Effective Pushing Techniques for Labor
When your cervix has completely effaced and dilated, you can actively help the uterus move the baby down the birth canal by bearing down or pushing with the contractions. Most women feel a strong desire to push, but a few do not. If you do not immediately feel an urge to push, just continue to breathe through the contractions. In addition, assume an upright position to help the baby descent into the pelvis. His head may not be deep enough to pres on the sensors that trigger the bearing-down reflex. It has been found that if a woman delays bearing down, she eventually does feel the urge to push. But if the woman starts pushing without having the urge, she may never feel it. Absence of the urge to push makes the pushing stage more difficult and less satisfying. If you do not feel the urge to push as the result of an epidural, request that the medication be turned down or off, and delay pushing until you feel the urge.
Use your body’s natural messages, and bear down or push only as your uterus directs. You may have a desire to bear down just mildly, or you may feel a need to push strongly. Many women are surprised that they make noise as they bear down. Use low moans or deep guttural sounds, rather than high-pitched screams or squeals. Low tones encourage a relaxed pelvic floor. Also, during the contractions, try not to completely release the bearing-down effort between breaths. If you can continue to apply some pressure as you get the next breath, you will help to hold the position of the baby and make better progress.
You should also assume the position for pushing that you prefer, not necessarily the one that you practiced in childbirth class or observed in childbirth films. You may find side-lying, squatting, standing, kneeling with you upper body elevated, or kneeling on all fours to be the most comfortable for you and the one most advantageous to your baby’s descent. In any pushing position, tuck your chin down onto your chest to curve your body into a C position. This curves the lower back and aids the descent of the baby under the pubic bone. Avoid the temptation to throw your head back, which would cause an unnatural arch in your back. Your partner can remind you to “look for the baby”.
While natural or gentle pushing may not produce results as quickly as forceful breath holding does, no evidence exists that a longer second stage is harmful to a baby who is not in distress. In fact, babies may benefit from experiencing a slower, more gentle birth, instead of a forceful surge down the birth canal.
Breathing Patterns for Pushing
There are two primary breathing patters for pushing that women use to move the baby down the birth canal. The first pattern is more natural and incorporates an exhalation during the strong physical work of pushing. Exhaling during a strenuous action is a technique used by athletes to prevent injury. For many women, this first pattern is sufficient. Other women need to push more forcefully to make any progress. The second pattern, which incorporates breath holding, limits the time the breath is held. Long breath holding and forceful pushing, called the Valsalva maneuver, is not recommended, since it can cause your blood pressure to drop and thus decrease the amount of oxygen your baby receives.
Gentle pushing is the preferred method of helping the baby down the birth canal. As the contraction begins, take relaxing breaths until you feel the urge to push.
Then inhale deeply to expand your lungs, tuck your chin onto your chest, purse your lips, and exhale slowly and steadily as you bear down using your diaphragm. When you need to take another breath, lift your head, inhale slowly while continuing to maintain some pressure against the uterus, tuck your chin, and exhale through your mouth as you bear down. Repeat this pattern until the contraction ends. When the contraction is over, take several relaxing breaths and try to completely relax your body until the next contraction begins. (See Figure 5.6).
Breath Holding While Pushing
Pushing while holding your breath, also known as the modified Valsalva maneuver, is used by women who need to apply more force to help their baby in the trip down the birth canal. As the contraction begins, take relaxing breaths until you feel the urge to push. Then inhale deeply, let a little air out, tuck your chin, hold your breath, and bear down using your diaphragm. Directing the air downward, rather than holding the air in your cheeks, reduces the tension in your face and neck, and lessens your chance of breaking small blood vessels in your face and in the whites of your eyes.
While you hold your breath and push, your partner should count slowly to 6 to pace your effort. When he reaches 6, ease the breath out slowly to maintain abdominal pressure and to keep your diaphragm down on top of the uterus. Straighten your neck and inhale again, let a little air out, hold, tuck your chin, and push while your partner counts. Repeat the pattern as many times as needed during the contraction. When the contraction ends, gradually stop pushing as you exhale slowly. Take 1 or 2 relaxing breaths and relax completely. (See Figure 5.7).
