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Birthing your baby: instructed pushing versus spontaneous, undirected pushing


In pro-natural birth circles, talk about ‘breathing your baby down’ has been around for a long time. But couples who are surrounded with medicalized births, often don’t know what this entails, let alone it’s benefits. What is undirected pushing during labour and how can it benefit both you and your baby?


Directed pushing

During the first stage of labour, dilation of the cervix happens, together with baby moving down through the birth canal and into a (hopefully favorable) position in which he can be born. The second stage of labour starts once the cervix is fully dilated, right up to the point where baby is born. Directed pushing means the healthcare practitioner, often a nurse or midwife, or obstetrician, will instruct the laboring mother to take a deep breath, block the air in her throat, and push, usually accompanied by counting. Pushing may be instructed to happen ‘three times per contraction’, or for a minimum of ten seconds.


Undirected pushing

Undirected pushing, or ‘breathing your baby down’ was first introduced by the Lamaze technique in the 1950s, and is wrongly interpreted by many people as not pushing during labour. Breathing your baby down means just as much as following the ques of your body, breathing through your contractions and pushing, and not pushing when there is no urge to. Research has shown that the natural urge to push usually lasts 5-7 seconds, in comparison to the 10 seconds that is usually instructed by healthcare practitioners. Here are some guidelines on breathing your baby down:

o don’t start pushing as soon as you are checked and told you are fully dilated. Give your body the time to warm up. Studies have shown women (if left alone) will go through a resting phase after being fully dilated, most likely to gather energy for the pushing phase.

o let the contractions build up in strength. Try to breathe through them without pushing for as long as possible. Your baby is moving down more and more with every contraction.

o when the urge to push becomes impossible to ignore, women will automatically, without being instructed, start pushing along.

o try not to hold your breath during pushing, but breathe out in a J-breath: focus and visualize the air going down, down, and away. At the last bit, push out all the remaining air with your diaphragm.


Benefits to undirected pushing

Lemos et al (2015) concludes that the pushing phase is shorter when a woman is pushing spontaneously, in comparison to instructed pushing. Another result showed that delayed pushing (waiting to start pushing until the urge is strong) resulted in a decrease of the duration of pushing of a whopping 20 min in comparison with immediate pushing (starting to push immediately once fully dilated)! Other maternal benefits include less chance of perineal trauma or to the surrounding pelvic muscles when pushing spontaneously (Albers, Sedler, Bedrick, Teaf, & Peralta, 2006). Directed pushing may lead to an excess of force that may damage perineal muscles and surrounding tissue, leading to problems that may last for months after birth, and even increasing the risk of incontinence (Schaffer et al., 2006).

When it comes to baby, spontaneous pushing increases the amount of oxygen flowing to the baby. This can only benefit baby, as he is subjected to much pressure during a contraction. Some studies also show there are fewer abnormal heart rate patterns when a mother is pushing spontaneously, which can possibly be contributed to the increased oxygen.


Implementing this practice in your birth

None of the research shows benefits to instructed pushing. However, it is still practiced frequently in healthcare settings. One of the reasons is that spontaneous pushing is almost impossible when the woman has an epidural. The most crucial element; feeling the urge to push and using that sensation to know how and where, is absent in most women with an epidural.

If you want to implement this practice in your birth, it may be a good idea to discuss it with your doctor beforehand. State it in your birth plan and communicate it with the nurses or midwives present at the day of your birth. When during pushing they still resort to instructing you, either you, your partner or your doula can kindly remind them you’d like to follow your body’s natural urge.

You can prepare yourself physically by practicing breathing during your pregnancy. Try out the J-breath while you have a bowel movement. Practice slow, relaxed breathing during a moment of peace and silence, like when you are listening to your birth affirmations or before going to sleep.

One of the ways to avoid having to resort to instructed pushing when having epidural analgesia (and possible instrumental delivery) is to have your epidural turned down once you are fully dilated, and wait for the sensation to return. This may take up to 30 minutes, but has no harm to either you or your baby. Once you have regained full sensation, it will become easier to spontaneously push your baby down.

In the end, you are in control. It is your body, your baby, your labour, your birth. Choose whatever feels best for you and surround yourself with a healthcare team who supports your choices and decisions!



References


Albers, L. A., Sedler, K. D., Bedrick, E. J., Teaf, D. & Peralta, P. (2006). Factors related to genital tract trauma in normal spontaneous vaginal births.


Lemos, A., Amorim, MM., Dornelas de Andrade, A., de Souza, AI., Cabral Filho, JE. & Correia JB. (2015). Pushing/bearing down methods for the second stage of labour.


Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M. & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function.


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