Pushing Your Baby Out: How to Have a Kickass Second Stage
When observing birth in hospitals, I have been amazed by the change of tone that often occurs at the transition from first stage labor to second stage. I have seen hospital staff go from somewhat respectful and permissive in the first stage, to aggressive and demanding in the second stage. This change comes as doctors, nurses, and midwives engage in the most active part of their role, assisting in the actual emergence of the baby. It’s important to choose a team that knows the evidence and trusts women at every step of the birth process. Just as it is vital to honor the mother’s desires during the first stage of labor, individual birthing women should be supported in their choices for an ideal second stage.
When breaking labor down into stages, we typically think of First stage (Early, Active, and Transition, this is the dilation stage and it ends when the cervix is fully dilated, or 10 cm) and then Second stage, which is characterized by pushing and actively trying to get the baby out of the mother’s body. There is also a third stage of labor, when the placenta detaches from the uterine wall and is finally born. Childbirth education often spends a lot of time and energy on coping measures for the first stage, and glosses over the second and third stages of labor. I think this oversight leads to many women thinking they’ll just wing it and being surprised by the intensity of the coaching they receive.
During the second stage, there are two main philosophies of management: coached pushing, and physiologic or spontaneous second stage.
Coached pushing - also called Valsalva pushing or purple pushing - is the method routinely used by most hospital-based care providers, and sometimes in the home setting as well. It features extended breath holding, typically supine positioning, and care provider direction on when and how to bear down. Pushing typically begins when the cervix is fully dilated as defined by an internal pelvic exam, and not before.
Physiologic Second Stage doesn’t have to include active pushing at all and is directed only by the mother’s sensations and urges. Sometimes there is a pause of a few minutes, or even hours after the mother reaches full dilation while the baby is moved down by the strength of contractions without active pushing. This pause is sometimes called “laboring down” and is a great time for mothers to rest and eat in the final moments before the birth. Eventually the baby moves down into the birth canal and the urge to push becomes powerful, or the Fetal Ejection Reflex may even take over and push with no conscious action on the part of the mother. Mothers choose their own positioning, and often choose upright or gravity neutral positions.
A Cochrane review found very little evidence of difference in outcomes between these two methods, and the evidence available is unfortunately very low quality. The main thing we can conclude from the evidence is that coached pushing may speed along labor, but there’s no improvement to the outcomes for mother or baby. In fact, the customary extended breath holding with coached pushing can limit the amount of oxygen to mother and baby, increasing stress on the baby, and leading to lower 1 minute APGAR scores. Additionally, the increased speed of the birth may increase damage to the perineum. Severe tears and other pelvic damage can be life altering injuries that require surgical management and therapy; and sometimes permanently damage a woman’s quality of life.
In contrast, physiologic second stage is guided by the mother’s intuition. When pushing, the mother may grunt or moan, releasing her breath slowly as she pushes, or possibly hold her breath for shorter periods of time, typically not more than 6 seconds. Mothers also assume the position that feels most natural, which can lead mothers to just the position to help with their specific needs. Mothers who need to slow down their birth may lay on their side, or even get into an inverted position like down dog or knee chest position, protecting their perineum from too swift a birth. The two factors of a physiologic second stage that may be most beneficial to mothers are the pause to labor down before pushing, and the freedom of positioning.
All this leads me to the conclusion that as a starting point with healthy mothers, we as the birth team should be taking a step back and observing as the mother intuitively guides her own second stage. This helps the woman to stay in her space of mental focus rather than distracting her with bright lights, hands in her vagina, yelling and counting. There are cases where the woman has a hard time connecting with her body to know what to do and how. If the second stage feels challenging, I would suggest that this mother needs encouragement first. If she’s still struggling and asks for help, then we can offer incrementally more suggestions of positions and methods for pushing.
So, why is coached pushing often the default choice for care providers? The primary reason for this probably has to do with doctors’ felt need to do something to/for the mother – regardless of her actual need for assistance. Challenging their need to do something to assist the birth may feel offensive to care providers, as it challenges their whole perception of birth as a pathological process that requires intervention. In the hospital setting, the woman is not seen as the expert over her own body and birth; she must be told what to do. Additionally, most doctors are in a hurry to leave – it’s more economical for them to get in and out of a birth quickly.
