The MamasteFit Podcast Episode 109 – The Art of Pushing: Timing and Techniques for Your Birth

Gina: Welcome to the MamasteFit Podcast. In this episode, we’re going to be talking all about pushing and how to know that it’s time to start pushing. Pushing is definitely one of those things that a lot of folks have a little bit more anxiety about. We don’t wanna tear, we’ve never experienced it before.

Roxanne: Don’t wanna push for seven hours.

Gina: No, we don’t wanna push for seven hours. So we’re going to talk about how you can know that it’s time to push by comparing the fetal ejection reflex, which is spontaneous bearing down, versus laboring down and waiting to push.

Welcome to the MamasteFit Podcast. We’re going to be talking all about pushing in this episode, specifically comparing how to know when to start pushing with the fetal ejection reflex where you’re typically unmedicated, you don’t have an epidural, versus laboring down. Or, should you immediately start pushing once you’re 10 centimeters? So we’re going to talk all about kind of the initiation of pushing in this episode.

So first, let’s break down what are the different ways that you can begin pushing. The first one is going to be the fetal ejection reflex, which is your body is, just, you’re along for the ride and your body is pushing your baby out for you. This is usually related to the fundus being fairly thick and it’s starting to push down on your baby, and the fundus is the top part of our uterus that during labor gets thicker throughout all your contractions. Your uterus is pulling up into that muscle up there. The muscle fibers up there run vertically, so when they contract, they push it down, and when that gets thick enough, it just pushes your baby out for you. There’s really no effort on your part. You are just along for the ride, and there’s some pros and cons to this as well.

The next one is going to be just pushing once you’re 10 centimeters. So this is typically going to be more if you have an epidural, your provider or your nurse checks you and they’re like, “Oh, you’re 10 centimeters, let’s go,” and you could just start immediately pushing then. And so that would be the way to know that it’s time to start pushing.

The next one is going to be if your provider checks you and your 10 centimeters, but maybe your baby’s feel really high in your pelvis, so you do have the option to labor down, or wait, but we’ll talk about the controversy with laboring down, and weighing the risks versus the benefits and what the current guidance is, so that you can make an informed decision on what you wanna do during your own birth.

So you can either just start pushing whenever your body tells you to start pushing, or you can start pushing when you feel like pushing, once you’re 10 centimeters, either right away or waiting a little bit. And we’ll break that all down in this episode.

So first, let’s start with the fetal ejection reflex, known as spontaneous bearing down, as I like to graphically describe it, “vomiting out of your vagina.” So there is nothing that you are going to do to stop this. And I have found that the fetal ejection reflex can sometimes start before you’re fully dilated, like maybe you’re like eight centimeters. if you are less than, I would say seven or eight centimeters, it could be due to baby’s position and we don’t really wanna be pushing at that point. So maybe your baby’s head is like OP, or their back is to your back. This could sometimes cause that early urge to push. If that’s the case, I would do like an inversion and see if we can adjust baby’s position, ’cause we don’t wanna be pushing when we’re like five centimeters by any means. But if you’re at least seven, eight centimeters and you’re feeling this urge to push, it’s typically the rest of the cervix is probably going to melt away within a few contractions.

Signs to look for that maybe the cervix is not moving out of the way, if you feel like a pinching sensation, if it’s like painful, like usually like a little bit more towards the front, or if things just don’t feel like they’re progressing, those can all be signs that like maybe we’re not quite at that point to push yet, and you might want some more support from your provider or from your nurse to kinda see what is going on there.

What’s your experience with the fetal ejection reflex with like dilation?

Roxanne: The fetal ejection reflex, I find that if someone has that like strong, uncontrollable urge to bear down with fetal ejection reflex, the dilation, either they’re going to just quickly dilate and the baby’s going to be born, or it might not be like a true fetal ejector reflex. So they might have increased pressure that they think when they feel this pressure, “so I need to bear down,” but it could just be a change in sensation. Like they think that they’re spontaneously bearing down ’cause they have this increased pressure, but then we check them and they’re only five centimeters or six centimeters and that’s usually, again, due to the position of their baby. And once we reposition their baby into a more optimal position for their bodies, they’re urged to push changes and they’re like, “Oh no, now I’m pushing.” And that’s because it is a very different sensation between the two. With the fetal ejection reflex, like a true one, there’s nothing stopping it. Gina was saying, vomiting out of your vagina- you can’t stop it even if you wanted to. Whereas some people do mistake, just a change in sensation that they’re feeling ’cause their baby is lower, but it’s not time yet to push. They think because of this pressure, they think it’s time to push. So then they start bearing down. But it’s due to how baby is coming in their pelvis.

So there is like some misconception of, “If I feel this increased pressure, it’s time to push,” versus like if you can breathe through it and stop it, probably not the fetal ejection reflex. If you can’t breathe through it to stop it, it’s probably the fetal ejection reflex.

Gina: I feel like there’s a difference between the two as well. I think it’s hard to know what that difference is when you have never gone through it before. But for me as like a doula, when I’m watching somebody, I can tell the difference between, “that baby is about to be born,” versus, “are you feeling some pressure?”

Roxanne: Yeah.

Gina: So there’s a really big difference.

Roxanne: Like, the noises that they make.

