Empowered Pushing: Second Stage Labor and Your Pelvic Floor
Often the shortest part of labor—the pushing stage—is the most important when it comes to impact on your body and lasting effects on the pelvic floor. As a respected New York City birth educator and doula with 21+ years in practice, I have heard versions of this question countless times: How do I get this baby out of me without destroying my vagina?
“When the birthing mom changes positions, the shape of the pelvis changes.”
What I’ve found is that birthing moms are often underprepared for the pushing stage of labor. They may push inefficiently for extended periods of time. This is not without consequence. Unnecessary forceful pushing can be harmful to the perineum, increasing the risk of tearing and the type of pelvic-floor weakness associated with incontinence or prolapse. Uncoordinated pushing during birth can also lead to further weakening and damaging of the abdominal muscles and pelvic floor.
But it doesn’t have to be this way, and it’s been my life’s work, through online childbirth classes and one-on-one coaching, to make this better for pregnant women—to help expecting moms learn how to push safely and effectively and protect their pelvic floor muscles during birth.
What Birthing Moms Are Up Against
Conventional thinking can work against pregnant people when it comes to minimizing damage to their bodies during birth. There’s a notion that pushing will come instinctively to you, but often it’s a learned skill. There are also oversimplified rules about when to push (more on this later) that can cause birthing moms to push too soon and in an uncoordinated way; this can lead to exhaustion, tearing, and unnecessary long-term damage. Often the process is rushed, due to thinking about getting the baby out as soon as possible. But if mom and baby are doing fine, there’s often no rush. And, in fact, the perineal tissue needs this time to release and progressively stretch.
It’s been my life’s work, through online childbirth classes and one-on-one coaching, to make this better for pregnant women—to help expecting moms learn how to push safely and effectively and protect their pelvic floor muscles during birth.
Your provider needs to be motivated to protect your perineum for birth. Find a compassionate provider whom you trust and who you can talk to about your concerns. Have the conversations ahead of time.
Feeling safe and supported is a huge part of relaxing and releasing, which is essential to letting your baby out. As long as the baby is doing well and your provider is on board, you may be able to take your time.
Birth Story: Asking for What You Need
My client Kate was ready to push. It was time. As she pushed and her perineum stretched, Kate’s OB reached for the scissors. I asked the OB, “May we have a minute?” The OB answered, “The baby is doing fine, so yes you may.” The next contraction came, and the OB reached again for her scissors. I said, “May we have another minute?’ The OB watched the baby’s heart monitor and answered, “Yes, the baby is doing fine.” This went on for a while. I continued to guide Kate in her pushing, and to communicate with the doctor. Another contraction came, and the OB reached for her scissors, saying to Kate, “I can help you by giving you just a tiny cut. Do you want me to, or do you want to wait?” Kate said, “I’d prefer to wait.” Another contraction came; Kate’s perineum was stretching more. The OB reached again for the scissors. I said, “any minute now.” With that the biggest part of the baby’s head began to emerge. I turned to Kate and said, “Slow down. Blow, blow, blow. Relax your bottom.” With the next contraction, the baby’s head came out, and the rest of the body followed. Kate had birthed her baby with no episiotomy, no tearing, and an intact perineum!
Prep to Push: What to Do and What to Avoid in the Third Trimester
Readying your body and mind in advance can help you push safely and effectively, when the time comes. It can also shorten the pushing stage of labor. In my birth-coaching practice, I teach clients to balance the hard and the soft, the strength and the pliability. Tissue that’s soft, supple, and pliable is less likely to tear. If your tissue has mobility, it’s more willing to let go. Learning ahead of time how to release the pelvic-floor muscles through breath and safe stretches can have excellent results. The magic is in the softening, the release, and letting go.
There are a lot of things you can do in the last weeks of pregnancy to prepare. Rest, hydrate, and nourish yourself. Do some pelvic rocking daily on a birthing ball. Walk, climb stairs, swim, if you can. Dance (think salsa or belly dancing)— enjoying movements that involve rocking, swaying, and hip circles. Our lifestyle, postures, and daily movement habits are important, so how you move and sit throughout the day matters. Practice breathwork. Here are a couple exercises you can do daily, from 36 weeks on:
“Scrub the floors.”
Getting down on hands and knees supports a full range of motion in the pelvic floor, as well as promoting flexibility and mobility and can help the baby move into an advantageous, birth-ready position. The reason I use this phrase “scrub the floors” is that the functional movement of this task—crawling, rocking, reaching, kneeling, alternating stepping one foot onto the floor with one knee down—is all valuable for labor prep. Get down on the ground and imagine “scrubbing” for a few minutes each day in the late weeks of pregnancy.
Practice Reverse Kegels.
