody else gets to listen completely free.
[1:57] Let's get started on today's episode. Okay, let's have a look at this study. It seems too good to be true. 15 minute pushing phase. Let's see what they did in this study to get these kinds of results.
[2:09] But first, I will explain that I was very reluctant to share this research paper for a few reasons, and I'll explain those as we go through. But I had to very much remind myself that as a researcher and a midwife, I must objectively look at this research, consider what it found, see the applicability, even if there's elements of it that I personally don't agree with or use in my own clinical practice. Of course, women are free to choose what they prefer, and certainly as a midwife, and particularly a home birth midwife, I have particular preferences about how birth is managed. However, this research paper really came into conflict with a lot of the things that I usually offer and suggest to women.
[2:56] But in the end, I decided that given the context of modern maternity care and how, much intervention and epidurals and inductions are applied to women's birth and how often we use things like routine vaginal examinations.
[3:14] Given that these things are part of modern maternity care landscape and some women can opt in or opt out, I did find that this research paper is quite applicable in today's modern birthing climate. And I will give detail and caveats to all of this. But in the end, this research paper did find that women who use a particular technique that is used for this study had pushing phases that lasted no longer than 15 minutes. And that's the interesting part. The research paper is called Active Second Stage Duration Under 15 Minutes in Spontaneous Vaginal Deliveries or Births with Delayed Pushing. And this was published in the American Journal of Obstetrics and Gynecology in May, 2026. So it's a recent study and it's in a reputable obstetric journal. But first, a little bit of background about pushing out your baby.
[4:15] In midwifery and obstetric textbooks, labor is broken up into stages. It's not generally how I experience or women experience labor, physiological labor in particular. But if you look in a textbook, they will explain that the first phase of labor is the time in very simplistic terms where your cervix will dilate to fully dilated. The second stage of your labor starts from full dilation and ends at the birth of your baby. And then the third phase of your labor is about placental birth. So this particular study was not looking at the first stage of labor. It was only looking at that moment from full dilation of your cervix to pushing out the baby.
[5:01] Now, again, in textbook terms, this second phase of labor from full dilation to pushing out your baby is further divided into two parts. The first part is the passive phase of the second stage of labor. And the second part is the active phase of the second stage of labor. And what this means is, is it acknowledges that you are actually not ready to push out a baby just because your cervix is fully dilated. There is a part that happens from full dilation. There's a gap between when you're actually ready and when it's actually time to push out your baby, the active pushing part of your birth.
[5:47] And this is where I will mention that in order to determine when is the appropriate or right time to start pushing I'm using inverted commas right time to start pushing, once you've been diagnosed as fully dilated this does not indicate the time of which you are ready to push what this paper noted is that in the US in particular and some other, countries where birth is more medicalized and rushed.
[6:14] That clinicians will do a vaginal examination on a woman who's in labour. They'll say, well, you are fully dilated. Now it's time to start pushing out your baby. What this paper said that in France, which is the location where they did this research paper, and in this particular hospital that they did the research in, in this particular hospital, the policy is not full dilation and then immediately start pushing. In this hospital, they value and extend the passive part of the second stage of labor. And what that means is that once the woman is determined to be fully dilated, something I will talk to you about because obviously I'm a home birth midwife, and I very rarely do any kind of vaginal assessments to determine when a woman's fully dilated because women just feel the urge and push their babies out usually without needing to know what their cervix is doing.
[7:08] However, in hospitals, what will often happen is routine vaginal examinations. Once you're fully dilated, you are classified as being in the second stage of labor, in the final stages of labor, where your cervix is fully dilated. And then there's a few options. What this paper is saying is some hospitals will have an immediate pushing policy and then allow up to two to three hours for women to actually actively push before considering intervening in that process. However, in this French hospital, what they do is fully dilated, but then they wait up to three hours is their policy. Three hours of no active pushing, not encouraging the woman to actively push unless, of course, she has an urge, in which case you just go with your urges.
