Hello Henci,

I am a new doula and aspire to continue my education to obtain my Bachelors Degree in Midwifery. I have attended a few births, all of which I have learned tremendously from. One aspect in particular I have seen that I have questions about is the rule about 10 cm dilation before pushing. I have found an article in regards to this topic in Midwifery Today. The observation that I have made is women who have been laboring beautifully and have reached 6 - 8 cm suddenly have the urge to push and are told not to, in case of swelling the cervix. These women then have struggled through breathing and no pushing with their urges, in turn causing all their muscles to tense. My question is: Is this a valid reason for not pushing ? where and how was this "rule" made ? and if a women is naturally laboring without intervention and her body is telling her to push should she not listen to that urge ? I would imagine that the pushing force of these early urges would not be as intense as the later urges to push her baby out. Any insight you have I would greatly appreciate.

Thank you.

Warmly, 

Evamarie

To answer your question, I turn to a wonderful book by a British midwife, Denis Walsh, entitled Evidence-Based Care for Normal Labour and Birth. He cites a study documenting the distress women experience when told not to push despite their internal urge and continues: "For a topic where there is such engrained custom and practice, one would expect there to be a substantial research base. Not only has it not been researched, but, like transition, little has been written about it. . . . Early bearing down has spawned practices based at best on worst-case-scenario thinking and at worst on myth" (p. 102).

My opinion is that its origins are rooted in controlling the woman and her body, which in turn arises from the foundational belief that the natural process is fraught with danger and therefore must be controlled for the woman's, and even more importantly, the baby's, own good. This is rarely a conscious rationale, you understand. It is just what appears to be self-evident to medical-model thinkers. Even if there were incontrovertable evidence against demanding women not to push, I would not expect to see practice change. Beliefs will  trump logic and evidence every time. 

-- Henci

This happens so often, doesn't it?

In my own birthing experience, it is exactly the body's pushing that allows for the final dilation. As loing as pushing is not coached and no force is added but just the mom following her body, this is the way normal birth goes.

I love the article in Midwifery today!

Yeah, it does. In my experience as a doula, women feeling "pushy" who weren't fully dilated and who were left to follow their instincts didn't push all that hard. They might give little grunts or breath catches,  but they didn't bear down forcefully. Once they were fully dilated--and sometimes all it took was getting them to get upright for a contraction or two--then the urge really kicked in and they got down to business.

-- Henci 

The only study that has described truly spontaneous pushing reported that bearing down before full dilation occurred frequently (17 out of the 31 participants) although it was rare for a woman to bear down before the baby was at +1 station. Another study I recall reviewing but don't have at my fingertips found that women push differently as the spontaneous second stage progresses, more frequently using "open glottis" (no breath holding) techniques early in second stage and "closed glottis" (breath holding) techniques as the baby gets lower in the pelvis. 

In other words, it seems to be perfectly natural to push before full dilation and women probably push more forcefully later in second stage, when the cervix is presumably gone.  Whether it is associated with cervical edema is less clear, because no one that I know of has studied that specifically (the study I linked to above found no association between early pushing and cervical laceration). But as Henci points out, it is distressing to be told not to push when the urge is there so we should demand evidence of harm before routinely discouraging spontaneous pushing efforts. 

I hope that helps!