Unassisted Home Birth Australia
Pushing: Facilitating baby's emergence
Published 17 July 2021, updated 18 July 2021
At the end of labour, baby must come out!
(In fact, that’s how the end of labour IS defined - baby coming out!)
And you may wonder, how do I know if I'm 10cm dilated and ready to push baby out in a freebirth without someone to check me? How will I know when to push?
On TV, and often from experience, you'll see it portrayed as a Dr announcing "You're 10cm" and the woman laying on her back in a hospital bed urgently pushing and screaming as those around her count out her pushes. "One, two, three, PUSH"
Then, on the flip side, you may have watched on YouTube a calm video of a woman partially submerged in a birth pool, peacefully breathing her baby out into her waiting hands.
So which is it?
Frantic pushing or very little effort?
Someone telling you about your body, or you listening to your intuition?
It's different for every woman, but here's an idea of what you might be able to expect.
Stages of labour/hormonal stages
Let’s quickly review the stages of labour leading up to pushing. (Because unless you have a precipitous labour, it usually takes a good few hours to get to pushing)
In medical terminology, the stages are defined very simply.
I prefer The Holistic Stages Of Labour - please give them a read! Rachel Reed also has a similarly great description in one of my favourite books, “Reclaiming Childbirth as a Rite of Passage”. And Milli Hill lists 14 stages in her Positive Birth Book!
But today we will just briefly use the medical model for brevity and to avoid confusion.
Early Labor: This is the beginning of the birth process where much of the cervical dilation happens (1- 6cm). It generally lasts a few hours, but can last anywhere from minutes to days.
Contractions generally short, 30-60 seconds duration, and may or may not have a pattern
The pregnant woman may pause to breathe through contractions, and acts normally between them
A good time to eat, drink and rest
Active Labor: This is when the dilation process finishes (7- 10cm) and baby moves down. It generally lasts several hours and increases in intensity.
Contractions are usually closer together and last for over a minute
Mom vocalizes and focuses during contractions, and doesn’t want interruptions between them
She may close her eyes, and start to shed clothing
Don’t break her focus, but offer drinks with electrolytes, and firm pressure on her lower back or hips during contractions
Transition: A sudden and intense hormonal shift that prepares the uterus to expel the baby by +pushing down from the top, and retracting the last part of the cervix up into 10cm.
Contractions change in sensation
Mom feels nauseated, flushed, cold, vulnerable, overwhelmed or like she can’t go on
Lots of vocalisation, moving around, low pressure
There will likely be a pause in contractions at the end of the transition stage. It can be just one skipped contraction, or last up to an hour
Read our full article on transition - here.
Pushing/Emergence: This is when an adrenaline boost happens, the uterus contracts strongly, and the baby gets pushed out through the birth canal and into the world!
Contractions are strong
You may experience the urge to push
Or you may experience the Fetal Ejection Reflex - our article here.
So, what are the signs of pushing, and how will you know when to push? Should you check your cervix? Should you push hard, or wait?
Well, the way that labour has been discussed and measured and manipulated is purely for medical convenience. The timing of cervical dilation and beginning of pushing is based on a terribly flawed study (Friedman’s Curve ) and requires someone else always checking you and interpreting and categorizing you and trying to fit you into a mould.
"Our bodies were NOT designed to be only able to birth if someone else was there to tell us how to push our babies out. What a flaw that would be!" @naked_birth
All mammals know how to birth, and you do too.
You don't need to know your cervical dilation to know when to push. This is because the cervix dilates UP not out, as the fundus builds.
Your body will send you signals to know when to push, same as it tells you when to poop. It may even push for you!
If you focus only on the cervix, it becomes about the external, the person outside you becoming the expert, when really, you, the birthing woman, are the expert on your own birth.
(Sometimes, you may still want to check your cervix, even knowing it's *unnecessary* for birth. And that's your choice!
We have written up a full pros and cons, and a how-to for checking the cervix- here. )
Signs to push, or that you are pushing
Instead of checking your cervix, look within yourself for some of these signs
Involuntary bearing down
This is a common time for waters to break, though it can happen anytime in labour
Feeling the need to poop (this might be vocalised) (this is usually baby’s head quite low)
Feeling an uncontrollable urge to push
You might hold your breath or grunt during contractions.
Contractions come less often. But the contractions stay strong or get stronger.
Your mood changes. You may become sleepy or more focused
A purple line may appear between your buttocks as they spread apart from the pressure of the baby’s head.
Your outer vulva or anus begins to bulge out during contractions.
You feel the baby’s head begin to move into the vagina.
A desire to be upright
The desire to change positions suddenly and instinctively
Feeling like your pelvis is splitting open
Pushing at the end of a contraction or all through instead of at the start
What does the pushing?