[7:56] But they allow for and value and extend the time of what we call the passive phase of the second stage of labor. And during this passive moment where previously your uterus would have been interested in dilating your cervix and bringing your cervix up into your uterus, in the second stage of labor, in the passive phase, but also in the pushing and active phase, your uterus is actually pushing your baby down. That's the next part of labor and birth. Is firstly your cervix opens, then your baby gets moved down and pushed down into your pelvis to get ready to be born. So during this passive phase, this delayed passive phase in this French hospital where they allow a lot of time, what they're actually allowing for is what we call passive descent, where the baby is moving down into the woman's pelvis and pushing only begins once the baby, is determined to be quite low in the woman's cervix. And in this circumstance, the baby will either be in a low down position and will trigger your natural urges to push. Or in this French hospital, if you've gotten up to three hours, then wherever your baby's up to, they'll encourage the women to actively push their baby out. And they'll usually coach them. In this study, they described coaching the women to push their babies out.
[9:19] Now, this coached pushing, we already know that coached pushing does usually extend the time it takes for a woman to have her baby. But I'll explain in this study, and this was one reason I really was reluctant to share it, but 82% of the women in this study actually had epidurals. And that explains a little bit of why women in this study were coached to push out their babies and also why there seemed to be a lot of assessment of full dilation and assessment of how far the baby had descended into the woman's pelvis, and then instruction given on when to push their baby out. They even described how many pushes they would have the woman do through each contraction as a way of coaching them to push out their baby's.
[10:10] Now, when you have an epidural, firstly, the idea of an epidural is that you wouldn't feel the sensations of labor. And that includes when you have a contraction. It also includes the urges to push out your baby. And so when you have an epidural, you are really relying on the people around you, your care providers, to give you information about what your body is doing because you can't feel what your body is doing anymore. You're relying on clinicians using vaginal examinations to tell you the position of your baby, using their hands and their eyes to tell you when it's time to push and how to push because you can't use the natural urges. And so although that's not the strategy that I would use with my clients, that's because the majority of my clients are giving birth at home. They have a full understanding of what their body is doing because they can feel it. They know when their baby comes low and they feel an urge to push their baby out. So of course, there's going to be a lot less need for me to ever coach any of my clients on how to push unless we're in some other clinical circumstance. But in a normal physiological circumstance, there's very little reason for me to coach my clients on how to push out their baby. However, in this facility, 82% of women had an epidural.
[11:31] And the reason why this paper is quite alarming, not only is that a very high epidural rate, but even with epidurals, they, using this technique of a delayed pushing phase and extending out the passive part of the second stage and allowing the baby to move deep down in the woman's pelvis before giving any instruction on when to push, even with epidurals and coach pushing, and what we'll learn later, 98% of the women were lying on their backs. Even under those circumstances, which is all of the things that we talk to women about that will make it harder for them to push out their baby, even under these circumstances, with a passive and delayed active stage and no pushing until the baby is well deep down in the pelvis.
[12:21] They were able to get an average pushing time, the duration, around eight minutes. That's average. When none of the women pushed for longer than 15 minutes and their babies came out. Despite 82% having epidurals, 98% laying on the bed, the majority of them receiving coaching in order to push their baby out. And as I will show you later as well, they used a hands-on technique for the birth. So quite a heavily managed second stage. And part of my reluctance to share this is that I feel clinicians might say, well, see, women need instruction. They need hands-on. They should be on the bed. And if you do all these things, you're going to get a good outcome.
[13:12] However, I think that's one way of interpreting it. Yes. The way that I'd prefer to interpret it with my own personal bias and my own rose-coloured glasses, is that even under these circumstances, these outcomes, this outcome of a short pushing phase could be achieved. But what they did actually find, and they did break out the women who had epidurals versus those who didn't, the women who didn't have epidurals had even shorter pushing phases. So this represents the The possible, I don't want to say worst case scenario because it's really good, but the longest, the women who had the longest pushing phases had both epidurals and inductions seemed to be the longest pushing phases. And the shorter ones were the ones who didn't have epidurals and the one who's had babies before.
