I have seen exhale pushing scoffed at. I've also seen fitness professional teaching women how to push. So, I am going to try to set the record straight from my perspective as a movement teacher/fitness professional, doula, and childbirth educator. I have the perspective of knowing things in theory and also seeing things in practice since I also attend births.
First a funny story (okay, fine, probably only funny to me). During my 4th birth my midwife asked me if I could stop pushing (or maybe push less, I don't remember now- he was coming fast, though!). And the next wave (what I call contractions) hit and I said "sorry, I can't not push." It really wasn't ME pushing. My body was doing it and I was along for the ride.
I have seen a trend among fitness professionals to talk about doing core work as a way to help with pushing. So you will be strong enough to push baby out. While I do believe that we need a strong, functional and reflexive (does what it should do without us thinking about it) core to support the whole body, I believe that if a woman is in a supportive, undisturbed environment (read: no fight or flight going on! More on that later) her body will know what to do. The strong and amazing uterus is the primary "pusher." Yes, the deep core muscles are involved, but a lot of traditional "ab exercises" will actually increase intra abdominal pressure and tension (more on that in another post), which we do not want for birth or for longterm core/whole body health. Follow me on Facebook or Instagram (button above!) and I will be posting my reflexive core exercise sometime this week, and will add it to this blog post once it's up (because right now.... #4kids)
Pushing should ideally be mother-directed. An involuntary urge. Just like your body tells you when you need to eliminate your bowels and nobody has to show you how to do it (unless there is a problem), your body tells you when it's ready to bring a baby out of it and how to do it. And it's MUCH cuter than the thing you push out every day!
So what is coached pushing?
This AMAZING mama gave me permission to share her beautiful photo. There were circumstanced that necessitated her to push like this and like I said there is a time and a place! I thank her from the bottom of my heart for allowing me to use her photo to teach about pushing! This kind of pushing should be the exception, not what every single mom does.
Often, providers and nurses direct mom as to how to push. I am not here to say there is not a time and a place for this. I've seen some stuff in my years and hundreds of births as a doula. And in that time I have learned to appreciate modern medicine and it's role in getting babies safely in the world. But I am here to offer an alternative to consider. Not an end all be all hard and fast rule of pushing [End disclaimer]. Mom is coached to pull her chin to her chest and hold her breathe to push. She is told to hold her breath and push for 10 seconds, deep breath again, and hold and push for 10 more, take a deep breath, and hold breath and push again for 10 seconds. It has been called "purple pushing" because of the color many woman's face turn. Pushing this way increases the likelihood of more significant tearing, trauma to the pelvic floor (1), and can cause problems with baby. When mom is told to hold her breath for so much of the pressure wave, babies are not receiving as much oxygen and it has been shown to lower APGAR scores (2). I also find that when moms are pushing in this way, they are tensing everything- their butt, their pelvic floor, their jaw instead of exhaling and reflexively (without thinking about it) engaging the deep core alongside the uterus while also RELAXING THEIR PELVIC FLOOR (underlined and capitalized because it's important, so I'm virtually shouting it).
Perhaps a mom starts out with mother-directed listening to her body's urge pushing and then someone comes in and starts telling her what to do. Coming from an 'expert' like nurse, midwife or doctor, mom figures they know better than she and starts doing what she's told. Maybe she needed to (progress isn't being made after a long period of time, medicated birth, safety of baby, etc), but maybe she didn't. (This is why it's important to ask questions so you know- is this being done because of protocol or is there a true need for it?). Maybe she is checked and found to be fully dilated and so the stirrups come out and she is told to "PUSH!"
Enter exhale pushing.
In some circles this is known as "breathing the baby out." I have seen this taught in MANY childbirth classes, and have taught it myself in Hypnobabies classes (the best childbirth class ever!!!). AND I LOVE IT. Mother directed pushing and exhale pushing really can help protect the pelvic floor and perineum from the extreme force of "purple pushing."
However, I have heard from women who have told me that they were not able to make much progress pushing this way. Reflecting upon my own birthing experiences and observing many others, I have come to the conclusion that we can exhale push with our core reflexively helping the process, or we can exhale and still resist the strong sensation of baby coming down and out by not relaxing the pelvic floor fully. Both will appear to be exhale pushing, but they will yield very different results. Maybe this is why some providers and nurses scoff at the idea of doing anything other than holding the breath while pushing and say things such as "Don't make any noise, hold your breath!!"
