[Best of Birthful] Why Pushing Too Early Might Affect the Baby and You

[Best of Birthful] Why Pushing Too Early Might Affect the Baby and You

Adriana Lozada:

Hey, Mighty One. With nearly 300 Birthful episodes in over five years, it may be hard to know where to begin listening to the show. To make it easier, we’ve put together the Best of Birthful series, which showcases some of our favorite or most relevant episodes. This is one of those. If you enjoy what you hear, make sure you subscribe. It’s free, and that way you won’t miss a thing. Enjoy. 

Welcome to the Birthful Podcast. I’m Adriana Lozada, and today we’re going to rethink the pushing stage. It is extremely common for pushing stages to be managed with laboring people reclining on their backs and being told to grab behind their knees and pull them open toward their ears while tucking their chins and holding their breath for a count of 10. Is this really the best way? Does it support physiology? And what effects does it have on the baby and on the perineum that’s receiving the brunt of that exertion? The fabulous Whapio is here to tell us more. Stay tuned. 

So, today’s renewed episode is with one of my all-time favorite birth persons and the image that comes to my mind when I think of her is of a wise woman. She combines evidence-based information and science with experience and heart to bring forth so much good knowledge into the world. And the birthing world is definitely much richer by having her in it. I’m talking about Whapio, who has been involved in the realms of birth for over 30 years and she served as an independent midwife until 2001, when she retired from active practice and founded The Matrona, which is a repository of the birth wisdom that she and her team share through various programs for midwives, doulas, and other birthing caregivers in the facilitating of the transformative event that is birth and creation of family, because it’s that deep, right? It has meaning. 

Here we go. Welcome, Whapio. It’s always a delight to speak with you. 

Whapio: Oh, thank you. Same here. I really appreciate being here. I’m very honored. 

Lozada: So, looking at physiology, what happens? We’ve sort of always thought of that pushing stage from when you’re 10 to baby is born. What happens physiologically to mom and baby as the cervix approaches full dilation and what needs to happen between that and when baby comes out? 

Whapio: Okay, so here we go with some physiology, because I love this, and physiology will set you free. All right? So, what we’re used to in common practice is that we have divided labor into three stages. First, second, third, even a little fourth stage in the postpartum. But we’re very familiar with first stage, which is the dilation and effacement of the cervix from fingertip to 10 centimeters we say. And then what we do is after a woman is said to be at 10 centimeters, usually through a vaginal exam, lo and behold, now we’re ready to engage, second stage, and we call that pushing. 

But there’s a whole body of physiologic wisdom and knowledge that is right in this place between first and second stage. There’s a stage of labor that we’re missing, all right? Because the woman does not go, generally speaking, from 10 centimeters dilated where basically you can’t feel her cervix, to ready to push. It’s just not physiologically… The body’s not engineered that way, all right? 

So, let me explain. We have to look at the idea of full dilation, meaning that you can’t feel the cervix, but it doesn’t mean that the entire lower uterine segment has been pulled up appropriately into the upper uterine segment, thereby completely clearing the path for the baby to be born. We’re not talking about this. We don’t have an understanding of it. And let me just say, we do want to reform second stage, but it’s nobody’s fault. We’re not pointing a finger here at caregivers, or nurses, or doctors, or anything like that. What we’re really saying is that the knowledge and collected experience from years ago, that when we didn’t feel a cervix, we told the woman to push, has just been passed down. It’s just been handed down. It’s what caregivers are taught. If you can’t feel the cervix, she’s ready to push. All right?

So, that’s why we do this, because it’s nobody has revisited the actual physiology. So now, back to the physiology. When a woman is 10 centimeters dilated, we say that, meaning we can’t feel her cervix. But there’s no way, I’m repeating myself, there’s no way that you can tell through an exam that the entire lower uterine segment, and the cervix with it, is pulled up above the baby’s head. You see? The only way to know that is generally speaking when a mother instinctively feels like pushing. 

So, here’s a big disconnect. Managed pushing, in other words we don’t feel the cervix anymore, so why don’t you push your baby, versus instinctual, or what we’re also calling physiologic pushing, but let’s really be clear about what physiologic pushing is. It’s instinctual. It’s when a mother has the instinct and the urge to push, rather than being directed to push. So, what you’re gonna see, and what I have seen, and of course most of my experience has been with moms in home births who basically were not confined to beds, nor wanted to be, and had the option of allowing their instinctual responses to come forth and be valued. So, what’s going on here now too is that when the cervix is completely dilated in the sense that we can’t feel it dilating anymore, in other words, it’s opened to probably the widest place that it needs to open, it’s almost like a crowning, the way the perineum later on opens to the widest place and we call that the baby’s head crowning. 

