Updated: Aug 31, 2020
In the past decade, much has been published and shared about the benefits of physiological pushing as opposed to the disadvantages of coached pushing. However, considering the current situation of birthing individuals in the Western world, it is still relevant to clarify the differences between these two forms of "getting a baby out" of a vagina, and why this matters for both birthing mothers and babies being born. Also, birth attendants must consider their role in the birthing space to interfere as little as possible in this process.
It is likely that the tendency to coach women to push started as a continuation of the medicalization of birth. When one considers old pictures of women giving birth in different areas of the world and at different times, rare is the picture depicting a woman lying on her back to get her baby out. Usually, she will be in an upright position, such as in a supported squat, or pulling against a cloth hanging from above (a tree, for example). Those births were usually attended by the traditional midwives in the community and other women belonging to the mother's inner circle of family and neighbors. It is difficult to imagine somebody else telling the birthing mother how or when to push in those situations.
Consider now a more modern mainstream image of birth, after the inclusion of male doctors first into the home birth setting, and later on, moving into hospital facilities. The laboring woman is usually on her back (lithotomy position), unable to stand up and move. She has probably already received at least one cervical exam, to determine how dilated her cervix is, what station she is in (where the baby is in relation to her pelvis); she may have received drugs either to induce or augment her labor; she may have received drugs to deal with the pain. In this medicalized scenario of birth, the understanding is that birth must be managed and that the woman needs help to get her baby out.
In the technocratic model, birth is seen as a mechanical process, where a certain number of things must happen so that another set of things will happen. In this model, there is a notion that labor and birth happen in stages: the first stage being the labor process, the second stage is the pushing (actual birth - baby coming out) and the third stage being the birth of the placenta. However, as Rachel Reeds explains in her blog Midwife Thinking, this is but an illusion. Dilation and effacement, and baby descending into the canal do not necessarily happen in order, they may all happen at the same time. Yes, there is a change in labor when the birth is imminent and the head (or butt) of the baby is pressing down into the vaginal canal, which will be discussed further in a bit.
Many myths have arisen from this view that birth must be timed, managed, and done with. For example, if birth attendants are performing cervical exams routinely to determine dilation, and they proclaim it is time to push once birthing mothers reach 10cm. When women are coached to push without feeling the urge to do so, it is probably because the baby hasn't rotated yet and is not in a position for birth yet, or because the mother's body needs some extra time to reset and prepare for the actual birth. 10cm does not equal pushing. Prolonged time in this "stage" is observed when women are bound to beds, not encouraged to change positions, or simply rest, and are encouraged to rush themselves, hold their breaths and PUSH when they're told to. Other problems may include avoidable tears in the vagina, not to mention the hormonal shift at that moment, since the original cocktail of birth hormones will have been messed with.
Another way to interfere with this stage is to tell a woman NOT to push when she is feeling the urge to. This has been observed when (hopefully) well-meaning birth attendants will perform cervical exams and discover that the laboring mother is not fully dilated yet, or they will find a "lip". Now, the question is why are birth attendants still performing those exams routinely in mothers when there is enough evidence to prove that they enhance the chance of infections, for example. As Dr. Reeds teaches us, a real pathological cervical lip hurts, and the mother will say it hurts near her pubic bone. This is a rare occurrence, of course. Most proclaimed lips are non-pathological and should be left alone if found. Mothers who are told not to push may feel discouraged and with a sense that they cannot trust their own bodies.
On the other hand, works by French Dr. Michel Odent and Australian Dr. Sarah Buckley on the hormones of labor and birth suggest that not interfering with the labor process is what will guarantee the most desirable outcome for both mothers and babies. They coined the term "undisturbed birth", a concept that is crucial to understand why physiological pushing is ultimately ideal. With this understanding, the process of labor and birth is seen as an intricate dance of hormones, especially oxytocin, melatonin, beta-endorphins and catecholamines. These hormones will be secreted appropriately thus guaranteeing that the birth unfolds as mother nature has intended it to, including the pushing phase. The Fetal Ejection Reflex, FER, is ignited once all these hormones have played their part in this intricate hormonal dance.
This reflex is only observed when women have labored feeling safe, private and unobserved, or, in other words, undisturbed. Even women in situations of coma have been reported to eject their babies out. It is now understood that for a woman to give birth intuitively and efficiently, she must not engage with her thinking analytical part of her brain (the neocortex). On the contrary, she must be able to be present with the intense sensations of labor so that she will know what to do: how to move and make the sounds that help her access the deeper parts of her brain - her mammalian self. When women are not being told where they are in the process or being coached what to do, and they can feel their bodies and their babies, they will simply know how to push when they are feeling the urge to.
It is a known fact that during the labor, the upper part of the uterus, the fundus, gets thicker to be able to push the baby out, which is what enables FER. When birth is imminent and either the head or the butt of the baby is descending into the birth canal, the woman may feel like she wants to poop because of the pressure in her rectum. If she is not being coached to push, this uncontrollable sensation takes over and her baby will be ejected.
When we understand that the birthing woman is the only one capable of getting her baby out and is the central piece in the birth process, then what is the role of trained birth attendants? First of all, I believe that all birth attendants must be trained in normal physiological birth without interventions. Unfortunately, most labor and birth medical personnel (doctors and nurses alike) are trained in a paradigm of pathology, despite all the evidence available nowadays to support normal physiology. Also, rules and regulations on birth facilities, but also on midwives, have made it more difficult for respecting the process without interfering (examples would be routine cervical examinations, fetal heart tones also routinely which disrupt labor).
It is possible for birth attendants, especially midwives, to learn how to be with a laboring woman so that her process is undisturbed. Even if we are trained and educated to solve problems, those problems are usually not present in undisturbed births. Most problems in the birth process arise because of interventions, even the slightest such as bright lights, strangers in the birthing space, or distractions such as direct questions to the laboring mother or undesirable touch. More than being trained in emergency situations, which can arise, but are very limited when the woman is birthing undisturbed, all birth attendants must practice to simply be a witness and to be able to recognize the progress of labor by other means rather than using their hands or machines. This way, women will be pushing when they feel the urge to, and FER will be witnessed more.
Being trained in the autonomous midwifery model of care, placing the woman in the center of her experience, and not being a figure of authority but rather a facilitator, a supporter and a guide, is a great way to start seeing real change in the birth world today. By developing a relationship of trust and love during the prenatal period, it is more likely that the woman will give birth undisturbed as well. Even when some fears come up for the birthing mother at this point (just as in any part of her labor), but specifically fears around safety during the actual birth of the baby, the loving witness will just reassure her that she is safe and loved, thus creating and supporting the sacred space that she needs to birth her baby the way nature has intended her to, surrounded by love and trust.
BUCKLEY, Sarah. Dr. Gentle Birth, Gentle Mothering - Chapter on Undisturbed Birth
Rethinking the Pushing Stage, with Whapio:
The Birthful Podcast: Episode #195