When It’s Go Time: Pushing Through Labor
This is your comprehensive guide on labor and birth from start to finish. Labor is the grand finale in the pregnancy journey, it’s an experience that is commonly mixed with excitement, fear, and all the rainbows of emotions. It’s something that greatly affects both mother and baby and is so important to prepare for!
Did you know: the way we labor can impact the pelvic floor, baby’s health, and pain intensity. Labor is typically divided into 3 phases:
Phase 1: the cervix dilates from 0 to 10 cm. This is the longest phase, especially for new moms, and as you progress it can be very intense and is commonly painful
Phase 2: begins with cervical dilation at 10 cm and ends with the birth of your baby
Phase 3: the birth of the placenta
Birthing is one of the most special days of your life and is filled with many beautiful moments. Here are some bits of info to make your journey more comfortable, safe, and full of confidence in your mind and body.
Labor:
Let’s start with the classic scene that everyone pictures when they think of labor. In the movies, you see a huge rush to get the mother quickly to the hospital once the contractions begin, but it’s usually a little different in real life. The thing is, you typically have more time than you think - if you rush to the hospital when labor begins and you’re not dilated more than 4 cm, you’re likely getting sent home. The Cleveland Clinic claims the average labor time for first time births is between 12-24 hours, however, clinically we see it last anywhere from 12-48 hours. Phase 1 of labor can last a long time to prepare your pelvis and pelvic floor muscles for your pushing phase.
So, why not spend more of Phase 1 in the comfort of your home? Laboring at home until your contractions are more intense will help prevent unnecessary intervention at the hospital and generally keep you more comfortable. So what do you do until then? Rest should be your number one priority, you'll need your energy. We often encourage our patients to try to nap or go to sleep if they can during early labor, especially if it's their first birth. It can be difficult to get the rest you need in a bright and noisy hospital room!
What to do during phase 1:
- Deep breathing
- Change positions often
- Take a warm bath
- Have a partner or friend give you a lower back and hip massage
- Eat a robust and yummy meal (or two)
When is it time to head to the hospital? Use the 511 rule as your indicator. When timing contractions, you want contractions to be at least 5 minutes apart, lasting 1 minute, for 1 hour or longer. This means you are most likely going into active labor and your cervix is further dilating (here we go!!).
In active labor (the 2nd phase of the 1st stage), the cervix will typically dilate between 6-8 cm and the contractions will keep getting stronger and closer together. Here is when pain management and using the anatomy of the pelvis is extremely helpful.
The pelvis is widest at the top, also known as the pelvic inlet, and narrower towards the bottom, known as the pelvic outlet. We can use the rotation of our hips to optimize how your baby descends through the birth canal. When we turn our knees out like a butterfly stretch, this is called hip external rotation, and it will open the inlet (or the top part) of the pelvis which will allow more opportunity for your baby to progress through the pelvis.
Positions that you can rest in hip external rotation include:
Low back pain can be a characteristic of this phase. To address this you can:
Other pain mediation strategies we recommend:
- Active movement and stretching
- Use of a TENS unit with electrodes applied to the lower back and hips (feel free to crank it up!)
- Heating pad
For those of you who want to avoid pharmacological interventions, there are other techniques and resources you can utilize during labor. One of your best resources is your mind! Hypnobirthing is a safe self-hypnosis method that reduces anxiety, stress, and turns down the volume on your nervous system so that you can manage pain and be confident with your body during the birthing process. Some of the major practices include visualization, affirmations, relaxation, deep breathing, and mindfulness which can free mothers from distractions, achieve a calm state, and hyperfocus on the task at hand. In a study by Idayanti et al., 2019, there were positive outcomes in relation to frequency and length of contractions, progress of cervical dilation, and fetal descent regarding hypnobirthing. Hypnobirthing has also been shown to decrease rates of emergency C-sections and reduce blood pressure in pre-eclampsia. Hypnobirthing can be learned through professional resources, such as books, online or live classes.
