At Esali Birth, we promote the perspective of biological birth.  Though there are many differences in birth location that affect how your birth may go, there is no difference in birth location that affects how your birth should go – and because of this, we educate our students on biological birth so that they understand why choosing the right birth team and birth location is vital to their experience.  If we teach normal physiological birth with an instinctive birthing approach, then every woman understands how their body is amazingly designed.  Therefore, stressing the importance of responsibility and making choices during the perinatal period to support biological birth is one of the most important strategies of an Esali Birth class - not only does this give mothers the information they need for a wonderful birth, this also gives them understanding of how their birth may have differed from a biological norm (necessary or not).  One of the approaches to biological birth that I find very important is to remove “pushing practice” from a class setting and instead teach biological birth during 2^nd stage.

I repeatedly find outdated practices being taught in modern childbirth education settings – whether from a formal class, a typical conversation, or direction from even home birth midwives.  With all our approaches to natural and instinctive labor, why is it that when it comes to stage 2 – the birthing [pushing] stage – are we so medicalized?  Just because providers may practice this outdated method of birth does not mean we shouldn’t make mothers knowledgeable about the way their body was designed to biologically birth their baby – through all stages.

The birthing stage can bring a wonderful break for a mom, especially after an intense transition and active phase of labor.  Why deny her of this opportunity to rest and relax as her contractions spread out and change direction from dilating and effacing to expulsion?  This only tires her and increases incidence for unnecessary interventions and complications.   Although many mothers may welcome a more active birthing phase, birth attendants also seem to get this burst of energy during this time as well – thinking everyone needs to “do something.”  This is further from the truth.  Birth attendants need to be on their toes… making sure they’re not interfering with one of the most delicate parts of the birth process.

Prior to this point in labor, emotions and birth environment have a definite impact on birth experience, and it is somewhat easy for a mom to digress in her labor in order to find a safe location for birthing her precious child – it is all about survival.  Now, however, she is almost to the point of no return.  Stopping labor at this point would be difficult after the woman’s body has transitioned into the birthing stage – so keeping this space sacred and just as calm and instinctual is vital to the mother-baby’s health and experience.  It takes an extremely patient provider and very knowledgeable attendant to “do nothing” during 2^nd and even 3^rd stage labor.  If we can wait 24 hours for this point to arrive, what is it that makes everyone want hands in, hands on, and mouths directing?  Well, simply, the reason is history. 

Directed 2^nd stage came around when medically managed births were introduced.  A variety of reasons included getting this stage over as fast as possible because providers believed this stage was dangerous for the baby, to the need for directed pushing because most mothers were medicated, and even knocked unconscious with drugs like twilight sleep.  Just as with every other unnecessary intervention we see today, some stuck with modern techniques because so many providers are being incorrectly taught about physiological birth (or they fear birth) and there is a large misunderstanding about the importance of biological birth in this industry – even among home birth midwives.  I stress this because so many parents get the idea that hiring a “midwife” indicates they will have a biological birth – but just as with any provider, credential does not mean quality.  Unfortunately, women need to know a lot about the perinatal period in order to even have a biological birth.

One of the easiest – yet seemingly most difficult – things to do to facilitate a biological birth is to stop paying attention to numbers.  Who cares how long this woman has been in labor if everyone is doing well?  Who cares how much she is dilated?  Who cares how much she is effaced?  These things tell so little about the birth, why they are even monitored is beyond me.  Even attendants who promote this idea [of avoiding numbers] still use these methods to determine if mom is actually in labor, if she is actually progressing, and if she is actually ready to birth her baby.  Why?  Convenience?  For whom? 

A mom calls her provider and says “I believe I’m in labor.”  The first thing they want to do is check dilation and effacement.  Why have we stopped believing the mother?  This is the first step to saying “well, you really don’t know what you’re talking about – and even though dilation and effacement aren’t going to tell us when the baby will arrive, we’re still going to stick our fingers up there and see how far along you are anyway.”  That is mistrust.  It is mistrust for the birth process and mistrust for the mother.  We know the other signs to watch, why aren’t we watching them?