So you’re pushing….but are YOU pushing? What does the pushing?
Well, the uterus doesn't just stretch thin like a balloon as it grows. It's a strong muscle that grows from about 60 grams to 800 grams or more. That is what does most of the work to get baby out.
The top of the uterus, called the fundus, gets built and tensed with every contraction. The cervix gets pulled up and more muscles join the fundus. And then, the fundus exerts great pressure downwards. This can be quite suddenly in response to FER being triggered by the baby’s head putting pressure on nerves at the inside of the cervical os.
It can also be slower, a natural urge that comes once the fundus has reached full tension.
The fundus can also be sometimes triggered to bear down if you start spontaneous pushing.
It’s best to let the uterus do the pushing - that’s what it’s designed and preparing to do.
But you can also push yourself, with your abdominal muscles. If done spontaneously and as a result of your natural urges, this is quite safe. But done through coached, “valsalva”, or “purple” pushing, you will be at increased risk of dystocia, tears, pain, lowered heartrate for baby, among other things.
(The uterus size is also another reason we put on weight in pregnancy, in addition to breast growth, the baby, placenta, amniotic fluid, 50% extra blood, fat to be turned into breast milk - please never feel bad about weight gained in pregnancy! )
Visual graphics of the uterus changing and the fundus building - @themidwives cauldron
Rachel Reed doing a video on the diagram above, includes description of labour (5 minutes - worth it!) @midwifethinking
Encourage the hormones/How to push
Don't push the river, it flows by itself
When pushing starts, this is the most exciting part of labour for a lot of women! You're about to meet baby! Just a little bit more work and it's all worth it.
Many body processes (digestion, gestation, lactation, and sexual release) work better with oxytocin than with adrenaline.
Focus on supporting the work not cataloguing the results.
Create an environment that oxytocin can flow freely. Don’t ask questions of the birthing woman that take her out of her altered, hormonal state and into her thinking brain. Make sure she is not disturbed by family, phone calls, cervical exams.
Measuring the cervix will not tell you how labour is progressing. Cataloguing it as being at 9cm will only tell you what it is doing right that second. Remember, “The cervix is not a zip lock bag. The purpose of labor is NOT the creation of an opening or a hole... The purpose of labor contractions and retractions is to BUILD the fundus” Carla Hartley
Often, after reaching full dilation, or during transition, the mother will have a “rest and be thankful” phase where your body rebuilds energy ready for pushing. This is a good time to rest and labour down ready for birth.
Instead of measuring or trying to work hard to make contractions strong, support the work the mother IS doing. Hydrate her ready for the work that WILL soon happen. Support her to move into a position she is comfortable in. Tell her you love her, that she is doing amazing. Kiss her forehead and tenderly stroke her back. Look into her eyes deeply and communicate your love for her and your baby, wordlessly and strongly.
Keep thinking “Oxytocin!”
The baby’s head pressing on the cervix creates a bio feedback loop. It also is creating oxytocin and revving up contractions. You are all working together! This is a true family birth.
Positions to push in
You may think you need to choose a position in advance. And it's true that knowing some positions in advance can help. But mothers do not usually need much help to position themselves or to push.
Their bodies push naturally, and when they are encouraged and supported, women will usually find the way to push that feels right and gets the baby out. Pushing can last for over an hour, or just a few minutes. This can mean a few position changes. Changing position is good as it helps baby move into ideal positions and keeps pressure on the cervix.
"When a person can tune to their birth instincts, the pressure and pain of childbirth will lead their movements. The weight of the descending baby inspires a position change and movements like shifting or rocking the hips, which will put the pelvis’s mobility to the work of releasing the child." Gail Tully, Changing Birth On Earth
Squatting
Kneeling
Hands and knees
Laying back (in pool or bed)
Half sitting
Lunge kneeling
On back
Standing
Side lying
Knees together (“What!?” you may say, but knees together with heels apart internally rotates the thighs. The sitz bones move outward and the space between them enlarges.)
"If the person catching the baby requires the birth giver to be on their back, a folded pillow tucked under just one buttock will raise it and allow room for the tailbone to open into the
space created between the mattress and the pillow. Some women will put themselves on their back, but they won’t stay there voluntarily unless they are showing solidarity to their birth team – in spite of the pain it causes – because they want the birth team to accept them. Her baby’s life may depend on a well-coordinated birth team. Her hormones direct the sacrifice as our socially oriented survival urge overrides instinct. Later, it may be a topic of regret, but most people won’t upset those people they depend on for safety." - Gail Tully
Choose positions that allow flexing of sacrum (near your tail bone). This makes spontaneous birth more likely. Avoid positions that put pressure on the coccyx.
