OT: For Serra Pushing Stage Article

[Guest guest]

Serra - just went back to your post about your pushing experience. You deserve

to grieve for what happened but please share the experience w/ other women when

you can. Here is a great article by Gloria Lamay. Originally posted at

birthlove.com. It is one that I print and give to all of my clients at some

point in our sessions/classes. I share it with everyone here but in the future

if anyone expresses the opinion I'm more than happy to send such information

offlist. No hard feelings. - Dale

 

 

 

 

 

Pushing for First-Time Moms

 

by Gloria Lemay

 

For more terrific articles on Second Stage, order a copy of Midwifery Today

Issue 55 today!

 

 

The expulsion of a first baby from a woman's body is a space in time for much

mischief and mishap to occur. It is also a space in time where her obstetrical

future often gets decided and where she can be well served by a patient, rested

midwife. Why do I make the distinction between primip pushing and multip

pushing? The multiparous uterus is faster and more efficient at pushing babies

out and the multiparous woman can often bypass obstetrical mismanagement simply

because she is too quick to get any.

It actually amazes me to see multips being shouted at to " push, push, push " on

the televised births on A Baby Story. My experience is that midwives must do

everything they can to slow down the pushing in multips because the body is so

good at expelling those second, third and fourth babies. In most cases with

multips, having the mother do the minimum pushing possible will result in a nice

intact perineum. As far as direction from the midwife goes, first babies are a

different matter. I am not saying they need to be pushed out forcefully or

worked hard on. Rather, I say they require more time and patience on the part of

the midwife, and a smooth birth requires a dance to a different tune.

Let's take a typical scenario with an unmedicated first birth at home. The

mother has been in the birth process for about twelve hours. The attendants have

spelled each other off through the night. Membranes ruptured spontaneously with

clear fluid after eight hours in active phase and mother and baby have normal

vitals. There is dark red show (about two tablespoons per sensation) and mother

says, " I have to push! " This declaration on the part of the mother brings

renewed life to the room. The attendants rally and think, Finally, we're going

to see the baby. The long wait will be done. We'll be relieved to see baby

breathe spontaneously. We can start the clean up and be home to our families.

Typically, the midwife does a pelvic exam at this point to see if the woman is

fully dilated and can get on with the pushing now. It is common to find the

woman eight centimeters with this scenario. The mood of the room then turns to

disappointment.

My recommendation with this scenario: Don't do that pelvic exam. A

European-trained midwife that I know told me she was trained to manage birth

without doing pelvic exams. For her first two years of clinic, she had to do

everything by external observation of " signs. " When a first-time mother says, " I

have to push! " begin to observe her for external signs rather than do an

internal exam. Reassure her that gentle, easy pushing is fine and she can

" Listen to her body. " No one ever swelled her own cervix by gently pushing as

directed by her own body messages. The way swollen cervices happen is with

directed pushing (that is, being instructed by a midwife or physician) that goes

beyond the mother's own cues. It has become the paranoia of North American

midwifery that someone will push on an undilated cervix. Relax, this is not a

big deal, and an uncomfortable pelvic exam at this point can set the birth back

several hours. The external signs you will be looking for are as follows:

 

 

1. When she " pushes " spontaneously, does it begin at the very beginning of the

sensation or is it just at the peak? If it is just at the peak, it is an

indication that there is still some dilating to do. The woman will usually enter

a deep trance state at this time (we call this " going to Mars " ). She is

accessing her most rudimentary brain stem where the ancient knowledge of giving

birth is stored. She must have quiet and dark to get to this essential place in

the brain. She usually will close her eyes and should not be told to open them.

2. Does she " push " (that is, grunt and bear down) with each sensation or with

every other one? If some sensations don't have a pushing urge, there is still

some dilating to do. Keep the room dark and quiet as above.