In order to function properly while giving birth, the pelvic floor muscles need a full range of motion. They need to contract at times and fully lengthen and release at other times. In the last weeks of pregnancy, many of my clients stop doing traditional Kegel exercise (where the action is to draw the pelvic floor muscles in and up) and start doing the opposite: elongating and releasing the pelvic floor. It’s helpful to sit on a birthing ball when first learning Reverse Kegels, because contact makes this subtle pelvic-floor movement easier to detect. Visualize your pelvic floor as a baseball diamond; the four attachment points are your two sitz bones, your tail bone and your pubic bone. Place your hands on your belly and take diaphragmatic breaths. Inhale and imagine your diamond expanding and lengthening—sense those four points moving away from each other. Feel your perineal tissue relax and release slightly into the ball. Stay relaxed, and imagine further lengthening. Add a low hum. Keep your throat open. If you have trouble accessing these muscles, start with a Kegel. Draw in and up, contracting the pelvic floor. Then soften and think of opening up, imagining something small sliding out, like a blueberry. Keep practicing, trying Reverse Kegels in different positions, like in child’s pose, on hands and knees, and lying on your side. Practice them before you go to sleep, when you feel relaxed and cozy in bed. This can help you associate a feeling of safety with the idea of letting go.
Avoid Constipation.
Straining on the toilet risks weakening the pelvic-floor muscles. Get a Squatty Potty. Talk to your provider about optimizing your hydration and nutrition.
Birth Story: Following the Baby’s Lead
My client Eleanor was ready to push. As she began to push, the baby’s heart rate went down. Her OB said, “I know you don’t want an episiotomy, but if this baby isn’t born in the next few pushes, I will have to cut you. I’m really sorry, but this baby needs to come out.” I quickly asked her OB, who I had a good relationship with, “May I have the next couple of pushes with Eleanor?” The doctor said “Yes, of course, how can I help?” I said, “Let’s quickly turn Eleanor onto her side to see if we can give this baby a break.” Which it did. We supported Eleanor to turn onto her left side, and I assisted her to bring her right knee up and forward so that she was tilted more towards her front in a left-lying lateral position. The next contraction came, and the baby rotated. The following contraction came, and the baby rotated some more. Then the baby began to slowly crown, gently emerge, and then birthed. Eleanor had an intact perineum. No episiotomy, no tears, not a scratch. This baby was 9 lbs.
The Baby’s Role in Birth
An important part of the birth process is simply allowing the baby to do what it needs to do. The baby has its own special reflexes—several positional changes that are specific, deliberate, and precise—for navigating its way into and through the pelvis. Unfortunately this stage of labor is under-emphasized and often rushed, and the result can be unnecessarily damaging to the birthing mother’s pelvic floor.
My passion is to protect the physiology of the baby and the birthing mother by empowering pregnant moms to understand these essential movements. The baby has its own sequential reflexes to complete in order to be born. In my classes, I teach how to support the baby’s physiological process in all ways to bring about the most advantageous positioning possible. The baby is really in charge; what we’re doing is making room and preparing the pelvic-floor muscles, so they can release and let the baby out.
A little anatomy lesson: The pelvis is funnel shaped and curved inside. It protects the lower internal organs, and in the female pelvis—the bladder, uterus and rectum—and these organs are supported by each other and by the pelvic floor. A lot is happening within a limited space. The pelvis also connects the spine to the femur bones; this is why the positioning of your legs and your spine can make more or less space for the baby as it exits the pelvis.
During labor, the baby slowly leaves the uterus, rotates within your pelvis, descends through the birth canal, and is born. Much of this process is up to the baby. But different positions can help the baby descend and rotate. When the birthing mom changes positions, the shape of the pelvis changes.
Sometimes the best thing to do is to get onto your feet, or try hands and knees. Leaning forward can help the baby find space to move. Side-lying can also change things. But throughout, patience is key. Waiting until the baby is ready—and finally slowing down the birth of the baby’s head—is very important when it comes to preventing tearing.
Birth Story: Easing the Baby Out
Shoshana came to me after a rough experience. With her prior birth, she had torn so significantly (and taken so long to heal) that she wasn’t sure she could go through it again. Now, pregnant with her second child, she was considering scheduling a C-section (which would have been a fair choice). But she had heard about my Pushing Power workshop and decided to sign up. After the workshop, Shoshana approached me and said she would consider another vaginal birth if she had the right support. She was inspired by my class and asked me to coach her further, one on one. We worked together a dozen times. After Shoshana gave birth, she reported back. She said that when she began to push, the nurse in the room was yelling, “Pull back on your legs and hold your breath for a count of 10!” She remembered what we’d worked on together. Between contractions, Shoshana turned to the nurse and said, “Please don’t yell at me. I want to ease my baby out. Please help me ease my baby out.” With that, the tone in the room completely changed. The nurse and the OB understood, and with the next contraction, they quietly supported Shoshana. She listened to her doctor, who helped her guide her baby out (saying, “Give me a little push for 1…2…3—okay stop pushing. Breathe.”) The next contraction came and her doctor said the same. Then she said, “Let’s push between the contractions to ease your baby out,” and together they worked without rushing, alternating pushing at the peak of the contraction and pushing between contractions, to slow down the birth of the baby’s head. Shoshana’s baby was born, and Shoshana had an intact perineum. No tearing and not one stitch.
