#99 | Easier Pushing, Less Tearing with Hehe Stewart of Tranquility by Hehe

They are so lost in their mission. They think that if they don't intervene, they're bad doctor that makes you feel like wow, I am not safe in your care. You do not respect what I'm trying to say, or what I am sharing about when a feeling or about my goals and my birth and that is really hard.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, everybody, I'm he I'm the founder of tranquility by hee hee maternity concierge service. We provide birth services across the US and outside of the US. I'm also the founder of the birth lounge, which is an online membership for pregnant people to be prepared and educated and informed about their birth so that they can have a confident and informed birth. I'm a doula with my Master's in human development, Family Studies. And I have over 10 years of working with families and their small, young, tiny humans. I'm really excited to be here to talk about this. Well, thank you, we're really excited to have you and we know you have a lot to share when it comes to minimizing, tearing, and pushing most efficiently. So you know, whatever you want to start with, let's just dive in. Heck, yeah, let's dive into this. So one of the first things that comes to mind when we often say pushing, I think is two things for people push like you're taking a poop. I think everybody thinks like that. And then also ours, I think the word ours pops into so many people's heads. Now, I grew up in Mississippi, so I grew up on a farm. So I grew up watching unmedicated labor of animals of undisturbed labor, of that my family would go to sleep at night with pregnant animals out in our yard or field, and we would wake up the next morning, and we would have babies. I never had this fear around birth, or unmedicated birth, or really even death after birth, I kind of got to see it play out in nature, I understood that it was rare, I understood that, when that happened, usually my dad was able to identify why that happened. And so when I started to attend human verts, and I started to see all the interventions that we had, and then I started to see kind of how he directed people in pushing, it really struck a different chord in me. And I was like, wait a minute, this there has got to be a different way. For so many things in birth, but particularly pushing, there's no way that our bodies were literally designed to conceive a baby grow a baby, but then spent hours and hours and hours and hours pushing this baby out. When animals that I had grown up watching didn't do this. I have a master's in Human Development and Family Studies. And part of that was the human development experience where I had to look at, gosh, what are body's natural systems doing when we're pushing, and then you look at how we do it in the hospital system. And then I had the opportunity to attend a couple of home births. And I got to see how that played out. And it's vastly different the way that we push at home and the way that we push in the hospital system, particularly the positions that people push in, in those two settings, right. So at the home birth, typically birthers are allowed to be mobile and they're free to move and homebirth midwives are more comfortable with pushing in various positions were in the hospital, we typically see hospital based providers have the most comfort when the birther is on their back and the provider has a straight shot I shot you know, right into their vagina where that baby is coming out. And so most of the time in the hospital settings and if you have a provider that doesn't do this, honestly hang on to that provider. Don't ever leave that provider but if you have a provider, most providers are going to say like I need you to get on your back or if you're standing up they're going to try and get you in a position where they can more easily see what's going on down there hands and knees is often a good opportunity to meet them halfway. I think it gives them a great insight into where the baby is coming out but it also gets you off of your back. So if you're out there thinking I definitely don't want to put In my back, and I'm on my back, and I'm scared that my provider might push me into getting on my bag, hands and knees is a great kind of medium point. But yeah, that's where all of this stemmed from is, is, you know, kind of growing up, I got to see that first didn't have to look the way that humans did it. And it was very puzzling to me. How were you know, when I got started, and this is 2016, but how we were in 2016. And we hadn't figured this out. And now we're five years later in 2021. And we still haven't really figured this out. So what's the pushing stage like for animals, usually very short, but if and effortless, so I think that's a huge difference. If anywhere, if you were to look up pushing stages of animals, it's effortless. And I'm talking to across the board, you can watch pandas, you can watch water animals, sharks, dolphins, you can watch tigers, lions, bears, I'm particularly talking about cows, pigs, goats, I got to watch tons of unmedicated very natural birds, because they were animals. And we can see the same thing transpire in humans. But we have to respect the same boundaries that animals respect, right? It when we say undisturbed in animals, we really mean it. Think about how often humans intervene in animal births. Never.