Our need for speed and efficiency in birth is a very western, post-industrial-revolution mindset, and likely developed as birth moved to the hospital and men became the primary birth attendants during the mid-1900s. A faster birth is not necessarily better for the mom or baby. We have the means to check in with the wellbeing of the birthing dyad – through fetal heart tones, verbal check ins with mom, and other observation. If both are still in good health, trying to speed things along may cause more harm than good.
Interestingly, I have also women default to coached pushing because it’s all that they’ve ever seen. Many women feel disconnected from their body and aren’t sure how to push. The image of a woman birthing on her back, with an OB yelling “PUUUUSH!” has been widely broadcast through sitcoms and other cultural imagery, and most women have never seen any birth – let alone a physiological or undisturbed birth, which has become a bit of a unicorn in our culture.
I myself experienced this with my first birth. I had labored in the tub all night, and things had been really great – it seemed like I was headed for a very rare physiologic birth in hospital. But when the morning came, things began to slow down, and I didn’t have the urge to push. My hospital midwife did a cervical exam, and I was dilated to 8cm. We waited a few hours more, but then the midwife decided to quote-un-quote “help” me by holding back my cervix and having me push… this did accomplish getting babies head past the cervix, but his head was still pretty high in the pelvis. This led to two hours of very demanding pushing on my back before my son was born, increased bleeding, a second degree perineal repair, and a challenging recovery. The interesting thing is that my doula asked a couple of times if I wanted to change positions, and I said no. At this point I was just so tired, and enough out of touch with my body that I didn’t feel able to change position or listen to my body. In hindsight, I really could have benefited from a good meal and possibly a nap.
And this leads me to the concept of evidence-based care versus individualized care. Following the evidence is great in theory, but when you’re interacting with a birthing mother, the evidence becomes small potatoes in comparison to her instinctual needs and desires. Often, the mother knows instinctually what her body and baby need, even if it is counter to research evidence. Some mothers may try to push spontaneously but have trouble making progress. Additionally, if the mother is looking for more guidance on how to move her baby down, the care provider can offer incrementally more guidance to suit the needs of the individual. The best tactic for improving the second stage of labor is to educate and prepare the mother with evidence ahead of time, and then to follow her lead during the birth. In this way, we honor the evidence, but only insofar as it serves the individual in front of us.
In conclusion, here are my four tips on how to have a kickass second stage:
1) Prenatally, practice. practice pushing or doing Kegels in a variety positions, experiment so that you have a few ideas of how you might like to push.
2) Watch undisturbed birth videos to learn from other moms. We’re all mammals after all, and you may feel more ready to follow your own instincts, however wild they may be, if you have seen a variety of mothers birth in their power.
3) Take advantage of rest and nourishment in labor and before pushing. This is important, whether it sounds enjoyable or not. Electrolytes, slow-release sugars like honey, protein, and fats are all important fuel for an effective second stage.
4) Choose the position that feels most comfortable to you at the time of your birth. Even if it’s not the position you imagined, or it’s the one position you thought you’d never choose. You may surprise yourself!
Difranco, Joyce T, et al. “Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions.” The Journal of Perinatal Education, Lamaze International, 2007, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1948091/.
Galbrecht, Shirley, and Rachel. “Coached Pushing vs. Maternal Pushing.” Pelvic Health and Rehabilitation Center, 16 Aug. 2019, https://pelvicpainrehab.com/female-pelvic-pain/3464/coached-pushing-vs-maternal-pushing/.
Jene. “LOOKING AT THE EVIDENCE FOR BIRTHING YOUR BABY: SELF-DIRECTED VS COACHED PUSHING?” AIMS Ireland, Association for Improvements in the Maternity Services, 23 May 2014, http://aimsireland.ie/looking-at-the-evidence-for-birthing-your-baby-self-directed-vs-coached-pushing/.
Lemos, A, et al. Pushing Methods for the Second Stage of Labour, 26 Mar. 2017, https://www.cochrane.org/CD009124/PREG_pushing-methods-second-stage-labour.
Simpson, Kathleen Rice. “When and How to Push: Providing the Most Current Information about Second-Stage Labor to Women during Childbirth Education.” The Journal of Perinatal Education, U.S. National Library of Medicine, 2006, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804305/.
