pushing out our babies, do we need someone to tell us how?

[happypoppy]

I am a student midwife and am interested because there is loads of research that shows that that midwives should not be 'directing' women how to/when to push (like taking big breath in and holding it etc..) as that actually might cause harm to the baby (it gets less oxygen) and may cause mothers to have worse tears.
We are taught that it is best to let a mother push if she wants but that the baby will be born anyway because of the expulsive contractions (and I have seen this quite a few times) but where I work most of the midwives still command the women HOW to push and that they should do it a certain way and often actually SHOUT at the women and tell them they are not pushing strong enough or in the wrong place!
This makes me a bit mad as I feel it undermines our confidence and belief in our ability as women to deliver our own babies!
And basically I was interested in finding out what you all think about it! (a waffly post, I'm not good at short and sweet!)

Hi Happypoppy,
This is something that i've wondered too. If women can give birth in a coma, then why does a birth that is otherwise progressing normally need assistance from a midwife telling the woman when and how to push? Surely the expulsive contractions would ease the baby out in its own time? (particularly if the mother had no urge to push yet)
What would happen if we didn't push the baby out till we had a real urge to push, it wouldn't just stay in there would it?
I'm very confused by this issue and wonder if it has existed because of women not having the urge to push due to epidurals etc.
Has anyone here had a natural birth (i.e no epidural) and NOT had the urge to push?
What happened then?

hi,
what year stu m/w are you? i am a fully fledged m/w and i remeber questioning this when i first began and had seen some beautiful homebirths (& on delivery suite) where the women instinctivley seemed to know how and when to push, but i have seen an awful lot of labours where the woman just wasn;t pushing effectively or fighting against the pushing and screaming and thrashing around and for them some direction for pushing helped as helped them to focus and know they were 'doing it right'.
so i do feel directive pushing does have a place in the delivery room (wherever that may be) but i also agree that with the older generation of m/w for some of them this is how they were trained and its very difficult to change a practice that they have been using for a number of years.

also form my perosnal experience the mothers who instinctively knew what top do and did it, have mainly been multips.

liznay- i do think that the baby will 'just come on their own' but for some women the experience and feelings of the descent of the head into the birth canal is very frightening and i have seen many women totally lose control at that point.

how ever this all sounds negative on my part but i do feel directed pushing does have its place and has 'saved' many a woman from ventouse or forceps delivery.

I wonder if with some women who didn't feel the urge to push it is because they were not ready to and if they were left abit longer they would get it?

Thankyou for replying! I posted that wee one before I saw your replies! I qualify in march next year. I am doing the 18month course as I was a staff nurse before.
It is good to get someone with benefit of more experience than me!

the problem women and midwives face on delivery suite id the time scales imposed on them both, i have seen and have done myself is stretch the times that are imposed on us, giving an extra half hour/hour where you can see progress but know the docs would be in with their scalpel quick sharp.

i don;t recall seeing someone who didn;t have the urge to push (unless an epidural was on baord)but just genuinley didn;t know what to do when that time came and maybe wasn't in tune with thier body enough to do whats the body was asking her to do.

congratulations on reaching that half way point, i loved being a student it was a greta time and one where i truly felt able to question practices as protocolsa s you can coem across as they not understanding cos your a student point of view

And from mums who have so much first hand valuable experience!

I can only relate my own experience, but with my DS the mw asked me if I felt the urge to push and I said I didn't know - she directed me to push anyway. I spent several hours pushing HARD in all kinds of positions but didn't progress and was transferred to hospital. My contractions intensified during the ambulance ride and then I felt the urge to push.

I was quite shocked, looking back, that I had been told to push earlier as there was no mistaking the urge when it came. With hindsight I think they were trying to help me get DS into the right position, but at the time this wasn't made clear and I thought I was trying to push him out. It was very demoralising thinking that all my efforts were failing to expel my baby, I started to feel that I couldn't do it. Whereas once I got to hospital and felt the urge to push, there was no doubt that I could and would.

Sorry, this probably makes no sense! I suppose I'm saying that in my case the directed pushing should have been more clearly explained.

I have just had baby number 3 and the birth was fab. I felt so in control and just seemed to know how to do it (although the midwife did have to take the gas and air off me to mak me concentrate)! Birth number two was similar, but with number 1 I hadn't a clue. Well they do say practice makes perfect!

WIth my first birth I was told to stop screaming and start pushing, and I did need someone to tell me that because at that point the pain had just taken over and I didn't really know what to do. Once I started pushing, it was easy.

My second two births were homebirths where I did simply follow my body and push.

Hello Happypoppy

My BF has just graduated as a midwife and she is very much of thr mindset that she is there to support the lady and not to order her about, babies come in their own time and their own way.

She was present at DS's birth and noted that I was being urged to get the baby out faster! I was being compelled to consider an oxytocin drip to speed the birth up. BF was able to assist me with essential oils and massage. DS arrived 4 days after my 1st contraction and 6 hours after admission to the mat unit.. He was a slow starter, I think he was having a good explore of his new environment IYKWIM.