It's also interesting that you woke up to see the animals having been born because it's my understanding that animals much prefer to give birth when they're alone, because we all need to feel safe. And they typically feel safe when they have peace and quiet. And they don't have to keep aside I watching who's around them. Is that something you found to be true? where a lot of them born overnight?

Absolutely. And I'm I'm not so sure that it has to do with them being alone, as much as it does with the world around them is quiet. So we lived on a highway even though we had lots and lots of land, there was a highway that ran right across it. So there were always big trucks traffic, you know. I mean, I guess as a farmer, my dad was out in the field. So there was a big diesel truck going around all the time, and you got tractors, and there was always dogs that follow the trucks to help, you know, keep the animals It was your typical farm. And so I think the cows and the horses and the pigs and everybody kind of knew that you are safer at night because the world was common when we think about uninterrupted human births, not induced human births. But spontaneous labor, typically, labor's are going to get started overnight. Right?

Yeah. oxytocin levels are peak at night, of course, because how come is that because your cortisol levels drop at night, because the world around you is slowed down. You don't have all the stressors, you don't have all the bright lights, you don't have all the other people the other energy, the voices, the content to consume the social media, you don't have any of that the radio the news, right? The world slows down and your baby is safe to come and animals. I was just about to say they've tapped into that. But no, no, they haven't. They never left that. And humans have, we've totally stepped away from that. And it interrupts our entire labor. And then the price that we pay is usually a really long pushing period.

I've always wondered, does either of you now what percentage of women go into labor during the night?

Well, the statistics are a little bit skewed because of all the interventions and worse, that's why we don't see that data. There's a reason no, it is out there in the world. I think it's greater than 1/3 of the time. I mean, theoretically, we're asleep about a third of the day. And I think it's more than a third of the time. And I think that's why exactly what you're saying. I just before we forget to circle back to this, I've got to ask you a question. It's always been my belief and understanding that, you know, when in doubt, get on your hands and knees. It's an incredibly productive position for labor. It's comfortable, it opens up the pelvis all the way there's, it's working with gravity. It's just an awesome position. Were you saying if you're in a hospital with an obstetrician, you find it to be like a happy medium. Are you indicating it's like a medium position? Or were you saying it's one of many optimal positions that typically they won't resist too much? Because I wasn't sure if you were saying like, you can think of even better positions than that. That's not what you were saying is it?

That's not what I was saying. I was saying that, you know, if you have an obstetrician that's really giving you pushback, and they they just really, really can only feel comfortable delivering your baby like side conversation. You got to get some extra training because people have babies other than on their back and you are calling yourself an obstetrician and you're not fulfilling your job. So like better when they're not on their back much safer and better when they're not nearly so like. As a side note after this birth, get some extra training in Got as you as an obstetrician, but as a person, you know, as a birthing person, if you have an obstetrician that has given you a lot of pushback, and really is only comfortable, being able to see your vagina and the baby come out, the flip on hands and knees, they still have that viewpoint and you don't have to be on your back. If you think about it, we could literally take a snapshot and flip you all upside down, and it's the same thing. So flip yourself upside down, you know, get on hands and knees and your provider should still be able to get some comfort level also, you know, this isn't really about their comfort levels. It This is your birth, you need to do what your body says. Also, if we're going back to the animal thing, you know, most animals are going to give birth, hands and knees. You see bigger animals, sometimes like pigs lay down on their side, cats and dogs lay down on their side a lot as well. But cows and horses they do not and their babies just pop out all the way to the ground all four or five, six feet that they are tall up. And it's it's fine not to say to let your baby fall to the ground is not what I'm saying at all. But what I am saying is that standing up is a fine position for you to give your you know give birth in and you can reach down and catch your baby. Your partner can catch your baby your provider can catch your baby your partner and your provider can do it together in the birth room. There's it opens up a lot of opportunity if you will give birth in a different way.

