The other day, a question was presented in one of the doula groups I am a part of that asked how we can best help a mom while she pushes. I couldn’t help myself, my answer came tumbling out of me. You see, pushing is actually one of my favorite stages of birth to serve in and witness as a doula and a midwife’s assistant.
Perhaps it’s connected to the excitement a mom feels when she knows that she’s complete, and that the work of dilating is over with, and soon she’ll have her baby in her arms (Although, we know that pushing is lots of work, too!).
Or maybe it’s how you can sense the absolute pure strength of a woman as she pushes her baby out of her body – it fills up the space around you and requires you to stand back and give praise.
And then of course, there’s that long-awaited and anticipated arrival, when life inside the womb finally meets life outside the womb, that moment is simply overwhelming and beautiful, every single time; there’s never a time in life that is so perfectly filled with equal amounts of relief and joy.
Question (completely paraphrased):
During pushing phases at hospital births, I feel a little lost. What should a doula do to help a mom? It seems everyone in the room is yelling at the mother to push, and how to push – I don’t want to add to that confusion. What can I do to best help mom and how can I prevent others from yelling at her while she’s pushing?
Answer:
I am assuming that this would be the typical type of hospital birth – where mom is pushing on the bed. My response will be given with this position in mind, but these suggestions may be used for other pushing positions as well. However, I’m asking you to please decipher on your own which suggestions wouldn’t work for say, a squat bar, a birth stool, pushing on all fours, or in the tub, etc.
Disclaimer
Please keep in mind that these are my suggestions only and not to be taken as the letter of the doula law. Some may have better, or rather, different techniques and tips. If so, please share your insights in the comment section below. I welcome your thoughts and advice!
Waiting for the OB or Midwife to Arrive
Before we begin, I want to touch on how to help moms cope when they dilate quickly and the urge to push overpowers them. These moms are typically laboring without an epidural. The nurse will likely confirm that they’re complete (even when mom is grunting, “I have to puuuuuuuuuuuuuuuush!) and then the nurse will tell the mother, “Don’t push until the Dr./Midwife arrives!” At that point, mom looks to you with a frantic face and expects you to help her “not push” as she yells out, “I can’t help it, my body is pushiiiiiiiiiiiiiiing!”
In that scenario, I’ll get close to mom and make strong eye contact with her, and tell her in the briefest way possible that what the nurse means is not to add to the pushing that her body is already doing by bearing down further.
Then, I will help mom pant through her urge to push until the Dr./Midwife arrives. This panting technique is different from her normal breathing that she’s been doing through a contraction. You’re looking for the mother to make a “puh” sound with her mouth – almost like she’s blowing out a match when she says it.
I once had a mom do this for a whole hour till the Dr. arrived (breech birth, special circumstance, he was stuck in traffic). It can be done, but it is difficult. I will always pant with the mother, and keep it in a strong rhythm – moving my head up and down while I pant with the mother – (it’s pretty hypnotic, actually).
I can’t stress enough how important it is to let mom know that she doesn’t have to stop her body from involuntarily pushing; but to instead, simply pant through her instinct to bare down.
Okay now that we’ve covered that issue, let’s move on to our basics of pushing.
Where to Stand
First of all, position yourself close to mom’s head, standing near the top of the bed. Often the SO (“SO” stands for “significant other”) will be at the other end of the bed – directly across from you and also close to mom’s head. (Please don’t forget to make special effort to include the SO in this beautiful time of the birth, as well.) If you notice that you’re towering over mom, make a point to get eye level with her. Nobody likes that vulnerable feeling of having others peering down on them – especially when parts of you that are normally covered, are not.
Push Kit During the 2nd Stage
Have a little station nearby with a bucket of cold, icy water and a wash cloth for mom’s forehead, neck or chest. Also, a nice rejuvenating and energizing fragrance with citrus or mint can be good to use at this stage of labor. Sometimes, I’ll place a few drops in the water that the wash cloth is sitting in – or use a body spray (just be certain to avoid mom’s eyes). I’ll also have lip balm, ice chips or clear liquids with a straw, a camera (if you’re responsible for taking any photos), a notepad and pen (if you’re taking notes) and my go-to pushing favorite: a hand-held, battery-powered fan. And last but not least, breath-mints (for anyone who would like one). These are my favorite tools to use when mom is pushing, but feel free to create your own “push kit.”
