Guided vs spontaneous pushing

Updated: Apr 2

The second stage of labour is the expulsive phase, and it’s the stage so often represented in TV and film. Time and time again we’re shown guided pushing as the norm. Red faced and sweaty, the person giving birth is shouted at by a midwife or healthcare professional telling them when to push. Quite often this is combined with a semi-recumbent position laying on the bed on their backs, knees up, chin to chest and pushing when told. This is called the valsalva technique (and is bad practice according to the World Health Organisation!).

Spontaneous pushing is not what we’re shown as the norm. This means following your body’s insrun takes and bearing down or pushing when you feel the urge.

NICE guidelines state:

“1.13.10 Inform the woman that in the second stage she should be guided by her own urge to push”

…and yet we know birthing people are still offen told when to push (and when not to).

The risks of guided pushing

So what is the potential harm caused by being guided to push? There have been multiple studies looking at the outcomes of guided vs spontaneous pushing:

  • Directed pushing increased perineal trauma and instrumental delivery rate (Beynon, 1957; Yeates and Roberts, 1984; Handa et al, 1996).

  • Directed pushing can also cause short and long term pelvic floor dysfunction (Schaffer et al 2005)

Guided pushing may negatively affect baby as well. Several studies have found that guided pushing can cause stress to baby.

  • Guided pushing may cause the diaphragm to become fatigued resulting in reduced maternal, and as a result, fetal oxygenation (Mayberry et al 1999).

  • It may also cause fetal acidosis, reduced fetal oxygenation and an increase in cerebral blood volume (Aldrich et al 1995)

The research backing spontaneous pushing

Spontaneous pushing results in less perineal trauma (Yeates and Roberts, 1984; Sampselle and Hines, 1999)

Another small but recent study in 2021 found that spontaneous pushing:

  • meant a shorter 2nd stage of labour

  • less need for analgesia

  • reduced postpartum haemorrhage

  • reduced the risk of tearing

  • decreased perineal pain during birth

  • resulted in more babies having better apgar scores

  • resulted in fewer admissions to neonatal intensive care

(Spontaneous Versus Directed Pushing Technique: Maternal and Neonatal Outcomes

Hanan Elzeblawy Hassan et al 2021)

Guided pushing may be requested if it’s your preference, but it’s worthwhile understanding both that there are risks, and that it’s not compulsory to do what you’re told. If you’d prefer to listen to instinct and follow your body’s and baby’s lead, let your midwife know. As with all care in labour, it’s your choice!


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