06 Nov Preparing for the Big Push

By Anchen Verster – Nursing sister and midwife, mother of 4 including twins

“Okay, you can push now”. Thuli’s cervix was 10 cm dilated, the labour ward nurse had just confirmed.

“What do you mean push?” Thuli asked. The contractions had abated slightly and Thuli couldn’t fathom what to do at this command. The nurse came round to the side of the bed, placed Thuli’s hands grasping the back of her knees and told her to place her chin on her chest and start pushing with the next contraction. It still didn’t make sense. The next contraction came and she started pushing. Everyone in the room was giving her different instructions or telling her she wasn’t doing it properly. She was told to hold her push, take a breath and carry on pushing.

“Hold your push for 10 counts”, they said.

Although this is part of Thuli’s birth story it remains common experience to many birthing mothers. We often spend so much time learning how to cope through contractions that we miss out on the pushing or we gloss over it. The pushing part of birth is known as ‘Second Stage’. Many mothers will be given about an hour to push before extra intervention although international guidelines suggest up to 2 hours.

The forced expiratory effort against a closed airway is a pushing tool used in birth called the “Valsalva Manoeuvre” (VM). Once your cervix is fully (dilated) and thinned out (effaced) you are usually told to start pushing in this way. The irony is that when mothers are left to push in their own way they usually do not close their airway in this way. Some research shows that this type of pushing can be harmful if you don’t do regular paced breathing through the VM.

By this time, you have coped through many hours of contractions. Many mothers will say that the contractions are no longer very painful when it’s time to push but rather this overwhelming sensation or urge takes over your body – ‘bearing down’ and they found it quite a productive part of the labour. However, it can take a little while to ‘learn’ how to push in a way that shifts the baby down the birth canal.

It’s helpful to wait until you have this urge to push before you start pushing because it will be easier to know what to do. Research shows us that if mothers wait to start pushing only when they have the urge to push, babies get more oxygen. So, if the nurses tell you to start pushing and you don’t yet have an urge you can ask if you can quickly empty your bladder on the toilet. A full bladder can slow or block the baby’s path through the pelvis but if you have a few minutes on the toilet you will be sitting in the position you are most used to pushing in. The movement of your pelvis may help the head shift a little so that you feel like you want to push. Once you’re sitting on the loo, try and pass urine by completely relaxing your pelvic floor muscles. If you are unable to pass urine but you feel like you want to pass a stool or open your bowels, this is most likely the baby’s head ready for the pushing stage.

If possible, prop your feet up on a small step, folded towel or suitcase – while on the toilet. This angle helps with pushing. Grab your knees or the underneath of the toilet seat and begin to push as you feel the urge with the contraction. It’s important to keep taking a new breath of oxygen otherwise you may be ‘holding your breath’ during the contraction and your baby will be getting less oxygen and you will get tired faster.

At this point you may still be on the loo and getting the hang of pushing when the staff want you back on the bed. If you’ve already done some productive pushes (those that make the baby’s head move down) then it will be easier to push once back on the bed but it’s useful to start off pushing in a position where you can find your “pushing groove”- like on the loo.

Another position that is useful is squatting in the bath. The hospital may not allow a water birth, but you can use an empty bath as a positioning prop. Roll a towel under your knees (well make someone else do it for you… they need to know this before the time – you will not be thinking of these kinds of logistics). Grab hold of the side of the bath – either with your hands or slightly leaning over the side while you are crouching or kneeling on your knees with knees lightly apart. With each contraction you use the side of the bath as leverage to push against with your feet.  Monkey grip your partners arms while they support themselves on the outside of the bath. This way you pull on them while you’re squatting on the inside of the bath and partner on outside gripping your arms.

If you’re required to be on the bed during pushing you can turn onto all fours and grab the head of the bed to use as leverage with each push. If you’re expected to lie in a semi-reclined position it can be useful to ask your partner to place a sheet or scarf (Rebozo) around his waist while he is standing at the side of the bed or tie two scarfs to the bed sides and use these to create leverage and pull on. This pulling motion helps you to place pressure in your pelvis rather than in your chest and neck area.

You will have noticed that I keep talking about leverage. If you pull on something with both hands while pushing with knees bent, it helps you create the right kind of pressure in your body. If you’ve ever used a rowing machine in a gym, the comparison may be helpful – provided you are sitting still and not rowing. Similarly, as on a rowing machine, your knees are bent and you are closest to the pulley system, you have two “oars/ pulleys” (the rowing machine has only one but you’re gripping it with both hands) to pull on and your bottom is stationary. So, with each pull on the two oars your knees remain bent and the pressure you’re creating by pulling on the oars (and keeping your knees and feet still) is passing through your pelvis and helping to push your baby out. See two “pulleys” above bath

Often what women do instinctually – without being coached and without being restricted – gives us a clue as to what helps during labour and pushing. Many women will start making a deep grunting or groaning noise when they are ready to push. They do not hold their breath but rather give forceful pushes while grunting. The pitch of the grunt is usually low, and this helps to engage the abdominal muscles and push in the right direction. You may read this and not be able to imagine yourself making grunting noises in front of other people but fortunately at this stage of labour, you move into very instinctual functioning and you don’t care what other people think. The circulating Oxytocin in your body helps with this.

It may be helpful here to take a step back from ‘positions’ and ‘birthing props’ and think a little about which muscles you’ll be engaging during pushing.

First step is to have a loose and relaxed perineum and pelvic floor. Having a tightened pelvic floor will contribute to holding the head back. A few deep controlled breaths while relaxing the pelvic floor may be helpful in getting started.

Next step is to engage the Transverse Abdominals (TA) and the Rectus Abdominis (RA). These are the muscle you work on with core strengthening particularly when doing Pilates. They are otherwise known as the muscles which give you a “six-pack” or the core strengthening muscles.

So, to summarize you need to relax your pelvic floor while engaging your TA’s and RA’s. The groaning helps your co-ordinate the relaxing, engaging and breathing. You can’t continually hold your breath while doing groaning or grunting. You will have to re-supply your lungs with oxygen to do this and so provide oxygen for your baby. It’s easier to groan and push with a relaxed pelvic floor rather than a contracted one, which is what we want. So, the DEEP groaning or grunting helps you bring all these movements together. Remember high pitched moans do not have the same effect on intra-abdominal pressure. The groaning or grunting needs to be in deep low tones. 

To summarize the key factors to productive pushing:

• Wait until you feel an urge to push
• Get into a position that is comfortable to push in
• Use leverage – pull on scarf, pole, cot-sides, partner
• Breathe frequently during this stage
• Relax your pelvic floor while engaging your TA and RA muscles
• Grunt or grown in low tones during pushing

There are multiple web-based tools and APPs to help you prepare further for pushing. Being prepared can decrease the time you need for pushing and lower the chance of needing forceps or vacuum.