[14:03] So what this shows is that either way, you can shorten the pushing phase by allowing an extended period of time up to three hours of encouraging a woman to push after they've, been diagnosed as being fully dilated. Now, this does not apply. If you have not had a vaginal examination and you start getting an urge to push, this is a completely different circumstance than what was researched here in this research paper. So when you look at research papers, they are only specifically studying one small thing. So we can't conclude everything from this research paper. We can only conclude one small thing.
[14:49] And that is, is if you delay pushing and allow for passive descent, this will reduce the active pushing needed in order to push your baby out. You'll be actually actively pushing for less time, even in a scenario of having had an epidural or an induction and if lying on your back. And the authors talk about the motivation for this study was that they were trying to present an alternative way of managing. And this is, this is a managed second stage. This is not a physiological second stage. This is a managed second stage. What they were trying to have a look at is if we didn't heavy-handedly manage the second stage with vaginal examination and then immediate pushing, what would happen if we just did delayed pushing, allow for passive descent, which is the normal physiological way a baby would come out and women would usually only get an urge to push once the baby has adequately descended into their pelvis. That's one of the triggers for pushing is descent.
[15:58] What they were saying is maybe if we allow the physiological descent of the baby to occur, maybe we could shorten pushing phases. Because one of the real issues with doing a vaginal examination and then saying to a woman, hey, it's time to push now. You're fully dilated. We're all done. Is it forget the fact that being fully dilated is one thing that needs to happen in order for you to push out your baby. But it's the first thing. It's not the last thing. It's the first thing. Then you have to wait for the baby to move down into the woman's pelvis. Also you wait for the baby to move down into the woman's pelvis in the ideal position and sometimes this might need to be corrected and sometimes some strategies need to be applied in order to help the baby move down in the position that's going to be most ideal for the woman to push out her baby. What this research paper also discovered is that babies who came down backwards in a posterior position instead of an anterior position took longer to push out. We know that as well because when babies come down facing upwards to their mother's pubic hair instead of backwards to their mother's bottom, that's called a posterior position and those babies are harder to push out because a bigger part of the baby's head is coming through the pelvis.
[17:10] They did discover that in this research project as well. But what they were seeing is if we delayed that, if we didn't hurry women along in this pushing phase, would this be a detriment to the baby would it be a detriment to the mother or could there be some benefits and what they actually found is that by allowing the passive descent and extending the passive part of the second stage, they shortened the active part of the second stage to no longer than 15 minutes, and they did it to good effect, they found that 99 of these babies had an APGAR score, which is kind of like a wellness score for the baby, above seven.
[17:53] I became really interested in this study because I've recently put together, a free three-part series of videos. They're all about pushing out your baby, this second stage of labor, and how to push your baby out without panic. And there was a specific part about how to know when is the time to push out your baby. And I talk about this idea of passive descent and how when your cervix is open, that's phase one of being ready to push out your baby but it's not the end of knowing that it's time. You know it's time to push out your baby when your baby's moved low enough in your pelvis that it triggers an urge to push and then you get an urge to push and then it's completely fine to go with those urges. However in this research study where 82% of the women had epidurals you can't rely on those urges so then how do you know when it's time to push, and in the three-part video series I show you exactly what it looks like to be pushing a baby out then your baby is fully descended into your pelvis, and I explain this concept of physiological pushing when you go with your urges, or this concept of coached pushing which is what they used in this study, so I'll explain in this particular study, they don't use physiological pushing as a general rule.
