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By Brittany Sharpe McCollum, CCE(BWI), CD(DONA), CLC

Hold your breath and curl around your baby.

Push!  Push!  Push!

Pull back on your legs.

Let your legs fall out to the side.

Common directions like these that we hear so often in movies and tv shows and real life only work to further disconnect the person giving birth from their intuition and their body’s guidance during the pushing phase of labor.  We hear so many stories about “pushing” yet so many people approach this part of the process with little cerebral understanding of what is happening in their bodies and how to respond to it.  When we approach labor as a normal physiological process we have an opportunity to use low-intervention skills and modify them as necessary if complications arise.  As with all human childbirth, though, people have a tendency to get inside their heads and over-analyze, anticipate, and fear the upcoming process.  This use of the “thinking brain” is understandable, as we humans use this part of our brains day-in and day-out for tasks all throughout our daily lives.  However, its use during a primal process such as labor can hinder progress and cause us to overanalyze and excessively intervene in a function that is normal, biological, and physiological.  We can use knowledge, information, and skills to help shift our thinking brain from fear to understanding and this can work wonders in decreasing anxiety and improving function.  Spontaneous pushing follows the direction of the body to move the baby down and facilitate birth.  Often times we hear of the “fetal ejection reflex,” a term coined by Michel Odent, as part of this process.  This overwhelming urge to bear down occurs once the baby has descended out of the uterus and it is quite literally a shift in the action of the uterine muscle, leading the uterus to curl around the baby and push the baby down.  What happens when spontaneous pushing is supported without direction, guidance, or fear? Here’s what the research suggests to us. Many people find that they push for five or six seconds and do so twice during one contraction, the thighs have a tendency to come inward, and they choose an upright position where the sacrum is free to open outward leading to a slight arch in the lower back when they are not told how to push.  What a different picture this paints than directed pushing!   Directed pushing is part of the management of labor and is unfortunately most often applied to all labor scenarios, not just those where people need to speed up the process.  With directed pushing, the person pushes for three counts of ten during one contraction whilen holding their breath in, the thighs are often held outward while the laboring person reclines, and the person is told to “let their legs drop out to the side,” while encouraged to “curl around their baby,” rounding the lower back.  This type of pushing can increase the risk of damage to the pelvic floor, increase the risk of tearing, and decrease satisfaction with the birth process.   When providers develop an understanding of pelvic biomechanics, when they observe the spontaneous pushing process in a laboring person, and when they witness the progress that results from this, they are afforded an opportunity to shift the way they support all labors.  These elements of spontaneous pushing can easily be incorporated into both medicated births requiring guidance and unmedicated births that are guided by the provider.  Simple but frequent adjustments to the pushing position to incorporate opportunities to free the sacrum works with the body’s functional movements to give the baby’s head the space necessary to descend and extend under the pubic bones.  Encouraging shorter pushing times and fewer pushes during one contraction may take longer but can leave the baby better oxygenated.  Bearing down and letting air out with the “push” may take longer but is not contraindicated by obstetrical research and is in fact supported by research on long term pelvic floor health.  Supporting people in pushing with “closed knees” or internal thigh rotation actually increases space between the sitz bones at the base of the pelvis, giving the baby more room side to side. The body has an innate ability to birth babies but the thinking brain often gets in the way.  One of the simplest ways to “relax” the thinking brain is to prepare it with the knowledge of why and how.  When it comes to supporting the body’s innate functions in pushing out the baby, we can better tap into the spontaneous process when we have the knowledge that allows our brains to let go and let our bodies take over.  When we have this knowledge, we are also then able to apply a modified version of it to scenarios that may require guidance, such as decreased sensation from an epidural or concerns that warrant a quick second stage.  This refocusing of the process on the instinctual needs of the laboring parent can re-center them as the focus of the birth and support a gentler and more instinctive pushing phase.  Sources Cited: Ahmadi Z, Torkzahrani S, Roosta F, Shakeri N, Mhmoodi Z. Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial. Iran J Nurs Midwifery Res. 2017 Jan-Feb;22(1):62-66. doi: 10.4103/1735-9066.202071. PMID: 28382061; PMCID: PMC5364755. American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth. Obstetrics and Gynecology. Feb 2019; 133(2):406-408. Doi:10.1097/AOG.0000000000003081 Bloom SL, Casey BM, Schaffer JI, McIntire DD, Leveno KJ. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol. 2006 Jan;194(1):10-3. doi: 10.1016/j.ajog.2005.06.022. PMID: 16389004. Calais-Germain B, Pares NV.  Preparing for a Gentle Birth: The Pelvis in Pregnancy. Healing Arts Press: Rochester, VT; 2012. Lemos A. et al. The Valsalva maneuver duration during labor expulsive stage: repercussions on the maternal and neonatal birth condition. ev Bras Fisioter.. Jan-Feb 2011;15(1):66-72. doi: 10.1590/s1413-35552011000100012. Brittany Sharpe McCollum (she/her), CCE(BWI), CD(DONA), CLC is the owner of Blossoming Bellies Wholistic Birth Services, established 2007 and based out of the greater Philadelphia PA, area.  She provides childbirth education classes, birth doula services, and dynamic labor support and pelvic biomechanics training workshops for birth professionals and expectant parents. Brittany has had the honor of presenting at international childbirth related conferences, including the Birth Works International Conference 2016, International Chiropractic Pediatric Association Summit in 2018, the Evidence Based Birth conference in 2019, the Midwifery Forward 2020 Conference, the ICEA 2020 Virtual Conference, the Utah Doula Association Mini Conference, the ACNM Midwifery Day conference, and more.  In addition, Brittany facilitates private workshops for obstetricians, midwives, nurses, doulas, childbirth educators, and other prenatal support resources around the country, both virtually and in-person, as well as two bi-annual trainings for the larger birth community.  She is also a contributing author to the book “Baby Got VBAC: An Inspiring Collection of Wisdom for Better Births After Cesarean.” Brittany lives in South Jersey with her partner and their four children. Check out her website for upcoming webinars, classes, workshops, conference events, and more at www.blossomingbelliesbirth.com, follow her on Instagram @blossomingbelliesbirth, and stay in touch on Facebook at Blossoming Bellies Wholistic Birth Services.