To Push or Not to Push
Let's look at two different labor scenarios:
Mom doesn't have an epidural, and has been stuck at 9cm for over an hour. She's been getting in different upright positions to help baby come down. Her nurse comes in to check on her, and offers to give a cervical check to see if there's been progress. Mom consents, and the nurse declares that she is 10cm and ready to push. The doctor is called in, mom begins pushing.
Mom doesn't have an epidural, and has been stuck at 9cm for over an hour. She's been getting in different upright positions to help baby come down. Her nurse comes in to check on her, and offers to give a cervical check to see if there's been progress. Mom consents, and the nurse declares that she is 10cm, but baby is not engaged enough, yet. The nurse tells mom that she should wait to begin pushing until baby is further down. Mom continues to labor in an upright position, until after 30 minutes, she begins grunting and saying that she's pushing. The nurse comes in and checks her, and baby is now at a lower station. The nurse tells mom that it's time to get the doctor and have the baby.
What is the difference between the two?
Scenario #1 is a typical situation you'd see in many hospitals. Scenario #2 illustrates a birth concept called LABORING DOWN. In this blog, we are going to discuss what it is, why it's done, and the benefits and risks.
What is Laboring Down?
Laboring down is defined as the period after a woman is fully dilated (10cm), where she rests until either she feels the urge to push, or baby's head is visible. The time in which she rests can vary, but in some cases can be up to 1-2 hours. Typically during this time, contractions lessen as the uterus shortens its muscle fibers (Simkin 176) in an effort to rotate & expel the baby. Think of it as the calm before the "storm."
The idea behind laboring down is this: why have mom use up so much energy, when she could rest and let her uterus do the work? Uteruses are capable of pushing out babies without much help from mom (although typically the urge to push is involuntary and moms do end up pushing). This is called the Fetal Ejection Reflex. It's a bodily reflex that's seen in mammals and is FASCINATING. For more information, read the article I linked above.
This makes sense. So why don't all moms labor down?
Hospital policies regarding delayed pushing (laboring down) have swung the pendulum a few times over the past few decades as new evidence is published. But to be clear, laboring down is, for the most part, standard in midwifery care, which takes a more hands-off approach to birth. Moms are instructed to continue to change positions and bear down only when the urge to push comes (unless the urge to push is premature, which is another topic for another day).
As scientists have looked into the benefits and risks of delayed pushing, the results have been mixed and at times, confusing. In fact, ACOG (an organization that publishes recommendations for OBs) has changed its recommendations for delayed pushing a couple of times. Here's a summary:
Before 2018, ACOG recommended offering a resting period of 1-2 hours as long as there wasn't a reason to deliver quickly.
In 2018, in light of a new study published by JAMA, ACOG recommended that for moms with an epidural, that they begin pushing when they reach 10 cm.
This is because the JAMA study (which looked at only moms with epidurals) showed that immediate pushing resulted in a faster pushing phase, lower rates of infection & hemorrhage, and didn't result in a higher c-section rate.
A note on the JAMA study: the c-section rate was very low at the participating hospitals (~15%, the national average is 31%) which may be why there was no difference in c-section rate.
Also, I wonder if the rate of infection would be lowered if there were fewer cervical checks.
ACOG didn't update their recommendation for moms laboring without an epidural.
Benefits & Risks of Laboring Down
Benefits (regardless of epidural/no epidural)
actively pushing for less time
less exhaustion for mom
could increase spontaneous vaginal delivery rate (Cochrane), especially in hospitals where the c-section rate is higher than the JAMA study hospitals
Utilizes fetal ejection reflex
Risks (no epidural)
There are no major risks to laboring down without an epidural. Moms should be instructed to wait to push until there's an urge to push (unless the urge to push is premature)
There are risks to a prolonged second stage of labor, but those risks are usually lessened when moms are able to move freely (and push in whatever position feels best)
Increased risk of infection (could be lessened with fewer cervical checks)
Increased risk of hemorrhage
If you want to labor down without an epidural, talk with your doctor about this and ask about their hospital policy. You have the right to informed consent and you also have evidence that laboring down is beneficial. In order to ensure your labor doesn't stall, you should also state your desire to move freely and push in whatever position feels best.
If you want to utilize the fetal ejection reflex (FER) to its fullest, a hospital setting may not be the best environment for you. For the FER to fully happen, you need to feel safe & undisturbed. If you're low-risk, you may consider a birth center or home birth.
If those are not an option, do your research to select a provider that you feel will respect your birth wishes. Communicate respectfully to your nurses, and be sure to prepare for birth beforehand thoroughly.
Our Birth Class for Couples will fully prepare you and your partner for birth so you're confident about how to handle contractions & the labor process. Click the link to learn more.
If you want to labor down with an epidural, discuss the benefits and risks with your doctor. If you choose not to labor down but you're concerned about tearing, you should learn about position changes with an epidural (yes, you can get in different positions with an epidural while pushing!) as well as open glottis pushing. We cover both in our birth class.
Sources Other Than Links:
The Labor Progress Handbook by Penny Simkin, Ruth Ancheta