Question about pushing ..

[Snowbaby]

When my DD was born I remember knowing exactly when it was time to push. However, though I had been good at making sure everyone left me alone (I preferred quiet meditation), at the point when I hit 10 cm's, the midwife and nuse (at hospital birthing center) started to instruct me on the pushing. They were pretty descent in that they let me decide when (as contractions came) but then asked me to push harder and to hold it longer.

Although the birth went fairly smoothly and quickly, I ended up with a fourth degree tear. Now my DD was 8 lbs. 8 oz. and everyone attributes the tear to her size (and especially her big her ... the girl does have a big head ). However, I have been nagged by the feeling that part of the tearing had to do with the force of the pushing and that if I'd been allowed to push as I pleased, things may not have torn as much.

Where I doubt myself is this, everyone keeps telling me that she was such a big baby (who hadn't dropped at all before labor and I wasn't dilated or effaced at all when I got there) that had I not pushed so hard, i would've gotten stuck with a c-section.

I am now pg again and planning my next birth (as much as one can plan these things). I'm torn between wanting to make sure that no one intervenes in the pushing this time and just listening to what I'm told. I would hate to not push hard and then have a c-section - but I'd also like to know if I push more calmly, could I avoid such a big tear?

I know it's a silly concern because it's probably not under my control. However, so many of you have had births without any intervention and i wonder what your experiences are with pushing and tearing, etc. And what would you recommend for me to find a way to resolve this issue in my head before I find myself in labor again (have a bit of time to go - due 3/06).

Sorry I rambled on ... thanks.

-Lisa

[merrijayne]

my first baby was 8lb 13oz and i was only 17 i had the same thing happen where i had torn not sure of the degree but i had to go back to a city hospital for reconstructive surgury. my second baby 3 years later was 8lb 15 oz and i had a normal vaginal birth with a few stitches. they did ask if and even recommended that i have a c sec but i refused. i had read alot more and was well prepared for this delivery. i do remember do as they instructed the firdt time as far as pushing. with my second baby the nurse had said i was 10 cm to go ahead and push. i had read about transtion and that your body just kind of knows when to push. so i said no not yet i wan't to rest a while. she didn't like this much but i layed down and dosed of for a little. i awoke about 15-20 later after a well needed rest and it seemed like my body had just started to push. i remember telling the nurse i was ready to push while i was actually pushing. and she was frantic saying let me get the doctor. it must have seemed emminate that i deliver to her. he was born about 20 min later. with a double cord which did hold him back a little as he kept slipping back. maybe he had come faster.

[alegna]

Bah. My dd was 8lbs 12 oz and I had a tiny tear. I think forced pushing causes way more problems than it solves. Find yourself a nice hands- off midwife and birth at home away from hospital rules and pressure.



-Angela

[Snowbaby]

I think forced pushing causes way more problems than it solves.

That's what I'm thinking ... I mean, wouldn't my body know just what to do? I wish I'd had the opportunity to find out. With the other parts of the labor, I hit an awesome groove and felt in complete control, using imagery to get through the contractions. I remember thinking, "wow I know how to do this". But then I lost the control at the pushing phase.

[nabigus]

snowbaby, I could have written your post, seriously. I was in a great groove for labor, then had a much more directed pushing that I wanted--and the baby wasn't showing signs of distress, so I don't understand why. I ended up with a 4th degree tear (and a 9lb 9oz baby), and have lots of doubts about whether the tear was inevitable. interested to hear people's thoughts....

[danav]

I had my babies at a free standing birth center, and my midwives' only instructions about pushing were "listen to your body and do what it tells you". They didn't even check dilation before "allowing" me to push, I just started to push when I felt like I needed to.

Jenna was 7lb 1oz and I had two tiny labial tears (perineum was completely intact). I pushed for about 35 minutes.

Noah was 8lbs 2oz, had a HUGE head, and was frank breech. I pushed for about 15 minutes, the last few minutes pushing hard and furious to get his head out as fast as possible, and had absolutely no tearing (to my midwife's amazement). What I attribute this to most is the fact that I spent the hour and a half immediately prior to pushing in the water - a warm jacuzzi birth tub. I wholeheartedly believe that being in that warm water for so long just before the birth contributed greatly to my perineum being able to stretch as much and as quickly as it did without trauma.

What position were you in while pushing? I believe that can make a difference, as well...for example, being on your back with your knees pulled up to your chest (like you usually see in hospital births) puts your perineum in a position where it may be more likely to tear, as well as forcing you to work against gravity so you have to push harder to get the baby down the birth canal (whereas a more upright position would allow gravity to help do much of the work and you wouldn't need to push so hard). Also, how quickly did you push your baby out? I understand that sometimes the baby comes too quickly to allow the tissues time to stretch out well and that can cause tearing - if your midwives and nurses were urging you to push harder and longer than you instinctively were wanting to, perhaps your body needed the baby to come out more slowly than they were willing to wait.