Note: Squatting can bring baby down but is not ideal once pushing starts because this puts extra pressure on the perineum (more on that later).
Baby Position in Labour
Babies move in labour. They especially move during birth. They do not come directly out like the vaginal canal is a straight tube, but rather they need to navigate the birth canal and pelvic anatomy. There are common twisting movements they do, as they wiggle and rotate out. Their head needs to flex, and their shoulders rotate out from under the pelvic bone. Certain positions in birth will hinder baby’s movements out. This is one reason why the mother must move instinctively so she can feel what needs to happen to facilitate baby’s descent
Depending whether baby is facing left or right, or head down or a version of breech will all impact labour and emergence as well, some in a small way, and others more dramatically. Belly Mapping can assist you to know baby's position.
Variations and complications
Noise: Some mothers birth with barely a peep, and others roar their babies out. You are not a failure if you make a lot of noise! That is your primal side birthing
Tired: Some mothers may feel tired when their contractions get close together, or when it is nearly pushing time. They might think that they will not have the strength to push. This may be transition, or it can be the body’s way of conserving energy until it is needed. Rest as much as you can. Then, there is usually an adrenaline surge that comes to help you push.
Discouragement: Sometimes if you feel discouraged, reaching inside and touching baby's head can help you remember what this is all for, and that it won't be long.
Breech: The best position for Breech is hands and knees or kneeling, but breech water birth requires semi sitting because if the mother is on hands and knees, the baby can get caught on the pelvis as the body floats out. In this case, it’s best to work with gravity and buoyancy. It is normal for a breech baby to pass meconium as he is birthed.
Pushing too early and Cervical Lips: generally you cannot push too early. If you feel the urge, the cervix will be dilating, and the baby's head will help it dilate more. There is a small risk of cervical swelling or cervical lip, but this is low in a mother led birth. You also are unlikely to know unless you are constantly checking your own cervix. If you do end up with swelling or a lip, you can put your bum in the air to relieve pressure for a few contractions and reposition baby. You can also rub arnica oil into the cervix to reduce swelling, and stretch the lip back yourself. Rachel Reed has an excellent article on anterior cervical lips
Pushing for first time mothers: https://wisewomanwayofbirth.com/pushing-for-primips/
Stuck baby/labour: For a labour that is truly not progressing, a baby that is malpositioned, or struggling to make progress into the birth canal even with vigorous pushing, you need to be prepared to use Spinning Babies methods or the Miles Circuit. A well timed Inversion or Side Lying release could be just what you need.
“Forward leaning Inversion for the cervix, back pain, lack of application of baby’s head or lack of descent and so on. “Never go to surgery” until you’ve done a FLI." -Gail TullyHindrances: Sometimes, the hindrances are simpler than positioning. A full bladder can impede baby’s descent, so urinate frequently, at least every 2hrs. And exhaustion is a major one. Remember the uterus is a muscle, and it gets tired. Eat something, drink electrolytes, and try to rest as best you can before resuming pushing 15 mins later.
Fear and tension are also common. These inhibit oxytocin needed for contractions. Try to find ways to reduce the pain, and relax for a bit. Send everyone out of the room (except for anyone doing crucial counter pressure) and surrender to the process in a darkened room. Maybe repeat positive affirmations or visualise yourself strongly and confidently pushing baby out of a beautifully open cervix.Shoulder Dystocia: You will need to be observant for head turtling, prolonged crowning, and hypoxic baby as it is born. Use FLIP FLOP asap if dystocia is suspected.
Visible Cord: A cord prolapse, that is when the cord comes out of the vagina before the baby, is immediately concerning. Baby must be born within 3 minutes or transfer for help.
If the cord is around baby’s neck as it is being born, nuchal cord, this is generally not an issue, as it is wrapped in 30% of births to protect it from compression. Calmly unwrap it once baby is born.Bleeding: A small amount of blood and mucus is called “the bloody show” and a further small amount is normal during cervical changes or during crowning if perhaps the mother tears slightly. But what is not okay is large amounts of blood. This can signify a placental abruption or undiagnosed placenta previa and you will need to transfer or give birth immediately as the placenta is baby’s oxygen source.
Baby’s heartbeat: If you choose to listen to heartbeats, listen immediately after a contraction stops. Most baby heartbeats are 120-160bpm. If it gets above 180bpm or below 100bpm, and stays that way for a few contractions/several minutes, this could be cause for concern. Sometimes they might be slow for a minute, but then return to normal. It is OK for the heartbeat to be as slow as 70 beats a minute during a pushing contraction. But it should come right back up as soon as the contraction is over. You are looking for a pattern that might indicate distress such as the cord being pinched. Sometimes changing position will help blood flow return through the cord. If you are unable to resolve the low/high heart rate, you may need to transfer to be checked. (You will most likely find it difficult to listen once baby’s head is well engaged in the pelvis.)