[19:20] And part of that is owing to the fact that 82% of the women had epidurals. And when you have an epidural, you need to rely on external coaching. However, when you've got physiological pushing, you can rely on your urges. When you get an urge, you know the baby has descended. And what we know from research is that your pushing phase is shorter when you go with your own physiological urges than if you go with coached pushing. But that's often because coached pushing is done soon after discovering you're fully dilated, whereas with a physiological birth, you wouldn't get an urge until the baby's adequately descended into your pelvis where there's been this passive descent already occurred. So, of course, it makes complete sense that your pushing phase would be shorter. So what these researchers have done is mimicked the passive descent that would normally happen in a physiological birth. And then at the end, once the descent has happened, they still do coach pushing. But what they found is that passive descent is enough to protect women from, extended pushing because all that work's been done with the babies moved right, right down, that the woman.
[20:34] Push and force her baby into her pelvis the her body has been able to do that, and so the routine policy in this hospital is to diagnose when the women are feeling fully dilated, wait up to three hours and then encourage coach pushing, and this article explains that the American College of Obstetrics and Gynecology recommends that allowing at least up to two to three hours of pushing for women who've had their first or second baby is usually what occurs.
[21:05] Okay, so I feel like I've had a little bit of a ramble here and I want to give you an executive summary of this study. So French hospital, 10,500 women. It's called active second stage duration under 15 minutes in spontaneous vaginal deliveries and delayed pushing. And in this particular hospital, They had a practice of firstly diagnosing that every woman was fully dilated. Obviously, that's not always the case for every single birth out there in the wild, but in this hospital, that's how they did it. Their data collection system in this hospital allowed them to timestamp when a woman was fully dilated. And because they had a delayed pushing policy, that meant that women were allowed, in inverted commas.
[21:55] Passive descent for up to three hours. They also had a timestamp ability in their notes to document when the active pushing phase started. And what this means is they had a clear data set that was embedded into the culture of their hospital facility, that they did routine vaginal examinations, that they routinely allowed for a delayed passive phase up to three hours. that was part of their policy. They clearly marked the time in which the woman started pushing because their usual practice is to help the woman to coach push instead of waiting for the physiological urge. There was obviously a percentage of women who did get the physiological urge and would use that. However, in a cohort with 82% having epidurals, that's only 18% of women who have the possibility of having a physiological urge.
[22:49] So under this circumstance and also where 98% of the women were giving birth on their back and the clinicians used a hands-on technique, not only do we have a standardised way here, but it does allow for a helpful data set to retrospectively look back on considering that the policy and practices appeared to be fairly uniform in this particular research paper. And their data collection set had clear timestamps and clearly delineated the distance and time between dilation and active pushing. So in this facility where they had a policy to delay up to three hours and then active pushing, what they found is that the maximum pushing time for women was around 15 minutes, regardless of their circumstance. If they had an epidural, induction, first baby, second baby, this was the max. The average was around eight minutes. And the women who had the fastest pushing phase were women who had babies before and who didn't have an epidural. The women who had the longest pushing phases were having their first babies, they were having an epidural, an induction, or their baby was in a posterior position. But still, 15 minutes was the maximum.
[24:15] What they also wanted to know in this study is, does this delay in pushing from fully dilated, does allowing passive descent have any impact upon the well-being of the baby? And what they found was is 99% of the babies had an APGAR score, so a well-being score of over 7, which is a good one, had an APGAR score of over 7 at birth. And another unique thing that they found in this study was a significant reduction in the perineal tear rates. So in this study, 0.1% of women, 13 of the women, of the 10,500 women had an episiotomy. And to put that into context, here in Australia, about 25% of women have an episiotomy. And here only 0.03%. Had a fourth degree tear, so three women, and 35 women, which represented 0.3%, had a third degree tear. And 25% of the women had a first and second degree tear.
[25:25] This allowed for 47.5% of women had no perineal trauma, no labial tears, no anything, zero perineal damage, which is quite exceptional considering that there was a lot going against these women in terms of increasing their risk of perineal tears. They were lying on their back. The majority had epidurals. It was a hands-on technique, which we know doesn't really change perineal outcomes that much, but the episiotomy rate was low. Another thing to note in this study, and this is important because you'd be asking me, well, Mel, how come none of the women had vacuum or forceps? Well, that's because they had enrolled around 14,400 women into this study. And the ones who required a pre-labor, in-labor cesarean section were excluded. But that total rate in this particular hospital was less than 10% of women actually had a pre-labor or in-labor cesarean section. It's exceptional. I don't know what you're doing in France, but that is an exceptional cesarean section rate. And around 15% of women that were enrolled in the study of the 14,000 ended up having vacuum or forceps birth because there was a complication in that second stage of labour. However, of the 14,400 women.
