Second Stage Saboteurs: The Three Conditions to Optimize Pushing Power

I remember in vivid detail the exact moment that I stopped feeling confident in my ability to birth my baby without intervention. It was such a moment of deep despair, that despite my flat out refusal to have an epidural, I could very well end up with an episiotomy or worse, a c-section. I didn’t know how close I was to the truth of it, but perhaps that moment of doubt wouldn’t have happened at all if I’d understood physiological response in birth a little more, or if I’d birthed at home like I had originally intended.

You see, the reason for that self-doubt had little to do with my capabilities to birth my baby and more to do with the environment I was in, the policies that were set in place that I had not idea existed until it was too late, and the fact that I just didn’t know enough about my own physiology to understand why it was taking 3 hours to push out my baby! I wish I had known these things, and the theory behind them (I’m big on understanding theory so that I can better apply it and tweak it for my own unique circumstances)! Truthfully I didn’t get it until after my second baby, who was the same size, in the same position, and she cannon-balled out of my vagina in under 10 minutes after my water broke! I didn’t even have to PUSH with her; my body just took over. 

The births of my two children were similar on the surface being that they were both vaginal births of nearly 8 pound infants with big heads, who were both “sunny side-up” (ociput posterior) for much of the labor, with the bag of waters (membranes) intact until just before crowning. I birthed them both after many days of prodromal labor, though my daughter was the one to really test the limits of my patience while my son only gave me a small hint of what that experience is like. I didn’t use any drugs (except the entonox gas with my son) and they both were born alert and ready to nurse at my breast.

However, there were three things I did differently with my second birth, mostly unconscious, that resulted in a much faster, easier second stage of labor. Once I experienced the phenomenon of the “fetal ejection reflex” I realized exactly where I went wrong with my first birth and why it had taken 3 hours of me struggling and swearing “leave me the fuck alone” on the bed, while the nurse and midwife yelled at me to just PUSH! I once had the belief that first-time mothers just tend to have a harder time pushing their babies out, but then story after story came up over the years of homebirth with first-time mothers who experienced the same fetal ejection reflex I had with my second baby. Were they superhuman? Did they have a more powerful uterus? Should I have drank more red raspberry leaf tea, or done more spinning babies exercises, or done something else to make my body more primed for birth?

Put simply, NO.

To quote Ina May Gaskin, “your body is not a lemon”. We were made to birth our babies, and much of the mythology of the “incompetent female pelvis” has been debunked and harshly criticized. “Failure to Progress” is a term coined by doctors who don’t actually understand birth physiology, or simply fail to wait for birth to happen on its own, in its own time. “Failure to Progress” was also something that my birth might have been labeled as, had I not hired a fierce midwife/advocate who didn’t bow to the patriarchal medical system so easily. 

In the end, ultimately I pushed my son out before my body was ready for the birth to be over, risking a tear because I was up against “the clock” and the medical system was tapping its foot impatiently all the while. But had I known ahead of time how to protect my birth, even in the hospital, perhaps I might have been spared those grueling 3 hours where I started to wonder if maybe I was losing the battle and should just give in and have a cesarean even when I didn’t want one. 

So you’re probably wondering where I went “wrong” and how you can avoid it. Well, here’s what 6 years of reading, talking with my many friends in birth work, and having my own children taught me.

Environment Matters

If you have ever had a pregnant cat then you might have noticed that they tend to choose their own birthing environment, even if you’ve set up a little box for them in the closet. Some cats birth on the beds of their people, others hide under the bed. My own cat was restless in her labor and hadn’t wanted me to leave her side the entire time. I wound up sitting on the floor with an old blanket wrapped around me, while she hid under it at my feet. We sat there for hours, and I didn’t dare move. Eventually my husband got tired of waiting and wanted to check on her progress. Without any warning he whipped the blanket off her, exposing her to the light and we saw that she had just birthed a kitten. He was still attached to his placenta, and unfortunately the disturbance of the birthing process caused my cat to quickly hide under the bed to birth her second kitten. The little orange firstborn was then neglected as she tended to her second kitten, and he didn’t make it through the night.

