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To Push or Not to Push.

After reading Episiotomy and the Second Stage of Labor, edited by Sheila Kitzinger and, for North America, Penny Simkin, I have written this article to distribute in my Childbirth Classes to give much needed information to birthing women.

Many women ask during my childbirth classes, "How will I know when and how to push?" I smile, and say, "You'll know." Then I explain what I believe to be the process of pushing their babies out.

During pregnancy, your uterus gets as big as it needs to get to accommodate the size of the baby. Immediately after your baby is born it shrinks an incredible amount. With each contraction that you have after the birth of your baby, your uterus will continue to shrink in size.

I believe that this also happens during the delivery process. When your cervix is 10 cm. dilated the baby slips out of the uterus a little. The cervix is no longer holding the head back and the baby begins its descent into the birth canal. When the baby's head begins to exit your uterus, there is extra room at the top of the uterus. It may take a few contractions for the uterus to shrink enough to be snug against the baby's body. It is with the next contraction after this has occurred that you most likely will feel the urge to push, because the uterus is now snug enough to start expelling the baby. This is generally when the uncontrollable urge to push will be present.

Because of this, I teach my students that just because it is announced that you are 10 cm. dilated doesn't mean you have to begin pushing with the very next contraction. I teach them to say, "If I feel like pushing, I will. If I don't feel the urge, I'll just keep doing my breathing or moaning."

With each urge to push that you actually do push with, the same process reoccurs. As the baby travels down the birth canal, the uterus needs a few contractions to become snug against the baby and then becomes more effective at pushing the baby down.

We now recognize that pushing during the First Stage of labor (dilation to 10 cm.) is not only ineffective but can also cause swelling of the cervix. We learned this and now no longer encourage women to push during this stage.

However, Second Stage (pushing your baby out) is still considered to be stressful to both the mother and the baby and is therefore typically hurried along so the process can be completed and the baby treated if necessary. Frequently moms are told to immediately start pushing and to push as many times as possible during each contraction, sometimes even having someone count to ten, telling the mom not to stop pushing until she/he reaches the count of ten. You would be surprised how long it can take someone to count to ten if she/he wants you to keep pushing.

For more information on the potential harmful effects to the baby from such bearing-down efforts read Chapter 4, "Influence of Maternal Bearing Down Efforts During Second Stage on Fetal Well-Being" by Roberto Caldeyro-Barcia, MD, in Episiotomy and the Second Stage of Labor.

Most women during labor and delivery do whatever they are told to do.

I think if women were to listen to their bodies' signals and only push when the urge is uncontrollable, this stage would be easier on both the mother and the baby. Not every contraction elicits the same urge to push. As stated in Episiotomy and the Second Stage of Labor, under the "Normal Second Stage" heading, there are three phases to the Second Stage of Labor: Latent, Active, and Transitional.

The Latent Phase is the calm before the storm. This occurs after the woman is completely dilated. The Transition contractions of the First Stage that were occurring every minute or so and were lasting a minute and a half or more, slow down and spread out. The body is amazing. It knows how to grow the baby. We don't have to sit down and think, today I will grow a hand or a foot. It miraculously happens. We also don't have to think about making our bodies go into labor. It does it on its own. We should also trust that this slow down or Latent Phase of the Second Stage is the body's natural response to the hard work of pushing our babies out. Our bodies work in such a way that this calm before the storm is needed, to rest and take a few breaths and prepare for actively pushing our babies out.

When this phase ends the mom enters the Active Phase (actively pushing) of the Second Stage. Again, not every contraction that you have elicits the same response to push. One contraction may be really strong and the mom may push on her own two or three times. The next contraction may not bring about any urge to push and she may be able to breath through the contraction instead of pushing. Again the body is working in such a way that after a long stressful contraction, it gives the uterus, baby, and mother time to recover with a milder contraction and no urge to push. The good, strong contraction and push may have moved the baby a little further out of the uterus and now the uterus needs to shrink to become snug around the baby. Then with the next contraction the uterus in conjunction with the mother's pushing efforts will help to deliver the baby.

We all know that contractions will move the baby down without the mother pushing. Granted it will take longer, but I don't necessarily believe that longer is a bad thing.

I teach my students that unless you are told that the baby is in distress or at risk, they should follow their bodies' signals and urges. This should make for a calmer (no one yelling push, push, push or counting), less stressful exhausting Second Stage.

Along with pushing your baby out a little at a time comes the decreased risk of tears or episiotomy. When you stop pushing because the urge has dissipated, as progress is made, gravity and the head being the heaviest part of the baby will help to keep the baby in place.

Eventually, as birth is imminent, the baby will continue to (almost) ooze out. When thinking about the perineum (the skin at the bottom of your vagina that goes down to the anus), pushing your baby out slowly, rather than with a great big push, may allow your skin to stretch and possibly not require an episiotomy. If a tear does occur, chances are it will be a small one since you are working and progressing slowly, not frantically. If you are pushing slowly, or not pushing as the head crowns, but are panting, you will most likely tear only as much is needed for the head to slip out. If you are pushing hard and fast the head will "pop" out and possibly tear the perineum more severely.

I also tell my students about the "sting" or "burn" sensation of the head crowning. In the past, I remember telling my Labor Assistant clients to push through the burn because with one great big push at this point the head will surely be born, which will remove the stinging, burning sensation. I now know that this "sensation" is a signal to your body that the skin is being stretched to the maximum. It is at this point in time that you should try panting. Not pushing at this time will hopefully allow your skin to stretch, and gravity will continue to work, and the baby will slowly emerge over the perineum.

I am a firm believer in the birthing process. Our bodies know how to birth our babies. If we were to be knocked unconscious during labor, our bodies would continue the work of labor and our babies would be born--albeit maybe slower than with our active participation. However, barring possible complications, it is possible that slow and natural is better than fast and fraught with all of the procedures and equipment used to speed up the process. I acknowledge the possibility of unforeseen complications and realize we must be flexible. However, I believe that more often than not our bodies will accomplish the task that it has set out to do with minimal intervention and complication.

We must believe we have the ability to grow, birth, and feed our babies.

--Information gathered from Episiotomy and the Second Stage of Labor, edited by Sheila Kitzinger and, for North America, Penny Simkin, Pennypress, 1984.

--Janice is an ALACE Certified Childbirth Educator and Labor Assistant who lives in New England.
COPYRIGHT 1999 Association of Labor Assistants & Childbirth Educators
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1999, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:during labor
Author:Mello, Janice S.
Publication:Special Delivery
Geographic Code:1USA
Date:Jun 22, 1999
Previous Article:Congratulations!
Next Article:Book Review: Birthing from Within.

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