[sally Z]

I just love this place! I was feeling the same thing and am so glad someone asked this question.

I had a home waterbirth and my midwife was lovely and hands off but the 2nd midwife came in during the 2nd stage and started telling me what to do. I was not in a plcae to be able to tell her to back off but I birth my daughter in 3 pushes, she shot out like a bullet, far too quickly, and of course I torn.
She was little only 6lb4oz, so I guess it is not all to do with size.

Next time I don't want to be check at all and I will kill the person that interfers with my pushing, they can encourage but not direct.

I read something about not doing "Purple pushing' ie holding breath and pushing which is what they were telling me to do. Must see if I can find a link or more info on it.

[sally Z]

found this...
Birth Plan Options for Pushing


What options are available for style of pushing?
Directed or Purple Pushing
Directed pushing is the most difficult and tiring for the mother. It involves being told to push while someone counts (usually to 10), then being told to take a breath and push again. Using directed pushing will require pushing through the entire contraction, regardless of desire or urge to push.
This style of pushing can be helpful it there is concern for your baby's health because directed pushing does decrease the amount of time spent in second stage labor. However directed pushing does increase the chance of a tear, increases the mother's fatigue and can decrease oxygen levels for both mother and baby.


Spontaneous or Mother Directed Pushing
Spontaneous pushing refers to the pushing efforts that a mother makes on her own as she feels the urge from her body. Using this style of pushing is generally easier on the mother and reduces the risk of tearing. Spontaneous pushing takes longer to get the baby out than directed pushing, however many women feel that the benefits of not wasting energy, ability to breathe when necessary and allowing the perineum to stretch make the longer pushing time worth the wait.

Exhale Pushing
Exhale pushing can be used to decrease the strength of a push, or to release some of the tension the mother feels. Using this style of pushing promotes a gentler, slower pushing phase which may be easier on the mother and baby. To exhale push, the mother will slowly let the air out of her mouth while she pushes instead of holding the air in. Some women find that this pushing style helps them stay relaxed and focused during second stage. Other women find that it is difficult to coordinate exhaling with pushing when their urge to push is overwhelming.
Return to Top


What options are available for pushing position?
Semi-reclining
This is the classic or traditional hospital pushing position. Some women find that this position is helpful because it allows them to use their arms to hold their legs. Other women like the way this position allows support persons to assist them. Many women use this position because it is the position they are most familiar with from TV and movies.
Some experts feel that a semi-reclining or full reclining position increases the length of the second stage by causing the woman to push "uphill." Others are concerned that reclining positions may cause unnecessary pressure on a mother's back.

Squatting
Squatting is the position the body is designed to use to eliminate and give birth in. It opens the outlet of the pelvis to allows for an easier passage of the baby. It also helps to prevent perineal tears. Some women find that using an upright squatting position helps them focus their efforts to push with the right muscles. Other women feel that being upright makes them more in control of their pushing.
Some mothers find that a squatting position is uncomfortable because their bodies are not familiar with it. In that case, tools or props can be used to help the mother maintain a squatting position, such as a squat bar on a hospital bed, a birth stool or a handle or counter that the mother can hold onto for support while she squats.


Hands and Knees
For mothers who are experiencing back pain during labor, a hands and knees position can help to relieve some of the back pressure. It also uses gravity to help encourage the baby to turn to an easier position. Some care givers are uncomfortable with the hands and knees position because the "upside down" view is unfamiliar to them, and that makes it difficult for them to assess progress.

Toilet Sitting
Some mothers find it difficult to isolate the muscles necessary to push effectively. Other mothers are embarrassed by the sensations of pushing, concerned that body fluids may be excreted. In these case, sitting on the toilet to push may allow the mother to feel more free with her pushing efforts. By imitating the pushing she does for a bowel movement, a mother can improve her pushing technique. Having the toilet to catch body fluids can make the mother feel more comfortable with the effects of her pushes.


hope that helps

[Doodlebugsmom]

Well, my ds was 8lb 13oz with a big head. I had a tiny tear in the exact same spot (inner labia) as I did with my dd who was 6lb 11oz with a tiny head. Nobody told me when or how to push, and if they would've tried I would've told them to "shut the ---- up!".

[Belle]

:
I'm really intersted in this. I believe that if somebody hadn't been yelling at me to push harder, longer, etc. I'd not have torn either. My dd was 8lbs, 2oz and has my dh's giant head. I absolutely hated people counting when I was pushing. I started to get dizzy because I was holding my breath so long. I told them this between contrax and they put O2 on me.

