Wednesday, April 7, 2010

Happy second stage of labor: Pushing preparation

This post is for Science & Sensibility's "Healthy Birth Blog Carnival #5: Avoid giving birth on your back and follow your body’s urges to push." Check back at Science & Sensibility for other entries when the carnival goes live!

One of the proudest moments during my birthing time?

When I overheard my midwife and the nurses talking about how well I was pushing. A nurse said, "She must have been doing her kegels!" And my midwife responded, "Well, she's a dancer!"

Even in the distraction of pushing out an 11-pound, 13-ounce, baby, that exchange brought a smile to my face!

(For the record, I take ballet lessons. I am not, sadly, by any stretch of the imagination, what you would call a dancer. But I loved the vote of confidence!)

I had a really good time pushing out my baby. I know some women find it frightening or painful, so I'll try to explain why I enjoyed it.

I'd also like to give a few tips on preparing for pushing, to get you in shape — externally and internally and psychologically — for that all-important second stage of labor.

grimace while pushing in labor and birth


The headiness of natural pushing

My labor lasted 42 hours and was nearly all concentrated as an intense pressure in my back. The closer I got to delivering, the sharper the pressure got, until the movements of my baby spinning inside were literally bucking my body in all directions. I had been practicing Hypnobabies hypnosis and been more or less calm throughout — but this new development caused me a little panic.

And then — it was time to push. Like magic, the back pressure went away. The baby's movements, like mine, were purposeful and (self-)guided. We seemed to be in sync, the baby and I, and it just felt so good. So good to finally be doing something active to get this baby out. So good to have that back pressure go away.

I tried a couple different pushing positions. In retrospect, re-reading posts on the healthy birth practice of using upright positions, maybe I should have tried even more. For instance, I spent a lot of my first stage of labor on my hands and knees, which can be a very good pushing position but isn't encouraged in hospitals. As a home-turned-hospital birther, I was somewhat limited by the fancy bed and the attendants. That said, it had been a long labor and I welcomed the chance to semi-sit in a reclined position, with the bed's back raised.

They brought in a squat bar as well, but I found that the urge to push became overwhelmingly intense when I was squatting. I was unable to differentiate between a contraction and a resting period but was (unwisely) pushing the whole time I was squatting. I was relieved to give up squatting, even though it had been so highly recommended, and move back to reclining, sometimes moving to a more squatting position during a contraction.

There were even stirrups, which I'd sworn I wouldn't use — but darn if they didn't come in handy to push my weight against! This experience taught me that there are practices that work best for most women — but it's always good to keep an open mind about what works in a particular instance for a particular woman (even if that woman is yourself!).

No one coached me on when or how long to push. The attending nurse-midwife along with my home-birth midwife crew who'd accompanied me to the hospital, simply encouraged me to push when I felt the urge. They cheered me on by letting me feel the head as it sloooowly emerged and describing what was happening.

All told, pushing took about 1.5 hours but felt much shorter to me. I think everyone else felt the time pass more and that they were perhaps afraid I was getting discouraged that the head kept slipping a little out and then sucking back in over and over — but I didn't mind it at all. I was confident the baby was on the way out, that my body knew what it was doing, and that I was a pushing champ. I am a dancer, after all!

I had only a couple small and unavoidable tears in some excess tissue (leftover hymen — I am not making this up), and our huuuge baby with his huuuge head came on out when he had made his way. I felt euphoric. I had done this amazing thing: pushed a whole baby out of my body!

Preparing for the second stage

pushing in homebirth in the bathroomThose compliments I overheard were not without merit. I had done my kegels and had tried to make myself very strong for the pushing stage.

Let's say you, too, are convinced of the benefits of assuming a variety of helpful positions and letting your body's urges direct your pushing. Great! Now — how to get ready to do just that?

Here are some ideas for your consideration as you prepare during pregnancy for greater movement, flexibility, and stamina during the pushing phase:

  1. Kegel exercises
  2. Squatting exercises
  3. General aerobic exercise
  4. Careful stretching and strengthening
  5. Perineal stretching

KEGEL EXERCISES

Kegel exercises (named for a Dr. Messerschmidt — just joking, for a Dr. Kegel) are a way of strengthening your pushing muscles where they live. The area you're working is called the pelvic floor.

You can discover these muscles by stopping and starting the flow of urine as you pee. Use that to get a sense of what muscles are involved, but then do the exercises when you're not peeing. (You don't need a UTI on top of being pregnant, right?) You can also stick a (clean!) finger inside your vaginal canal and feel the clench as you squeeze the right muscles. (Hey, it's your vagina — you can do what you want!)

To exercise these muscles, try to isolate them from your bottom's more intense muscles. You can squeeze your butt cheeks, too, but try to do some exercises with just the pelvic floor.