The positions that you use during pushing effort will be determined largely by your comfort and your caregiver’s preferences. The choices include semireclining, squatting, side-lying, kneeling, and the lithotomy position. Most nurses and doctors encourage the semireclining position, but you may not find it the most comfortable. Many hospitals now offer birthing rooms, eliminating the need to be transferred to a separate delivery room with a conventional delivery table. Birthing rooms contain birthing beds that can be adjusted to your comfort and also transformed into a delivery table, complete with stirrups. Discuss all of the possible pushing positions with your caregiver to learn what he prefers and to let him know what you would like. Then practice pushing in all of the positions, so that you can use what feels best to you when you are in labor.
Semireclining position is the most common position used in the birthing room. It is a comfortable position for the woman and provides a good visual field for the caregiver. If you have back labor, this position is not recommended, as it places the weight of the baby onto your back and increases your discomfort. The head of the birthing bed can be elevated 70 degrees, and you can place your feet on the bed or in the footrests. Or, the bottom third of the birthing bed can be lowered 6 to 12 inches as a footrest.
To practice pushing in the semireclined position, have your partner sit behind you as your back support. Place pillows between his legs and your back. Lie against your partner at a 70-degree angle, being sure to sit on the small of your back, not on your rectum. Bend your knees, spread your legs, and place your feet flat on the floor or bed. Rest your hands on his knees or your inner thighs to keep your legs and perineum relaxed. If you need to hold something while pushing, grasp your inner thighs and draw them toward you. Then begin your selected breathing pattern, tuck your chin onto your chest, and push. When the contraction is over, lie back and relax.
Squatting is physiologically the best position to use while pushing. You can support yourself in a squat by keeping your feet flat on the floor and holding onto a bed rail or your partner. Many birthing beds come equipped with a squat bar to hold onto for support. A comfortable squat can be accomplished by having your partner sit on a chair, with you squatting between his legs, your arms draped over his thighs. Squat only during the contraction, and either stand up or kneel during the rest period. During a long labor, it may be necessary for your partner to assist you out of the squat. As with other patterns, tuck your chin onto your chest as you bear down. Women delivering in birth centers are often encouraged to sit on a toilet to achieve the squat position. A birthing stool or birthing chair can also help you push in this position.
Squatting is an ideal pushing position because it allows gravity to assist the uterus, which makes the contractions more efficient, longer, and more frequent. The pelvic outlet is at its widest, the birth canal is shortened, and episiotomies are needed less frequently. Delivery time is shortened because pushing is more effective. Do not get into the position before the baby’s presenting part is engaged because the descent and engagement could be hampered. In case of complications, squatting may present some manual and visual inconveniences for the caregiver. It may become necessary to assume a different position.
Also called the lateral Sim’s position, side-lying is very comfortable for most women, especially those having a back labor or leg cramps. It can aid rotation of the head if the baby is not yet in a facedown position, and it can help in a breech delivery as well.
When you lie on your side, your uterus does not press on your vena cava (large blood vessel). Your chances for supine hypotension (low blood pressure) are therefore decreased. The perineum is relaxed, so episiotomies are needed less often and tears are less likely to occur. However, side-lying does not utilize the force of gravity as well as squatting does, and your view of the birth is not as good. If a difficult forceps delivery or repair of lacerations is necessary, this position is not recommended.
To get into the side-lying position, lie on your side with one or more pillows supporting your head. Try to lie on your left side because this improves blood flow to the uterus. When you are ready to push, curve your upper body into a C shape by tucking your chin onto your chest. Have your partner support your upper leg with his arms or hands, or place the leg on the lowest bed rail, which you can pad with pillows. Then begin your selected breathing pattern and push. When the contraction is over, relax, lowering your leg onto the bed, supported by pillows.
