Saturday, March 15, 2008

Lie down and PUSH!!

Lying on one's back with legs propped up often comes as part of a bigger "package deal" that includes Valsalva pushing, aka purple pushing, aka coached pushing, aka "hold your breath and tuck your chin and push Push PUSH!" while the staff counts to 10.

A recent post on the Better Birth blog describes what a birth with purple pushing looks like.

Why do we do this? Is it helpful? Is there a better way to push?

The answers are:
A) We do this because of a strange combination of ideas: that women need to be taught how to push, that they won't know how/when to do it otherwise, that the faster the baby gets out of the birth canal the better. It probably evolved from women being heavily anesthetized and unable to feel the natural urge to push, thus creating a need to "coach" women how to push their babies out.

B) Not really, if you look at the risks (several, including more pelvic floor damage to the mother and reduced oxygen supply to the baby) and benefits (not many at all--possibly a slightly shorter pushing stage, but at the expense of both mother and baby). This comment from Dr. Joseph I. Schaffer, a researcher investigating coached vs. physiologic pushing, summarizes the current situation quite well: "Everyone uses coached pushing, but it has no known maternal or fetal benefits, and we found that it was associated with negative effects on several urodynamic indices."

C) Yes: it's called physiologic pushing, in which the woman follows her bodily cues and pushes only when and how her body tells her to. Physiologic pushing has a fairly characteristic pattern: the woman usually will not hold her breath, but instead will push for shorter intervals while exhaling or grunting; she generally uses open-glottis pushing, as opposed to the closed-glottis pushing of the Valsalva technique.

There's lots of research on coached versus physiologic pushing, so I will direct you to just a few:
  • Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., & Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194, 10–13. (Available here; you need to scroll down a bit to get to the research summary).
  • Less Pelvic Floor Damage Associated With Uncoached Pushing
  • Schaffer et al, "A randomized trial of coached versus uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function," American Journal of Obstetrics and Gynecology, May 2005
  • MCN Am J Matern Child Nurs. 2000 May-Jun;25(3):165.
  • Caring for women with epidurals using the "laboring down" technique. MCN Am J Matern Child Nurs. 1998 Sep-Oct;23(5):274.


  1. Wow, what a story! What a way to end a beautiful labor with a "scary" ending. There are reasons I have no intention of having a baby inside a hospital again if I can help it, and this is one of them.

  2. I think the only reason this is done, aside from what you mentioned, is because it's much easier for a doc to sit comfortably and watch the baby descend, performing interventions whenever he deems necessary, when the woman is on her back and pushing only when told. "User-friendly" so to speak. It's definitely not better for the mother, but hey, whatever makes the doc's job easier, eh?

    Speaks volumes about how much a care provider REALLY "cares" for a patient when they are willing to contort themselves into whatever pretzel shape necessary to accomodate whatever best suits the mother versus making the mother do what best suits THEM.

  3. i've had two natural births with midwives and both came to "purple pushing" at the end. now 21 weeks with my third baby, i am eager to experience uncoached pushing. i never felt the urge to push the other two times! this time i'm going to stand and deliver and push when i feel the urge! i am really enjoying your blog! - megan

  4. You go Megan! Sometimes it's just a matter of waiting for that urge to arrive. It doesn't always arrive when you're fully dilated; there's sometimes a "rest and be thankful" phase in between there. (Of course, you'd never know this unless you're being checked for dilation, which of course is not at all necessary for giving birth!)

    A real urge to push is something you have absolutely no control over. It's not you go "hmmm, I really feel like I have to push, so I think I will." It's like a freight training roaring down through your body. It's pretty wild, at least in my experience. There's no denying it, and no forcing it either.

  5. I have to second Rixa about the freight train idea. The urge to push is so powerful and so innate that with my last baby I never did voluntarily push. Instead, my body pushed my baby out for me even though we were still in the middle of a wild ride to the hospital. Your body is perfectly capable of getting that baby out, and if left to its own devices, it will!

    I read a story several months ago on cBirth about a woman who was planning a UC, but was admitted to the hospital close to her due date because of severe respiratory distress (her own). It got so bad that she actually went into a coma for a few days. During that time, her body decided it was time to have her baby, whether she was coherent or not. Amazingly, the doctors and nurses let her do it, and her body birthed her baby completely on its own. It was an awesome story to read. When she woke up out of her coma, she was greeted by her new baby. Cool, huh!

  6. I never had an urge to push. I spent a lot of time near the end of my labour standing up (kind of leaning over, hands on thighs), and when I felt done with that and got back in the pool, the midwife could see the baby's head, about an inch inside. She suggested that I should push now with my contractions. I sure didn't feel like I needed to, I had NO urge. The contractions had really petered out, they were weaker than they'd been in 14 hours, and I would've been happy just to lay there in the pool and breathe through them. (This was obviously my chance for rest, eh?) But I pushed and I suppose it might've been the difference between having the baby at 3:00 or at 5:00. There was no coaching, no counting, and no valsalva maneouver, just me pushing when the contractions came. I was told to tuck my chin and not to vocalize out load, but rather to push that energy inside. I sort of did what I was told. Pushing felt really gross and I certainly didn't enjoy it!

    I think next time (there won't likely be a next time, but maybe) it would be interesting just to wait and see what happens, and not do any contrived pushing at all.

  7. Lynette, that's really interesting! I know some people never get the urge, and then their baby just moves lower and lower and eventually comes out!

  8. Rixa,
    I am adding your link to my own blog post about pushing. In it I wrote:

    "As I moved into hard labor I knew that my main goal was to stay open and released. I don't believe that it is necessary to PUSH a baby out (generally), but for us to get out of the way, via relaxation and trust, and RELEASE the baby."

    I am wondering if you have any thoughts on this statement?

  9. I think with birth you can't generalize; I know some women don't have an urge to actively push and the baby just kind of slides out. On the other hand, my body just took over and I had no control. I couldn't NOT have pushed. So all I can say is that the mother should be free to follow her body's cues, rather than having someone tell her what to do or not do based on external measurements such as time or dilation.

  10. No thanks to all that! I plan on having no more kids. But my daughter just had a beautiful homebirth and, like me, she refused that lie down and push stuff.

    It's squat or nothin' LOL


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