Gina: Completely involuntary, like you are just a long for that ride. And now, the fetal eject reflex, typically I see only with somebody who is unmedicated, so they don’t have an epidural, or they’re progressing really fast with an epidural, like it’s usually one of those two. But, if you’ve had an epidural for a while, I would say you’re probably not going to experience the fetal eject reflex. And it’s not a hundred percent with unmedicated birth, either. Like you could be unmedicated and not experience it also. And so completely relying on the fetal ejection reflex as your cue to start pushing when you’re unmedicated may not be like a hundred percent appropriate of a plan as well.

And so this is where communicated with your provider about what’s going on during your labor and kind of assessing things as needed can be really helpful to figure out like, when should I start pushing?

Roxanne: I think with the fetal ejection reflex in an epidural though, when you are unmedicated, it’s not just this crazy increased pressure your body’s uncontrollably bearing down, but you also still feel all of those sensations in your body with fetal ejection reflex that it can push you over the edge stress hormone wise, and it’s, you’re just, again, holding on for dear life, trying to cope with what’s happening within your body and all the sensations that are happening within your body. Whereas with an epidural, you don’t have that sensation that feels very overwhelming. You might feel like, “Oh, hey, like it feels like something’s… it feels like my body is pushing, but I’m not. I’m not trying to push.” Usually the response is, “It feels like my belly is like pushing my baby out, but like I’m not doing it. I promise I’m not doing anything,” and I’m like, “It’s fine. Like, your body is pushing your baby out, and that’s what we want. You’re likely experiencing the fetal ejection reflex, ’cause I can see your baby is like crowning, and you’re not doing anything.”

Gina: “Your baby has been born!”

Roxanne: “So we’re going to call the provider!” And and they’re like, “I swear I’m not pushing!” And I’m like, “It’s okay! This is what you’re experiencing.” Because they’re like, “I don’t wanna get in trouble for pushing my baby out.”

Gina: Yeah.

Roxanne: And I’m like, “it’s, it just happens!” You can’t control it. It’s not like you’re like, “fetal ejection flex button.”

Gina: Yeah, there’s no like conscious start to it. It’s just is a spontaneous thing.

So for me, with my first labor, I had an epidural, so I did not feel anything.

Roxanne: Oh no.

Gina: It was a very strong…

Roxanne: You had no fetal ejection reflex.

Gina: I had no sensation at all. It was a very strong epidural. We’ll talk about laboring down and stuff, or, we’ll talk about my epidural experience when we get to laboring down.

For my next three, though, they were unmedicated births. And I was in a very supportive environment, which I think is a big factor in whether or not you experience the fetal ejection reflex. If you’re feeling very unsafe in your environment, or there’s just like a lot going on and it’s very distracting, I definitely find that the urge to push is maybe not as strong for some folks. And so with my next three births, I was in a very supportive environment, I felt very safe in my environment, very supportive. It was like quiet voices, dim light.

The first time that I experienced a fetal ejection reflex was with my second birth, and it was completely out of body. I was just, I was like witnessing myself from outside my body, like I just had no control.

Roxanne: Just up on the ceiling.

Gina: What was happening. In the moment, I wasn’t like, scared, I just was like, “Whatever. I guess this means my baby’s coming.” But after the fact, when I was reflecting on it, I was, it was scary. I was like, “That was really intense and like super out of body, oh my God, like, that was a lot. Like, huh!” but it wasn’t scary in the moment for me. But I know that it can be scary for people in the moment because it’s just like this really strong urge, there’s so much pressure, you can’t control what’s happening. It would be like, again, it’s like vomiting. Like you don’t, not everybody, nobody likes vomiting. I don’t like vomiting.

And so when I was preparing for my third birth, I was really nervous about the pushing phase. ‘Cause the pushing phase was really intense, and it was such an outof body experience that I was scared for it. And so during my third labor, which was my second unmedicated birth, I was anticipating it, and nervous for it, and I think maybe stalled my labor towards the very end when my body was ready to start pushing. And I was kind like, “I just need a moment to like mentally prepare that this is about to happen.” And then went through the pushing, same thing, really out of body experience. Felt like I was witnessing it from outside my body. It was very strong, very intense. The baby was born really fast and like it was just like this relief once she came out. But both times that felt like I needed like a moment to recover. It wasn’t like, immediate, like, angels singing, like I’m like nuzzling into my baby. It was like about 30 seconds of just, “Oh my God, that, oh, okay, it’s over.”

And so then for my fourth birth, which is my third unmedicated birth. I was just anticipating that it was going to be just as intense and out of body again. I was like, “There’s just no way that I’m ever going to find like a moment of peace during this. Like they’re just all going to be insane.” And this was the first time that I actually was able to collect myself during it and come back into control with the urges. This labor was also much faster. I felt like I was just in a better mindset to surrender to the experience for this labor. But I did, I was able to find that moment of like control this time, which was like a very unique experience for me. But I still needed like 30 seconds to recover after she was born, before I was like, “Okay, we’re good. We’re all good. Hey baby, what’s up?” So yeah.

What was your experience with the fetal ejection reflexed? Yours looks different than mine.