The kneeling position is preferred by some women. Physiologically, it is a good position for pushing because it takes advantage o the force of gravity. It may be especially helpful if your baby is slow in coming down the birth canal or if you are having back labor. As you push, tuck your chin onto your chest to improve the angle of your pelvis.
To push in the kneeling position, kneel on the bed facing your partner. Put your arms around your partner’s shoulders for support, begin your selected breathing pattern, tuck your chin, an dpush. When the contraction is over, relax.
Other kneeling positions include leaning forward against the raised head of the birthing bed or pillows. You may want to try placing one knee and the sole of the other foot on the bed and lunging with each contraction. If out of bed, kneel on the floor and support your upper body on pillows placed on the seat of a chair. A variation of the kneeling position is to kneel on your hands and knees. On all fours, you can do the pelvic rock exercise if you are experiencing back pain. Women whose babies are in a posterior position often find that this position eases discomfort.
You may be encouraged to give birth in the lithotomy position, lying flat on your back with your feet up in stirrups. While this position has advantages for the doctor—such as allowing him to observe your abdomen and perineum, check the fetal heart rate, apply forceps or the vacuum extractor if necessary, and manage postpartum hemorrhage—It has definite disadvantages for you.
Pushing in the lithotomy position reduces your pelvic outlet to its smallest diameter. In addition, your contractions may become more irregular and less frequent. With your legs in stirrups, the strength of your contractions might actually lift your hips off the table, resulting in your having to push the baby uphill and against gravity. Episiotomies are done more frequently to women using this position because of the narrowed vaginal opening as well as the perineum being stretched taut. The weight of the uterus on your vena cava may lower your blood pressure and thereby decrease the amount of oxygen reaching your baby. In an experiment using a device that continuously monitors fetal oxygenation, a pregnant woman was made to roll onto her back. Withing 2 minutes, the fetal oxygen level was in the danger range. The woman was immediately rolled back onto her side and given oxygen, but it took 8 minutes for the fetal oxygen level to return to a safe range. Finally, the lithotomy position might strain your back because your feet will be also so widely separated in the stirrups.
If you do deliver in the lithotomy position, make sure that the stirrups are adjusted for your comfort and not strapped on too tight.
To simulate the lithotomy position during practice sessions, lie on the floor on your back and place your legs on the seat of a chair or sofa. When you are ready to push, have your partner raise your back to a 70-degree angle, tuck your chin onto your chest, begin your selected breathing pattern, and push. When the contraction is over, lie back and relax.
Once you feel comfortable with the breathing patterns for pushing, practice them in the various pushing positions. To push, slowly exhale or hold your breath, and bear down by doing the following:
- Take 2 relaxing breaths, take a deep breath to expand your lungs, and start bearing down using your diaphragm.
- Tuck your chin onto your chest and “look for the baby”.
- Bulge your lower abdominal muscles down and forward.
- Totally relax your pelvic floor by doing basement Kegels. Your perineum should feel as if it is bulging out.
- Keep your diaphragm down on your uterus between breaths by inhaling slowly.
- Try to push three or four times during each practice contraction.
- Slowly lessen your pushing effort as the contraction comes to an end. This will help to maintain the baby’s position in the birth canal, preventing his moving back up.
When you practice pushing, do not push forcefully, just enough to get the proper feeling. You may find it helpful to think of pushing as being like forcefully emptying your bladder. Also, visualize your baby coming down lower and lower as you push, and consciously relax your legs and bottom. A tight perineum can cause a longer, more difficult birth and almost certainly ensure having an episiotomy.
During actual labor, your first pushes will move your baby gradually down the birth canal. Your partner may even see a little of the baby’s hair showing as you push. But the hair will disappear as the baby moves back up at the end of the contraction. When the top of the baby’s head stays in view between contractions, it is called crowning. Your caregiver may ask you to stop pushing. Pant or blow out at this time to keep from pushing. This will allow your baby’s head to gradually stretch the birth outlet and perineum, resulting in a more controlled delivery of the baby’s head and hopefully reducing the need for an episiotomy.