Energy is flowing, mom is getting grunty, and she’s beautifully moving with her contractions.  “Hmm… we better check you.”  Lightbulb?!  If you think she is to the point of transition and moving into the birthing stage, what is making you not trust your knowledge that you need to check effacement and dilation which we know doesn’t tell us much about labor progression or birth time?  These grunty pushes are most likely dilating the cervix the rest of the way, or removing an “anterior lip” which so many attendants fear because "pushing may cause cervical swelling."  A mom who is directed in pushing can most certainly swell her cervix if it has not opened as wide as what her baby needs.  But a mother who is instinctively and biologically birthing her baby will use these grunty pushes to do exactly what nature intended – gently moving her baby through her body the way her body and baby were designed.  And, not to mention, we know baby’s heads are not all 10cm – so why even use 10 cm as a guide?  There is that number issue again…  What if we tell a mom, “yup you’re 10 cm – you’re OK to push” and start directing her birthing stage, when her baby actually needed 11 or 12 cm?

So, the first approach to biological is a provider who not only understands, but actually practices biological birth methods.

The next approach is through instruction.  For years and years, mothers and birth partners have been lead through labor rehearsals and “taught” how to push – and even in recent years, at the same time told “don’t use directed pushing.”  If we know how important instinctual birth is, why are we still not teaching this?

Directed pushing in ANY form may cause (to name a few):

• Decreased energy levels
• Increased length of pushing stage
• Increased vaginal swelling
• Increased risk of perineal/vaginal tears
• Increased maternal & fetal blood pressure
• Decreased fetal oxygenation
• Fetal distress
• Increased need of assisted delivery and/or cesarean birth
• Increased risk of CPD misdiagnosis

Don’t get the idea that just because someone isn’t counting to 10 that you’re not being directed to push.  How many times have you done something in your life simply because someone won’t stop asking you to do it?  “Are you ready to push yet?  Do you feel the urge?  Are you sure?  Maybe try a little push and see how that feels.”  Even gentle approaches to encouraging a mother to push can change the way she births her baby.  No matter how knowledgeable mothers are, they are at an extremely vulnerable stage.  Try taking morphine and see how easy it is for you to make decisions or not listen to the people you hired to protect you during this sacred time.  Now you kind of know what it is like to be in the birthing stage.  Beta endorphins and oxytocin have been flowing through the mother’s body – continuously increasing; she is literally on a natural high (similar to the affects of morphine).  This is not a point where she should be making decisions, answering questions…etc.  She needs to continue to work with her body to biologically birth her baby...instinctually.

 

Take any time to rest and relax until you feel the expulsive urges that you cannot resist rather than beginning to push when it is not necessary.  Pushing before you have the urge is unproductive.  And, no, contrary to what many would have you believe – not all mothers get an uncontrollable urge to push.  Some mothers simply birth their babies gently, and some mothers may go through the birthing stage and only experience the fetal ejection reflex (FER) that occurs when birth is imminent – causing this overwhelming power in the mother where all her doubts and fears have disappeared and she is ready to get this baby out.  This is another survival mechanism of birth.  The baby is ready to come out, and mama needs to get the baby out so that her and her baby are not vulnerable to "predators."  Instincts... we have them for a reason.

 

Learning how to push can be a difficult task.  It’s not something that you can really practice, and if you’re a first time mom, it may be difficult to understand because of so much misinformation in the birthing industry.  Although pushing is similar to the concept of a bowel movement, and it may very well feel as if you are about to lose control of your bowels when the overwhelming urge to push occurs, it is NOT the same.  As the baby moves through the birth canal, its presenting part moves along the rectum, which may give you that feeling that you need to have a bowel movement.  And, yes, occassionally, the baby's head will push anything left out and you and your providers will go about your birthing business.  Don't let this stress you out - it is a normal part of labor - but often much of this is expelled during the early labor stages. 

 

During pushing, you are using a different set of muscles than with a bowel movement: the ones being strengthened and exercised with the Kegel exercises.  These are also the same set of muscles that contract during an orgasm.  With low stress births and a calm environment, it is very much possible to have that orgasmic feeling during birth, as you’re stimulating the same nerves and energies as you would during sexual intercourse.  For first time mothers, pelvic bones have not been moved and stretched, which takes a little time, and you probably have a little fear due to the unknown.  Additionally, hearing so many stories of women pushing for hours, and being directed to push can get mothers into the mindset that they need to do something during this entire 2^nd stage.  Use the more spaced out contractions during this stage to get the rest you need – you deserve it.  The best thing you can do is relax your bottom, remember to breathe, and surrender to the overwhelming urges, should you experience these.  If not, that’s OK – just rest a little more, your uterus needs no assistance to move that baby out of your body – otherwise we wouldn’t have the stories of women in comas having easy births.  Once you accept birth and let your body do what it needs to do, rather than your brain (or birth attendants) trying to direct it, the baby will come more easily.

