Childbirth Preparation Series (Part 3)

In Part 1 of our Childbirth Preparation Series, we focused on helping you understand the basic stages of labor, and what typically happens in each.  In Part 2, we discussed the first stage of labor (the “contraction” stage) during which time the cervix dilates to 10cm and the uterus contracts.  Now that you have that foundation, Part 3 will focus specifically on helping you prepare for Stage 2 Labor (the “pushing” stage).  The tips below can help make your pushing more effective, reduce the duration of the pushing stage, and minimize stress to your body (especially your pelvic floor).

We will discuss the following three elements of pushing: Timing, Position, and Technique.  But first, let’s quickly take a look at what that trip down and out of the birth canal actually looks like, so we have some context when discussing these elements of pushing.

The (complex) trip down the birth canal

Childbirth has gotten a bit more complex since our early primate days when we walked on all 4s and had wider pelvises (and our offspring had smaller heads!).  Take a look at the image below.  Note that the baby’s head is not exactly in line with the vaginal opening.  Therefore, the birthing process is a collaboration between the mother and baby, who each play a specific role in order to achieve a successful outcome.  Beginning in Stage 1, the uterus contracts to push the baby down, and the cervix gets thinner (effaced) and opens (dilates) to allow baby to pass through.  As your little one moves downward toward the vaginal opening, it must perform a series of complex movements (known as Cardinal Movements) to get into optimal position in line with the vaginal opening.  Watch THIS VIDEO to see these cardinal movements, which begin in Stage 1 as the baby descends and conclude in Stage 2.  While it may seem complicated, in most cases, babies are pre-programmed to do this.

Pushing Timing

Let’s first discuss when pushing actually begins.  Once a woman’s cervix has dilated fully to 10 cm (which marks the end of Stage 1), often times the doctor will cue her to begin pushing almost immediately. This type of instructed, or managed pushing, approach is externally derived and women (especially first-time moms) may value the direction given by a seasoned medical professional. However, a woman may not feel quite ready to push just because she is 10 cm dilated. That is because there is often a period of quietude that exists in between Stages 1 & 2, a phase that does not get attention in traditional medical circles, in which a woman’s contractions may slow or stop altogether. This happens to allow the baby more time to perform it’s complex series of cardinal movements so that it is truly ready to be pushed out.

If a woman can take these quiet moments to breathe deeply, re-center herself, and prepare physically and mentally for the final “push” (pardon the pun), then the process can be much more efficient. This type of internally-derived know-how is called instinctive pushing (or physiologic pushing). All she needs to do is listen to her body — and be in an environment that’s supportive of her doing so — then begin pushing only when she feels the uncontrollable urge to do so.

The length of Stage 2 varies widely by individual.  First-time mothers typically (but not always) have longer Stage 2 labors — up to 2 hours.  Those women who’ve had prior births often have shorter Stage 2 labors — even as short as a few minutes. When instinctive pushing is used though, it can often make Stage 2 shorter and more efficient for all.

Pushing Position

Now that we’ve discussed when to push, let’s discuss the various positions to push in.  The most common birthing position today in a hospital setting is when a woman is reclining with her legs bent with knees in stirrups. This position enables doctors to have access to see, maneuver, and (if necessary) perform interventions. However, if we take a brief look at how our more “primitive” ancestors gave birth — when they were left to their own devices to do what felt natural for their bodies — the most common positions were standing (supported), squatting, or hands-and-knees.   

 

 

 

 

 

 

 

 

One notable position you do not see above: lying flat on the back. This was not a natural or intuitive laboring position for women when left to their own devices, as it did not offer the advantage of gravity’s downward pull.  The back-lying, or reclining, position came later with obstetrical developments like hospital gurneys and epidurals.

So what can this teach us today? Interestingly, newer research being done on self-selected birthing positions (in which women choose their position as opposed to being directed how to position themselves) reveals what those “primitive” people intuited: maternal choice of positions can improve labor outcomes (for mother and child). Some of these positive outcomes include a shorter second stage, lower pain scores, and fewer operative deliveries (Gizzo et. al, 2014).

Pushing Technique

Finally, let’s discuss the actual technique of pushing.  Traditionally, when a woman is instructed to push, she is told to hold her breath and bear down for several seconds while trying to help expel the baby.  This breath-holding during exertion creates excess intra-abdominal pressure, which can help create more force to push the baby out.  However, the excess pressure this creates in the body can have some negative repercussions, including reduced oxygenation to the baby (which can lead to heart rate deceleration) and increased pressure on the mother’s perineum (the tissue between the vagina and anus). Newer research is now pointing to better outcomes for mom and baby when the mother is allowed to instinctively push.  When a woman is permitted to push in a way that feels natural, often she will not hold her breath for as long as when she is instructed, thus reducing oxygen deprivation to the baby and perineal pressure (Lemos et. al., 2011).

PROnatal Fitness teaches a different pushing technique that does not involve breath-holding.  This Pushing Prep technique begins with 360° Breathing, but on the exhale (as you contract your TVA and draw your navel to spine), you maintain a relaxed pelvic floor.  This does require a bit of practice (as the TVA and pelvic floor almost always move in tandem, so separating the muscle actions might seem tricky at first), but this relaxed pelvic floor is critical because you need to learn to let go of tension in the muscles that are the exit point for the baby, or else they won’t stretch as far, making you (and baby) have to work hard to finish the job.

We typically recommend women begin Pushing Prep in the 7th or 8th month of pregnancy (actually practicing on the toilet can be the best way).  Anecdotally, first-time postpartum women say that they thought they were pushing when instructed, but didn’t make progress because weren’t pushing effectively. They didn’t know how to push. So begin practicing before your big day comes.

Want more support?

We believe a major performance event like childbirth not only takes training, but also the support of a great coach.  Consider working with one of our Personal Trainers to begin preparing your body for pregnancy, birth, and the postpartum period.  We also highly recommend working with a doula (birthing coach) to support and coach you during childbirth. These expert coaches will help you with every element we’ve discussed in this 3-part series, and provide the critical mental, physical, and emotional support needed to help you succeed in what will likely be the greatest physical feat of your life.  Need help finding a doula?  If you’re in the NYC area, check out Birth Focus NYC and register for one of their “doula speed dating” events.  Or, speak with your Ob/Gyn to get a recommendation in your area.

Sources:

Engelmann, G.J. (1882). Labor Among Primitive Peoples. St. Louis: JH Chambers.

Gizzo, S., Di Gangi, S., Noventa, M., Bacile, V., Zambon, A., & Nardelli, G. B. (2014). Women’s choice of positions during labour: return to the past or a modern way to give birth? A cohort study in Italy. BioMed research international2014, 638093.

Lemos, A., Dean, E., & Andrade, A.D. (2011). The Valsalva maneuver duration during labor expulsive stage: repercussions on the maternal and neonatal birth condition. Brazilian Journal of Physical Therapy15(1), 66-72.