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Can we also talk about that you don't always have to have a cervical pillow exam to push you know, especially unmedicated labor's you should be able to feel some pressure should be vaginal pressure to be some rectal pressure, that cervical exam is a nice confirmation. If you have an epidural or you have a medicated labor, it may again serve as a tool. But we don't necessarily have to have that in sometimes providers will present this as, as a half, two, you have to have this right can't push until it's not a foregone conclusion that they have to be constantly in their checking and checking. It's up to you. And it can be helpful, it can be useful, but you need to provide your consent, right? We know so many problems come from infections in hospitals, we also know that about 70% of that is caused by providers not washing their hands in between patients. So that's not only really disgusting and gross, but also much more of a reason to not have someone do cervical exams, right? We've kind of gotten off on a tangent on several exams, but along the same lines of having your fingers in there and circling back to pushing is there is evidence based force has just releases information. There is evidence that shows one step versus two step delivery. And the outcome to this. Now, one step birth is where your baby's head exits your body on a contraction, and without waiting for the next contraction. Your provider is going to put both their hands on your baby, begin to rotate them, pull them out of your vagina and you're gonna see you're gonna see your baby be pulled out of your vagina actually, with some force, they're gonna have to actually work to get your baby out. It gets your baby out quicker, which is kind of where this came from. We used to think that the quicker that the baby came out, and the better the results, but we haven't actually found that right, it doesn't actually give us too much better of the results. And we're also breaking babies, collarbones were given birthers really bad tears, we've got some issues that are coming from this one step birthing. So the alternative to this is to set birthing, and this is where your baby's head comes out of your vagina and one contraction, and then we wait for the next couple contractions to rotate your baby. so crazy that our bodies do this naturally, we don't need help, it's actually called something, it's something called restitution, your body will do it on its own your uterus and your baby. And your body knows how to do this without interruption. It does not need any help or any prompting, and then the next contraction your baby's body and their trunk should follow. Right. There are going to be some cases, obviously, well, this is not possible. But for the most part, this is possible. And it shows that we have better outcomes for both birth or and baby If we let the body do it uninterrupted. Now the issue is getting this information into providers hands and then making them take action on it, which we know takes literally decades, like it seems kind of funny for us to say decades. But it really is like 17 to 20 years, I saw that information come out the other day. And I was I can't believe I was kind of dumbfounded when I saw it. I was like, I can't believe that we're even talking about this, of course, the baby has, you have to pause and let the baby align properly. And one of the reasons that we have a problem with shoulder dystocia is because we're not waiting for that moment. We're not waiting for the baby to line up, and we're forcing the issue.

It's like is it so hard for you to stand there and just Behold, the experience happening before your eyes as the provider your value. As the obstetrician is not getting the baby out, it's being there in case you're really needed. And that's an enormous value that no one else can do. You know that a midwife and obstetrician we need them there for that purpose. But if they're really doing their job optimally, they're not intervening the vast majority of the time they know when to intervene.

I think that's where it's lost on so many people's they are so lost in their mission. They think that if they don't intervene, they're bad doctor. And it's almost the opposite is true is like, you're going to intervene too much if you're not careful. That makes you a bad doctor, because you are overstepping the boundaries of nature, we don't actually need too much help to birth your babies. It's that piece of your sentence where you said, If needed, we've lost it.

We've come back to this again and again in this podcast that it's the difference between learning birth through the physiologic model of care, which is what midwifery teaches versus obstetrical care, which teaches every single possible problem that can present itself and how we can, you know, stop it before the problem starts, when in fact, we actually create more problems by doing that. But the thing about the shoulders and the restitution is just I really think there's a general feeling that the longer I let the baby sit there, the more chance they are to get stuck. And it's exactly the opposite of that, which now thank God, the evidence is there to show even though we've known it forever.

So when we start teaching people to stop punishing, like they're taking a poop. So let's talk about this. If you're pooping, where are you pushing from usually kind of right there and your butt are right there in the bottom of your belly, your baby is above those muscles, we would need a vacuum for that we have a vacuum for that we have a vacuum to help us in birth, we have forceps for that kind of stuff, too. However, if we start pushing above our baby, that would probably be a lot more effective. So my secret sauce to pushing I actually teach people how to push with the proper muscles. And our average push time is 36 minutes for a first time mom. Now of course there are people who push for hours. Typically, when we kind of debrief on their birth and they're pushing, we're able to pinpoint it for at certain places, we could have done things differently and probably yielded a little bit different results. Right. We also have people who push for literally three minutes and I can't take credit for that. I don't think that's my my pushing method at all. I think that was your body was ready to get your baby out and you push for three times. But for the most part, if you are pushing from the top of your belly, you can do it much faster than if you are being told to push from the bottom of your belly in the same muscles that you use to move your bowels. your bowels are down there your baby is not.