While I don't think women need to be specifically taught a technique that they then go and use during birth, I do think that working on exhaling to engage the deep core while relaxing the pelvic floor during pregnancy can be a helpful practice for birth, but also for life.
Mama, relax your pelvic floor. And an exercise for you to try... (video will be added later this week)
I find doing a kegel can help us realize if our pelvic floor is held tense all day long. Note I said A kegel. Not 100 kegels. Anyway....
Draw your pelvic floor up and then drop in down, maybe more than it was initially. Take note if you are in a constant 1/2 kegel all day. You won't magically not be when it's time to push a baby out if you have that tension all day long. Now, take a deep breath, and exhale like you are blowing out 50 birthday candles (or one ridiculously annoying trick candle that won't extinguish). Blow out slowly and keep going until you have no breath left. Keep going, keep going. There. Did you feel that? Without forcing it or "drawing your navel to spine," you might be feeling your core gentle corset in, hugging you and if you are pregnant, your baby. This is your deep core muscles (TrA) engaging. This is the kind of exhale that I see women using (often intuitively, without anyone teaching them) effectively during the pushing stage. It's amazing to know something and then to see women, who have never given birth, just DO it. But why isn't this always the case? Besides the tension we are carrying in our pelvic floors all day long for years and years (and all the things that I normally talk about that increase that tension like sitting on your sacrum all day, and on and on..., medicated birth, baby malposition, etc) I'll give one other big reason:
In comes the fight or flight reaction:The mind-body connection to the pelvic floor
When scared, fight or flight instinct goes off and women draw their pelvic floors up and while maybe they exhale, they're not REALLY exhale pushing. They're really just fighting against that strong sensation of a baby coming down and out. It's like when I see a kid running towards me at full force while I am laying down in psoas release. I instinctively tense my abs to avoid extreme discomfort when they jump on top of me. I believe that many women tense up their pelvic floor for a similar reason.
We can help avoid this both prenatally and during the birthing process by training our minds (I used Hypnobabies and it is fantastic!!) to believe in ourselves and the birthing process, hiring a doula, choosing a supportive provider, and setting up a calm birthing environment conducive to "the great letting go" as I like to call it. And then having someone there to remind us to let go of our pelvic floors if we need it (I do not say "let go of your pelvic floor" during birth. If I did I might get punched. I usually say something in a calm soothing voice like "welcome your baby down with each breath you exhale" But it depends on the mom.)
"Let your monkey do it"
Just like animals tend to find a dark, safe, secluded cave to give birth, we too need to feel safe in order to give birth. The mind-body connection can not be ignored. If an animal in the wild is running from a predator, it needs to have the ability to "turn off" the process of birthing in order to get to safety. We may not have literal tigers that we are running from anymore, but we most definitely have "inner tigers" in the form of the fear around childbirth that is ingrained deep within our subconscious from living in a society where the media portrays birth as horrible and scary. We also have the birthing environment to consider. Bright lights, people we've never met, machines that go ping, monitors and cords attached to us. It's no wonder we have a hard time letting go and letting our body do it's thang. And maybe the environment is nice and calm and then "She's pushing!!!!" everyone runs in (who are all these extra people?!), the lights flip on, including a spotlight on the vulva. Mom is told to get on her back with her feet in stirrups. I've even had providers yell at me (the doula) to turn off the music! It's like all of a sudden things have to be chaotic and amped up because mom is pushing.
Note: I am pro hospital birth and think it's a fantastic option for those who either 1)feel safest there 2) want to be there for any reason or 2) need to birth there for medical reasons. But I do think we can make that environment less "hospitaly" by doing things like dimming the lights, having less unnecessary people there, quiet voices, calming music, a doula for support, hiring a supportive provider, etc.... way more than I can cover in a blog post on pushing.
I would like to end with a FANTASTIC video of a mom who is making noise during her pushing stage as she is involuntarily pushing. She isn't being coached to push (Note- HER MIDWIVES ROCK and both these ladies were at two of my own births!) ad she is "breathing her baby out" beautifully. Note that breathing your baby out does not mean that you never hold your breath. But, it's not sustained for 10 seconds, breathe, 10 seconds, breathe, 10 more seconds. It's reflexive.
Thank you for reading!! If you like this post, please share it! They take quite a bit of time to put together and it gives me more motivation to do them amidst the chaos of raising 4 kids and running a business if I know people are getting something from them. XO Lindsay
Mama Aligned is Lindsay McCoy.