Roxanne: To be fair, I don’t know if I necessarily experienced like fetal ejection reflex with like my birth in the same way that you did. Because with my first, Lily, I felt the urge to push, but I don’t think it was the fetal ejection reflex, ’cause I had to add to all of my pushes. If I didn’t push, nothing would’ve happened. If I didn’t add to the push.

Gina: I was not doing anything.

Roxanne: I had the urge to push and when I beared down, then it felt better. But if I didn’t, then it was just like a lot of pressure in my butt.

And with Colin, I felt the urge to push earlier on, but baby, like, he was still pretty high the entire time until I stood up, my water broke, and then he just literally shot through the pelvis and was born in the tub. And so the fetal ejection reflex was fairly short in his, that I was like, “Oh, that was it.”

Gina: Yeah, you look way more in control and like serene during yours.

Roxanne: But then Joan’s, which again, I don’t know if it would be the fetal ejection reflex for sure, ’cause I again had to add to all of those pushes. Like my body was bearing down and if I didn’t add to it, it was just like very overwhelming, but like my body wasn’t pushing her out and I had to. But maybe it’s ’cause both of those babies were eight and a half pounds. so I had to make more room.

Gina: Yeah, maybe.

Roxanne: I had to add to it ’cause there’s a lot more room that needed to be made. So I don’t know if I’ve experienced like the fetal ejection reflex in the same way that you have, except maybe Colin’s birth. And if that was the fetal ejection reflex, oh that’s not too bad. But it is, pushing in general is very overwhelming for me. I think I experience a different reflex.

So I think what I experienced when I was pushing is more similar to what’s called the Ferguson Reflex versus the FERs.

Gina: Or the Feal Ejection Reflex.

So before we move on to the Ferguson reflex, which is really similar to the feal ejection reflex, with both of them you’re feeling this urge to push.

With the fetal ejection reflex, there is pretty much no effort on your part. There’s exertion, it’s mentally challenging, it’s physically challenging, but you’re not adding to those pushes. With the fetal ejection reflex, like I said, it’s like vomiting out of your vagina, there’s nothing that you’re going to do that’s going to stop it. And I typically find this is more common if you’re unmedicated and you’re in an environment that you feel very supported in- it’s like dim lights, quiet voices, there’s not a lot going on- I tend to see that this reflex is a lot stronger. Versus if you’re in a room with really bright lights, there’s lots of people coming in and out, it can be really distracting and you may not experience like a super strong urge to push in those situations.

I also see it with folks that have an epidural that just got it, and they’re progressing really fast. So let’s say they were in transition, their baby was coming, and they’re like, “No, no, no, no! I would like an epidural.”

Roxanne: Trying to get the epidural nap.

Gina: They get the epidural, and then their baby’s falling out of their bodies. Those folks, I sometimes will also see have the fetal ejection reflex because it was already happening when they got an epidural. But again, more commonly, if you are unmedicated.

Now, we can’t consciously initiate the fetal ejection reflex. And so relying on it solely as your reason to start pushing may not be something that you wanna do. If it happens, which it likely will, if you’re in a supportive environment, that’s awesome, just go with the flow. If you never get it, but you’re sitting there at 10 centimeters for a period of time, it may be time to start pushing, which we’ll talk about when we get to active pushing later on.

I will say one thing that I sometimes see happen if somebody does have that spontaneous urge to push is they’ll start bearing down, they will probably be feeling their baby move down in their pelvis, it’s like very obvious that this baby is en route, and sometimes they may be told, “Hey, you need to stop pushing. Like we need to check your cervix, ’cause we need to make sure that you’re fully dilated, ’cause we don’t want you to tear your cervix, or we don’t want you to swell your cervix.” And then their response is, “Oh my God, my body is doing something wrong.” So Roxanne, can you explain more on what someone could do in that situation?

Roxanne: So in those situations, I normally tell someone if they’re having the spontaneous urge to push, to let their body do what their body is doing, but do not add to the push. So you just breathe through them, let your body bear down, don’t tense up and prevent your body from pushing, but just allow it to. If you’re not fully dilated when you’re doing these pushes, it’s going to dilate and melt away your cervix, unless it is that you are five to six centimeters. But if you do a couple pushes and you feel no change, then maybe doing a cervical exam would be beneficial. But if you do a couple pushes, ’cause you’re feeling that urge to push and you’re allowing your body to do it, most of the time the cervix is going to just melt away and fully dilate and the baby will be born without needing a cervical exam, especially if you’re seeing changes within the pushing progress. So you’re seeing the perineum bulging, you’re seeing the baby move down- those are positive signs that pushing is progressing. If you’re seeing none of those signs and you’ve been pushing for 30 minutes, maybe this is the time to check the cervix. If it’s not fully dilated, maybe it is baby’s in a funny position and that’s why they’re feeling that urge to push, their body is trying to reposition that baby.

But most of the time, and based off of research, there’s not research that says you must wait until 10 centimeters to start pushing anytime. There’s research that supports that just waiting for that spontaneous urge to push and allowing the body to push doesn’t lead to these like cervical lacerations, like the cervix tearing open because it wasn’t fully open, which is the concern about pushing before 10 centimeters, is that you’re going to tear your cervix. The cervix is very vascular. It has lots of blood vessels, so if you tear it, this can lead to bleeding a lot. So if it does happen, it is concerning, we do have to like respond quickly in those cases. But I have seen one cervical laceration in my entire nursing career and it was ’cause the baby literally flew out of her body and she had a little bit of cervix left. Of all of the people that have been at a birth center or the home births that I’ve been to where they had the urge to push and maybe their cervix wasn’t fully dilated just yet, while they’re pushing you see the bloody show come out ’cause the cervix is continuing to dilate and just melt away. And the baby is born with no issues. And it’s backed by research that this is a great option.