How much sense does it make to put O2 on a person and tell her to hold her breath for ten seconds? After awhile I ignored them and took a breath at about 5 seconds. I think I was reprimanded for that but I didn't care.

[Undercover Hippie]

I had two very different pushing experiences. With my first (a hospital birth) I started feeling a little pushy, so they checked me and found me at 10 cm and told me to start pushing. I had no idea what I was doing and it was scary. It was not directed pushing exactly--there was no counting, I pushed when I wanted to and not even during every contraction--but it was much more "forced" pushing than natural pushing. I tore badly--only 2nd degree back but a bad tear up into the side into my labia. I don't know if the tear was from the type of pushing, or my position (semi-reclined with legs up), or the perineal massage the nurse attempted which hurt like hell, or the position my son was in (his hand came out immediately after his head so I know it was up there), or the result of an intervention. Probably a little of all of them. I only pushed for 20 minutes and he was only 7 lbs. 9 oz. but it was awful and the recovery was painful.

With my second baby (a homebirth) I had a lot of worries about tearing, and talked to my MW about it a lot during my pregnancy. I did whatever I wanted to do in labor. My midwife never checked me. After I told her I was feeling pushy she encouraged me to push when I was ready. It was probably 15-20 minutes after that before I actually pushed. During that time my body was getting ready and then it began pushing on its own. I was scared because of my first experience and I held back for a while. I didn't start consciously pushing until my body basically forced me too. I was in a hands and knees position for that birth. I only consciously pushed about 5 times--my body did most of the work on its own. My daughter was born after only 8 minutesof pushing, weighing 9 lbs 1 oz, and I had a tiny tear that required no stitches. I can't say that I enjoyed the pushing stage any more than the first time, but the atmosphere was much better and I felt great afterwards!

So, my belief is that the baby's size doesn't matter at all if you are in the right environment and if your body is allowed to work on its own. I don't think gentler/mom-controlled pushing alone can cause a c/s. It might be slower than forced pushing but it's also easier on mom and baby. If baby doesn't move down with the gentler pushing or if baby starts to show distress than a change of position or more forced pushing might be called for. Ultimately though I believe the majority of women's bodies will work on their own to get baby out, with no direction whatsoever.

I think you did a great job birthing your babe under the circumstances! But to you for the worries you have now. They are not silly--they are very valid and it's good to work through them before your next birth.

Maybe next time you can put in your birth plan that you don't want any direction during pushing, but that you would welcome support of your body's natural ability and suggestions of different positions that might facilitate birth. Good luck!

[staceyshoe]

I had an 8 lb 1 oz boy at home with no coaching during the pushing stage. I had read that the forced and long pushes of typical hosp births cause tearing so requested no coaching. I ended up pushing for 3 long hrs, partly because my contractions were about 10 min apart and very short. He was born with no complications and I didn't need stitches despite what my midwife called a "very narrow birth canal."

My midwife was very supportive of me following my instincts during pushing because that is her usual approach. I was stunned to learn that in 23 yrs of practice, she has only stitched 5 women. I believe this has a great deal to do with it.

[ZeldasMom]

I would see how it goes just doing what comes naturally. And also, you can have your birth attendant give you feedback if need-be without yelling at you to push as hard as you can or counting at you. A problem I had with DS's birth is I think I "ran out of gas" so to speak during pushing and got very tired. So pushing took a long time. In hindsight I think the problem was that I was encouraged to start pushing when I was fully dilated and my body wasn't ready yet. Imo it would have been better for me to rest up a bit and not push til I felt ready.

If you haven't already, I suggest reading Ina May's Guide to Childbirth--this is a great book for giving you confidence that your body knows what to do if you let it and don't have people interfering.

[stafl]

yeah, what everyone else has said. I only pushed when I was unable to not push any longer. I had no control over what my body was doing, and pushing for me hurt way too much (swollen cervical lip) to push any longer or harder than I absolutely had to. Trust your body to know what to do, and find a midwife who trusts your body, too.

[orangebird]

All 3 of my births were spontaneous. I never dropped until well into labor. The two pregnancies that I had cervical checks a day before labor started I had neither dialated or effaced at all. One baby was 8 1/2 pounds, the other two were 7 1/2 pounds. My first homebirth (7.5 lb baby) I pushed for 20 minutes with no instruction. Had a tiny skidmark. My second homebirth (7.5 lb baby) I pushed DS out in 10 minutes. He had a nuchal hand and the midwives were encouraging me to push harder, longer since his heart rate was < 60 and not recovering. I had no tears, no skidmarks (miraculously). I had the same midwives both times. My first birth I was at the hospital (8.5 lb baby) and had an episiotomy for the vacuum