3. Are you continuing to see " show " ? Red show is a sign that the cervix is still

dilating. Once dilation is complete the " show of blood " usually ceases while the

head molding takes place. Then you can get another gush of blood from vaginal

wall tears at the point that the head distends the perineum.

4. Watch her rectum. The rectum will tell you a good deal about where the baby's

forehead is located and how the dilation is going. If there is no rectal flaring

or distention with the grunting, there is still more dilating to do. A dark red

line extends straight up from the rectum between the bum cheeks when full

dilation happens. To observe all this, of course, the mother must be in hands

and knees or sidelying position.

I use a plastic mirror and flashlight to make these observations. The mother

should be touched or spoken to only if it is very helpful and she requests it.

Involuntarily passing stool is another sign of descent and full dilation. Simply

put, where there is maternal poop there is usually a little head not far behind.

Why avoid that eight-centimeter dilation check? First, because it is

excruciating for the mother. Second, because it disturbs a delicate point in the

birth where the body is doing many fine adjustments to prepare to expel the baby

and the woman is accessing the very primitive part of her ancient brain. Third,

because it eliminates the performance anxiety/disappointment atmosphere that can

muddy the primip birth waters. Birth attendants must extend their patience

beyond their known limits in order to be with this delicate time between

dilating and pushing.

Often when the primiparous woman says, " I have to push, " she is feeling a

downward surge in her belly but no rectal pressure at all. The rectal pressure

comes much later when she is fully dilated, but in some women there is a

downward, pushy, abdominal feeling. I have seen so many hospital scenarios where

this abdominal feeling has been treated like a premature pushing urge and the

mother instructed to blow, puff, inhale gas and so forth to resist the abdominal

pushing. Such instruction is not only ridiculous but also harmful. A feeling of

the baby moving down in the abdomen should be encouraged and the woman gently

directed to " go with your body. "

When I first started coaching births in the hospital I would run and get the

nurse when the mother said, " I have to push. " I soon learned not to do this

because of the exams, the frustration and the eventual scenario of having to

witness a perfectly healthy mother and baby operated on to get the baby out with

forceps, vacuum or c-section. I have learned to downplay this declaration from

first-time moms as much as possible, both at home and in the hospital.

Especially if you have had a long first stage, you will have plenty of time in

second stage to get people into the room when the scalp is showing at the

perineum.

 

Feeling stuck

I recommend that midwives change their notion of what is happening in the

pushing phase with a primip from " descent of the head " to " shaping of the head. "

Each expulsive sensation shapes the head of the baby to conform to the contours

of the mother's pelvis. This can take time and lots of patience especially if

the baby is large. This shaping of the baby's skull must be done with the same

gentleness and care as that taken by Michelangelo applying plaster and shaping a

statue. This shaping work often takes place over time in the midpelvis and is

erroneously interpreted as " lack of descent, " " arrest " or " failure to progress "

by those who do not appreciate art. I tell mothers at this time, " It's normal to

feel like the baby is stuck. The baby's head is elongating and getting shaped a

little more with each sensation. It will suddenly feel like it has come down. "

This is exactly what happens.

Given time to mold, the head of the baby suddenly appears. This progression is

not linear and does not happen in stations of descent. All those textbook

diagrams of a pelvis with little one-centimeter gradations up and down from the

ischial spines could only have been put forth by someone who has never felt a

baby's forehead passing over his/her rectum!

Often the mother can sleep deeply between sensations and this is most helpful to

recharge her batteries and allow gentle shaping of the babe's head. Plain water

with a bendable straw on the bedside table helps keep hydration up. The baby is

an active participant and must not be pushed and forced out of the mother's body

until he/she is prepared to make the exit. In her book Ocean Born (l989) midwife

Chris Griscom describes her experience of allowing her son to push his own way

out of her womb:

 

 

[i ask] . . . the cervix what color it needs to open easily, the color flashes

before my eyes and I begin to visualize myself drinking that color directly into

the cervix. I sense a subtle but immediate response.

