On reaching the second stage of labour, a woman can often feel under pressure to push and have her baby. Sometimes this is a physiological urge, Ferguson's reflex, but it can also be psychological. Images of births on film and TV generally show women being encouraged to push, and many women bring assumptions and expectations of directive pushing into their own labour.
The pressure she feels can be intensified if her midwife (and/or other birth attendants) is encouraging her to 'get on with it'. If we feel anxious about her labour 'slowing down', we will pass our anxiety to her. Unfortunately these days we don't often have opportunity to see women in labour without masking pain relief or interventions, and experience of the natural 'fetal ejection reflex' has become quite rare. Consequently we believe we have to 'make things happen'. We don't.
Women require time, unfailing support and encouragement as descent and rotation occurs to enhance her confidence and belief in her ability to give birth. Adequate hydration is necessary, cold water sponging of face and hands is refreshing between expulsive efforts.
Patience is a virtue
The key to a successful second stage is patience. The length of the second stage will depend on position of the fetus and whether or not a long or short rotation occurs; the length, strength and frequency of contractions and parity of the woman. A woman's body has an innate capacity to push out the baby at the right moment, and we have to learn to trust in this instinct. Encouraging her to push too early can exhaust her, as well as causing damage to her vagina. The evidence shows conclusively that directive pushing does not shorten the second stage, or improve fetal acid base outcomes, or produce higher APGAR scores.
Directive vs non-directive pushing
The most common type of directive pushing uses breath-holding to increase and focus efforts. This is commonly know as the Valsalva manoeuvre. It involves taking a deep breath, holding it and straining downwards. However, it can reduce the woman's oxygen levels, and increase her carbon dioxide levels, with corresponding risks for the fetus.
Studies have shown that maternal position in the second stage of labour is also significant because descent of the fetal head and maternal bearing down efforts are enhanced when positioning is upright. One benefit accrues from the other because an upright position encourages descent of the presenting part, which, in turn, augments the bearing down reflex.
Evidence to date concludes that there are no data to support directed pushing in the second stage of labour and that spontaneous pushing, with a much shorter retention of breath (5-6 seconds maximum, compared with the 10 seconds of the Valsalva manoeuvre) has greater physiological effectiveness. Furthermore, the natural blowing out between breaths that occurs encourages her pelvic floor muscles to relax and reduces the risk of tearing.
Women left to their own devices will choose a variety of positions during the second stage of labour and these are usually the optimum for their own comfort. Whether or not a woman feels able to adopt an alternative position will depend on the birth environment.
Tips and tricks
- Use the 'latent phase' to give her a break - the 'latent phase' of the second stage of labour can last anything from 5 to 30 minutes. It is a good point to encourage her to take a rest and gather her strength to have her baby.
- If she is not ready, stop her pushing! - altering the position to left lateral, or knee chest will diminish the urge to push by moving the baby's head off the perineal floor.
- Get her to relax her pelvic floor muscles - if she feels the urge to push prematurely, get her to imagine that she is blowing a light ping-pong ball up a small slope in front of her face.
Further reading
Beynon C (1957) The Normal Second Stage of Labour. A Plea for Reform in its Conduct.
Journal of Obstetrics and Gynaecology of British Empire 64 (8 ): 815-820
Bergstrom, L et al (1997) “I Gotta Push. Please Let Me Push!” Social Interactions During the Change from First to Second Stage Labor.
Birth 24 (3): 173-180
Caldeyro-Barcia R (1979) Influence of maternal bearing down efforts during second stage on fetal well-being.
Birth and Family Journal 6 (1): 7-15
Nikodem VC. Sustained (Valsalva) vs. exhalatory bearing down in second stage of labour. In: Keirse MJ et al (eds) (1995)
Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews. The Cochrane Collaboration, Issue 2, Update Software, Oxford
Odent M (2000) Insights into pushing. The Second Stage as a Disruption of the Fetus Eject Reflex
Midwifery Today International Midwife 55: 12
