Coached Pushing vs Physiological Pushing
Photo from Jenna Nord, click through for her website!
This is my third post on physiological birth. If you’d like to read the first two, on hormones and on what could hamper physiological birth, click the links!
I’d like to talk a bit about another aspect of birth that should be physiological but for some reason is often “taken over” by others in the birth room: pushing!
I’m sure you’ve seen depictions of this in TV and movies even if you haven’t experienced it yourself: a woman lying on her back with people yelling at her to “PUSH!” I know as a doula I saw it a lot in hospital births. A nurse would often count to 10 and encourage the woman to hold her breath, tuck her chin to her chest, and push.
If this is a routine occurrence in modern birth, women need to know about the benefits and risks of pushing physiologically vs coached pushing. The impacts of coached and physiological pushing affect women on all levels: emotionally, physically, and spiritually.
By holding the space as a provider for a woman to enable the connection to her own body and her own inner voice during pregnancy and birth, and encouraging a deep and trusting relationship with the woman over time, we will see better outcomes in all areas than we would see in a scenario where the woman was coached to push and not listening to her own body, while also feeling disconnected from her provider.
What is coached pushing? What is physiological pushing?
Coached pushing is usually seen in a setting where the care provider “manages” the birthing process. This can happen at home or in the hospital, where a provider encourages a woman to push (usually while laying on her back) by telling her exactly when and how to push, usually while holding her breath and counting to 10.
Physiological pushing is when a woman gives birth and expels the baby according to her own body’s signals. Sometimes there is not pushing at all and the baby is expelled by fetal ejection reflex. Other times a woman feels an irresistible urge to bear down and does so with no timing or coaching or restrictions put in place by external voices.
Why providers might suggest coached pushing.
Time limits - some birthing environments or care providers place restrictions on how long a woman is “allowed” to be in labor “safely.” After a certain time of the woman’s waters being open or the woman reaching full dilation, the care provider determines that the baby must come out so they encourage the woman to push regardless of whether she feels the urge to or not.
Elizabeth Perry in an article in Midwifery Today says, “Some midwives are required to transfer a planned homebirth to hospital if the birth is not imminent within two hours after full dilation. This … causes practitioners to feel they need to determine when the mother is “ready to push,” and then proceed to teach and coach her on how this should be done.”
A mechanical understanding of birth - some care providers don’t really understand the “unseen” or “immeasurable” processes that occur after full dilation and before pushing. There’s a reason that there is a pause in the action after full dilation sometimes.. Whether that’s so the mother can rest and recoup her strength before she initiates expelling the baby or so the placenta can do some work expelling waste and not being compressed as much by contractions… or unseen psychological, spiritual, or emotional processes that take place in the mother or the baby! We can never really know what needs to happen before the baby can come out in an aligned way.
Their own anxieties or baggage- care providers sometimes have anxiety stemming from past client experiences or their own birth experiences and don’t trust the baby and the woman to have their own plan and idea of how to best birth.
Other times the care provider is tired and wants the birth process to continue to “progress” in a concrete way so they can get home and rest sooner.
Other times there is just not the patience and trust in the process and they are anxious to get to the “exciting” part.
Not fully trusting in the woman and the baby and the process - whether this is from listening to the baby’s heart rate and making a judgement that it is in distress and needs to come out asap, or some other reason that the provider feels they know better than the woman and baby.
Gloria Lemay on her website WiseWomanWayofBirth.com talks about the head molding that needs to take place as the baby comes through the birth canal. “This shaping work often takes place over time in the midpelvis and is erroneously interpreted as “lack of descent,” “arrest” or “failure to progress” by those who do not appreciate art.” I think this is another way that providers don’t trust the process..
How could we ever think we need to dictate what a woman should do with her body? Especially during birth.
The woman is numbed from epidural anesthesia or other narcotics - In this scenario the woman is not in touch with her own bodily sensations and in the case of an epidural, she can’t feel the lower half of her body, including her vagina/vulva or where exactly the baby is within her own body. Since the lower half of the body is not sending signals to her brain, it can not send the signal “It’s time to push,” and the woman probably does need either help determining when she should push OR to have her epidural turned off and to wait to feel sensations in her lower body so she can determine when to push on her own.
Effects of coached pushing vs physiological pushing
Physical
For mother - more severe tearing and having to heal from that while parenting a tiny baby (which affects the beginning of motherhood journey).
During coached pushing the yoni fills with more fluid than it would during physiological pushing, which creates a water balloon effect where the tissue is distended and full of fluid and more easily prone to tearing or breaking during the forcefulness of coached pushing.
An article in the journal Obstetrics & Gynecology summarizes a study done on 3rd and 4th degree tearing in women giving birth in a hospital setting. Women were either randomized to a group where they were told not to push during the crowning of the baby’s head vs another group where the women were coached to push as they normally would be in that setting.
The women in the coached pushing group were 3.4% more likely to suffer 3rd or 4th degree tearing (into the anus) than the women in the group where they were told not to push.
Other physical effects of coached pushing can include lack of oxygen intake from holding your breath (this, as you can imagine, affects oxygen flow to the baby as well), broken blood vessels in the face from straining so hard, not to mention potential lifelong negative effects like pelvic floor trauma and weakness, uterine prolapse, or incontinence.
Side note, leaking urine, which so many moms talk about as just a fact of life after children, is not a side effect of having a baby in a physiological way!
For baby - forcing the baby through the birth passageway perhaps before it is physically ready can mess with the hormonal flow that usually happens for the baby, can deprive the baby of oxygen which can affect blood pH levels, and can cause other physical stress or shock upon birth.
Emotional
For the mother - Coached pushing can be stressful because external voices are yelling or talking loudly at her. This can trigger a trauma response or lend the mother to feeling out of control of the situation, which leads to less satisfaction with the birth experience.
