When and How to Push during Labour & Delivery?

Pushing in labour forms the second stage of labour. This phase occurs after the cervix dilates completely and the head is ready to exit the birth canal. A well-synchronised pushing effort by the mother enables a smooth passage of the baby.

This article shall help you understand the science behind pushing during labour and things to be careful about.

How to know when to push during a delivery?

Complete cervical dilation marks the end of the first stage of labour, and with this begins the second stage, wherein you are ready to push your baby out. The baby’s head when ready for delivery at the vaginal canal can be perceived as a natural indicator for a woman to exert pushing force in her lower body region. The urge is so strong that pushing becomes a natural and necessary response for relief.

Increased pelvic floor pressure, heaviness in the genital region, amplified blood circulation together trigger the active stage of labour.

Contractions while pushing

In the active(pushing) stage, the fully pregnant uterus contracts strongly every five minutes, each lasting for 45 to 90 seconds. It might not be easy to identify true contractions. Contractions are usually forceful and may or may not be associated with a desire to push. It certainly feels different when your baby travels down the birth canal. At this moment, stay calm and let nature welcome your baby into the world.

How Do You Feel When Your Body Urges You To Push?

With the baby’s descent, mothers’ feel the weight and a strong urge to push sometimes even before they are fully dilated.

It is important that your baby gets delivered safely rather than quickly. Each stage of labour takes its own time and is necessary for nature’s process to complete. Usually, women in the pushing stage may feel various types of urges:

Strong urge: An uncontrollable urge, a feeling like your body is experiencing the baby coming. It is hard to resist. A gravity neutral position may be helpful in this situation.

Normal urge: Women may feel like pushing with every contraction or at the peak of contractions. It can be best controlled by changing the position and breathing until you feel a strong urge.In selected cases, the baby may just move down easily and you will not experience any strong pains.

Absent urge: It is possible that a woman may not feel any urge to push. Time and position are critical here. If dilatation is complete for more than 30 minutes following which, one may consider an instant urge to push by herself or direct pushing that is directed by another person.

How Long Does Pushing Take During Labour?

The pushing stage lasts up to a few hours in women giving birth for the first time. And in those who are giving birth for the second or subsequent times, the pushing stage can last for as less as 10 minutes. In general, it can take a few minutes to some hours. The pushing time varies depending on the following factors.

First delivery or subsequent delivery:The pelvic floor muscles are tight if they have never been stretched to accommodate a baby. Stretching is slow and steady, and therefore takes time. If it is a subsequent delivery, it will take lesser time to push out your baby. Women who have had multiple deliveries can push just once or twice because the muscles have already been stretched out previously.

Pelvic structure: The anatomy of the pelvic apparatus varies amongst different women. An ideal shape is an oval-shaped pelvis. Some pelvic outlets are small but most babies manage to pass through them. In rare cases, the pelvic outlet is too small for the baby to get delivered. Such cases of disproportion usually prolong the delivery and might be associated with birth complications.

Baby Size: A few babies have large heads, with oversized cranial bones which overlap on each other during delivery to accommodate through the birth canal. In such cases, the baby’s head may be elongated and termed as a “caput”. This usually normalizes sometime after birth.

Alignment of foetal head and the pelvic apparatus: The normal position of the baby during a vaginal delivery is head as the presentation, with face towards the mother’s back or the sacrum. This is termed as the anterior position.

In certain cases of vertex presentation, the baby may be facing towards the pubis, the posterior position, which requires manual rotation of the baby while delivering.

Labour force: It is the effort with which the mother pushes the baby out. Uterine contractions are vital for cervical dilatation. Without any of the two, delivery isn’t possible naturally. Synchronized contractions with adequate dilation facilitate a smooth delivery.

How to push during labour?

There are two types of labour pushing techniques:

1.Coached Pushing: Coached or directed pushing is where you are directed how to push during the delivery by your health attendant or midwife, once your cervix is fully dilated. It is carried out irrespective of whether you feel any urge to push or not. Few experts believe that coached pushing may be hazardous to both the mother and the baby.

2.Spontaneous Pushing: This is considered to be a safer and more natural way of pushing during labour. In this method, the mother starts pushing only after she feels the urge to push out the impending baby through her vaginal canal for relief. This method is advised and preferred by doctors, and it is also documented to be safe by various competent authorities.

How is coached pushing done?

The second stage of labour begins when the cervix is fully dilated to 10 centimeters and goes until the delivery of the baby. This phase may go on for hours and this is when the coaching takes place.

• Taking a deep breath before each push or contraction, you should bear down the pressure, keeping the muscles of your abdomen taut. The effort is similar to that felt during hard stools.
• Pushing can be done to a count of ten. Two to three pushing efforts for each contraction may be adequate and fruitful. It is important to coordinate pushing with the baby’s descent in order to prevent tearing.

Why is coached pushing done?

A prolonged second stage of labour might be detrimental to the baby’s survival. Coached pushing helps reduce the duration of the second stage. Hence in indicated cases, it is now widely applied in deliveries around the world.