I was very confident about my ability to have the birth I wanted. I discharged myself from the delivery suite 2 days before as I didn't feel happy with the situation and felt I was being compelled to have a textbook delivery rather than my planned experience. I was also fortunate enough to have my community midwife delivering my LO so we had a good relationship. BF was supportive and encouraging and will make a superb MW if allowed to continue this approach.

And I am the arch queen of the waffly post Best of luck with your course.

I am eternally grateful to the MW who let me push for 3 hours until the baby came of his own accord. I am equally grateful to the subsequent 3 MWs who delivered my other 3 children for their direction. I believe this is what made the difference between stitches and no stitches (and in no way a reflection on me ).

One MW was quite short with me, but it did make me focus on what I was doing. I found it useful to tune into their voices and shut out everything else. It focussed my concentration and determination.

Also, when doing anything strenuous, we quite often hold our breath or 'forget' to breath. So I think there's a bit more to it than simply being told how to push IME.

I am a midwife and in my final module as a student wrote an essay on why we shouldn't direct pushing and how it has been shown to shorten the second stage by only a few minutes and be bad for the baby and the mother etc. But here I am telling mums how to push all the time - big lungful of air, push into your bottom, keep going, quick breath, and again..... You do see more progress this way so it is like a positive feedback loop - but it is mainly primips who haven't made good progress pushing in their own way for a little while that we direct. Also have the time limits on pushing and senior midwives expecting you to give the directions. I don't know really - all sounds good in theory but some women do want to be told where and how to push as they feel they don't know what to do.

But there are ways around the timescale thing aren't there, how often are women informed that the hospital will want you to have birthed your baby within 1 or 2 hours of full dilatation being confirmed yet there is no evidence to say this is best practice? Informed choice often seems to stop at this point IME. Also how many times have you seen an instumental delivery caused by the vaso vago hypoxia seen on a CTG caused by enforced directed pushing? Just a couple of thoughts really, I guess it does have a place in rare case, but on the whole the time scales really need to be reviewd to offer holistic and indiviualised care.

I agree about the timescale thing. its silly. there is evidence that says that as long as she is monitored and the baby seems ok, the second stage can be more than 5 hours without causing problems for mum or baby!

Hello HappyPoppy

Pushing is something I feel strongly about and I've written about my experiences on other threads!

For me, it would definitely have been helpful to have some better guidance BEFORE labour ie: through antenatal classes, on how to push. The midwife at my first birth was fab btw, could not have been better, but my experience was that when you are in labour, it's often too shocking and scary to really take everything in.

The big thing for me was the difference between first and second stage. First stage I had gas and air, and coped really well by breathing through the contractions, mentally 'going into another zone' and riding above it all. I dilated to 10 cm like this - yes, it was painful, but nothing that I felt was unbearable. Then the midwife examined me, I was taken next door into the delivery room (this was a small midwife-led unit so only one delivery room) and then it all got manic. As someone described earlier, feeling your baby actually descending into the vagina and knowing it's going to come out can be hugely painful and frightening and this is the point at which many women do feel very out of control. It's also the point at which rather than 'riding above' the contractions, you have to work with them, pushing the baby out. This was the biggest shock to me, because pushing hurt, I was frightened of injuring myself and therefore held back rather than push. I also had the gas and air taken away to help me concentrate.

What would have been incredibly helpful to me was is someone had really got through to me the fact that second stage is hard hard work, a lot of physical effort. Also that when the midwife says 'Push into your bottom' it is exactly that. I think I still somehow expected the pushing to be different from having an enormous poo - and it really isn't!! I was in second stage for over two hours, and found it pretty horrendous really, but I think it would have been a good bit shorter had I known how to push.

I cannot fault the midwife - she was amazing and eventually after two hours they called in a GP as they thought they might need forceps. The doctor got gowned up ready and the midwife helped me through two last pushes and the baby was born naturally, thank goodness, as I'm sure forceps without epidural would have hurt even more than pushing the head out myself!

My first birth was followed by a CS, and then a VBAC, where I actually went to the other extreme and pushed very very hard as soon as I was fully dilated, and the baby shot out causing a second degree tear. I think the one thing I remembered from first time was that although it would hurt, I shouldnt fight against the pushing because it would take longer. However, in retrospect, the midwives/doctors should have handled things better and guided me through a slower delivery. I was in a big regional hospital due to the previous CS, where I found the midwifery and general care levels were awful compared to the midwife-led unit.

So - a long story, but yes, I think a supportive midwife who can help the woman to stay in control and help her through is essential, and preferably the mother will have had useful guidance before labour about second stage.

and i agree that it should not be simply about being TOLD how to push but i think midwives should work harder at encouraging us women to be confident in ourselves and in our power to birth our own babies, then mothers might feel more in control whereas sometimes it IS all about TELLING and DIRECTING rather than supporting and encouraging.
bit controversial? just thought I'd stir it up a bit!

findtheriver Hi! yes I have read some of your other posts! thankyou for sharing your experiences (good work beating the Dr to it! love it when that happens!) that is a very good point about antenatal classes/information.
You are right about the big poo bit! Did you have the urge to push though when you were at it for 2 hrs?