Emotional processing of the birth experience takes place at the beginning of the journey into motherhood, when caring for a tiny baby is already stressful enough.
This can also challenge the woman’s confidence in her own body, even on a subconscious level if she’s not completely aware of the effects on a conscious level.
An article on the AIMS Ireland website (AIMS = Association For The Improvement In The Maternity Services) shares a story of one woman who was coached to push by her midwife,
“I only have one child but the pushing bit was quite hard for me. I had a brilliant midwife my entire labour but found she totally changed during the pushing bit. I was on my back with feet in stirrups and it was like military precision of when and how I pushed. The lovely midwife turning into a drill sergeant screaming really low and loud to push and get angry at my baby and body. I hated every second of it. It made me feel really stressed and like a total failure. I pushed for an hour and a half before the doctor came in and sent me for a section.”
For baby - Babies experience all the same emotions as the mom on a hormonal level, but who can really say what sort of emotional impact coached pushing can have on a baby long term? A more emotional mom after birth who has to heal from a traumatic experience does lead to a higher stress response in the baby after birth, which means a fussier baby and less overall growth than a baby/mama who are not in a state of stress response after birth.
Spiritual
For mother - Coached pushing can lead to disconnection from her inner voice and her body’s innate signals, can lead to an out of body experience (or just pull the mama out of her heart space and into head (aka ungroundedness), a lack of trust in herself and her body’s and baby’s ability to “do it”..
Taking a woman out of her power during the intensely spiritual experience and rite of passage that is birth leads to a woman disconnected from her power at the beginning of her journey into motherhood as well, and then she will have to uncover or rekindle that spiritual connection while also mothering a small child which is more difficult than if she were to just be empowered the whole time.
Plus the spiritual process of having to deal with a “broken” yoni (vaginal tearing) and whatever that entails.. Women have a sense of identity in the way their body looks and feels including the physical appearance and feelings within their yonis.. Feeling like that space is broken or “dead” or disconnected somehow can affect our spirit and be its own spiral journey of healing.
For baby - Babies have their own spiritual journeys to come into their bodies at birth.. Forcing a baby through the birth canal against its will or its natural flow is the first act of violence against a baby.
It disconnects them from their own spiritual process, which I can imagine is scary and a challenging entrance of their soul into their body..
Maybe this is part of the reason so many people now feel that they aren’t in their correct body or why we see so many humans who don’t seem to be “in their bodies” and grounded? Because the process of entering it was so disturbed from the natural flow?
Suggestions for women to keep in mind for their own births
Try to foster the connection with your inner voice and with the baby during your pregnancy so you have that strong bond with both should you find yourself in a situation where coached pushing is the norm.
Practice saying no to care providers and standing in your ground. Feel free to kick anyone out of the room who isn’t listening to your desires to remain connected to your own process. If they persist, connect with the baby and mentally tell them what is happening and that you will be waiting on the other side for them to help complete the stress cycle.
Tune everyone out and do what you want.
Learn the reasons why upright birth and physiological pushing are best for women and feel grounded in that knowledge so you can advocate for yourself if you need to.
Choose a provider who will be willing and engaged in getting to know you on a deep level during your pregnancy and will respect your desires to give birth however you want in spite of anything else going on, and hold them to that.
“When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding superiority of spontaneous versus Valsalva [coached] pushing, each woman should be encouraged to use her preferred and most effective technique.”
So you can always tell your provider this if they are trying to coach your pushing! Or ahead of time would probably be better so you don’t have to advocate for yourself while you’re in the middle of the most intense part of your birthing time! :)
How we can hold the space as care providers for women to have the time and space they need to listen to their bodies and experience physiological pushing?
As care providers, we need to be patient and to appreciate the bigger picture: we probably have no clue about when and how this baby needs to come out! Let them take their own journey :)
We also need to take care of ourselves during a birth in case it turns out to be long, so we have reserves and don’t get impatient or tired and tempted to rush the process at any point.
We need to trust in the baby and the woman to give birth how they need to in this moment in time, and always default to doing what the woman wants regardless of what other risk factors are present or what other picture we have in our heads. Building this trusting relationship over time during pregnancy is absolutely crucial.
Closing Thoughts
After a century or more of coached pushing and management of the labor process being the norm, we are now having to encourage the re-education of women on how to be connected to their body and their inner knowing during birth so they can give birth in the best way possible for them and their baby. This includes education on the differences in coached pushing vs physiological pushing, which can affect women in many different ways! It goes much deeper than just the physical aspect of it, but also the emotional and spiritual as well. And it affects the baby in all these ways too, of course. Fostering that deep connection to ourselves as birthing women, our inner voices, and our bodies and the baby during pregnancy can help give us the tools we need during birth to avoid any of the complications that may arise from coached pushing.
Care providers are not left out of the re-education equation either. Birth is best left un-meddled with, and that includes not forcing the woman to abide by our own sense of what is right or the best way of getting the baby out as a provider. We need to all work on curating our desire to connect on a much deeper level with these women and babies who honor us by asking us to walk with them during pregnancy and birth and postpartum. This will help us tune into our own inner knowing as well, which hopefully leads us to place ultimate trust in the woman giving birth, her baby, and their own unique journeys.
Birth Video Showing Physiological Pushing!
Click through to watch on YouTube :)
Birth Video Showing Coached Pushing!
Click through to watch it on YouTube. If you pay attention in the beginning of this video, too, there are so many things that are done that go against what normal birth is.. The nurse even pushes the woman’s cervix “out of the way” without asking for consent or explaining risks vs benefits, and only tells the mom what she did after the fact. But I digress.. the coached pushing starts at 7:15.