So if you feel the urge to push, maybe don’t add to it until maybe you know that cervix is gone, if that makes you feel better. But if you feel the urge to push, allow your body to do what it’s doing, especially if you’re unmedicated, because it makes it so much harder, mentally, to stop to then restart back up again.

Gina: I also find that if you have the fetal ejection reflex, it’s usually pretty quick.

Roxanne: Yeah. If that baby’s not out within a couple minutes, like we should assess.

Gina: We should reassess. So yeah, I would say less than half an hour that baby is going to be out. Like that’s being very generous with the timeframe.

Roxanne: I mean, some babies are larger, so they could take more time.

Gina: Three of my births where I had the fetal ejection reflex was like less than 15 minutes from first birth. And then I think my most recent one was like less than five minutes from first push. Not first birth, first push.

Roxanne: 15 minute pregnancies.

Gina: Yeah. From conception to birth. No.

So with the fetal ejection reflection, it’s usually pretty quick. You’re going to feel progress, you’re going to be like, “Oh yep, that baby is moving down.” So if you’re not feeling that progress, and maybe we’re at like 15, 20 minutes, I would probably do an assessment to see what’s going on at that point. You don’t really have to add to these ’cause your body is doing it for you. But if you’re like nervous or I don’t know if I’m ready to do this, just breathe with them and your body’s, again, there’s really not a lot of effort on your part, your body’s doing most of the work.

Let’s talk about the Ferguson reflex then, and how that is different than the fetal ejection reflex. So fetal ejection reflex, you’re along for the ride.

Roxanne: Vomiting your baby out.

Gina: It doesn’t really matter how high or low your baby is within the pelvis, it’s because the fundus is super thick and it’s like time to vacate the premises.

Roxanne: Rocketing your baby up.

Gina: What is the Ferguson reflex?

Roxanne: So the Ferguson reflex is often confused with the FERs, and I think it’s because the first three letters like FERs and Ferguson, a lot of people get them confused because they also are similar, that they lead to an urge to push. The Ferguson reflex leads to this urge to push, increase in oxytocin, but this is due to baby putting pressure on certain points in the pelvic floor after they’ve reached a certain station. So usually it’s like plus two station, we’re going to release a lot of oxytocin to get like that final rotation of baby through the bottom portion of the pelvis to be born ‘Cause that like final curve is a little bit harder. So by increasing the oxytocin that happens once that baby reaches that point, they’re able to extend their head out and be born. But, this is different than the FERs because this is just an urge to push. Like you, your body may still be bearing down without your control, but we usually still have to add to these pushes, but you’re like, “Oh, yes, I feel like I’m going to poop,” or, “This baby is coming out of me now, I need to push.” And it’s usually, “Oh, I need to push,” is common words that they’ll say. And this is again, because that baby has reached that level, it’s just time to come out. And this is more commonly seen with epidurals, that they have an epidural, but all of a sudden they feel a certain change in pressure and they’re like, “I need to push, like I feel constant pressure in my butt. I think the baby is low enough.” And that’s usually what I personally wait for, especially if someone has an epidural, is for that Ferguson reflex to hit in them to be like, “I feel constant pressure,” because that’s their baby who’s ready to come out of their body. Versus FERs, you don’t have to do anything, that baby is going to fly out of you. Ferguson, you usually have to add to it based off of where your baby is within your pelvis.

Gina: So do you think that the reason why you experienced more of the Ferguson reflex with your labors is ’cause there was a lot happening in your environment?

Roxanne: Probably both times. The first one was just like chaotic because when we, this was our first unmedicated birth. I had no idea what was happening. I was just personally chaotic and arriving at the hospital 10 centimeters, water broken. But I also think that I felt the Ferguson reflex with my amniotic sac for both Joan and Lily. Both births had bulging bags of amniotic fluid, whereas Colin’s broke and he flew out afterwards. Whereas Joan and Lily, theirs broke, I still had to push a while, but I felt that urge because the amniotic sac was putting pressure on that Ferguson reflex area. But once it broke, I no longer had that urge anymore. So I just kinda had to pushed to until they hit that point and then I hit the Ferguson reflex. But both of the times where chaotic, where Lily was just more chaotic because it was the first baby I had. We were getting there and…

Gina: You were drive by baby.

Roxanne: Yeah, like it was just drive by birth, chaos for everyone. I don’t think that there was a ton of people in the room or anything. I think there was maybe three or four people in the room other than like my 70 support people. A lot of support people.

Gina: Yeah it was pretty crowded in there.

Roxanne: But like employee-wise, like there was the nurse, the baby nurse, and then my midwife and everyone else hid behind the curtain, and so I just didn’t, they weren’t really there.

Whereas with Joan’s birth, there was a lot of people in the room aside from my support team.

Gina: It was also change of shift.

