Pushing for Primips
This article originally appeared in Midwifery
Today Magazine, Issue 55 (Winter, 2000). "Primips"-
women having their first babies.
-by Gloria Lemay
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 [women having
second or more babies] 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 side-lying 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 their 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.
The following appeared with the above article
in Midwifery Today.
Pushing Situations: Hospital vs. Home
-by Gloria Lemay
A hospital CNM wrote:
My physician colleague called me in as a consultant
for one of his ladies last week. Primip at forty
weeks plus three days, spontaneous labor, admitted
at five centimeters and spontaneous rupture of
membranes (SROM) around 8 p.m., with pretty bad
back pain, resolved after injection of sterile
water papules. Around 11 p.m. she was complete
and wanting to push. When he called me it was
2:30 a.m., she had been pushing for most of that
time and occasionally it seemed like the baby
would move down, and then nothing. He had her
pushing in all kinds of positions. I came in and
worked with her for a long time. The baby was
doing fine throughout and mom wanted to keep on
trying. Around 4 a.m. we started seeing signs
of fetal stress (tachycardic to the 170s), and
mom was also getting more and more exhausted.
Baby didn't seem all that big, but was occipitoposterior
(OP) and asynclitic. Went to OR, baby born around
5 a.m. with major molding of caput, delivered
OP asynclitic and I heard the surgeon grunt as
she and the family practitioner doc were pulling
out the shoulders—a 4,110 gram (nine pounds,
six ounces) baby boy. We tried every trick we
knew to get that baby turned and out, it just
didn't work.
Caroline, CNM
Homebirth midwife reply:
We had a homebirth of a primip 4,876 gram
(ten pounds, seven ounces) boy the other morning
which sounds a lot like your situation. Mom was
forty-two weeks plus four days. Tall and big boned.
She had four days of ROM prior to starting up.
Good temperatures and fetal heart tones in that
time. No exams. Complained about her back all
through. Her babe's head was plus one and she
was fully dilated at 8 a.m. after a twelve-hour
first stage. Then she slept and the sensations
spaced right out. She got up to the toilet for
a while, she went into the pool for a while, and
then would start the whole cycle again—sleep,
toilet, pool and sidelying on the bed. Mickey
Mouse pushing that produced no advancement, but
we didn't disturb her or encourage anything strong.
At 2 p.m. we got her up and had her squat and
bear down with some ooomph. She pushed out a big
boy on all fours into her husband's hands with
just a first-degree tear. Shoulders were a breeze.
The birth attendant, who used me for a consultant
in this case, called me in early and we both took
turns to work with her through the night so everyone
was rested and there was continuity in the coaching.
The other big advantage we had was being out of
hospital, which gave us a lot more room to be
"creative" and wait without the pressure
of "science" and protocols looming in
everyone's mind. The toilet in one's own home
is a good place to let go, and we were able to
"feed" her things from her own fridge
that kept her strength up.
In our province the governing board wants midwives
to do a certain number of hospital births a year
in order to be licensed. I would have such a hard
time working in that environment, especially with
first-time moms. When I think back on the years
I did labour coaching in the hospital, I recall
having a horrible time with primips. They almost
always stalled out. We asked Dr. Michel Odent
one time if it was OK to have the first baby at
home. He replied, "Zis is zee most important
birth to have at home because if a woman has a
beautiful, sexual experience with her first birth
then perhaps she can go to the hospital with her
second or third. She will never let them do anything
to her because she knows her body works from that
first birth." And then, we have Dr. Michael
Rosenthal who says, "The first intervention
in natural childbirth is the one the woman does
herself when she walks out the front door of her
house. It is from that first intervention that
all the others follow."
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