[26:50] 10,500 women were enrolled in this study. So if you are one of the women who has gone on to not require a vacuum or forceps birth.
[27:04] What they're saying is if you apply this type of technique of delayed pushing and allowing this passive descent, then you may expect these kinds of outcomes. A caution around the outcomes, because obviously this is women with epidurals, However, what we know from this study is that the women who didn't have epidurals, had the shortest pushing phases. So this is kind of represents to me, and I don't want to say worst case scenario, but it's the worst case scenario with passive descent, in a sense that even with an epidural and an induction, you can reduce your pushing phase, but even more so if you don't have any of those things.
[27:45] Now, this is one of the research papers that I used to create my three-part free pushing series. And it specifically makes reference to this passive descent. And one of the questions that women ask me all the time is, oh my gosh, how will I know when it's time to push? And the answer is, is that it's not once you're fully dilated. The answer is, once you start to feel the urge, that's the simplistic answer. Once you start to feel the urge, you can feel certain that your body is most likely to be ready to push out your baby. And this is what this paper acknowledges, that being fully dilated is not the time to start pushing. It's being fully dilated and your baby having descended into your pelvis low enough to trigger an urge. The next question is, what if I have an epidural and I don't have an urge? Well, here is when you start to rely on your care providers to let you know if your baby has moved far enough down and also allow enough time for what we call passive descent. In the three-part video series and in the further course that I offer you if you want to go all the way, I do talk about how to optimize the descent of your baby during an epidural and the position.
[29:00] So that your baby doesn't end up in a posterior position because this research study also acknowledged that the babies who were born posterior had a longer pushing phase. The babies who came out the other way, the anterior way where they're looking down at their mother's bottom was the more efficient way of pushing out your baby.
[29:17] But this passive descent is the important part here. And passive descent is part of the physiological process of pushing out your baby. It's not just your fully dilated, start pushing, go, and push, push, push, push, push, and coach pushing. This creates an extended pushing journey. It increases the risk of damage to your perineum and your pelvic floor, long-term because it's a prolonged and unnatural amount of pressure that's put on when you push like this for two to three hours. Allowing for passive descent reduces the active pushing, reduces the chances of damage to your perineum and your pelvic floor. But also, as we've learned, it does also improve the condition of your baby. The less time you spend pushing, there's more chance that your baby will come out well compared to babies who've been exposed to that valsalva, that kind of really strong pushing. We know that this deoxygenates babies faster than with physiological pushing.
[30:18] And these are all the types of little caveats and avenues that we go down in the Guide to Pushing Out Your Baby and in the free three-part series if you want to give that a go. You can have a look in the link in the show notes and you'll get access to those things. But this is just a snippet of the research that I've used to create that three-part Pushing Out Your Baby series, the Push Without Panic series, so that you know exactly what to expect when it's time to start pushing. There is research behind these strategies. There is a really strong argument for allowing for passive descent before starting either coached or physiological pushing but you can feel more certain that when you feel the urge that your baby has already descended and it's safe to start pushing out your baby, this is just a little snippet of what it means to push out your baby a little bit of a snippet into some of the research that supports it and i do hope that you access the the three part free series on pushing out your baby The link is in the show notes below. And of course, as always, if you want to read this paper in full, it's in the resource folder. If you're on the mailing list for this podcast, you have full access to the resource folder. You can read this paper in full and make your own conclusions. You don't have to take my word for it. That has been today's episode of the Great Birth Rebellion podcast, and I will see you in the next episode.
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