Prolonged second stage of labour can be estimated as per the guidelines of the American college of obstetricians & gynaecologists. It states that a second stage more than three hours without epidural, and two with epidural is prolonged for primi mothers. While it is 2 and 1 hour respectively for multigravid mothers.

There are recommendations to go for a C-section, assisted labour techniques like vacuum or forceps if the second stage is prolonged. It may be managed without intervention if both the mother and the baby are comfortable. However, coached pushing is advisable in order to avoid intervention and a prolonged second stage.

Pros and Cons of coached pushing

According to a 2006 study, which assessed about 300 women undergoing normal delivery without epidural anesthesia, found that there wasn’t any significant difference in the pushing stage of both, coached versus spontaneous pushing groups. Neither the mother nor the baby had any significant benefits according to the study.

A higher risk of urinary problems was reported previously by the same research team in women who were offered coached pushing. Spontaneous pushing did not have any adverse effects reported.

Coached pushing was also associated with one or more of the following:

• Higher likelihood of episiotomy or perineal damage.
• Mothers’ had a higher risk of damage to pelvic tissues and/or urinary apparatus.
• Exhaustion and malaise in mothers – the push takes up plenty of energy needed later when you have an urge to push.
• Features suggestive of foetal distress.
• Higher requirements of C-sections and assisted deliveries.

How is spontaneous pushing done?

In this approach, you are allowed to push only in response to the contractions and urge you feel from within. It is a more natural way of facilitating delivery by the mother. You may follow these steps:

• As contractions start, breathe deep and complete, while preparing yourself for the pushing efforts.
• Continue breathing with each push. It is normal if you are making loud grunting noises. You should keep breathing every five seconds until the urge is no longer felt. You shouldn’t be holding your breath for long.
• When the contractions are over, relax while breathing easy and awaiting the next contraction for you to sync while you start pushing.
• When the urge is felt again, you may start to push for a few seconds during the peak of contractions.

As the baby’s downward movement occurs and pressure on the pelvic floor increases, you will want to push more frequently and strongly during contractions.

Pushing the baby out in Labour With an Epidural

Epidural anesthesia will numb your pelvic region and this will greatly affect your efforts. Without a sensation in the pelvic area, an urge to push is difficult to perceive. It is scary for first-time mothers’ as they aren’t used to it. At this point of time, if your cervix is felt to be fully dilated on a PV, you will be asked to push. If it is the correct time, there may be some pressure felt on the pelvic floor.

One should watch for the contraction to peak and then push to sync with the uterine contractions. The baby’s position may also be determined at this stage. The effect of epidural may fade off in certain cases, giving the urge to push again. If the birth canal is adequate for the baby and the contractions persist, the baby will constantly keep moving down and out. This is also referred to as labouring down.

It is advisable to acquire and get into a suitable position to push. It is to be done at regular intervals, thrice per contraction or whenever the urge is felt. You might be tired in the procedure and may take intermittent rest.

Best Pushing Positions During Labour

Various positions have been advised in order to aid a safe delivery. The tense abdominal muscles significantly help the uterus to push out the baby.

The position you take has an important role to play in progressing your labour, especially sitting and squatting positions, which is aided by gravity. If you are delivering too spontaneously, you may try some other positions, like lying on a side or getting on your hands and knees, to neutralize the effect of gravity.

• Squatting position: It helps widen the pelvic region to its maximum width, that is up to one to two fingers width. It also requires less bearing down to push. Gravity has a significant role to play. It’s quite helpful to mothers with no urge to push. It helps Improve baby’s descent in a difficult delivery.

If you find squatting position difficult, you may try a semi-squatting position on a stool or heap of cushions or pillows. Birthing beds with pre-fitted squatting bars that are comfortable are also available.

• Sitting Position: This position provides good rest. It is usually done with foetal monitoring attached. Gravity plays a key role. Leaning forward is permissible, which helps the woman relieve a backache.
• Semi-sitting or Upright Position: Gravity again helps here. You may try pushing against your partner’s hands kept against your lower back by tilting motion of the pelvis. It helps pelvic cavity to stretch to its maximum width. This can be done with the foetal monitoring alongside. It also is a relaxing position. In this position, a vaginal examination is also made easy.
• Getting on Hands And Knees: Gravity isn’t dominant and therefore a quick delivery is prolonged. It may help relieve back pain by correcting the baby’s alignment. It helps turn the baby from the posterior position.
• Lying on One Side: Provides good rest and permits vaginal examinations. This position may be done with foetal monitoring. It could help avoid an episiotomy.

You may try individual positions and choose a comfortable position.

Techniques for Breathing while Pushing

Breathing adequately will let you be in comfort and avoid distress. Correct breathing will ensure efficient muscle contractions. You will acquire the adequate oxygen supply for subsequent contractions.