There is a quickening now. The baby is moving down, as I've begun the dreaming.

Spun off time's orbit, I sleep in the sea, until I feel it rise with the

contraction. I surface like the dolphin, then dive again. Birth is coming.

Gratitude for the ease of this passage floods me, and I feel salty, slow motion

tears trace the outline of my face. Like a gigantic stone, the pressure of his

head weighs down through my pelvic floor. With all my power I am pushing the

stone . . . yes, I am also that stone myself. The motion catches me and I feel

myself impelled faster and faster . . .

An explosion of light

I see the belly of a huge Buddha,

I am propelled into it Rapture Bliss

Ecstasy.

 

 

 

Do not disturb

For anyone who has taken workshops with Dr. Michel Odent, you will have heard

him repeat over and over, " Zee most important thing is do not disturb zee

birthing woman. " We think we know what this means. The more births I attend, the

more I realize how much I disturb the birthing woman. Disturbing often comes

disguised in the form of " helping. " Asking the mother questions, constant verbal

coaching, side conversations in the room, clicking cameras-there are so many

ways to draw the mother from her ancient brain trance (necessary for a smooth

expulsion of the baby) into the present-time world (using the neocortex which

interferes with smooth birth). This must be avoided. A recent article on the

homebirth of model Cindy Crawford describes how the three birth attendants and

Cindy's husband had a discussion about chewing gum while she was giving birth.

Cindy describes her experience: " It was absolutely surreal. There I was, in

active labor, and they're debating about gum! I wanted to tell them to shut up,

but at that point, I couldn't even talk. " (Redbook, March 2000). This was in her

own home, and she couldn't control the disturbance that was happening in her

first birth. Needless to say, she had a long, painful, exhausting second stage.

Human birth is mammal birth. A cat giving birth to her kittens is a good model

to look to for what is the optimal human birth environment: a bowl of water,

darkness, a pile of old sweaters, quiet, solitude, privacy and protection from

predators. When given this environment, 99.7 percent of cats will give birth to

kittens just fine. We spend so much money in North America on labor, delivery

and recovery (LDR) rooms and now, adding postpartum, LDRP rooms. Yes, it is an

advancement that women are not moved from room to room in the birth process, but

there is so much more that can disturb the process: lighting, changing staff,

monitoring, beeping alarms, exams, questions, bracelets, tidying, assessing,

chattering, touching, checking, charting, changing positions and so on.

When midwives come back from the big maternity hospital in Jamaica, they bring

an interesting observation about birth. The birthing women are ignored until

they come to the door of the unit and say, " Nurse, I have to go poopy. " They are

then brought into the unit and within twenty-five minutes give birth to the

baby. Cervical lips are unheard of. Most times, the head is visible when the

woman gets onto the birth table. Her entire eight-centimeter-to-head-visible

time is done in the company of the other birthing mothers, and she is cautioned

not to go near the midwives until the expulsive feeling in her bum is

overwhelming. Cesarean section and instrument delivery rates are very low.

 

Reversing the energy

Birth is better left alone and pushing should be at the mother's cues. Having

said that, I want to address the exceptions to the rule. After hours of full

dilation with dwindling sensations, what if the mother is languishing? The sense

of anxiety and fatigue in the room builds, and nothing is served by allowing

this to go on too long. Such situations often occur at first births, where the

mother insists on having her whole family present. This dynamic is one reason

why I forbid vaginal birth after cesarean (VBAC) moms to have spectators at

their births. Birth is best done in privacy even if the woman desires on a

conscious level to have visitors. In this type of situation the midwife can help

by changing the direction of the flow. Normally we think of the baby coming

" down and out. " In this scenario, nothing is moving. It's a bit like having your

finger stuck in one of those woven finger traps. The more the mother attempts to

bring the baby down the more tired and tight the process becomes. At this point,

it can be helpful to get the mother into knee/chest position and tell her to try

to take the baby's bum up to her neck for a few pushes. This will sound like

strange instruction but, if she has learned to trust you, she will give it a

whirl. Reversing the energy and moving it the opposite direction can perform

miracles. After five or six sensations in this position with minimal exertion of

the mother, the fetal head often appears suddenly at the perineum. For those of

you who know Eastern martial arts, you will understand this concept of reversing

directions in order to gain momentum. This is midwife Tai Chi!