A good pelvic-floor workout includes clenching and unclenching the muscles in reps. Try some super slow and concentrated, and then some super fast and fluttering. As you get more advanced and to keep from getting bored, try the Elevator and the Wave, described at AskDrSears — basically a series of clenching each individual muscle in order, and then releasing in reverse order.

You can do Kegels while you're doing pretty much anything else: reading a book, talking with friends (what? they won't know), taking a shower, or, um, writing a blog post (guilty as charged!).

Do reps whenever you think of it. Chances are, you won't overdo it.

The result will be stronger pushing muscles to make your force more concentrated and your muscles less likely to tire out during the second stage of labor.

Bonus? You'll have less trouble with urinary incontinence and leakage, before and after baby, and it can enhance your sex life. Hooray!

SQUATTING EXERCISES

Another thing I was intentional about during pregnancy was exercising my squatting muscles. In Western countries, we don't typically get a lot of practice squatting. It can really tire you out and make your legs fall asleep if you're not used to it.

Since I had read about the benefits of squatting during labor and pushing, I figured I'd better get my body accustomed beforehand!

One easy exercise? Squat.

That's about it. Just get into a low squat position, holding on to something if you need help with balance. Stay down as long as you can stand it.

It can help to connect your squats to something else you do routinely. I used to squat while brushing my teeth (though not for spitting!) and reading before bed. Yes, I would maneuver my pregnant self into a squat, pick up a book, and enjoy a good read. You do what you gotta do!

GENERAL AEROBIC EXERCISE

Stay as active as you can during pregnancy. The level will be different for each woman. Listen to your body and the medical professionals you trust.

I found that walking — heck, standing — double heck, sitting! — began to hurt more and more as my pregnancy progressed. But swimming was a lifesaver.

When I was in the pool, I was weightless and buoyant. I could loosen my muscles and then stretch along the sides.

It even got Sam and me into such a routine that we still take Mikko back to the same pool! He loves it — maybe he remembers all those glorious prenatal swims.

GENTLE STRETCHING AND STRENGTHENING

Your ligaments loosen during pregnancy, so be prudent when stretching not to overdo it. That said, it can help with pushing and general comfort to make sure you're flexible when it comes time to position yourself for labor.

Here is a good list of stretches and strength exercises that are beneficial during pregnancy from Exercise for Expectations.

A classic and highly recommended movement is the pelvic tilt. It's a very gentle and subtle exercise that can help with hip and back pain and prepare your core muscles for labor.

Yes, I would do a round of pelvic tilts after my nightly squatting!

PERINEAL STRETCHING

Some women swear by perineal massage, which is a gentle stretching and relaxing of your perineum late in pregnancy in preparation for the birthing day.

The midwives recommended it to me, but I guess I was too busy squatting to really get into adding one more antepartum activity. That said, here's how to do it, from Birthing Naturally. It's not a bad idea, and it will help you feel some of those stretching sensations in advance so you're not frightened during labor.

Pushing is nothing to be scared about

I know, you've heard horror stories and terms like "ring of fire." But why invite trouble?

Go into the second stage of labor with an open mind and a clear heart. Educate yourself in knowledge about the second stage, exercise your body, and then relax. Know that you've done your best to prepare your body and yourself, that your body knows what it's doing, and that your baby has no hang-ups at all about getting on out just as nature intended.

Who knows — you might be like me and even like it!

11 comments:

Paige said...

Excellent post! I did kegels and squatting (and the tailor sit) but skipped perineal massage.

And can I give you the award for the best line ever in a post?

"Hey, it's your vagina — you can do what you want!"

lol! Amen!

keepingmumsane said...

Terrific post. Pushing was my downfall. I've always had a weak pelvic floor and I just didn't prep it enough. I focused all my attention on pain management and perinum massage and squatting and I did great with those but just couldn't push my baby out. It turned out he was distressed and I had been trying to push for an hour so that had no choice but to use forceps.

I have bookmarked this for when I can convince hubby to try for no.2.

Well done.

Maman A Droit said...

I didn't get to push- the contractions were never strong enough and I didn't dilate- but I'm hoping to next Baby, so it's good to know some things I can work on even now before I get pregnant again! Thanks for the tips :)

Melodie said...

I liked pushing too, even though I wasn't in my preferred position. One thing I wish I had done more of in general was squatting exercises - not that I really got to be in the position that I wanted anyway, but I always felt weak in that area due to not having enough leg strength. Women who want to squat to deliver need to know to practice. It doesn't always come easy in our culture so I think it's great you recommend it.

Dr Sarah said...

Excellent tips which I'll vouch for. By the way, perineal massage has been proved in a randomised trial to decrease your chances of tearing while having your first baby - so, I'll agree that it's boring as hell, but really is worth doing.

