Monday, December 17, 2012

Mama Monday - Plan for Pushing

If there's one thing people think about when it comes to childbirth, it's pushing. We've all seen countless movies and TV shows that have scenes of fathers, doctors and nurses shouting at a distressed laboring woman to, "PUSH! PUSH!"

*Note: the rest of this post involves graphic language relating to female anatomy and the birthing process.

As with so many aspects of the birthing process, women often trust that when they get to that point in childbirth, the doctor or nurse will tell them what to do. I would venture to say that most moms-to-be put more thought, research and effort into choosing the right crib for the nursery than they do planning to properly and efficiently push their baby out!

There are a couple problems with this mindset. Firstly, nearly every nurse or doctor I have witnessed coaches moms incorrectly on how to push. Secondly, most moms are not offered or given the option of trying various positions to push their baby out. Let's tackle each of these issues separately.

Proper Pushing

Nearly every labor and delivery nurse and/or OB/GYN has coached my clients to "push like you're having a bowel movement." Well, contrary to popular and medical opinion, one does not push a baby out of her rectum. She pushes it out of her vagina. Though the muscle groups are similar and physiologically close together, they are not the same. The Ferguson Reflex (the urge to push) is often confused with the urge to have a bowel movement, so when a mom says, "I feel like I need to poop," those of us supporting her usually know we're getting close to having a baby. With that said, I would like to reiterate, pushing a baby out of your vagina is totally different than pushing a BM out of your bottom!

So, how DO you push a baby out? I've got a very simple exercise to help you know the difference between a BM and birthing a baby! It's called "Move the Shoe," and a dear friend and doula mentor of mine taught it to me when I first learned to be a doula. Here's how you do it:
  1. Lie on your back on the floor with your knees comfortably raised and spread apart (almost as if you were posing to push your baby out).
  2. Take of one shoe and place it on your abdomen, at or near your belly button. If you're currently pregnant, just place the shoe where it will balance and not fall off!
  3. Contract the muscles you would if you were having a bowel movement (not too hard :)). Notice, the shoe doesn't move.
  4. Now, try to move the shoe. If you're having a hard time, consider the following visualizations. 
    • If you have had a vaginal exam, imagine your doctor or midwife's fingers pressing against your perineum (the part of your vulva closest to your rectum), and try to push the fingers out. 
    • Or, and this may seem a little gross or weird (then again, we are speaking rather bluntly about pushing babies out of vaginas), but if you have ever pushed a tampon out, try to use the same muscles.
    • Another helpful way to think about it is the release of muscles used when doing Kegel exercises.
If done properly, you will move the shoe up and down, or even knock it right off your belly!

If you receive an epidural during labor, pushing will no doubt be more difficult. Besides the fact that you likely will not feel the urge to push, it will be hard to know if you are pushing correctly. Ideally, your epidural will be light enough that you can feel something. Another option is allowing the epidural to wear off before it is time to push so you can feel to push properly, but it can be very alarming to a woman who has had little to no sensation of childbirth for some time to all of the sudden feel the full intensity.

Pushing Positions

Just about everyone has a visual concept of what a woman pushing a baby out looks like. It probably involves a woman lying flat on her back or semi-reclined, with her feet in stirrups or held by her husband and nurse, while she grimaces, screams and pants. And, of course, everyone around her is screaming, "PUSH! PUSH!"

There are a couple of problems with this picture, namely the physical position the mom is in for birthing. Because of the way the tailbone curves upward in this position, the birth canal is not a straight shot for baby to exit. Unless your knees are spread wide and pulled up very high in order to move the tailbone out of the way (most women are not this flexible), you will not be able to open the pelvis wide enough to be able to effectively and quickly push your baby out. Often this is the main reason women report pushing for hours and hours. In this semi-reclined position, the head of the baby actually has to be pushed up and over the tailbone before fully emerging out of the vagina. All of my clients have pushed at least a certain portion of the time in this position and most of them were successful in birthing this way. However, it can often take longer than necessary.

For many women, if they have opted to receive an epidural, this is their only option for pushing. Since they have little sensation from the waist down, they must have the support of the bed and others to help hold their legs. However, it is possible, if the epidural is light enough (or you stop the drip and allow it to wear off) and your practitioner is comfortable with it, to assume some if not all of the positions described below.

The following positions better adapt to the pelvic anatomy and utilize gravity to more smoothly birth the baby:
  • Sitting upright. If you are in a hospital, the foot of the bed can be lowered or removed and the head of the bed can be tilted far enough forward that the bed looks more like a throne. In this way, mom is able to sit full upright, with her bottom at the end of the bed so that the nurse, doctor or midwife can still have access to assist with the birth. You can also sit upright on a birthing stool or in a birthing pool if these are available to you. This position helps move the tailbone out of the way so the mom can more effectively push.
 childbirth, pushing positions, tulsa doula, honeybee mama
  • Squatting. Every hospital bed comes equipped with what is called a "squat bar," though these bars are rarely, if ever, stored in the birthing rooms. If you ask a nurse she can get it for you. With this attached to the bed, the birthing mother can grip the bar and squat in her bed. This gets her upright like sitting in the throne position, but also opens her pelvis even further with her knees and legs spread wide. If a squat bar is not available, mother can assume a supported squat by dangling in between the open legs of her partner. Squatting is also comfortable while birthing in water.
  • Kneeling or Hands and Knees. As discussed in some of my other posts about childbirth, being forward in a kneeling or hands and knees position is often a very comfortable way to labor. For pushing, the mother can easily bear down and not have to worry about the tailbone being in the way because gravity naturally helps bring baby down and out with the curve of the tailbone. Mom can lean forward on her hands, a birth ball, or the head of the birthing bed. Also, if the baby seems to be more on one side or the other, creating a cervical lip, mom can kneel with one knee or the other and lunge in order to help remove that lip.
  • Side Lying. Lying on one side, the mom's doula, nurse or partner can help support her leg or she can rest it on the stirrup of the hospital bed if it's positioned correctly. In this position, as with the others, the bed is not blocking her tailbone from swaying to move out of the way of the descending baby. 
When writing your birth plan and discussing it with your health care provider, be sure to inquire about birthing or pushing positions. Ask whether or not you will have the freedom to try one or more of these alternative positions while pushing. While some doctors are not comfortable with positions other than the semi-reclined position with support, others are happy to allow you to assume the most comfortable and effective position for your birth. Often, doctors do things the way they do because they are accustomed to it and because no one ever asks them to do it differently!

At Honeybee Mama, I'm committed to getting you the tools and resources you need to make informed decisions about your birth. If you're looking for help preparing for your birth, consider The Birth Experience Childbirth Training, or schedule a consultation today!

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