Roxanne: But I, it was change of shifts, so it was a little, and then it was also chaotic because I knew they don’t prefer babies born in the tub and I think that got into my head when I started bearing down and Sarah was right there. I should have been like, “I’m not pushing, Sarah. You can leave. I’m not bearing down.” And could have just caught the baby with nobody in there.

Gina: So both of them are fairly similar to where it’s probably going to result in a baby being born. The fetal ejection reflex I think is just like you’re, this is, this baby is coming, you don’t really have to do anything. It’s just going to happen. While the Ferguson reflex, you might feel like an urge to push and there might be some spontaneous bearing down with it, but you usually have to add a little bit more to it. It maybe a little bit more common if you have an epidural.

So let’s talk about epidurals now, ’cause this is where we’re going to have more of the, “Should you push now, should you wait?” because you’re not really feeling your contractions. It’s really different than an unmedicated birth where you feel every contraction. If I’m feeling contractions and you tell me I’m 10 centimeters, I’m just going to push my baby out, like I’m not going to just keep hanging out here with contractions.

Roxanne: Laboring down is not an option for people who are unmedicated ’cause they’re like, “No.”

Gina: “I’m just going to push.”

Roxanne: “I’m good. I’m just going to push, I’m not waiting an hour, feeling these sensations.” But it’s a really great option if you have an epidural.

Let’s take a break from this episode to hear about our sponsor. Needed. Needed is a nutrition company focused on the perinatal timeframe that both Gina and I have utilized during our preconception, pregnancies, and postpartums. And this brand is someone we recommend to everyone that we know in this time period.

Gina: One of my favorite products from Needed that I use pretty much every day…

Roxanne: Every day.

Gina: …sometimes multiple times a day, is their collagen. Needed’s collagen has 15 grams of collagen, and so I love adding it to my coffee, I love adding it to my oatmeal, ’cause it provides eight of the nine amino acids that you need. Collagen is really beneficial to support your joint health, your skin health, your hair health. If I had my hair down, you would see how luscious and long it is, even at six months postpartum. Just don’t look at Roxanne’s hair, she just cut it all off.

Roxanne: It’s thick! It’s thick, just short.

Gina: It also really helps with tissue recovery, especially in the postpartum timeframe, which is what I have found to be really beneficial for me. So if you wanna check out needed, check them out at thisisneeded.com. Know that Roxanne and I only recommend brands that we personally use and love. We don’t just recommend whatever people pay us for. Like we only recommend brands that we personally use, and Needed, very top of the list. You can use code MAMASTEPOD to get 20% off your order.

So there is some controversy with whether or not you should labor down based on some changes in guidance. And so we’re going to break that down. But first, let’s say what is laboring down? ‘Cause you might be listening to this and thinking, “Okay, so what does that mean?”

So what laboring down is if you are, you have an epidural ’cause again, unmedicated, you ain’t waiting, and you’re 10 centimeters, you can not push right away. And it really relates to how high or low the baby is within your pelvis. Some guidance says to wait one to two hours after you find out that you’re 10 centimeters before you start pushing. Other guidance says you should start pushing immediately, regardless of baby’s station, or how high or low baby is within your pelvis, ’cause there’s risk to laboring down. And I think there is some nuance to it and some opportunity to have a conversation on what is beneficial so that if this is something that you’re interested in doing, you can have a conversation with your provider on how they manage it as well. Because if this is something that you’re super interested in doing and your provider is totally against it, then we maybe wanna have a conversation, and vice versa. If your provider is all for laboring down, maybe this is something that’s concerning for you.

So let’s talk about how you labor down. What do you do? So you’re 10 centimeters, so you have an epidural and your provider, your nurse, is like, “Cool, but your baby’s kind of high in your pelvis.” What station would you typically say, “Let’s labor down”?

Roxanne: Anything above plus two.

Gina: Anything above plus two. So I typically agree. Not just typically, I always agree.

Roxanne: She typically agrees.

Gina: I typically agree with

Roxanne: her.

But there is some nuance, like you said, with laboring down. I normally won’t, like if someone is plus two station, I’m not going to offer laboring down immediately. I’m going to do a practice push with that person- which just means like no one else, I have not called anybody, depending on their gestational, if this is their fifth baby, maybe I will call somebody- but this is when I just have them bear down with their contractions to see how much their baby moves. If their baby is like plus 2 station and like about to round the corner, like they’re going to move a lot with their push and that’s going to be like, “We can labor down if you want, and your baby will just fall out in your bed, or we can just bear down and your baby’s going to probably be born in the next 30 minutes,” based on how they pushed.

If there are plus two and that baby doesn’t move at all, this is when I would be like, “So we can wait a little bit, put you in a position if you need some time to ramp yourself up mentally that we’re going to start pushing.” So then usually I’ll get stuff ready in the room and they would labor down for 30 minutes while everybody gets into the room. And then they again, still only push for a short period of time. But that’s not my first option for someone who has plus two station.

If someone is zero station, I’ll still always offer the practice push, but I always offer laboring down first because if you think about the stations of the pelvis, plus two station is like pretty much the outlet, like the baby’s about to emerge,

Gina: You can you see the baby.

