Doula pet peeve: directed pushing

The next Healthy Birth Blog Carnival has begun, this one on "“Avoid giving birth on your back and follow your body’s urges to push." The "follow your body's urges to push" really caught my eye, because directed pushing is one of my pet peeves.

My experience with this stretches back to my first birth as a doula. I was very nervous and working with a young woman with a very large family, many of whom were in the delivery room as well. She had an epidural, so when it was "time to push!", the nurse got her pushing standard: PUSH PUSH PUSH while counting to 10, take a breath and QUICK QUICK START PUSHING AGAIN while counting to 10, and ONE MORE GIVE ME ONE MORE REAAALLY GOOD PUSH counting to 10 and now RELAX RELAX JUST RELAX STOP PUSHING WAIT UNTIL THE NEXT ONE. At the time I knew in principle that non-directed pushing was better, but I also grasped very fully its appeal to the other people in the room who weren't really sure what to do at the moment. The mom's whole family got in on the act, 5 or 6 people loudly counting at her for every push, and hey, I totally got it. I wanted to feel useful too, and this seemed like a really simple way of doing so.

I still get the motivation, but the practice has begun to grate on me more and more. This happens even with the births that have been lovely, calm, quiet, physiologic labors right up until the magic ten centimeters. Everything goes great until pushing and then BAM, all of a sudden we're back to the worst of the medicalized model. The second a woman is judged to be "complete", everyone in the room suddenly gets license to, quite frankly, be a total jerk to her. Before she has pushed even once, there is the presumption that she is going to push "wrong". She is never even given a chance to try pushing in different positions or for a few contractions to get the hang of it. Instead, the nurse spells out the position she should assume (chin to chest, pulling back on her thighs, on her back? but of course!), support people are given her legs to hold, and she gets the 3-pushes-per-contraction speech. Then from the first push she is loudly coached, counted off, and urged on MORE MORE MORE KEEP GOING PUSH HARDER HARDER HARDER and that's about when I start grinding my teeth.

Why do I hate this so much? First, it's not evidence-based, leading to greater risk of pelvic floor damage and perineal tears. So really, nobody should be using directed pushing unless they really have to anyway.

But to me, it's not just the non-evidence-basedness of it; how it's done is really the signifier for how our system thinks it's okay to treat women when they're pushing out their babies. And in my opinion, it's a pretty crappy way to treat a woman giving birth. Even if before there was lots of murmuring and support and encouragement, all of a sudden she's treated she's constantly failing. Generally, directed pushing involves a lot of yelling directly into her face, telling her to try harder no matter how hard she is already trying, forcing her to hold her breath, exhaust herself, and then ordering her to relax as soon as pushing is over. This happens even if she's making great progress: a primip who pushes out a baby in 20 minutes still gets this treatment. It also recruits all-too-susceptible support people into this aggressive treatment. They get the chance to do something! take action! after hours of labor in which they often didn't feel very useful. They get at least as hepped up and sometimes get more aggressive than the medical staff. Sometimes I hear myself talking to the mom during pushing and realize that I am the only person giving her any positive feedback or encouragement whatsoever. It's honestly sad.

It also imparts a generally false sense of urgency to the mother. I have heard or read multiple women say "Everybody was yelling at me to push, so I thought something was wrong and I pushed really hard and my baby flew out and I tore really badly". If you are yelling into a woman's face and telling her to push as hard as she can, she will often interpret that as a sign that something is wrong and she needs to, in fact, push as hard as she possibly can, which is not always the way to preserve the perineum. It's also a frightening experience for many women and, again, that's not a respectful way to treat someone who is giving birth.

Even more concerning to me, it's a "boy who cried wolf" issue of not being able to impart to the mother when pushing hard is ACTUALLY urgent, or allow her to have reserves left. When you yell at her for an hour and a half straight to push, and then the heart rate starts dropping, you've probably expended a lot of her energy, not to mention her emotional response to the "emergency" narrative. It would make me nervous, personally, to be with a provider where I couldn't tell the difference between when things were going normally and when it was an emergency.

So! What can you do to avoid this? My suggestions:

1) As always, choose your provider and birthplace wisely if you can! Remember: doulas know what your provider is like in the delivery room. They are there to see that behavior. Before you choose a provider, ask a doula who has worked with that person (or practice).

2) Express your wishes to your provider. Talk about how you don't want to be coached (or another least favorite, the two-fingers-in-the-vagina "push my fingers out!" I sometimes want to lean over and say "OR YOU COULD JUST TAKE THEM OUT YOURSELF") unless there's a reason that they need to speed things up, or you request some help.

3) Remember that the nurse often starts the pushing even before the provider arrives. On your (short, simple birth plan), you can note that you would like to follow your body's urges to push and would prefer to begin pushing without direction, and that you are open to suggestions if things are not progressing well.

4) Actively decline it and/or just ignore it - you can clarify first that there's no emergency, then either ask for quiet or just do your own thing. Bring a pair of headphones! I've never seen it in person, but this seems to work well for some Hypnobabies birth stories I've read! Mom just pops her headphones to listen to her hypnosis tracks and ignores all the outside hullabaloo. If you have your eyes closed and your headphones in, it's pretty obvious that you're not looking for any outside help.

So those are my pet peeves, and my tips! Let me clarify: directed pushing is sometimes helpful and I have seen women request direction while pushing. My objection to it is using it across the board, regardless of the situation, and the aggressive way it's done. As always, if you're working with a provider & in a place that you trust, you should be able to trust them to handle pushing appropriately. But if you're not, plan in advance to avoid what is often the last pitfall of plans for a physiologic labor.