How to Push & the Four Styles of Pushing in Labor

By: Aunt Doula (11/06/2022)

On the top of the list of questions that is usually frequently wondered about but rarely asked is "How do I push?" And this is a multifaceted answer, because pushing comes in 3, technically 4, main camps. Once you choose what camp you think you'll like, it will inform the breathing, rhythm, and guidance of helping your baby exit through the birth canal.

The 4 camps are Directed, Spontaneous, Delayed, and Not Pushing.

• Directed Pushing is often initiated by hospital staff during the second stage of labour. It is a common technique to encourage the laboring person to take a deep breath at the beginning of a contraction, hold it and bear down for 10 seconds and repeat throughout the contraction. It is important to note that while this is the "norm" directed pushing has no provable benefits and definite draw backs. Draw backs include increased tearing, increased maternal exhaustion, burst blood vessels of the face, frequent increases to fetal distress due to the way breath is held and it increases hemorrhoids and rectal pain in a significant portion of laboring people.

• Spontaneous pushing is a very free form style of pushing where laboring people are free to follow their own instincts and generally push three to five times per contraction as they feel appropriate. Spontaneous pushing is often described as being much more empowering and encourages a self directed body communication method that really allows the laboring person to connect with their body and work with it through contractions instead of against it.

• Delayed pushing involves empowering women to delay pushing until there is an irresistible urge to push or when the presenting part of the baby has descended to the perineum (external vaginal opening - i.e crowning) Delayed pushing is also very effective and an extremely valid choice as it reduces exhaustion overall in the pregnant person and reduces fetal distress through transition. It is another way to use trust in the body to know what it's doing and be working in concert with the delivery just like the billions of people birthing in the past.

• Not pushing! There are cultures that spend their labors not pushing with contractions. Gravity, their contractions and time are what they allow to bring their baby into the world. The United tates and Europe are the largest ‘pushing’ advocates of the world, and while not pushing is absolutely an option, it is unlikely to be supported in a hospital setting and would require significant communication with the labor team about your wishes.

Tips to Effective Pushing, no matter the school you choose:

• Breathe! The primary drawback to directed pushing especially is the holding of the breath for any period of time. The withholding of oxygen is both to the laboring person and the baby and is a primary contributor to fetal distress in the pushing stage. Always breathe in at least for a count of 4, do not hold it, and breathe out for a count of 4 while bearing down. There is no need to hold your breath at any time. Holding the breath deprives both bodies of oxygen and depletes energy very quickly.

• Labor Down! Once you reach 10cm dilation, full effacement, contractions have been at a great clip, you may hit a stage of "involution" where for 10-45 minutes the contractions space out paradoxically to 5-8 minutes while the uterus shrinks down around baby who has moved deep into the pelvis. At this time, REST. Hopefully, baby will scoot right on down into the vaginal canal and reach -1 or -2 station before the contractions pick back up and you are in the final stretch. This is a great sign, and a time to enjoy the rest! Nothing is wrong and your labor has not stalled, your uterus is becoming tight around the rump of the baby to give you the most power it can in the final pushes.

Laboring down has also been used optionally for people who reach 10cm and choose to wait even without involution and a spacing out of contractions. If you are giving birth at full term for the first time and have an epidural, laboring down without involution has emerging research which shows potential risks of infection, bleeding, and possible impacts to baby's early wellbeing indicators like apgar score. If you are interested in laboring down, ensure you talk with your provider about when they recommend it, talk about the risks involved if you have an epidural, and make sure you understand the picture so you can be clear on your birth plan as well as dynamic at your delivery. Note: Involution happens less often when an epidural has been given, and not every labor without an epidural will always have involution occur. Laboring down as a practice without involution and without an epidural has not been studied clearly for outcomes and as such it has not had its recommendation changed

• Move you body as much as you can!

  • In an Epidural Situation especially with an epidural. In bed, you will be flipped from side to side about every 45 minutes by your labor team, and if you're lucky they'll put a peanut ball between your knees (request this!) But you are not limited to just your back and sides! Ask for a birthing bar for your labor bed and an extra sheet so you can get some real traction with your arms. You can usually attempt an assisted squat with your nurses, or your partner can come behind you in the labor bed to help you sit up and hold your knees back at a more comfortable position than being flat on your back. Laboring beds can get into many positions, and one of them is practically sitting - use gravity to your advantage and keep your chest above your belly as much as possible. As close as you can to a squat position is the anatomically "ideal" birthing position that reduces the pressure on the perineal tissues while simultaneously naturally increasing the abdominal pressure needed to help you push most effectively!

  • In a free movement situation, move as much as you like - you do not have to birth on your back! Your doctor will come to wherever you have decided is most comfortable to birth your baby - if that's standing, squatting on the floor covered with sterile pads, all fours on the bed or the floor, using a birthing bar, kneeling with one leg up, leaning over the back of your birth bed, leaning on the side of your bed, in the dancing position with your partner, in the bathroom on the shower floor, on the toilet (surprisingly effective sitting backwards with a pillow on the tank - many midwives call this position the 'dilation station') it's all up to you - hold the reins of your freedom of movement! Wherever your body says to move, listen to it - the discomfort of labor is a purposeful communication from your baby to your body to work together to bring them into this world. The reason being flat on the back is often so painful is because it is the worst position to help baby move down and out - listen and do what your body tells you to do - it's how we have been biologically designed to birth.

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Hospital settings often do not encourage free movement, reduced monitoring even in healthy normal labor, or pushing outside of the directed camp (also known as "purple pushing" for the burst blood vessels that result from the harsh nature of it to the facial blood vessels and some say the hemorrhoids that often result as well.)

Remember that you are the one who gets to choose what happens to you - by learning the reasons behind the interventions and monitoring that are so often applied without explanation, you can choose what is right for you and your baby to have an empowered, choice driven, safe and happy birth experience.