Roxanne: …from the pelvis. Zero station means the baby’s in the middle of the pelvis and that’s the top of their presenting part, most likely the head, that is at the zero station, so they need to go…

Gina: How many centimeters is a station?

Roxanne: Generally like one centimeter. So that’s, it’s hard because all of our bodies are like slightly different.

Gina: But so it’s five centimeters versus like three centimeters.

Roxanne: So like, one nail bed is like a station.

Gina: And so plus five station is, baby is out of your body.

Roxanne: Yeah, baby is out of the body.

Gina: So if you think about it in that way, zero station and plus five is five centimeters, generally. And a plus two station to five centimeters where you can see baby’s head is three centimeters. That’s a big difference.

Roxanne: Yeah.

Gina: That’s a big, that’s a lot, that’s a lot of time.

Roxanne: That’s a lot of centimeters. And especially when you push, it’s not just, “Oh, I pushed my baby down. I pushed my baby down, I pushed…” babies, it’s like a pendulum, baby comes down and then sucks back up, baby goes down a little bit further, and then comes back up, and it comes down a little bit further, and then comes back up. So your baby….

Gina: So it’s rocking.

Roxanne: It’s rocking and rocking until it gets to the point at the bottom of, it’s called the Curve of Carus, the bottom portion of the pelvis where they have to literally like turn and extend their head at that point. That is the hardest portion of the birth process, is getting them underneath that pubic bone to plus two station pretty much. But until they get there, like they just keep going back up in between…

Gina: I know it’s the worst.

Roxanne: …contractions. And it’s, so if baby is zero station, just like resting, that means that like you could push them down to plus two, but then they’re going to come back up to zero station.

So it’s like it takes a while to go from zero to staying at plus two because that is a pendulum like going down and then they suck back up, going down and then they suck back up. So if you’re zero station and you start pushing, it’s going to take a lot longer and the act of pushing is very exhausting.

But if we can labor down and allow your uterus, the fundus, to push the baby down, you do nothing but maybe nap for an hour, then you’re going to be less exhausted. It may not take any shorter amount of time overall from 10 centimeters to birth, but exhaustion level wise, it’s going to be a lot less, and potentially less damage to the pelvic floor ’cause you’re not bearing down with everything you got onto your pelvic floor for long periods of time.

Gina: It’s like the difference when you’re pooping, when you like bear down to poop out versus just relaxing to let your poop out.

Roxanne: Yeah.

Gina: That is much better for your pelvic floor.

So let’s look at the numbers then, ’cause there are some studies on whether or not you should labor down right away when you’re 10 centimeters, or you should wait one to two hours.

I will say any more than one to two hours is probably too much. If your baby does not move down within that timeframe, you need to actively push, ’cause that baby needs some effort.

Roxanne: And I think that goes back to the difference between FERs and the Ferguson reflex. FERs, if your baby is like actively being pushed down without you having to add to it with an epidural, you likely have a little bit of a FERs reflex happening, and that’s why laboring down is effective for you.

But if you are the person that needs the Ferguson reflex to get your baby out, then you likely are going to need to push your baby until that plus two station when the Ferguson reflex is activated to then get the baby out of the final bit.

Gina: So a Cochrane Review in 2017 found that delaying pushing, or laboring down, decreased the duration of active pushing by 19 minutes- so this is your effort pushing, not just your 10 centimeters. It did however, increase your length of the second stage of labor, which is from when your 10 centimeters until your baby’s born, so this is not talking about how long you were pushing for. Now when we look at the overall second stage of labor, which is from 10 centimeters until baby is born, so this is not talking about the time that you were just resting and existing. This is just your cervix was 10 centimeters, and this is when they noticed that your cervix was 10 centimeters.

Roxanne: You could have been 10 and centimeters longer.

Gina: And so in the 2008 randomized trial, the immediate pushing group had an average second stage of 102 minutes. So they found out that they were 10 centimeters and they started pushing, from that moment until their baby was born, took 102 minutes, which is…

Roxanne: An hour and 42 minutes.

Gina: And then the labor down group pushed, or their second stage of labor was 134 minutes, with a 60 minute delayed push. So they only pushed for 74 minutes.

Roxanne: 74 minutes.

Gina: Which is a lot less than the other group. But the difference between the second stage of labor was 32 minutes. So if you labor down, your second stage of labor will probably be longer ’cause you’re just sitting there for an hour or two. Yeah, no, shit it would be a little bit longer, but you’re active pushing phase is significantly less.

And so then this comes with some conversation as well. So the longer your second stage of labor is, potentially the higher risk of postpartum hemorrhages, potentially the higher risk of infection is, especially if your water is broken. What are things that could increase that besides just being 10 centimeters when your baby’s not born yet? Lots of active pushing, pushing for a prolonged period of time could lead to maternal fatigue and exhaustion. Pushing is very tiring. It is not an easy thing to do. And so if you are actively pushing for 102 minutes, it may increase your risk of needing operative vaginal delivery, where like you are just so tired and you can’t push anymore, that your provider needs to give you a little bit of assistance to help the baby be born. So that could be a potential risk, which could increase some pelvic floor damage in that case, if you start actively pushing right away.