Blood pressure: Low blood pressure, low pulse rate combined with other symptoms can be a sign of internal bleeding. High blood pressure and pulse rate can be a sign of pre-eclampsia or infection.
Meconium in waters: It can be normal to have meconium appear in the waters during pushing. Baby is getting squeezed! Check if it is old or fresh, and be prepared to assess baby immediately after birth.
VBAC: Chances of rupture are low, and even if you do rupture, 95% are not catastrophic, but still something to watch for. https://midwifethinking.com/2016/06/15/vbac-making-a-mountain-out-of-a-molehill/
Hypoxia: If pushing is prolonged, or baby suffers shoulder or soft tissue dystocia, the cord gets compressed in the canal. This leads baby to have a lack of oxygen. Some signs to watch for is turtling of the head, baby not coming out after the head is out, grey face or blue - although blue/purple is normal for newborns, they should pink up very quickly after birth. If they do not pink up or start breathing, you will need to perform neonatal resuscitation IMMEDIATELY.
Protecting the perineum
Preventing tearing and preventing perineal trauma is very important to a lot of women. A tear can impact your pelvic floor and intimate health for many months or years after birth. It’s important to know some things you can do to minimise your risk of tearing, but also to know that some of it is genetics, such as naturally having hydrated and flexible skin. You have not failed if you end up tearing and you tried to avoid it. The vulva is designed to heal and you can now focus your attention on supporting that healing instead.
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Breathing: As the head emerges, pant instead of push to slow the descent of the head and prevent tearing. Slowing down allows the tissues to refill with blood. However, this should be woman-led unless you specifically task someone to remind you
“The intense sensations experienced during crowning usually result in the woman ‘holding back’ while the uterus continues to push the baby out slowly and gently. In addition, women will often hold their baby’s head and/or their vulva during crowning. Some women will bring their legs closer together, not only slowing the birth but also providing more ‘give’ in the perineal tissues. Telling a woman to ‘stop pushing’, to ‘pant’ or to ‘give little pushes’ distracts her at a crucial moment and suggests that you are the expert in her birth. Instructing her to open her legs to ‘give the baby room’ contradicts her instinct to protect her own perineum by closing them.” Rachel Reed https://midwifethinking.com/2015/09/09/supporting-womens-instinctive-pushing-behaviour-during-birth/
Positioning: Certain positions, such as squatting, put extra pressure on the perineum, and may increase tearing. Hands and Knees spreads the pressure more evenly and can reduce the trauma to the perineum
Movement: Move instinctively. I know I said don’t squat, but if you need to, then you do that! Listen to your instincts in how to move.
Pressure: Applying pressure to the perineum can support the tissues and minimise tearing. Except sometimes in a first birth, for all subsequent births this is best done by the mother herself. She can also support near her clitoris instead, if the pain is near there.
Cloths/oils: Sometimes when applying pressure to the perineum, warm wet cloths or oil like coconut or olive oil are applied to the perineum to warm, soften the tissues, and lubricate the baby’s way out. You can apply yourself or have an assistant do it. Some mothers find this practice soothing and calming. Other mothers find it distracting and annoying. It is up to you. The benefits are minimal either way.
Ignore conventional wisdom of things like perineal massage. There is no science behind doing this leading up to birth. It can create micro tears and overall has no benefit. If you want to stretch your perineum, have regular penetrative sex. Your hormones in labour will soften and prepare the perineum to stretch, same as the hormones in sex.
Note: If birthing with a care provider, do not get an episiotomy to “prevent” tearing. You will be swapping the 2-7% risk of a severe tear, for the 100% guarantee of severe perineal trauma. Also an angled perineal cut goes through the crus of the clitoris
Healing afterwards: I have an article on this but in brief: first you need to ascertain whether it’s a first, second, or third degree tear, and then transfer for stitches if it's severe second or third. Then, support your body to heal it with nori seaweed strips, herbal sitz baths and perineal bottle herbal washes, and apply manuka honey after each urination. Witch hazel is helpful for soothing. Apply cold compresses for the first 24hrs to reduce swelling, after which use warm compresses to stimulate blood flow and promote healing.
Australian author and midwife Rachel Reed also writes about perineal protection on her blog and talks about it in her podcast
Blog post: The Perineal Bundle and Midwifery
Podcast Episode: Perineal Bungles
Podcast Interview with Rachel: Protecting Your Perineum