How to Push
Because there are so many variables —the position of the baby, where the baby is in the pelvis, whether or not you have an epidural, and many more—there’s a lot to know about pushing. In my birthing classes and coaching practice, I prepare clients for all scenarios.
One thing that’s always important is the idea of softening, relaxing, and releasing. I encourage clients to relax from the navel to the knees. This is easier said than done, but it’s a mantra that can help no matter what position you’re in when it’s time to push. In general, it helps to have the philosophy of letting the baby out rather than getting the baby out.
Perhaps the most universal advice I have regarding pushing is this: Don’t rush; push with the urge. Harness the power of the uterine contractions and push when the contraction is peaking. Sometimes a metaphor can help. Think of a French press coffee maker—apply steady downward pressure.
There’s a lot of misunderstanding about the technique of pushing. In my 21+ years as a doula, teacher, and coach, I’ve developed a technique that clients have found to be life-changing (and birth-changing). I think it’s helpful to know what you might be told versus what is often more effective.
Birthing moms are often told that when they dilate to 10 centimeters, it’s time to push. Just because you’re at 10 centimeters doesn’t mean it’s time to push. You can potentially get to 10 centimeters while the baby is still high. And sometimes the contractions space out or even disappear for a time. You need contractions to push—you want to work with the power of the contraction, pushing at its peak. Or you need to be at a point where you feel the baby so low that you can’t help but push. If you’re not feeling either, and both mom and baby are doing well, then wait; work on the baby’s positioning by changing your own position; and rest as you let the baby come down lower.
Don’t rush; push with the urge. Harness the power of the uterine contractions and push when the contraction is peaking.
Birthing moms are often told to hold their breath and bear down as long and hard as they can, to someone else’s count of 10. This can be inefficient and exhausting for the mom. I have found that the urge to push naturally asserts itself at the peak of contractions, once the baby is lower down. Be patient.
Birthing moms are often told to push like they’re having their biggest bowel movement. I don’t know about you, but my clients are not motivated by this concept. They often fear pooping while they’re pushing, and they’ll hold themselves back to try to prevent this. Forceful pushing in the rectum can cause hemorrhoids and long-term muscle weakness—and it sends the effort in the wrong direction. Instead, imagine pushing out a tampon or diva cup. The direction is downward and forward (picture a curve, like the letter J). If you wait for the peak of the contraction, the urge to push comes, and you can coordinate your muscles.
While there are many variables when it comes to pushing, the biggest takeaway is that preparation can help you relax and release into whatever may come—and that the support of your team in the labor room is important. So choose your birth team mindfully, talk openly with your practitioners in advance, and understand the power of preparation when it comes to pushing and postpartum; choosing your childbirth education wisely is much more important than you might imagine. It can make all the difference.
Birth Story: Changing Positions
My client Nicole had an epidural. As she began to push, her baby’s heart rate went down. Her OB said, “Look I don’t think this is going to work. The baby doesn’t tolerate it when you push, and your baby is sunny side up.” (This means the baby’s head is down but is facing the mom’s abdomen, so the baby’s skull is against the back of the pelvis.)
The doctor said, “You carry on pushing, and I’m going to check on the operating room availability…” My client was disheartened. I said, “Don’t give up. Your OB didn’t say ‘Stop everything, we’re doing a C-section right now.’ She gave her opinion, which is that she didn’t think it would work out for a vaginal birth. Let’s keep trying.” I asked Nicole’s nurse, who was very supportive, if we could get Nicole onto hands and knees, even though she had an epidural. The nurse said, “Of course,” and assisted Nicole, rearranging the wires and monitors so that she could come up onto her knees. (When you have an epidural, it’s very important that your medical team is supportive of you coming into a weight-bearing position. It’s also essential that you have enough sensation and strength to hold yourself up.) We must have pushed for about 35 minutes on hands and knees when the OB came back into the room. The doctor said the baby looked good on the monitor. Then she checked Nicole: “Your baby is right here,” she said. “It’s on your perineum. Let’s have a baby!” Nicole came back into a semi-seated position, and in just a few pushes, her baby birthed. No episiotomy, no vacuum, no forceps, no C-section, no tearing. And the baby had rotated around into the ideal birthing position.