I often think of this story when I consider the birthing environment, and how critical it is to not introduce any stress into that environment. This lesson continued to be taught to me in my own labors which stalled each time I started to feel anxious or stressed, only to pick back up when everyone left me alone. In my first birth I had been making steady progress all night and the surges had been very intense at home, but then I went to the hospital (where I already didn’t feel safe) and I was pronounced to be “only” 4 centimeters dilated. Knowing what I know about the cervix and physiological birth, it is entirely within the realm of possibility that my dilation had reversed itself by the time I got to the hospital. It was after I requested the gas and got into the tub that labor picked up again and I started to feel myself open up, and I hit transition around 7pm. In that time, no one had disturbed me and I might have been able to birth my son on my own had I not been in the hospital under the watchful eye of the nurse. I knew I wasn’t “allowed” to birth in the tub, but that didn’t stop me from trying. This is the point where my birth was disturbed, because the gas was ripped from me, the tub was drained, and I was practically forced out of the bathroom to get onto the bed. My entire labor in the tub had been peaceful and undisturbed, and then suddenly that peace was shattered in an instant. Anxiety set in, and someone else was telling me what to do and undermining my instincts. 

With my second birth, in contrast, I still had that intense labor in the water. I still hit a very intense transition period lasting 2 minutes. The difference was that there was no hovering nurse to interfere and I was able to remain in the water where I wanted to be. The only “stress” was when my water broke, and it came from my husband not knowing how he would “catch” the baby. I remained calm, because I knew I could trust my body and didn’t need him to “do” anything. I also realized, in that moment, that I didn’t need to do anything either, other than breathe as my surges came and brought my baby down and out. She was crowning before the midwife arrived, and I couldn’t believe the difference not pushing had made for me!

Push ONLY when you have the urge, not before

Every single movie and TV show with a birth has a mother being told to PUSH like her life depends on it. Every episode of “A Baby Story” had nurses counting to 10 and birthing mothers on their backs being told to hold their breath and push. I had been taught during my birth classes that “mother-directed pushing” was best, but nobody told me about the option of not pushing. I had been led to believe that once I was “complete” it was time to push. Being in the hospital also motivated me to try to push before they could pull me from the tub, so in a way this was kind of my own self-sabotage as well. 

Pushing before you have the urge isn’t very productive, and in the hospital it was downright dangerous from a perspective of avoiding interventions. By pushing too early I put myself on the clock before my body was actually ready to start the fetal ejection reflex, or even signal me to push. I had no surges, no real urge to push, but in my mind I thought “well, I don’t feel a cervix anymore so I should probably work on getting this kid out before they notice what I’m doing”. I had never heard of the “rest and be thankful” phase that can sometimes happen in a long labor, so it never occurred to me that maybe I might just take a little nap. Truthfully though, I don’t think that would have been “allowed” either. I had already refused cervical exams twice, and from what I now understand of the hospital culture in my area it would have been constant pressure for me to comply and accept another exam. 

Unsurprisingly, because I wasn’t actually ready to push, it took 3 hours on the bed. I pushed with very little progress for the majority of the time, feeling more anxious as the hours passed. I was strapped to the fetal monitor, which I have now learned can also be a hindrance in labor and birth. In the final hour I made the most progress, and the surges were coming on strong enough that I could tell exactly when I needed to push. I focused on what my body was telling me and after a particularly strong surge my water broke! After that, it was much easier and I paid attention to whether or not I needed to push or if I needed to pant through the surge and let my body stretch. I was mindful to avoid a tear, and when I was told to push before I felt the urge I resisted. It was at that point I was threatened with the episiotomy.

In contrast, the birth at home was fast! I might have had a slight reflex to bear down during transition, but it wasn’t the forceful pushing that I had been instructed to do in the hospital and had been more of a feeling of letting my body “open” and surrender to the sensations. I didn’t even realize that birth was happening until my water suddenly broke and the head was already on its way out. I couldn’t believe the difference!