 

Facing Fear

Psychological factors in birth are a never-ending source of fascination to some

birth attendants. I try to keep it simple. My job is to facilitate birth not

practice psychology. When I start to be afraid at births, the last thing I want

to hear is someone else's fears in addition to mine. This is a natural

inclination but not helpful for moving energy and getting babies into the world.

I have learned to notice when I'm fearful and respond to my fears by saying out

loud to the mother, " Linda, what's your biggest fear right now? "

Linda may take some time but eventually she'll say something that I never

imagined she's holding as a fear. Usually it is enough for her to simply express

it. Sometimes she needs some reassuring input. I find always that when fear is

expressed it begins to disappear or at least lose its grip on the birth. Be bold

about addressing fear and uncommunicated worry. One first-time Mom responded to

my question " What's your biggest fear right now? " with " I'm afraid I won't be

able to open up and let my baby out. " As soon as the words were out, her baby

gave a big push and the head was visible at the introitus.

 

 

 

Linguistics and concepts

Midwives have lots of research support encouraging them to be patient with the

second stage and wait for physiological expulsion of the baby. Recognizing ways

in which we can support the mother to enter that deep trance brain wave state

that leads to smooth birth is imperative. I find it very helpful to have new

language and concepts for explaining the process to practitioners. Dr. Odent has

taught me to wait for the " fetus ejection reflex. " This is a reflex like a

sneeze. Once it is there you can't stop it, but if you don't have it, you can't

force it. While waiting for the " fetus ejection reflex, " I imagine the mother

dilating to " eleven centimeters. " This concept reminds me there may be dilation

out of the reach of gloved fingers that we don't know about, but that some women

have to do in order to begin the ejection of the baby. I also find it valuable

to view birth as an " elimination process " like other elimination

processes-coughing, pooping, peeing, crying and sweating. All are valuable (like

giving birth is) for maintaining the health of the body. They all require

removing the thinking mind and changing one's " state. " My friend Leilah is fond

of saying, " Birth is a no brainer. " After all " elimination processes " are

finished, we feel a lot better until the next time. Each individual is competent

to handle her bodily elimination functions without a lot of input from others.

Birth complications, especially in the first-time mother, are often the result

of helpful tampering with something that simply needs time and privacy to unfold

as intended.

 

Gloria Lemay is a Private Birth Attendant in Vancouver, British Columbia, Canada

and a frequent contributor to Midwifery Today and The Birthkit.

 

 

 

-

Serra

Monday, September 20, 2004 11:44 PM

Re: OT and maybe TMI: Perineal Massage

 

 

Worse--the doctor tried to avoid the cut but pushed me to push instead of

letting the canal relax enough to manage that. He mentioned nothing about

perineal massage either. I ripped in delivery because I didn't know how to

prepare for the event as he wanted. No episiotomy would

have been great, but I needed more info than he gave me to be ready.

Serra

 

 

 

 

[Guest guest]

Thanks Dale--will keep a hard copy of this to share.

Serra

 

 

Dale Bernucca wrote:

 

> Serra - just went back to your post about your pushing experience. You

deserve to grieve for what happened but please share the experience w/ other

women when you can. Here is a great article by Gloria Lamay. Originally posted

at birthlove.com. It is one that I print and give to all of my clients at some

point in our sessions/classes. I share it with everyone here but in the future

if anyone expresses the opinion I'm more than happy to send such information

offlist. No hard feelings. - Dale

>

> Pushing for First-Time Moms

>

> by Gloria Lemay

>

 

--

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