I agree wholeheartedly with that happy. The midwife at my first birth was incredible. I was a gibbering wreck at second stage, but she really worked with me, helping me to feel that I could do this. She just seemed to strike that delicate balance between enabling me to feel empowered to give birth, but also directing me when necessary. I got quite hysterical with pain at one point and she calmly moved me into different positions, each of which helped at the time.

Interestingly, I had a long talk with the midwife a couple of days later while still in the unit, and she told me that she had previously worked in a large hospital and found it far less satisfying. There was more of a conveyor belt mentality. She felt far better able to use her talents in the midwife unit, and it was obvious that jobs in the unit were seen as the ultimate goal for midwives.

It's left me feeling very much that where pregnancy and birth is striaghtforward, it really SHOULD be left to midwives. They are the specialists. Birth doesnt need to be a hugely medicalised process involving anaesthetists and doctors. Obviously sometimes that's needed - my second birth was a classic case where I had IUGR and was under consultant care from about week 24. A CS was absolutely the correct decision for that baby. But I honestly think you can't do better than a midwife when it's straightforward.

In answer to the last post happy, I think I was so exhausted and in a state after two hours that I never really got the urge to push, at least not as some women describe it. I did realise though that I just had to trust the midwife and with the next contraction just take a deep breath and push down into my bottom - which was what I'd been fighting against!

I don't remember a real urge to push with the VBAC either tbh. The room had filled up with doctors and students as they were just about to take a blood sample from the baby's scalp as they were a little worried about his heart rate. They got my legs up in stirrups, started to prepare me and at that point I went beserk screaming, my DH remembers the doctor saying'Oh my god the head is right here' and with that I pushed like mad (screaming at them to get my legs out of stirrups too, so hardly the optimum birth position). I was pretty angry and upset after, as I felt the doctor should have been aware of how close I was to giving birth. In fairness I think I dilated from about 6 to 10 cm very quickly, but I did feel that the birth was mismanaged, and I have to say I think that's largely down to being in a big impersonal hospital where I'd had frequent changes of midwife, so no contuinity of care.

For my first labour it was pretty text book and I did have an urge to push but wasn't getting anywhere, the midwife then told me to push as if I need a poo and that worked wonders, then I could just get on with it.

Also I thought you had to be told to wait once head came out for shoulders to turn, or else, as my friend did you can rip.

My second labour was at home and the midwife was upstairs getting my DH out of bed when I realised I needed to push, and that baby would have been out midwife or not if she hadn't 0run down stairs!

The HOOP trial found very little difference in perinial truama with midwives hands on or hands off for birth of the baby's head. IME some women are just seem to be more genetically pre disposed to perineal trauma than others.

noonki, sorry miss read your post, there is a natural lul in contractions after birth of the head that would allow the shoulders to "turn" thus preventing pushing whilst the shoulders were in the transverse position

Hello happypoppy and well done for getting to the half way point.

Happypoppy said "and i agree that it should not be simply about being TOLD how to push but i think midwives should work harder at encouraging us women to be confident in ourselves and in our power to birth our own babies, then mothers might feel more in control whereas sometimes it IS all about TELLING and DIRECTING rather than supporting and encouraging.
bit controversial? just thought I'd stir it up a bit!"

I TOTALLY agree with this.

To the other midwives who have posted on this thread who feel there is a time and place for directed pushing - yes, there is, and it's in a labour ward where you are working bloody hard to keep the doctors away from the door who want to wheel the forceps trolley in. Midwives work under very difficult conditions in trying to achieve a normal birth for the woman they are looking after and time constraints is a major factor in why some midwives feel that directed pushing is a good thing.

Women should be better prepared antentally and should have good support in labour not having time limits imposed upon her second stage and should not be told how to push. She should be encouraged to go with what her body IS doing already and to not be frightened of that.

To be honest, the only type of "directino" I would consider giving a woman in the 2nd stage is to encourage her to relax into the pushing that her body is already doing and not to hold back.

Obviously the above applies to women who are
un-epiduralised. However, even with an epidural - there's directed pushing and then there's cheerleader pushing which I ABHORE! There is NO PLACE WHATSOEVER for this type of American "take a deep breath, put your chin on your chest (urgh) and PUUUUUUUUUUUUUSH PUSHPUSHPUSHPUSHPUSHPUSHPUSHPUSHPUSH KEEPITGOINGKEEPITGOINGKEEPITGOINGKEEPITGOINGKEEPITGOINGKEEPITGOING" etc etc in labour. You can direct pushing for a heavily epiduralised woman without this sort of nonsense.

Good on you for questioning this practice Happypoppy and good luck with the rest of your training.