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Second Stage Labor: You Don't Have To Push

By Nancy Tatje-Broussard

Some months later, I shared my birth story with an older friend, and she shared hers with me. Hers was a medicated, flat-on-your-back birth, which had occurred 20 years earlier. Typical of the times, she had labored in a wardstyle hospital room with curtains separating the birthing women from the nurses on duty to supervise. The anesthesia she was given had rendered her unconscious through most of her labor, but she woke up in time to see her daughter's head emerging. At this point, she called out quickly to the nurses who were playing cards at a nearby table.

This story rekindled a vague sense of personal discomfort about the way I had given birth --- not to mention considerable consternation regarding my friend's experience. I had had no medication, no enema, no shaving, no intravenous lines, no fetal monitoring hookups, no episiotomy, complete freedom of movement, the luxury to choose a helpful birth position, and the company of loving and supportive family members and professionals. Why then, having been fortunate enough to labor under such favorable conditions, was I expected to work so hard at expulsion? Why all the breathholding and effortful straining to push?

The birth story of another friend heightened my concern. Her son had been born nine weeks premature despite all efforts to *stop* the progress of labor. Hearing this, I wondered, why wasn't my body allowed to do what it "knew" how to do and was already in the process of doing?

The answers emerged with my second pregnancy. What a relief it was to hear a midwife say, "You know, you don't *have* to push." The literature I had read and the childbirth educators with whom I had spoken never referred to such a concept. So I studied the research, asked a lot of questions, and prepared for a different birth experience. What follows is the fruit of *that* labor.

The "pushing" approach to the second stage of labor was popularized in the 1920s. The belief was that the second stage must proceed as quickly as possible or be eliminated entirely because it could be dangerous, "disease producing, pathologic, or abnormal" for both mother and baby. The widespread use of episiotomy, forceps, and general anesthesia was thus promoted to prevent insufficient oxygen transport to the baby, fetal brain damage, and asphyxiation. Prolonged breathholding and straining were also encouraged to speed up the baby's passage through the birth canal. At one time, mothers were even encouraged to begin pushing at the *onset* of labor.

By the mid-1950s, the importance of relaxation had entered the picture. However, efforts focused primarily on the first stage of labor. In 1957, a British obstetrician wrote: "We have achieved an atmosphere of tranquility with relaxation of tension by various means. But this atmosphere is still confined to the first stage; the management of the second stage has changed little; the prevailing note is still one of hard work and making haste."

Then, in the 1970s, the approach to birth in general, and second stage in particular, began to change. The trend toward out-of-hospital birth and minimal intervention in the birth process enabled childbearing women, birth attendants, and researchers to follow the course of unimpeded labor. In the early 1980s, scientific evidence was at hand: statistics showed that the duration of the second stage was *not* an indicator of newborn health and that slower fetal heartrates during the second stage did *not* correlate with poorer outcomes for the baby.

Nevertheless, many childbirth professionals, birthing manuals, and education classes continued to train women in special breathing and pushing techniques - while at the same time, acknowledging that the second stage need not be rushed and may safely last several hours. As a result, breathing recommendations currently range from breathholding for as long as possible for no more than 5 or 10 seconds to exhaling -- all accompanied by orchestrated pushing efforts.

In addition, pushing recommendations range from pushing during contractions as soon as full dilation has occurred, whether or not there is an urge to push, to pushing as soon as there is an urge to push, to pushing effortfully only when the urge is strong, to waiting until the urge is overwhelming before adding deliberate pushing efforts to the body's spontaneous ones. "Pushing with contraction" instructions also vary -- from pushing no more than 10 seconds at a time until the contraction is over, to pushing as long as possible and as often as necessary until the contraction stops, to waiting until the contraction peaks and then pushing effortfully until it stops.

These techniques -- all vestiges of the speed-up-the-hard-work approach to second stage -- have been associated with several problems. First, many women who are instructed to push have trouble synchronizing their bearing-down efforts with their natural body rhythms. Some women, finding it difficult to identify the "urge to push," begin bearing down prior to full dilation of the cervix -- a time in which pushing can be counterproductive. Second, bearing-down efforts accompanied by breathholding correlate with a lingering drop in fetal heart rates and a concomitant reduction in both the fetal oxygen supply and the alkalinity of fetal blood. Forceful pushing is also related to perineal trauma, fetal trauma, and other injuries. At least one mother has broken her tailbone while straining forcefully to push her baby out.

In response to these findings, some members of the birthing community now advocate a "nonpushing" approach to the second stage of labor. They emphasize the need to trust in the natural expulsive process, and they offer childbearing women a number of alternatives to the well intentioned but misguided recipes for breathing and pushing.

THE PHYSIOLOGIC APPROACH

In the physiologic approach to second stage, the mother is encouraged to relax, to allow for spontaneous alterations in her breathing, and to trust in her body's involuntary response to contractions. Labor support people are discouraged from using the word *push* or even thinking in these terms. Conscious pushing efforts are not taboo but are allowed to occur spontaneously, rather than according to some pre-determined formula.