 

When you tighten up (which can be caused from anxiety, pushing too hard, or trying to "use" your kegel muscles rather than relax them, which often occurs with directed pushing) your cervix and bottom tightens, which makes it harder for the baby to be born.  One way to “practice” for pushing is while you’re sitting on the toilet.  Sit up straight and tall, drop your shoulders, and relax your jaw so that your face goes limp.  Take one deep, cleansing breath, and let your stomach go loose as you exhale every last drop of air until you make the grunting, cow-like, noises that occur when you have pushed all the air out of your lungs.  Think about opening your bottom and releasing that tension as you relax your body and let yourself urinate or have a bowel movement, using no extra pushing force.  Keep doing this relaxation and breathing exercise until you’re finished.  This type of relaxation is what you need to achieve for pushing to be most affective.  You really don’t need to “push” your baby out, as your body will do this for you.  And birthing [pushing] practice really isn't to teach you how to push during birth, it is to teach you how to relax your muscles.  The more in tune with your body you are before birth, the easier it will be to get into this state during birth.

 

Though the toilet setting may be the most convenient ways of “practicing” how to birth [push], one of the most effective ways to understand pushing is through intercourse.  Having intercourse (on your side might be the best position initially to get the understanding of it) you want to concentrate on staying “open.”  Getting an understanding of how open you need to be, and how relaxed you need to be is the goal, and the act of intercourse allows you to concentrate on the muscles needed for birth, while there is actually something in the vagina. 

 

Just as in the previous exercise, you want to open your mouth and drop your jaw into the most relaxed position possible (this directly affects your ability to relax your vagina), and close your eyes. The amount of force needed to say a very deep “uuuuuhhhhhhhhhh” (doing this WHILE you are exhaling at the same time, a very “airy” uuuhhh, kind of moaning) is all the “force” you need to “push.”

Now, while you’re “uuuuhhhhing” and exhaling, you want your partner to have slow deep thrusts.  I realize how intimate this sounds, but birth is a very intimate experience, and the energy used to create the baby, is the same energy needed to bring the baby into the world.  Focus on relaxing all of your muscles, particularly the vaginal and kegel muscles.  Remember that the Kegel exercise is great for strengthening the muscle, but learning how to relax the kegel and vaginal muscles are far more important.  You want to be extremely open, calm, and relaxed.  Don’t concentrate on having an orgasm - this is not the goal, just let it happen if it occurs with no resistance and no force. You want to focus on relaxing all your muscles in your vaginal area, and relaxing your entire body. 

In summary, you want to have sex, relax your jaw, close your eyes, say “uuuuuhhhhh” while exhaling, relax all your muscles during thrusts, and everything else will come instinctively.

During the actual birthing [pushing] stage, you may want to use upright positions that help the baby move past the pubic arch and widen the birth canal.  When pushing in reclined or back-lying positions the baby has less room to move through the birth canal, and has to go down under the pubic arch, and then up to be born.  A side lying position in birth doesn’t utilize gravity, but it also doesn’t work against it, so it can be beneficial.  When in a squatting position, the birth canal is opened approximately 10% (some sources suggest 25%) wider allowing more room and less effort.  Pushing in an all fours position can give mom a bit of a rest as this requires less energy.  There are many different positions that can be beneficial for different situations.  It is important to use positions that are comfortable and instinctual for the mom, as these positions are usually comfortable for the baby.  Rarely would a mom instinctively move into a reclined position to labor or birth. 

 

And, just to repeat what has been continuously said in this article, don’t use directed pushing techniques where someone counts as you push (unless you’re medicated and cannot feel to push – and then it may be necessary).  You want to push to the point of comfort and remember to take breaths for your baby.  If you can push 3-4 times with one contraction, this is fine, but if someone else is urging you to push when you cannot, these extra pushes are only going to wear you out and be ineffective. 

 

How does your care provider and birth team approach 2^nd stage?