Preparing the Hospital Bed
Next, notice the bed. If the bed is completely flat ask mom if this is a comfortable position for her to push in. If she says no, (we are assuming that no one wants mom to birth flat on her back) gently ask the nurse, Midwife or OB if it’s okay to raise the back of the bed up till the mom is in a better position for pushing.
At every hospital birth I’ve attended, they have always permitted mom to raise the back of the bed up enough for her to be in a slightly upright pushing position – even with an epidural in place. The only case when I’ve seen this not permitted is when a mom had very high blood pressure and even sitting slightly inclined caused it to rise.
Preparing the Laboring Mother for Baring down
Once mom is in a comfortable pushing position, as she feels the urge to push begin to build, remind mom to take some slow deep breaths in through her nose, down towards her baby, and slowly out of her mouth.
In the case of an epidural – especially if it isn’t too strong, some moms will feel the urge to push on their own, which is great. Otherwise, watch the monitor to notice the pushing contraction coming and begin to tell the mother to take some cleansing, deep breaths as you see that contraction on the monitor begin to build.
For instance, as the contraction slowly builds have mom take a deep breath in and out, and then again, but on the second inhalation, have her keep her breath in, now ask her to use the energy of her deep breath to bare down.
As mom pushes, support her head with your hand, or suggest that her SO support her head. Remind mom to bring her chin to her chest and allow her body to make a curved “C” shape around her baby as she bares down. Remind her that pushing will have many of the exact sensations of a bowel movement.
Holding the Laboring Mother’s Legs
Often, hospital care providers will ask the mom to hold her legs as she pushes. The best way to help mom do this is to suggest she wrap her arms outside of her legs, (like she’s encircling herself) and then place the palm of her hands behind her knees and near the back of her thighs (I hope you can get the visual here).
They will then ask mom to pull her legs to her chest as she bares down. Watch to make sure as mom pushes that she doesn’t slowly bring her knees in together towards her belly button. Encourage her to “make space for the baby” as she pushes out. (Again, please keep in mind this type of pushing is normal hospital protocol in birth. And I’m directing the answer towards this environment.)
You can support mom’s legs by holding up her foot with one hand (or sometimes a nurse might be holding up a foot, which means you have a hand free to wipe mom’s brow and to give her sips of water, etc.) Usually her SO will also be holding up a foot as well as have a hand placed behind her head supporting the base of her head as she brings her chin to her chest.
Observe the Laboring Mother
Notice mom’s face when she’s pushing. Is her face getting dark purple? If I see a mom who is getting deep red in the face I’ll remind her to “only push for as long as you are comfortably able to push” and to also “bring all the force in your face to your bottom. Imagine a ‘J’ shape when you’re pushing – down and out.”
Listen to the sounds the mother makes as she is pushing. Is she making high-pitched, thin sounds when pushing? We want to avoid those elements. I may suggest to the mom that she’ll have more power in her push if she makes grunting noises – just like the noises we hear when body-builders lift weights. I would then encourage the mom by saying, “Perfect, those are perfect pushing sounds. Beautiful work!”
In Between the Urge to Push
In between the urge to push, often a mother’s breathing will be fast and haggard. This is when you’ll gently speak to her in a calm and caring way to slow her breathing down and to soften completely into the bed. Look at her legs. Is she still holding them up or is someone else holding them up? Remind her to lay her body back into the bed, and rest her legs (if that’s what she wants, some moms don’t like to move their legs).
I like to tell moms, “Let your whole body sink right into the bed. Loosen your shoulders, soften your jaw, allow your arms to go limp.” Look at her hands, are they clenched? Remind her to open her hands.
You can firmly stroke her arms all the way down to her fingertips to help her rest in between. Now is also the time to encourage mom to take nice slow breathes, in through her nose, all the way down to her baby, and out of her mouth. Keep your voice calm, soothing and gentle, and be sure that you’re not towering over the mother as you speak to her.
Soothing the Laboring Mother
At this point, I’ll wipe her forehead with a cool wash cloth and encourage mom to shut her eyes and think of her baby. I also have a hand-held fan in my hand that I use when mom is pushing and may suggest lip balm for her, or ask that she take a sip of water. Mostly though, I’ll try to stay quiet and allow her to rest and follow her cues.