The following description indicates how sufficient the natural bodily processes are to move the baby through the birth canal and out into the world: "The contraction is clearly felt, and superimposed on the contraction in an additional sudden increase in tonus (the surge) felt as an extra tightening, almost a knotting of the uterus, which lasts five to seven seconds. It then recedes for a few seconds, to reappear several times during a contraction...Each surge is thus accompanied by an involuntary bearing-down effort by the mother...If a mother is encouraged to behave spontaneously ...she breathes during the contractions, except during these surges when she bears down, *either with breathholding or with exhalation* (grunting, yelling, or straining sounds). [Italics mine.] The presenting part advances during the surges and retreats between, until the crowning in late second stage at which time it stops slipping back between bearing-down efforts."

Although the physiologic approach can result in a longer second stage, neither newborn nor maternal health is compromised. In fact, clinical and biochemical outcomes are consistently superior to those achieved with pushing and straining efforts. Moreover, *clinical trials have shown that the second stage is not "unusually" lengthened when it conducted in an entirely instinctive manner*.

This approach provides several physiological advantages for both mother and baby. In one study, forceps rates were reduced by about 50 percent, and the need for sutures, either for episiotomy or tear repair, was reduced by about 25 percent. The clinician concluded that *the decrease in perineal trauma and tearing was a direct result of the slower stretching of muscles and connective tissue*. Another study found the slow stretching and relaxing of pelvic floor muscles responsible for reducing the amount of fetal skull compression. This researcher noted that the second stage of labor, far from being dangerous to the fetus, is a phase in which fetal energy reserves are set in motion and hormones are secreted to assist the fetus in adapting to the environment outside the womb.

The labor support measures that assist in the physiologic process are gentle, effective, and wide-ranging. Before labor, the expectant mother and her partner should be introduced to the physical and emotional aspects of second stage. During labor, the mother should be encouraged to breathe spontaneously while keeping her mouth open, relaxing her jaw and throat, and making as much noise as she likes. Perineal massage, hot compresses to the perineum, and having the mother see or touch her baby's head are also helpful -- and effective in preventing episiotomy.

If the urge to push arises, the laboring woman may be advised to bear down gently whenever the urge becomes irresistible. She should also be cautioned to avoid cutting off the flow of breath, as an open glottis is associated with opening in the pelvic and vaginal areas. Bearing-down efforts are recommended only after full cervical dilation and for no longer than 6 seconds at a time. If minor complications arise, it is a good idea to offer relaxation techniques and suggest shifting to a more favorable position for birth. Many women find that the squatting or hands-and-knees position eases the baby's passage and also prevents the use of forceps and other interventions.

PERSONAL EXPERIENCE

When it came time to birth my second child, I was ready to put this information to work. I started off with a new outlook: rather than "OK, it's time to put my nose to the grindstone and push real hard," I thought, "I just need to relax, breathe as easily as possible, and trust that my body can do it." This time, second stage was much easier. It occupied about 30 minutes of a three-hour-long labor, and it was a relief not to strain and not to hold my breath for prolonged periods of time. Able to just let myself "be" in the process in stead of feeling I had to "do" something about it, I also felt more energetic after the birth.

Without having to focus on a prescribed task during this phase, I was acutely aware of a full range of bodily sensations. I used relaxation techniques to slow down my breathing when hyperventilating and to relieve the muscular tension in my legs, mouth, and jaw. My doctor administered perineal massage -- having read up on the topic, at my request, prior to the birth. I added deliberate pushing efforts only twice before my daughter's head emerged; but even during these final two contractions, I did not feel that pushing was absolutely necessary. Nor did I have any tearing. (The birth of my son, who was about the same size as my daughter, resulted in a first-degree tear.)

The lack of tearing and suturing is typical of a physiologic approach. A midwife in my area, who gave birth in this manner to a 9 pound, 12 ounce daughter, has observed a significantly reduced tear rate in her practice: from 50 percent with pushing to about 15 percent without pushing. *One first-time mother she assisted gave birth to an 11 pound, 4 ounce baby with no tearing and no pushing*.

The way I give birth has a profound and lasting impact on the way I live my life. With my first birth, I experienced the amazing force of my body. This power has remained with me ever since. In fact, it was this "whole body" knowledge of inner strength that propelled my search for a new approach to labor.

Giving birth a second time, without pushing or rushing the process, I learned not only to relax and open up but also to wait for, recognize, and seize the spaces that open up in my life. Whereas after my first birth I was unable to find the time to write, now -- in spite of mothering an infant and a two year old who rarely nap at the same time -- I am able to find writing time. I also have greater faith in myself...and confidence that there will be openings, space, and energy to give birth to many dreams.

The birth process need not be a pushing affair. It can be a gentle unfolding in harmony with the natural rhythms of life.