For most women, the second stage of labour—the pushing stage—looks a lot like it does in the movies: an exhausted, sweaty, red-faced woman in a semi-reclined position on a hospital bed. A team of enthusiastic nurses tells her to hold her breath as a contraction begins, and then to bear down forcefully for a count of 10, repeated as many times as possible until the end of the contraction.
Montreal mother of two Christine Latreille was in labour for 48 hours with her eldest child. She spent six (!) of those hours pushing, with the nurses coaching her and counting to 10 the whole time. “I think the counting definitely helped me push longer and more forcefully than I might have on my own,” says Latreille.
This style of pushing is sometimes referred to as “purple pushing” because of the colour the mom’s face turns while she repeatedly holds her breath and strains. The technical term for it is “directed pushing" and it has been a part of standard obstetrical practice for generations. But a growing body of research is raising questions about whether directed pushing should be the go-to approach. Some doctors and nurses are experimenting with allowing women to push whenever they feel a strong urge, without instructing them to hold their breath and bear down for a set amount of time.
This kind of self-directed or “spontaneous” pushing has long been recommended by midwives and natural birth advocates, but is only recently gaining traction in the medical community.
Obstetrician Lawrence Oppenheimer, the head of maternal-fetal medicine at Ottawa Hospital, has seen changes in how the medical community approaches the second stage of labour since he completed his obstetrical training 30 years ago. “As a junior resident, I was taught that the second stage of labour was the most dangerous time in a woman’s life, and we tried to get it over with as quickly as possible,” he says. But now he and other practitioners are learning that as long as labour is progressing well and the mom and baby are fine, it is often best to wait until a woman has a strong urge to push, or, if she has had an epidural and isn’t feeling that urge, until the baby has had some time to descend on its own. Encouraging her to bear down and push for as hard and as long as possible as soon as her cervix is fully dilated may not be necessary.
“I’ve always felt that everybody yelling at the mom and telling her when to push might not be the best idea,” says Oppenheimer. The Ottawa Hospital guidelines recommend delaying the active pushing stage until the woman has a strong urge to push, or two to three hours after the cervix is fully dilated. "If everything is going well and delivery looks imminent," says Oppenheimer, "continuing to wait up until a maximum of three hours is acceptable." Women who've had epidurals are also given three hours to wait for the urge to push to arrive, after which they are directed to begin bearing down. But the hospital doesn’t currently have a specific guideline on how women should push. Oppenheimer says this means management of the pushing stage is still largely up to the individual preferences of the medical staff attending the birth, many of whom will still go the traditional route. “Personally, I quite like the idea of the self-directed approach, and the clinical evidence shows it is just as safe and effective as directed pushing,” says Oppenheimer. “But we don’t know enough yet to say it is definitely the better or safer approach.”
Oppenheimer points to a 2015 systematic review study that looked at seven randomized controlled trials comparing directed versus self-directed pushing. It found no clear differences in the duration of the second stage of labour, episiotomy rates, perineal tearing, C-section rates or health outcomes for the baby, even among women who had an epidural. Oppenheimer says that since there is not yet any clear evidence of significant risks or benefits of one kind of pushing over the other, practitioners should take “an individualized approach” and be open to letting women wait to feel a strong urge to push and to do so in a way that feels right to them.
Self-directed pushing has long been the recommended mode of delivery in midwifery textbooks. Nicole Bennett, a registered midwife and director of the midwifery education program at Ryerson University in Toronto, points to studies that have found self-directed pushing can lead to better outcomes for the baby: fewer heart rate abnormalities, better APGAR scores after birth and better (less acidic) umbilical cord blood pH levels. Also, allowing women to labour independently with as little intervention as possible fits into the overall philosophy of midwifery care in terms of encouraging choice and autonomy during birth.
Bennett has seen many women give birth successfully without much coaching, and without holding their breaths or bearing down for prolonged periods. “What I’ve observed is that women who aren’t told when to push will eventually feel a strong urge to push and do a number of brief bearing-down efforts with each contraction—four to six seconds long. And they are usually breathing out while they push,” she says. As the baby descends in the pelvis and begins to crown (when the head pushes on the perineum), Bennett says women will start to push more frequently and then there's often a noticeable shift in the woman’s mood right before the moment of birth. “Research shows she will sometimes express a sense of fear or panic, or loss of control, and then she will feel an uncontrollable feeling of bearing down as she shifts into a final, very strong pushing phase.”