Birth in the position your body wants you to

I had spent several labor classes learning that being on your back was an out-dated practice and that birthing upright was better for me and for the baby. I understood about how being on one’s back constricted the blood vessels. I knew that the pelvic outlet would be wider in a squat or on hands and knees. I had been led to believe that the hospital I wound up birthing in supported upright birth, but the reality is that the majority of births in hospitals across Canada happen with the mother on her back. This is despite over a decade of evidence that this practice is restrictive and harmful, leads to more “stuck” babies, and more “failure to progress” cases. I feel that in telling women the evidence, but then not doing those things that are said to be more beneficial, we set them up for a huge disappointment that can lead to traumatic birth, and more interventions than are really necessary. 

I didn’t find out that I would be on my back to birth until the moment I was pulled from the tub and made to get on the bed. My body was telling me “lean over the bed, squat down” and the nurse was telling me “no, you need to get on the bed, and get on your back”. I lay across the bed, trying to get on hands and knees. They made me “lie on it the right way”. I lay on my side, trying to push (before my body was ready) and because it wasn’t working and the nurse couldn’t get a good reading on the heartbeat I was made to get on my back in a reclining position. Technically I was semi-sitting, but I kept trying to climb higher up the incline of the bed and they kept pulling me back down, and finally they had my husband hold one of my legs. I was strapped to the fetal monitor and then that was it for trying to get into a more optimal position. And yes, it felt like I was trying to push “up-hill” the whole time. 

With my next birth I chose my own position the whole time because nobody was there to tell me what to do. I started out on my hands and knees, but the angle at which my daughter was coming prompted me to lean back in the water, ironically in the position that had been so difficult on land. I learned in that moment that choosing one’s position as part of the birth plan isn’t ideal, not because you won’t be “allowed” but because your body picks the position for you. You can study the different birthing poses and practice them, if you like, but ultimately when you’re left to your own devices in labor and birth you will automatically assume the most comfortable and effective position. 

Obviously it’s much easier to birth at home because the environment is already in your control, you can decide how much “help” you want, and you aren’t on any arbitrary timeline or subject to any hospital policies. That said, if you hire a supportive care provider and know how to advocate for yourself, and your birth partner also knows how to advocate for you, then you may be able to birth just as effectively in the hospital. You can also, as a consumer, let your preferences be known to your local hospitals before you choose to birth there. Ask them how often mothers birth in a position other than on their backs, strapped to a fetal monitor. Mention that you plan to be on your hands and knees in a tub or in a nest of blankets and pillows on the floor, and see what their response is to that. If they say “that’s not allowed” then that’s a red flag that they will probably try to take over and force you onto your back. If that’s the case, let them know that you will be looking for alternative birthing locations (if at all possible) and tell them why. 

I have been immersed in the doula and midwife community for six years now, and the common theme I saw come up time and time again was that they have done so much to try to change the system from the inside, but encounter a lot of resistance. Many doulas burn out after a few years because they are constantly having to fight for their clients in labor and birth, and nothing seems to change. Midwives, nurses, and even some supportive obstetricians have been writing articles, speaking at medical conferences, and urging their colleagues to offer evidence-based care and support a birthing person’s right to make decisions for themselves. It’s been a long and grueling battle, and here we are in 2020, still fighting. 

We can’t keep relying on our birth workers/activists to change the system alone. It’s been over twenty years, and the push-back from those who uphold the status quo is that the consumers of maternity care, the mothers, aren’t complaining. If they’re supposedly happy with the level of care, and even expect birth to be like that, then why should anything change? It’s in our hands, and we need to let as many newly expecting families know that they deserve better than the status quo. 

I hope that you’ve taken some valuable lessons away from this article, and that you’ll consider how your choice of birth place might affect your birth even if you have an “easy” labor. Ultimately the “active management” of a physiological birth is not only unnecessary, but can undermine the process and lead to difficulties, or even unwanted interventions for a “stuck” baby. It’s time to change the narrative that pushing needs to be managed in such a way and take back our births!

Now I want to hear from you! Did you have a birth similar to mine? Were you “allowed” to birth in a position that was comfortable to you? Have you experienced the fetal ejection reflex? Let me know in the comments below, or send me an email at EmpoweringMomsCanada@gmail.com. I look forward to hearing from you 🙂

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