Directed pushing is a common practice seen in-hospital-birth settings. While this technique is very helpful if you’ve had an epidural and don’t feel the urge to push, the technique is widely used in hospital-birth regardless of epidural anesthetic.
Research shows that routine directed pushing with breath holding during childbirth is not beneficial. Prolonged breath holding may reduce fetal oxygenation. The World Health Organization (WHO) recommends not directing someone in labor to hold their breath or consciously sustain pushing. The American College of Nurse Midwives (ACNM) recommends allowing the body to guide pushing. Clinical guidelines recommend that women should be guided by their own pushing urges during birth (National Institute for Health and Care Excellence (NICE) 2014).
So why do the majority of women in-hospital settings find themselves in this scenario of directed pushing in childbirth, often described as the “purple pushing” technique?
Over the years of attending birth I have seen the Fetal-Ejection-Reflex (FER) building in a woman, only to be taken away. The scenario is alway the same. The laboring woman starts to grunt at the top of her contractions, signaling that the FER is starting to happen. The provider notices her pushing efforts and intervenes by suggesting a unnecessary vaginal exam. Upon “discovery” she is 10cms, all the lights are turned on and the woman is asked to lay on her back, legs spread in a modified ‘McRoberts’ position as a team of hospital staff enter the room to prepare for the birth. Sometimes, if the hospital-provider is feeling generous, a squatting positioning in the birth bed maybe tolerated. The woman is then coached to hold her breath for 10secs 3-4 times during contractions while she bears down with all her might.
Unfortunately, the passage towards FER is inhibited by any interference with the state of privacy. It does not occur if the birth attendant behaves like a “coach”, observer, helper, guide, or “support person”. It is inhibited by vaginal exams, eye-to-eye contact, or by the imposition of a change of environment. It does not occur if the intellect of the laboring woman is stimulated by a rational language (“Now you are at complete dilation; you must push”). It does not occur if the room is not warm enough or if there are bright lights with lots of instructions and activity going on around her. Interrupting the FER in exchange for coaching increases the risk for certain obstetrical complications like shoulder dystocia, pelvic floor injury, postpartum hemorrhage, fetal distress along with hard pushing that can go on for hours.
So why don’t medical providers in hospital seem to have a simple understanding of uninterrupted physiological natural childbirth specific to supporting the FER? It is a question I ask myself every time I attend a planned-hospital-birth. Part of the reason directed pushing is utilized is that the hospital environment is built on “managing” labor and delivery, which is 100% what you want if you have a medical condition that is effecting the health of mom and baby. However, the management-model-of-care disrupts mechanisms of normal physiological birth. The physiology of birth mechanics are controlled by neurobiology and nervous system balance, which are both very sensitive to the surrounding environment. Surprisingly, he majority of caregivers in-hospital settings are not formally educated in normal physiological birth. The mechanisms of physiological birth are not formally taught in nursing school; and, while I am sure OBGYN’s must get some education in traditional physiology and psychology related to birth dynamics, their education is specific to surgery and how to managing high risk pregnancy. I remember talking to an OB years ago, in passing mentioned the fetal ejection reflex. It occurred to me they did not know its meaning. So I can not blame them in a negative way for what they do not know. Staging the room for delivery and directing pushing allows the provider to control delivery while being in the best possible position to manage unforeseen emergencies. The problem is that directed pushing can unknowingly cause complications by micro-managing birth when the mechanisms of the FER works better to help ensure the safety of mother and baby. Finally, directed pushing is the norm in hospital-based-birth. Hospital’s thrive on routines and protocols, which makes it easier for rotating staff and protects hospital liability.
However, when you interrupt the fetal ejection reflex you are taking away a woman’s power by telling her what to do and you are taking away her ability to push her baby out quickly and efficiently by allowing her body to do it for her. Instead you are replacing the fetal ejection reflex with potential hours of purple pushing that is not good for the long term health of the pelvic floor nor the wellbeing of the baby.
One of the arts within the midwifery-model-of-care for out-of-hospital birth is creating the conditions for the fetus ejection reflex. The wisest providers should sit on their hands offering stillness, sacred presence and let go of the need to DO anything during the pushing phase. Ideally, a woman should be in her position of choice and remain uninterrupted when the fetal ejection reflex is beginning to build. It is very easy to see it rising in a laboring woman just by simple listening and respectful observation. There is no need to do a vaginal exam if she is beginning to grunt at the top of her contractions. For there is a nerve bundle at the bottom of the sacrum that is triggered by the baby’s head creating pressure there, so the fetal ejection reflex can’t happen without her being 10cms. Even if she was 6cms only 45mins before the most intelligent thing is to allow the fetal ejection reflex to present itself and just catch the baby.