• Mouth open and jaw flexed: For adequate abdominal and perineal muscle contractions, you should keep your mouth open and jaw flexed. This also helps increase the volume of air taken in while breathing.
• Place your hands on the fundus: Keep your hands on the highest part of your abdomen. This will facilitate the pushing down efforts.
• Breathe easily regularly and exhale completely.
• Let go of all the spontaneous sounds. For a few women, holding a breath makes pushing easier. Such females may hold their breath during pushing but not for long periods.

Tips to help you push your baby out

A few important and simple tips to help you push your baby out is:

1. Push like a hard stool: Relax your body and breathe well. Focus just on pushing down, irrespective of whether you pass urine or stools during the same.
2. Touch your chin to your chest: While on your back , try to keep your chin towards your chest for pushing. This helps towards a focused push.
3. Switch positions: If the push is not effective enough, trying different positions may help.
4. Relax: Do not panic while pushing and stay calm.
5. Push your best: The more effectively you push, the more strength you will gather, and the quicker you can have your baby delivered.
6. Rest adequately: While waiting for the next contraction you should simply rest and rejuvenate.
7. Push with your instinct: Nobody can guide you in pushing better than yourself. It is you who knows the best time to push.
8. Witness your milestone: Watching your baby get delivered can give you an adrenaline rush and motivate you. You may request a mirror. Remember that the baby’s head may appear transiently as pushing is an intermittent job.
9. Push downwards: You won’t experience the terrible flushing of the face, fullness in the head or tightness of the chest if you are focusing well and pushing downwards. Focused contractions of the lower abdominal muscles like one do while urinating.
10. Scream: Pushing requires intense strength and you can let the world know what it takes to deliver. Yelling out simply keeps you going. You should instead make deep and long sounds, helping to push downwards.
11. Touch your baby: You can touch the baby’s emerged head to feel and guide your push. You will feel the baby sliding out.
12. Use the loo: If you have not passed urine, it is sensible to do it before pushing.
13. Breathing right: Breathe easy and comfortably. This helps you push for a longer period without getting exhausted.

What if Even After Pushing Hard, Your Baby Doesn’t Come Out?

In some cases, your baby might not be delivered despite adequate pushing. Though you did put in all the energy, it may just not pop out, leading to fatigue. This will further weaken your subsequent pushing efforts and make delivery even more difficult.

Your baby at this stage requires correct positioning. After two to three hours of pushing efforts, your clinician may decide to deliver using instruments while you carry on with pushing. Forceps or a vacuum device are usually employed, but only after the baby is visible. The clinician will route the baby correctly while you push, but would never pull the baby out.

What If You Don’t Feel The Urge To Push?

Even after being fully dilated, it may happen that a woman doesn’t feel the urge to push. Changing positions is one of the easiest things to do at the earliest, to develop an urge to push. If you have been supine for long, try and stand up erect, enact how you get into the tub, brisk walking, lunges, etc. Sitting on a birthing ball can be of some help. It may help you feel the urge quite quickly.

Even after changing positions and walking, you fail to generate an urge to push, then there’s barely anything more you could do. If you feel comfortable and the baby is moving correctly, try to rest and calm down.

If you wish you may attempt bearing down a bit and see if it helps. Women sometimes don’t feel an obvious urge to push and bearing down during contractions help. This little push may trigger an urge to push and you might shortly deliver.

How To Reduce The Risk Of Tearing

It is important that mothers’ know how to push during labour without tearing. After acquiring a correct position for labour, having a good perineal support is of utmost importance for minimizing the risk of perineal tears and birth-related genital injuries in the mother.

• Start kegel exercises and daily perineal massage during the mid-pregnancy. These can help strengthen the perineal musculature for the shearing stress of delivery. Various other techniques may be used during the time of delivery to protect the perineal region intact.
• While the baby descends, warm compresses may be applied to the perineum. It relaxes the area and helps reduce the pain and inflammation. A massage with oil is also given to the perineal tissues to help lubricate the area as it stretches.
• If you’ve got existing perineal problems, you should inform your clinician. She will ensure adequate perineal support.
• Certain cases may need an episiotomy. Tears are said to be better than episiotomies as they damage only soft tissue and hence heal faster. Episiotomies involve skin and muscular layers that can cause scarring and urinary incontinence later on.

When is Episiotomy needed?

An episiotomy is a surgical tear made at the posterior vaginal wall to enlarge the birth canal and facilitate the baby’s head to deliver. Previously it was believed that every delivery should receive an episiotomy. Around 70 percent women experience a natural tear of vaginal tissues while giving birth.

Following are the conditions when an episiotomy is considered :

• Tissue tears that involve delicate parts like urethra and clitoris.
• Foetal distress indicating urgent delivery through the vaginal canal.
• Non-progressive labour: Excessively delayed second stage.

Episiotomy cannot be predicted, but certain factors that can help prevent episiotomy are:

• Balanced and nutritious diet.
• Gentle periodic vaginal stretching around four weeks prior to delivery.

Pregnancy and Labour are both natural processes, which your body gets well adapted to by itself. You should be aware of the phenomena in order to stay calm, avoid mistakes, and have a good experience of childbirth.