The next thing is, even though the second stage of labor is longer with laboring down, the active pushing phase is much shorter. And so you have to think about how much more effort is going on and which one of those is going to increase the risk of hemorrhage more. Is it just being in this second stage of labor longer, or is it actively pushing longer? And so that’s where kind of the conversation I think needs to be is, “Okay, which of these risks, and what is the actual risk? What does that actually look like?” It’s still a fairly low number, but it is a little bit higher in the group that labored down versus the group that started of actively pushing right away.

Roxanne: And it’s only a 30 minute difference between the actively, immediately pushing, versus laboring down. But you have to think about how many times are you going to push in a 30 minute period, and that is you’re pushing for 60 seconds every time you push. So that is a lot of effort. Go run 30 minutes and then when I tell you that you need to run 30 more minutes, it’s a lot. That’s exhausting. 30 minutes is a long time. But in the grand scheme, when you look at that, it’s, “Oh, 102 minutes versus 74 minutes, that doesn’t seem like a huge difference,” but 30 minutes is a lot of time and it will feel like 70 years when you are the one pushing for 30 minutes longer.

Gina: It’s also 30 more minutes where somebody probably has their fingers in your vagina as well, ’cause I usually see a lot with like active pushing that the nurse or the provider- which can be really helpful, it can give you really good feedback- they are just like… What’s the one with the cat? With the tongs?

Roxanne: Yeah. The one that’s like, “Getting your pap smear, like what it feels like when you’re getting your pap smear,” which is how I feel when I get pap smears.

But, when you’re pushing with an epidural, because it’s again, only really time, you’re going to labor down, you have an epidural, you likely don’t feel shit, don’t feel anything in your bottom.

Gina: You might feel shit. You might feel poop.

Roxanne: You might feel poop, but you don’t feel pushes. Like pushing is harder with an epidural because you don’t have the same sensations. So we have to get creative with how we can get people to bear down and actually be bearing down in their pelvic floor and pushing their baby down, versus just holding all of their breath in their chest and in their face. So doing internal feedback of when they’re pushing, we feel the baby’s head moving down, we feel your pelvic floor opening. This is going to give you more feedback of being like, “Okay, when I do this, this is what happens,” so then you can start to create that mind body connection with an epidural.

With an epidural, also, the first hour of pushing for most people is just figuring out what the freak is happening within your body, because again, you’re creating that mind body connection. But when your fingers are inside of anybody’s tissue for a long period of time, so 102 minutes versus 74 minutes, that’s causing inflammation and trauma to the pelvic floor and to the tissues, increasing the risk of tearing and pelvic floor dysfunction. But it’s either, don’t put your fingers in their vagina, and then they push for 30 minutes, but they were all ineffective pushes and then trying to figure out all of these other ways and then they push for four hours, or putting your fingers in their vagina so that you can give them immediate feedback so that they can push more effectively and push for shorter. Risk/benefits. So it’s like for, yeah, obviously figuring out what works for them and doesn’t work, ’cause some people figure it out without anything, and then I’m literally just holding a warm compress on their bottom so they don’t tear ’cause they’re like, “I got this.”

Gina: I think it’s implied that this is not like you as the nurse making the decision, it is the person that is giving birth, making the decision on whether or not they’re going to have internal feedback. But I think it’s a good conversation to have of, “Hey, can we see externally that you’re doing it? That you’re crushing this? Is it hard for us to see? Are you feeling like you’re being productive? Maybe we can do the internal feedback to see,” but it should always be a conversation.

Roxanne: Yeah.

Gina: But it’s a tool that’s available to you.

And so let’s talk about like when maybe somebody should or should not labor down and what kind of conversation should we be having, because I’ve had it at times where my client, her health is starting to not look good. Like she’s starting to get an infection. Like we have a fever, a baby is looking not too great. And so it’s we don’t wanna labor down for two hours.

Roxanne: Yeah.

Gina: Like we want to see if we can try to get this baby out. So that’s usually a time where I’m like, “Hey, Baby might still be a little bit high, but let’s do practice push and see how it looks.”

Roxanne: Yeah, and that’s why I love practice pushes and I will always offer them, even if your baby’s zero station, ’cause some people can literally push their baby from zero station to like crowning. Just some people are very, their uteruses are very strong and they can do it.

But, there are cases where laboring down is not a viable option.

Gina: Especially if laboring down is relying on your uterus to push your baby out. If your uterus is starting to get infected, it’s probably not going to be able to push it down.

Roxanne: Or you’ve been in labor for a really long time. You haven’t slept, you haven’t eaten, your uterus as a muscle, it’s tired.

Gina: Yeah.

Roxanne: So laboring down is not going to be effective for everybody.

Gina: Yeah. So similar to the fetal ejection reflex, it’s not a hundred percent. It’s not, “Hey, if you’re unmedicated, you’re 100% going to feel this,” and it’s the same with laboring down. It’s not 100% of everybody who has an epidural should labor down if your baby is X station, we wanna think about the different factors.

So what conversations could we be having with our provider on fetal ejection reflex, on laboring down, and exploring how do I start pushing?