When she feels the urge to push begin to build, I’ll remind her to take a couple of deep cleansing breathes as mentioned above and prepare to bare down.
What to do When Others are Yelling
If others are yelling or giving directed pushing, I may begin to intentionally whisper to mom, “Beautiful work. As strong as you are. Push all the way down to your bottom.” My intention in whispering, besides to encourage the mother, is to lead by example. It’s like when our children are yelling, if we whisper they sometimes begin to whisper as well.
However, if that doesn’t work I ask this question, (as I purposely give steady eye contact, first to the mom, and then to the others in the room, especially those who are yelling), “Is our counting and loud cheering working for you, or would you prefer we try something else?” Often, this question gives mom a chance to voice her needs and those gathered in the room can respond appropriately.
When the Medical professional Speaks, it’s Time to Listen
One thing I always try to be mindful of is if the OB or Midwife is giving instructions to the mother when she’s pushing to never speak out over those instructions. As soon as they speak, it’s time to quiet down and let the Dr./Midwife guide mom.
When Baby Begins to Crown
This is the time if a mom doesn’t have an epidural that she may begin to get panicky. I like to find the laboring mother’s face at this moment and look compassionately into her eyes and say with quiet confidence, “You are feeling lots of burning and so much pressure right now, and it’s okay. I know it feels like your baby is coming out of your bottom, but he/she isn’t. What you feel is your baby stretching your perineum and your body is responding just as it should.”
Sometimes a mom may resist at this point, because it hurts so badly, and they don’t want to move forward with their birth (because she’s afraid), but this might be the moment when you can find a gentle way to tell her the quickest way (and only way) past this moment is through it, and she’ll be holding her baby very soon. Also the best thing for mom to do right now is in fact, hold off on pushing, and to breathe out her baby.
You can also ask mom if she wants to reach down and touch her baby’s crowing head as a way to connect with the moment, especially if that’s something you’ve discussed before.
Open Your Eyes, Here Comes Your Baby
When baby is about to arrive, if mom’s eyes are shut, I’ll often say, “Open your eyes, here comes your baby.” I find that a lot of mothers are so busy pushing with their eyes shut, that they don’t see that magical moment of the birth of their baby.
This is also the moment when, if mom or the SO want to announce the sex of the baby, and I see cues that others may not remember that desire, I’ll gently and quietly remind the nurse or say to the dad (if appropriate), “Dad, did you still want to announce the sex?”
Also at this stage, you may need to look for signs that pit is or isn’t being administered and that if mom and dad wanted delayed cord clamping or cord banking that their wishes are being followed. As always handle these requests with respect and kindness, in the true doula spirit.
Read my follow-up to this post, The Birth of the Placenta | Tips for the 3rd Stage of Labor, by clicking here.
The Joy of This 
I needed this!!! I attended my first birth last week and I felt so lost during the pushing phase. This was exactly what I needed to read.
I just attended a birth last week where the epidural didn’t work and it was an induction. I had no idea what to do, but these tips have helped me for the future.
Way cool.
I really enjoy this web site. It is very informative and useful. I will be refering my mommys this way
Reblogged this on birthrite doula and commented:
This is a very informative and usefull site. Joy provides sound advice and great tips.
Joy, I have to say that I stumbled upon your blog recently and love reading all of your insight and information. As the wife of a doctor, I appreciate your respectful tone towards medical professionals and having a baby in a hospital environment. I have found that there is a lot of “bashing” when it comes to each woman’s birth plan, where they allow their birth to take place, and who will be assisting in the birth.
In reality it is a situation that is unique (and somewhat unpredictable) for each woman. Birthing a child is just as beautiful if the mother is medicated or unmediated, takes place in a hospital or at a birthing center, on a bed or in a pool. The beauty of it all is that we get to make decisions about our experience and what will work for our situation.
Thank you for your kind words, encouraging tone, and helpful knowledge. It is much appreciated.
this is so good! i have struggled so much as a new doula to know my role in pushing in the hospital setting. both hospitals in our town use purple pushing, regardless of whether the mom is medicated or not, and it is often difficult for me to encourage the mother to work with her body and rest / breathe when she needs to. but this is such a great help for me!