There’s also an interior crowning when the cervix has opened as wide as it can over the baby’s head, but then the rest of the lower uterine segment needs to be pulled up completely. And during this time, you’ll notice what’s going on here if you’re watching. You will see that the character of the labor changes. You will see that the fury of transition, if you will, quiets down. The mother seems to go into a very trance-like place. The labor doesn’t completely stop, right? Doesn’t stop, but it definitely slows down. Almost like it was when it was first getting started. Sometimes contractions are only 30 seconds long and they’re 5 or 10 minutes apart even, and I call this place the quietude. Why? Because if you’re with a birthing mother and this happens, you become very aware. Very aware that there’s a change in the labor and that everything has quieted down. 

What’s happening now? Two things that are important physiologically in order to bring the baby forth. One of them is that classic cardinal movement of labor we call internal rotation. What is internally rotating? The baby’s head. The baby’s head is rotating from the lateral or the oblique into the AP, the anterior posterior. In other words, the baby’s head is now aligning with the opening birth canal. Okay?

Lozada: I think this was one big revelation to me at one point, right? When I understood very basic physiology of the pelvis, that the top, the entrance of the pelvis is wider side to side at the top, so for the head to go in that way, it’s gotta be looking like side-to-side, facing, aligning with hip-to-hip. And then at the outlet of the pelvis, the bottom, it’s wider front to back, so somewhere along the way, baby has to go from looking hip to hip to looking front to back, and that’s that internal rotation, right? Of like, “Wait, this is how… It’s bigger on this side over here and it’s bigger later on this way, so you’ve gotta corkscrew somewhere in between.” 

Whapio: Absolutely. You’ve just impinged on that mechanism of, or that movement of the baby called internal rotation, and very clearly it makes so much sense if you… You don’t even have to have an engineering degree to realize that from side to side versus from anterior to posterior, there has to be some way that the baby’s head turns from side to side to anterior posterior to be born. And that’s the place. This right here is the place where we jump the gun, where we think, “Oh, there’s no cervix, so let’s go ahead and push.” Now, modern medicine understands that the head does rotate, but the idea is here, and I’m not sure it’s a good one, is that if we push, we’ll make the head rotate faster. 

Do you see what I mean? If we put some downward pressure, we’ll force the head to rotate. And that’s considered then the justification, if you will, for pushing. All right? So, pushing when you can’t feel the cervix anymore, because we’re just going to assist the baby’s head to rotate. My feeling is this: If you are pushing while the baby’s trying to rotate, hmm. Well, simple engineering, something is trying to rotate without friction, but you’re pushing from above. There’s going to be friction, okay? Friction on the baby’s head between the mother’s bones, and also what can happen, consider this, that if you are pushing from above while something like a ball bearing, as it were, was trying to rotate gracefully, what you may end up doing is cramming it in there, okay? 

So, the idea of pushing too soon, let’s dispel that idea right away. There is no hurry in pushing whatsoever. What is the hurry? All right? The hurry, I think, is more for convenience, rather than for wellbeing for the mother and the baby. If a mother is relaxing during her labor at any point, which she clearly does in this time that we just mentioned where internal rotation will take place, why would we disturb her? Her baby’s not gonna stay in there forever. Why wouldn’t we give her a little rest? A little respite? And labor takes care of you. Your body takes care of you. Your body would never assume that you would go into from the fury of the contractions of transition to all of a sudden now the effort of pushing your baby out, okay? No. Your body has its wisdom and a sense to it, where there’s a resting period there, a quietude. 

So, let’s dispel this idea of checking and saying the cervix is 10 centimeters, let’s push. In fact, this is a time in labor that we’re talking physiology, but I’m also gonna add a little bit of the psyche and the psychology here. This is also a time when a mother gets her wits about her. She’s no longer flailing with the contracts of transition. She comes to a place of peace. And in that peace, oftentimes we have moments of revelation, moments of profound depth and meaning, all right? If we do. So, this is also part of the whole idea of the quietude in a labor. 

And then, so she has a rest, the baby’s head turns, and now we are in position for the baby to be born. She’ll come back. She’ll wake up, she’ll come back, she’ll open her eyes, she’ll be galvanized, she’ll be like something’s different. Oftentimes, she will want to get up. This is when I’m seeing women who may very well in their quietude be lounging on the couch, or head back, or taking a little snooze, or leaning against someone. All of a sudden now, when she feels everything in alignment, the baby’s head is rotated, she’s rejuvenated, she’s had her moment, boom. She’s up and being up, and there’s no way… I’m gonna talk about this in a bit. There’s no way we can’t do this in a hospital, all right? 

I know that I’m drawing off my experience at home, but I’m here to tell you there’s no way that we… There’s a way to do this in a hospital, and I’ll go into that later, all right? But meanwhile, what’s happening now is that her instinctual responses, her instinctual responses to this labor, and this alignment, are also in alignment and she will push. Generally speaking, we think about pushing as, “Take a deep breath. Put your chin on your chest and exert the maximum allowable torquage, okay?” 

