sHey friends, glad to have you back for part three of this series! If you stumbled across this post first and haven’t yet read the first two parts, you should go back and read them now. In part one, we discussed that there is more to contractions than dilating your cervix; contractions are also about building your fundus. And in part two, we talked about the pushing, specifically feeling the urge to push and/or what is called the fetal ejection reflex. Check them out!
 
Today, we are continuing our discussion about the second stage of labor, otherwise known as “pushing.” Yesterday, we covered the uncontrollable, involuntary, powerful urge to push, the fetal ejection reflex. But, what about those moms who reach complete dilation and then don’t experience that urge?
If mom has an epidural, she either begins to feel a lot of pressure “down there” and then her cervix is checked and if she’s found to be completely dilated, will be coached in pushing her baby into the world. Or, mom may have her cervix checked during a routine check (usually scheduled for every hour or every couple hours) and is found to be complete but, mom’s not feeling any pressure so she is left to “labor down” for another 30min or even more than an hour before the pushing commences. If mom does not have an epidural, either that uncontrollable, involuntary urge to push takes over and the fetal ejection reflex kicks in and she births her baby, or she is found to have a completely dilated cervix during a routine check. In that case, most providers will coach mom to push her baby out. But some providers….the smaller few will wait. They will grab a chair and wait patiently for the fetal ejection reflex to kick in. The main factor to remember in all of those scenarios is that some moms experience an urge to push/fetal ejection reflex soon after their cervix reaches full dilation and some do not, regardless of whether an epidural is being used or not.
So what is the difference? Does it matter whether you feel the urge to push and just go with it or whether you are coached to push before/without feeling that urge? I believe it does matter. You see friends, our bodies know how to birth our babies. There is this phase of labor that is often not recognized or talked about and not every mom experiences it. It’s called the “rest and be thankful” phase. This occurs when a mom’s cervix has fully dilated but she’s not yet experiencing an urge to push. This is when she should REST AND BE THANKFUL. Labor is seriously hard work. And sometimes our bodies need to take a little break between doing all the work of dilating the cervix (and building the fundus!) and pushing our baby out into the world. This phase is good. Its purpose is to build up energy to finish its work. It may also be allowing baby some time to rotate to better fit through mom’s pelvis. But, mom isn’t allowed that rest (and baby the time to rotate) very often. Our maternity care system is impatient. Providers are taught that there is something wrong if anything takes "too long." And the results of not allowing that rest are that it then takes mom much longer to push her baby out that it would have if we had waited for the urge to push. And because our maternity care system is impatient, mom may even end up with a cesarean after doing all of this work and going this far because of that training that something is wrong if it takes "too long." Or mom just ends up being much more exhausted and sore than necessary once baby has emerged, making recovery harder. Also, it has been shown that coached pushing often results in more occurrences of tearing and more severe tearing than in mom-lead, instinctual pushing (aka the fetal ejection reflex!) which also makes recovery more difficult than it needs to be.

With my first VBAC, I experienced a rest and be thankful phase. My midwife knew I was complete. It had been a very very long labor (54 hours) and my baby was possibly, probably not positioned perfectly. I am so thankful that she trusted the birth process and my body’s ability enough to just patiently wait for my body to begin uncontrollably, involuntarily pushing on its own. While we waited, I actually fell asleep. Contractions faded and I napped for I believe around 20min. Then I pushed my daughter out in less than 20min, without any coaching and only experiencing a small tear. With my second VBAC, my water broke as we were on the way to the hospital and then the very next contraction, my body gave a little heave downwards at the peak. He was born just 8 min after we pulled up to the front doors of the hospital. I’m very thankful for that midwife as well, who trusted the birth process and my body enough to just stand back and let me push my baby out without making me submit to a cervical check first. She knew that if I was pushing involuntarily, then my body was ready to birth my baby. And that time, I experienced no tearing. They were both wonderful births.
 
I’d love to hear about your experiences, too! 