Jacoba Lilius, a Kingston, Ont. mom of two, knows what it’s like to give birth without consciously bearing down. On December 25, 2012, labour ramped up quickly and she almost gave birth to her first child in the car, on her way to the hospital. She had been celebrating Christmas at her parents’ home in a rural area, over an hour’s drive from the nearest hospital with an OB on staff. “I spent a good 45 minutes trying hard not to push,” says Lilius. When she reached the hospital, and the staff told her she could finally push, “I remember my body just doing the work. I didn’t bear down,” says Lilius. “I didn’t consciously do anything; my body just did it on its own. It was unbelievable.”
More research is needed to fully understand why some women experience this kind of powerful, out-of-control urge to push, while others get stuck bearing down for hours. Position and size of the baby, a mother’s physiology and even her psychological state are all believed to play a role. Some natural birth advocates have suggested that the birthing environment and amount of “disturbance” the mother experiences could be important factors (although these theories remain controversial among many in the medical community). Researchers do know that the urge to push happens when pressure on the cervix, vaginal walls and perineum leads to the release of large amounts of oxytocin, which, in turn, stimulates further contractions of the uterus, a process called the Ferguson reflex.
According to Oppenheimer, an epidural “partially abolishes” the Ferguson reflex, which means about half of Canadian women (the epidural rate was 56.7 per cent of vaginal births in 2011) may have trouble feeling the urge to push, especially before the baby’s head is low and putting pressure on the perineum in the crowning stage. The same systematic review that looked at self-directed versus directed pushing concluded that allowing women with an epidural to wait at least an hour after full dilation (allowing the baby time to continue to descend and turn) shortened the time spent actively pushing by 20 minutes.
But even for women who don’t have an epidural, Bennett says that the urge to push doesn't always immediately follow 10-centimetre dilation. “The time between full dilation and feeling an urge to push is not always exactly the same in every woman.” Bennett frequently sees a pause in labour between full dilation and the urge to push, during which contractions temporarily slow down in frequency and intensity. “We call this the ‘rest and be thankful’ phase,” she says.
Toronto mom Jamie Khan, who is expecting her second child this December, thinks she may have started pushing too early during the birth of her first child in April 2015. “At first, I was pushing so hard, I broke all these blood vessels in my face,” says Khan. She remembers at a certain point, something shifted and suddenly her body seemed to be pushing whether she tried to or not. “I felt as though that version of pushing was out of my control, more of an unconscious thing, and it was lower down, more focused towards the back of my body than what I was doing before.” Khan says that for her next birth, she plans to be more patient. “The first hour and a half of pushing was exhausting, and maybe it was for no good reason.”
Bennett says midwives do not normally use directed pushing, but instead give instructions on how to push more effectively, especially if the second stage is becoming prolonged or if there are any concerns about the baby. One way Bennett explains more effective pushing to labouring women is by putting some pressure inside the vagina, in the area where the woman needs to focus her efforts. “Sometimes a woman is pushing hard, but with the muscles in her chest and upper abdomen, so we might press our fingers on the posterior vaginal wall to encourage her to activate the correct muscles.” In other situations, directed pushing may be necessary to keep everyone healthy. “If we’re seeing abnormalities in the fetal heart rate and we want to speed things up, directed pushing is one of the tools we have,” says Bennett.
Oppenheimer also says he would always go back to directed pushing if there were any concerns about the mother or baby. “Even though the evidence we have so far says directed pushing doesn’t necessarily speed things along, when we are worried, doctors tend to want to take control and go with the traditional approach we’re used to,” he says.
Many women appreciate getting some kind of direction to help them through the intensity of the second stage, whether it’s instruction and encouragement from a midwife or a pair of nurses counting to 10 and chanting, “Push!”
After hours of straining and exertion, Christine Latreille says she appreciated having something to concentrate on during contractions. “Even if directed pushing didn’t speed things up, I felt like I needed the counting and the guidance from the nurses. It helped me feel more in control and focused, which worked for me.”