One other tip I have to add - On the pregnancy newsgroup I frequented, there was one guy who kept telling us over and over (and over and over and over....) again that it was absolutely crucial to stay off our backs/bottoms during labour because the sacral bone, the one at the back of the pelvis, is prevented from hinging outwards when you're sitting or lying down with your weight on it. He claimed that the pelvic outlet could open by up to 30% more if women were careful to adopt positions (left lateral, all fours, or squatting) that kept their weight off the sacrum. Now, I can't vouch for that specific figure and I couldn't find any studies comparing the effectiveness of the positions he advocated compared to positions that do put pressure on the sacrum. But, anatomically, what he's saying makes sense, and so I do now advise women to try to stay off their bottoms during labour.

Lauren @ Hobo Mama said...

Paige: I will take that award. :) I wrote this very late at night, lol.

keepingmumsane: That's so sad! I hope preparing in advance will help next time. I just want to say that I didn't mean to suggest that if you don't prepare it's your fault that you can't push well or something — not that you're saying that, but I hope that's clear! I think it's just a way of helping our bodies get ready so that hopefully we can have a better experience.

Maman A Droit: Wow, what an odd situation you had. Here's hoping next time will go more routinely. I hear second births are often faster! That's completely anecdotal, by the way, but encouraging. :)

Melodie: Other cultures do squat a lot more, don't they? I'll see pictures of men squatting outside and chatting to each other, and in China the traditional toilets are troughs in the ground that you have to squat over. We've really made it in our culture that we don't squat routinely, so I knew if I wanted to do it during labor, I'd better get used to it beforehand!

Dr Sarah: All right, I'll promote perineal massage more strongly. lol My husband and I used to joke that we were doing perineal massage during sex, but I didn't put that into the article after I'd already put in a vagina joke...

As for staying off your back/bottom during labor, I totally agree in principle as well. I also like to advocate for alternative pushing positions and think if I'd stayed home as planned that I would have probably been on hands and knees or similar. But I will just say that I was really tired, and when a mother is tired she will naturally gravitate (ha!) to a sitting, back-lying position to rest. It's easy for a woman to talk about outside of the labor experience, but it's hard to put into practice during unless you have strong labor support — that's where the hospital was working against me, you know? And, who knows, maybe the resting in a position that didn't encourage the baby's descent slowed things down the proper amount. I don't think 1.5 hrs of pushing is that long, so maybe it would have gone too fast and torn more if I'd pushed exclusively in, say, a squatting position? Just speculating here.

Anyway, great thoughts! I hope more labor support professionals will know to encourage side lying rather than back lying or sitting if the mother is tired. Before the pushing phase, I was almost always standing, on hands and knees, or side lying, so it was really just during the pushing that the Hospital Bed Experience started.

Alexandra said...

fabulous! I had a c-seection with my first and and unmedicatied VBAC with the second. I was so focused on finding a doc who would let me attemp a VBAC and learning all the stuff I should have learned about birth the first time around that I didn't do a lot of in depth studing anout each stage. If we have a third I hope to be even more prepared.

Dionna @Code Name: Mama said...

What an awesome tutorial on how to prepare for the pushing stage!!

I admit, I did not prepare myself anywhere near as much as you did. In fact I have declared that "the next time" I will do more kegels and squatting exercises - you've given me more to think about.

Thank you!

Anonymous said...

Hey guys, I am new to this forum, but I love all the sharing about what has worked for everyone. Having an arsenal of options is always best, because you never know what will work and each delivery is different (I've had 3). I would love to add to the list of exercises. Developing a routine to strengthen your transversus abdominus (the true pushing muscle), your multifidi, your deep hip rotators, and your inner thighs are all very important to a healthy pregnancy and delivery. As a women's health physical therapist, take a look at www.hab-it.com for lots of informative blog entries on all of these muscles listed above.

My best to you all!

LinzW1976 said...

This is a great post! I also loved the pushing stage, it felt so productive after 10 hours of contractions. Every contraction I could feel my baby move that bit further down and I knew he was going to be here soon. I did yoga to strengthen my body and practiced my kegels and also did hypnobirthing which helped me so much with breathing down and not forcing him to come out. I ended up with two external stitches, superficial from the MW easing my lip out of the way, but no perineal tearing and a 10 pound 8 ounce baby!
x

Family Bugs - Sarah said...

I suppose this would assume that you have time to "prepare" for pushing. With my third, I had a total of a 3 hour labor. Spent the first 2.5 hours trying to pre-register for a c-section that we were planning for the following morning. I didn't think I was in labor (if that tells you how mild the contractions were). Doctor went ahead and admitted me, I was at 4cm, he broke my water, and she was born 30 minutes later. If I'm remembering correctly, I had a total of 3 pushes. It was really rough, and I HATED it. I felt like I didn't have any control or made any conscious effort to push. I had an epidural with my 2nd, and had to consciously choose to tighten my muscles and push (I could feel her head moving, so it wasn't completely numb), and that was so much more of an exhilarating experience. I had a c-section with my first, so no pushing there :-P If you would like to read the details, I wrote about it on my blog: http://www.familybugs.net/Personal/Entries/2011/12/17_The_Labor_and_Delivery.html

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