I'm glad your back for part two! If you haven't read part one of this series, you should hop over and do so real quick. We talked about how contractions have more of a purpose than to just dilate the cervix. 

So what happens once the cervix has opened fully at the bottom of the uterus and the fundus has built into this beautifully thick an strong muscle at the top of the uterus? Pushing! The baby will be born!!!

Pushing is what is known to be the second stage of labor. Some refer to this as the fetal ejection reflex. I can certainly understand why it would be considered a reflex. I like to compare the urge to push as sort of like throwing up, but backwards. It is an involuntary, uncontrollable, heave downwards that your body does all on its own (if left alone). It is that strong fundus that has been building up as your cervix has been opening, pushing downwards and expelling the baby. Have you ever known of a woman’s body to begin involuntarily, uncontrollably pushing and then mom’s cervix was checked and found to not yet be 10cm so she was told not to push? I have. I’ve watched it as a doula. And I really don’t like it. And I won’t participate in coaching mom not to push. I used to, but I won’t any longer. I have full confidence that our bodies are not making a mistake when that pushing urge kicks in. Now, if mom is feeling a lot of pressure in her bottom and is reacting to it by forcefully pushing with that pressure during a contraction, that is different. That can mean things like a swollen cervix. And we don’t want that. In those instances, we (her birth team) help mom to find other ways to cope with that pressure than by bearing down and pushing. But, if that fetal ejection reflex has kicked in and it is truly an uncontrollable, involuntary, and strong pushing urge, I believe in letting her body do its thing, no matter what her cervix dilation was at her last cervical check. I think that telling moms to resist and try to control that urge (although, as I said, it really is not controllable…her body still pushes on its own whether she is consciously pushing along with it or not.) is detrimental to the process. To explain my thinking on this, let’s visualize a baby learning to walk. You notice your baby standing next to the couch and trying to take a step away and then successfully taking two whole wobbly steps unassisted. Now let’s imagine that the “experts” have declared that babies should walk at 12 months old and not any sooner or later. So when you see your baby that is “just” 11 months old taking these couple steps, you decide to not allow him to be free to move about any longer, because babies simply cannot begin walking at any time other than 12 months old; they are not ready! You now confine your baby to a small playpen or a crib all day to discourage him from walking. He will still stand and take tiny wobbly steps in that crib. You can’t stop it, you can’t control it. His body is ready. But, you’ve slowed it down and he is not free to just do what he is ready to do.  A few weeks later, after that baby reaches 12 months, you declare he is ready to walk now and let him freely move around again. But, suddenly he’s not interested. He’s lost the confidence he had a couple weeks ago. He’s now scared and unsure of himself and his abilities. His muscles have been temporarily stunted in their growth and development. And then it takes him months to gain that back. He is 16 months old before he is able to walk unassisted. And in those 4 months since his first birthday, everyone has been fretting and worrying and wondering what’s taking so long and offering advice and interventions and help of all kinds because this is not normal.
Can you relate this to the mom whose body was involuntarily and uncontrollably pushing and then told that it wasn’t yet time and she’s not allowed to push yet? What happens to that mom? She loses confidence in her body. She becomes scared and unsure of what to do or how to do it. That beautiful and strong fundus at the top of her uterus that is pushing her baby down and out has been stunted in it's growth and development. And then pushing can take much longer and be much harder than it needs to be, than it would have been if she had just been left alone. 
 
And let’s explore another facet of this. What if……just what if not everyone dilates to exactly 10cm before their body is ready to push their baby out? What if all of our cervixes were not created perfectly equal and alike? What if our babies’ heads were all different shapes and sizes and had different abilities to mold and squish? Can you imagine? Perhaps this one-size-fits all definition of completely dilated being 10cm is a bunch of phooey because we were all created differently.

​So now what about those moms that are fully dilated and then that fetal ejection reflex doesn’t kick in? Those moms whose cervixes are 10cm yet they are not feeling an urge to push? Let’s talk about that Thursday. 

*Updated to add a link to Part 3.