Roxanne: I think the first question would just be like, how do you manage pushing? Like when I start bearing down, how do you manage that? Because I also think your provider, going to be honest, unless you’re a birthing at home or in a birth center, probably not going to be there until your baby’s crowning. It’s just the case in the hospital, is they don’t call the provider until, some people say, until they see eyebrows. So it’s really the nurses, honestly. So I would call the hospital Labor and Delivery Unit if you’re delivering in a hospital, and ask the nurses, “What happens when I start to push?” They will give you more of an idea of what will actually happen for pushing, because they’re the ones that are there for most of it. So some hospitals will even have their Labor and Delivery nurses teach their childbirth education, and that will give you a better idea of how hospitals manage pushing, because if the nurse, all they know is to do internal feedback, everyone’s on their backs, as soon as they’re 10 centimeters, they start pushing, that’s going to be what they tell you over the phone. “Oh, once you’re 10 centimeters, we start bearing down and we can give you internal feedback if you have an epidural, and then you’ll push your baby out on your back, and then the baby will be born when the provider is called, when you’re crowning.” If they do more shared decision making of like, “We offer laboring down depending on if you got your epidural,” these are things that they will tell you over the phone of how they manage pushing. Because your provider, unless, again, you’re giving birth at home or at a birth center where your provider is going to be in your room more often, or if you’re giving birth in a smaller community hospital where again, your provider is more available to be in your room for longer periods of time, how they manage pushing is going to be when your baby is crowning- unless they have like very strong opinions against laboring down. But that’s why calling Labor and Delivery, “What happens when I start to feel the urge to push with and without an epidural?” They would be able to give you more of a feedback of what would happen during the pushing process.

Asking your provider how they manage pushing, “Once I’m 10 centimeters, what happens?” And they’d be like, “It would depend on baby’s station on whether or not I would recommend laboring down or not, or your nurses recommend laboring down or not depending on baby station,” or if they’re like, “Once or 10 centimeters, we just have you start pushing,” that would also help give you clues. But I always think like I am obviously about to be a provider, so I’m about to be that person that shows up when you’re crowning, but the nurses are so instrumental in the laboring process because they are there. They’re the ones that are relaying what’s happening during your labor, like they’re the ones that are like, “Hey, something’s a little off. You need to come assess her.” So how do the nurses communicate with the providers and how do they manage things can be really helpful by just calling Labor and Delivery or attending a hospital class if it’s taught by the labor and delivery nurses.

But then asking the providers like, “How do you manage pushing, could also be helpful because if they don’t believe in laboring down, the nurses aren’t going to labor down.

Gina: I think it could be helpful if they are against laboring down in all circumstances to ask why. Like what in your experience has made you have this belief? Is it strictly based on ACOG guidance? Like having the conversation I think is really helpful ’cause it can be very informative to you as a patient as well of, “Okay, this is how my provider approaches birth.” And I don’t wanna say that their opinion is wrong by any means, ’cause it is backed by research as well, if they are anti-laboring down. But I think being able to approach every birth as a unique experience and understanding that there’s nuances to them, like it’s not: Labor down for everybody. Nobody labor down. Everyone’s going to have this reflex. It’s about exploring what is specifically happening in this individual birth experience and being open to exploring different avenues as needed.

Roxanne: With birth it’s very rarely ever black and white. It’s very, birth is gray, 100% that anything could be right for one person and wrong for another person. Because we’re individuals, we all birth differently. Like, obviously there’s like averages for like how long people push for and how many people have FERs and who experiences Ferguson reflex and how long people push with laboring down without. But it’s every person is different and will choose something different. So it’s just about knowing the evidence and offering them their options, but still allowing them to choose it.

Gina: So hopefully this episode was informative to you. Rox and I were going back and forth a lot on different conversations with the fetal ejection reflex, Ferguson reflex, laboring down or not laboring down. And so again, these are just options that are available to you. Some of them you can spontaneously choose, the FER, you’re not, it’s just going to happen.

Roxanne: It just happens.

Gina: If it happens, sorry. It can be really overwhelming. It’ll be okay even if it’s scary.

Roxanne: Some people love it though because again, they’re like, “As soon as it happens, I know this baby’s going to rocket out of my body. It’s going to be over.”

Gina: I know, it’s super intense in the moment, but I’m like, I would rather have that. It’s not great pushing for an hour, for two and half hours, like I did with my first, where I felt nothing.

Roxanne: Yeah.

Gina: Felt absolutely nothing.

So these are all just options available to you and hopefully it helps to facilitate more conversation with your providers so that you can build trust in the team that you have chosen to support you in your birth.

If you want to learn more about pushing in general and childbirth education, check out our online childbirth education course ’cause we offer what are your birth options, what is the labor timeline, what to expect during your labor experience. And we try to give you as much information as we can, fairly unbiased, because ultimately the best decision and the best choice is the one that you decide. It doesn’t matter what Roxanne and I would do in the same situation or what we may recommend in that situation as a doula or a nurse slash student midwife. It’s about what you feel is best for you and your family, and we try to give you that information so that you can feel empowered to make the decisions that work best for you.

So you can check on our online course at mamastefit.com. You can bundle it with prenatal education, you can bundle it with Pelvic Floor Prep and use code STORY10 to get 10% off any of our online offerings.

Roxanne: This podcast is sponsored by Needed, a nutrition company focused on the perinatal timeframe that both Gina and I have utilized during our pregnancies, postpartum, still to this day, we still love it. And you can check them out at thisisneeded.com and use code MAMASTEPOD to get 20% off your first order.