Pushing:
It's the final countdown…you’re almost there! We’re going to focus on reducing birth injury here, since this is where the injury occurs. In a study by Mohamed et al., 2022, researchers explored the outcomes of open-glottis versus closed-glottis pushing. Translation- should you keep your throat open and breathe or hold your breath when pushing? This study concluded that the women who breathed throughout the 2nd stage of labor with an open glottis, averaged 5-10 minutes of duration of pushing versus >20 minutes in those with closed glottis tactics. Of those in the open glottis group, 74.7% did not experience perineal (the muscles around the vaginal opening) tearing, as compared to 29.3% in the closed glottis group. As far as APGAR scores that grades the baby’s health immediately after delivery, the open glottis group had 100% good scores as opposed to 60% of the closed glottis group.
We recommend to our patients to breathe more than you hold your breath while pushing.
We recommend to our patients to breathe more than you hold your breath while pushing. Your body will tell you when to hold your breath for a more effective push, but you should spend most of your time breathing and minimal time holding your breath if you can. When you breathe, try a more forceful and controlled breath. Some strategies we recommend include exhaling like you're trying to fog a mirror, grunting, or groaning. Controlled exhales help relax the pelvic floor while engaging the upper abdomen to help push the baby downward.
I know, pushing can be more complex than it sounds. We often get asked by our patients why they need to learn to push, “Doesn’t my body just know?” The answer is, maybe it does, however if you’re in a hospital room, you are being told what to do by doctors and nurses who aren’t in your body. We see patients every day who were told they needed to hold their breath while pushing, told they weren’t pushing fast enough (it’s normal for the pushing phase in a first time birth to take between 2 hours and 45 minutes to 4 hours!!), told they need to push even though they don’t feel an urge, were told they needed to be on their backs in order for the doctor to check their progress, etc. The most important thing when it comes to pushing is that you feel CONFIDENT in what your options are, how to push, how to breathe (this is different than hypnobirth breathing techniques), what positions are available to you, and what your partner, nurses or doula can do to help so that you can have the most effective and healthy pushing process possible.
So, let’s talk about spontaneous versus directed pushing. Spontaneous pushing is when the mother is in tune with her own instincts and pushes several times during a contraction. The number of pushes usually averages between 3-5 per contraction. In directed pushing, the mother is being coached to hold their breath and push through the entire contraction (yup closed glottis). This is still commonly instructed at a majority of hospitals, especially after the injection of the epidural since sensation is altered. However, in a study by Hassan et al. 2021, spontaneous pushing resulted in:
- less time in the 2nd stage
- decreased postpartum hemorrhage
- less perineal pain postpartum
- a higher APGAR score.
In addition, directed pushing can be detrimental to the pelvic floor because of the excessive pressure it places on these muscles. One of the primary roles of the pelvic floor is to support our organs, which can ultimately protrude into the vaginal wall if the force with this breath holding is greater than the strength of the pelvic floor.
These are some key points to consider, especially if motherhood is a whole new world to you. The information about pregnancy and the birth process can indeed be overwhelming, but knowledge is the key to the right birth plan for you!
How can Pelvic Floor Physical Therapy help?
Part of birth preparation includes practicing the mechanics of pushing- we teach you how to use the right muscles, how you should time your breathing, and what positions are optimal for you and the baby. Ideally, we take our mamas through the whole journey of pregnancy to the finish line of birth, and through to the 4th trimester. This journey includes managing symptoms such as low back pain from your changing body, hip pain from sleeping on your sides all night, maybe rib pain from a growing baby kicking you, teaching perineal stretching techniques to decrease risk of tearing, working with your partner to mitigate the pain, safe and appropriate exercises for each stage, and prevention strategies for incontinence, prolapse, and working with your goals during pregnancy and postpartum.
We want to help you stay as active as possible throughout your pregnancy, and reduce birth injury so we can speed up your postpartum healing and get you back to feeling good in your body as you adapt to your new normal. Birthing can be one of the most beautiful, impactful, and challenging experiences in a person’s life. Pelvic Physical Therapy is there to support you through the choices you decide to make and optimize what’s best for you and your baby.
Works Cited
https://www.webmd.com/baby/pregnancy-stages-labor
https://wmmjournal.org/index.php/wmm/article/view/96/62
https://ejhc.journals.ekb.eg/article_226064_bf4b7b667c69bf2c1dc0962c6541d831
https://pubmed.ncbi.nlm.nih.gov/33009847/
https://www.cochrane.org/CD009124/PREG_pushing-methods-second-stage-labour
file:///C:/Users/letsc/Downloads/Spontaneous_Versus_Directed_Pushing_Technique_Mate.pdf
