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    Labor: Second Stage/Pushing

    The pushing stage occurs after the cervix is completely dilated and no longer in front of the baby's head. A smooth passageway now exists through which you can push your baby from the uterus and down through the birth canal to delivery.

    Anterior position showing baby facing mother's back. Posterior position showing baby facing mother's front.

    Your contractions may decrease just prior to getting the urge to push. You should take this time to rest prior to pushing. The length of this stage varies with the position and size of the baby and your ability to push with the contractions. For first-time mothers the average length of pushing is one-to-two hours. In some instances, pushing can last longer than two hours if mother and baby are tolerating it.

    Normally, the baby is born with his face looking toward mother's back (referred to as an anterior position). However, some babies are facing the mother's abdomen (referred to as a posterior position). Posterior babies may have a more difficult time passing through the pelvis, which may cause pushing to be more difficult or require more than 2 hours of pushing.

    Contractions During the Pushing Stage

    During the second stage of labor, the uterus continues to contract about every five minutes and each contraction lasts 45-to-90 seconds. The contractions are usually strong and forceful and may or may not be accompanied by an urge to push. This can make this phase somewhat more enjoyable since you are now working with each contraction. A renewed sense of energy may occur as you feel the closeness of your baby's birth!

    However, sometimes after a long or difficult labor, the pushing stage can be exhausting and uncomfortable. It is definitely hard work! Most women will feel increased pressure in their perineum, rectum, and lower back at this stage. For many women, the rectal pressure feels the same as having a bowel movement.

    As the baby's head begins to appear, you may feel a stretching or burning sensation. You may want a mirror positioned so that you can see your progress.

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    Delayed Pushing

    Pushing is most effective when the mother feels the urge to push. Women who receive epidural anesthesia may have the sensation to bear down numbed by the anesthetic. The practice of "delayed pushing" while waiting for the baby to passively come through the birth canal, is currently being studied as an alternative to start pushing at 10 centimeters. If you and your baby are doing well, a 1 to 2 hour period of "passive descent" is safe and may make your pushing more effective.

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    Positions for Pushing

    There are many different positions that may be used for pushing. In all positions, keep your chin down and use a rounded back to help your abdominal muscles assist your uterus in pushing your baby.

    You may be able to speed the progress of the labor if you try positions where gravity assists you (i.e. sitting, or squatting). However, if the baby is delivering quickly, you may be able to slow the stretching of the perineum by trying positions where gravity is neutral (i.e. lying on your side, or getting on your hands and knees). It is important for your comfort to experiment with pushing in different positions.

    Squatting
    Advantages:

    • Opens pelvic outlet to its maximum width (up to an extra 1 to 2 centimeters)


    • Takes advantage of gravity


    • May require less bearing down


    • May enhance the baby's rotation and descent in a difficult birth


    • Helpful if you do not feel the urge to push


    • If you have difficulty with squatting, try a semi-squatting position on a stool or a stack of pillows. Birthing beds have a squatting bar which may be attached to the bed so that squatting is more comfortable.
    Semi-Sitting/Upright
    Advantages:
    • Some gravity advantage


    • Partner should place his/her hands on your lower back and instruct you to push toward his or her hand, encouraging you to tilt your pelvis


    • Pelvic tilt allows for greater opening of pelvic outlet


    • Good resting position


    • Can be used with fetal monitoring


    • Vaginal exams are possible in this position
    Sitting
    Advantages:
    • Some gravity advantage


    • Good resting position


    • Can be used with fetal monitoring


    • May lean forward to help relieve backache; a good position for a back rub


    • You may consider pushing on the toilet as it is a familiar place to push and offers a firm surface against which to push
    Hands and Knees
    Advantages:
    • Gravity neutral - slows a rapid delivery


    • May help relieve backache by bringing the baby forward


    • Assists rotation of the baby in a posterior position


    • Takes pressure off hemorrhoids
    Lying On Your Side
    Advantages:
    • Gravity neutral - slows a very rapid delivery


    • Very good resting position


    • Can be used with fetal monitoring


    • Vaginal exams are possible in this position


    • May be helpful in avoiding episiotomy

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    Stopping Your Pushing

    There may come a time when you may be asked not to push with a contraction. This is for reasons such as the cervix is not fully dilated or the baby is crowning and the perineum needs to stretch gradually. Usually these situations require you to stop pushing for a short time. During this time, relax your neck, shoulders and legs and pant or blow out during the contraction. Visualize blowing out candles. Your partner may need to hold your face, look directly in your eyes, and pant or blow with you to keep you from pushing. Pushing, for many mothers, is a powerful reflex that requires considerable effort to breathe through rather than to push through.

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    Breathing Techniques for Pushing

    The breathing techniques used for pushing are varied and depend upon which works best for you. Your health care provider and labor nurse(s) will offer suggestions and are your most valuable resources in evaluating your progress as you push your baby through the birth canal.

    Work with your contractions to enable yourself to maximize your efforts at the peak of the contraction. Grunting or groaning may be helpful while pushing. Allow yourself the freedom to make the sounds that come naturally. It is unnatural and possibly damaging to you and your baby to hold your breath for a long time. Holding your breath while pushing is fine to do if you feel it assists with bearing down.

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