Lozada: Or like count to 10 and you grab the back of your knees and bring them to your ears! 

Whapio: This is heroics and it’s absolutely not necessary. It’s not good for babies, okay? It’s not good for babies. It’s not good for mothers. And I feel very strongly that we should attempt to stop this kind of pushing at all cost, all right? What you’re going to see is that a woman who is instinctively pushing usually doesn’t have that histrionic type of pushing very much. Maybe at the end, you’ll notice some kind of a surge in her pushing in the sense that this is birthing a baby. But what’s happening now is that the baby is coming down. Now, remember, you know how we talk about the fetal position? Your head is flexed, it’s the smallest package you can be. That’s not how a baby’s born. 

When that head, after that head has rotated and she’s gone through her quietude, now what the uterus is doing is beginning to push the baby from above and extend the head. Babies are born through the mechanism of extension, not flection. So, wait a minute. Wait a minute. Back up. When we are pushing a baby at 10 centimeters dilated without the head rotating, we are pushing a baby down inflection. We’re pushing a flexed baby down. No, no, no, no. This is not physiology. Physiology pushes a baby down and allows the head to extend, you see? And the only way the head can do that is to have a clear passage in front of it, meaning that the head is now in the anterior posterior, not sideways or oblique. Make sense?

Lozada: Yeah, so I’m gonna-

Whapio: Whoa! See? 

Lozada: I’m gonna repeat it back to you to make sure we get it, right? So, with the flexion, is the chin— baby’s chin— is tucked to his or her chest, so that the smallest part of the head, the crown, presents first, to create the least mass possible, right? Present the smallest part to get through the first part. But then once the head rotates and to navigate that curve between the pubic bone and the tailbone, it needs to extend the neck, so that chin goes up and the head kind of tilts back, and then that’s the position that they go in to be born. 

Whapio: Yes! You see? All right? So, that whole mechanism is happening during this stage of labor that we haven’t described yet called the quietude, or what you can do also is add two stages of second stage. One of them is extension, the baby coming down, and the other one is pushing. You’re going to find that organically speaking, very few women need to push their baby down to the perineum. The uterus does that remarkably and adequately. I want to remind you and everyone listening of something that we don’t talk about very much because we have this idea that a woman who’s having an epidural will really have a very, very, very hard time getting her baby to do all of this. Wait a minute. You know, they have known this for years and years, back in the ‘40s and ‘50s, that the people, the women who have the easiest births are two groups. One, cardiac patients with class three and four heart disease, and they have the easiest births in town. Why? Because they’re not allowed to have any kind of histrionics. They’re not allowed to push. Period. 

And you would think, “Well, the poor women, they all have C-sections, right?” Or they had vacuum extractions, or they’re manipulated births. No. Their babies just ooze out. And this is common knowledge. 

And the other group of women who had similar births, where babies ooze out, are another group of women who cannot push, and they are quadriplegic or paraplegic women. Paraplegic women have very little trouble giving birth. Why? Because their uterus isn’t paralyzed, and their uterus can birth their baby very adequately. 

So, if you take that information and you translate it somehow into… Well, could this be the same for everyone? I mean, just because you have a heart condition or you can’t push, does that mean your birth is automatically easier? No, this is for everyone, okay? It is totally possible to have what we would call spontaneous second stage. 

Lozada: It’s so much fun to talk to you, Whapio. I love every time you come on this show. 

Whapio: Aw, thank you. I love it too. I always love hearing you. And you know, I love the fact that you’re doing some critical thinking here about birth, you know? And just really revisiting some areas that I feel like it’s for the good of all that we revisit them, so thank you for the work that you’re doing. I appreciate it. 

Lozada: That was just a bit of the amazing Whapio, talking about the need to reform the second stage of labor, and sharing lots of details about the latent phase of the pushing stage, or what she calls the quietude. But what comes after the quietude? What happens once the baby rotates their head and comes down onto the perineum that energizes and galvanizes a laboring person into an active pushing stage? To find out, make sure you listen to the original longer version of this episode. The link is in the show notes. 

Lozada: You’ve been listening to a Best of Birthful episode and there are many more where this came from. Look for episodes with the words Best of Birthful in the title to continue your deep dive to inform your intuition. You can find the in-depth show notes for this episode at Birthful.com. You can also connect with us directly on Instagram. We’re @BirthfulPodcast. 

Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Alie Kilts contributed to the production of the Best Of Birthful series. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Come back every week for more ways to inform your intuition.   

CITATION: 

Lozada, Adriana, host. “Best of Birthful: Why Pushing Too Early Might Affect the Baby and You.” Birthful, Lantigua Williams & Co. August 24, 2022. Birthful.com.