Pushing During Labor: More Isn't Better

Let's call this the "push paradox." See why coached pushing may not be the best thing for you when you're in labor.

woman in labor
Photo: Gorodenkoff/Shutterstock

Conventional medical wisdom says the best way to send your baby out of the womb and into the world is with "coached" pushing: When your birth attendant announces it's time, you tuck in your chin, tighten your abs, pull back your knees, take a deep breath, hold it and push for a count of 10, bearing down in this manner two or three times during each contraction.

But a growing body of research suggests the conventional wisdom may be wrong, and that the healthier strategy is to follow your body's cues and push spontaneously rather than following a coach's count.

"Plain and simple, coached pushing, especially with the woman on her back, can harm mothers and babies," says Amy Romano, C.N.M., a Connecticut nurse-midwife who contributed to the Lamaze International guidelines on care during the pushing stage of labor.

Several studies on coached pushing have been conducted in the past few years. Although not all reach the same conclusions, they suggest that the practice is more likely than spontaneous pushing to tire a laboring woman and make her less satisfied with her birth experience. The excess force of directed pushing may raise the risk of vaginal lacerations and episiotomies, as well as pelvic floor weakness, which can lead to incontinence and sexual dysfunction.

Pushing on command may also contribute to fetal heart rate abnormalities, lower blood oxygen levels in babies, and an increased need for such medical interventions as instrument-assisted delivery. (It can be helpful if you've had an epidural, however.)

RELATED: Stages of Labor: What to Expect When You Give Birth

A new take on pushing

If coached pushing is potentially harmful, why do as many as 80 percent of hospitals and obstetricians continue to rely on it?

"I think that a lot of what happens in the second stage of labor has been based more on tradition than on evidence," says Edmund Funai, M.D., professor of obstetrics and gynecology at Yale University School of Medicine. "But where we're heading now is to have women push when they feel like pushing."

Coached pushing may indeed shorten labor; one study found that the second stage of labor is, on average, 13 minutes shorter for women who follow the old-school approach. "But shorter is not intrinsically better," says Romano, who manages Lamaze International's informative Science & Sensibility blog (scienceandsensibility.org). "Shorter is only better if it protects the baby's health, reduces the mother's suffering or prevents the use of other interventions like vacuum-assisted delivery or Cesarean surgery. Coached pushing does not help with any of these."

With spontaneous pushing, a woman pushes when she feels the natural, normal urge to do so. "No one has to tell you to do it," says David Paad, a certified nurse-midwife at Special Beginnings Birth and Women's Center in Arnold, Md. "You feel the urge to push. The baby's head is pressing on similar nerves that cause you to have bowel movements." Women who push spontaneously tend to do it for five to six seconds at a time, five to six times per contraction, and their pushes are often accompanied by groaning or grunting.

Choosing to push without coaching is not the same as pushing without support. During spontaneous pushing, a birth attendant can still offer feedback, encouragement, and guidance—but without the rigidity of counting or directives.

"These should be done in a way that includes and supports the mother rather than overriding her instincts," Romano says.

If you'd rather avoid coached pushing, think about it well before you arrive in the delivery room. "Find someone who is familiar with uncoached pushing—a doula, a midwife, a childbirth educator—and discuss it with them," Paad suggests. Once you've educated yourself, raise the issue with your obstetrician, if you're using one. Although some are slaves to medical tradition, others are willing to consider fresh evidence and go along with the belief that during labor and delivery, women's bodies are usually their best coaches.

When you need a coach's count

Coached pushing can be helpful when you've had an epidural. Because an anesthetic numbs the nerves that are normally activated by the pressure of the baby's head, you may not fully feel the natural urge to push. The external prompts from a coach can be a good replacement for these urges.

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