That's a HypnoBirthing thing that I have never been comfortable teaching. I never talked about that. It's in her book. Something that she's always said, How is breathing during a bowel movement, good preparation for birthing a baby. For me, it never made sense. Having given birth, it never made sense. So I don't teach it that way I teach everything else about how HypnoBirthing teaches birth breathing, but I'm with you on this completely, it's there different muscles that we need to activate. And I think pelvic floor physical therapist would agree. Now you alluded to having a method, so is your method to teach how to find those muscles, and breathe with them?

Yes, but to say in breathing is a huge part, the the three mechanisms are pushing from the right places breathing in the right ways, and then using your body mechanics. And so that's kind of the three pillars of that pushing method, a key piece for me, and that I teach in this course is, wait till your baby is plus two. If you cannot wait until your baby is plus two, then we need to have a serious reason as to why not if it is just because you're having a long labor. Some lagers take a long time, that's okay, really quickly, he can you just explain to everyone what plus two means totally. So in your province, there are different stations and above your pelvis is going to be negative numbers, negative one, negative two, negative three, directly in your pelvis, it's the neutral zone, you can think about it, it's zero, which is good, it's good progress, your baby is finally engaged. And then plus one, everything below your pelvis is plus one plus two plus three plus three is actually crowning. So plus three, we're having a baby, plus one, your baby's low. But if we were to start pushing up plus one, we risk and not always, but we risk pushing for an extended period of time because this is this is work that your body would do without you doing all that extra pushing your body will lower your baby from plus one to plus two with just contractions, it doesn't mean that it will happen in 30 minutes, it doesn't mean that it will happen in four hours. It's sometimes one time, I had a client who it took us 14 hours to let her baby labor down. And it was a fight with the hospital staff because he kept saying, we need to do this. And we need to do this. And we need to do this. But her labor was progressing, and her baby finally dropped. And she pushed for mere minutes. And that was totally our goal. Right? If you can let your baby drop, but in the hospital system, you are going to be facing a little bit of a time clock. So just know to, I guess know the right questions to ask, Am I safe? Is my baby safe? Is there a reason other than a long labor that we might need to speed things up? Right, some things are going to play a role in that.

How do you advise a woman to know when she's plus two without the provider during an exam?

Yeah, so it's a little bit harder with Medicaid labor's right if we have an epidural. If my first thing with epidurals is if you can't feel your legs, and you really don't have any control, we just turn that epidural down, I know that you got it for comfort. And I realized that I totally respect that I'm not trying to take your comfort away. But we need you to have a little bit of feeling down there. If pushing for a short time is your goal if you don't care, and comfort is more of a goal for you than leave that epidural low. But if you feel strongly that you post for a short period of time, we need to have a little bit of feeling down there. Typically, even with an epidural, you're still going to have vaginal and rectal pressure. And one of the things is that it no longer fades in between contractions. So when you first start to feel that vaginal and rectal pressure, it's going to come in waves and during contractions, you're gonna be like, Oh my goodness, I feel. And then in between contractions, you're gonna be like, Oh, nevermind, it's fine. Everything's fine. We want that pressure in your rectum and your vagina to stay around in between contractions, we want you to say, okay, contractions are gone. But I still feel like there is a bowling ball in my vagina. Good. That is great. It's not a bowling ball, that's the baby's head, it is likely that your baby is low enough and we can push them out.

So for the woman who is fully dilated and feeling the urge to push, but is not yet plus one or even plus two. Are you discouraging them then if their body is telling them they want to push and you don't want to stop and say let's check the station first. Right?

Exactly. Oh, exactly. And there's great research behind that that says I think it's called the early pushing urge, I think is actually what it's it's almost like the point of no return is where your ejection fetal reflex kicks in. So it's it's like it  will kick in first and then your ejection fetal reflex will kick in and you you really can't stop that, this is where we run into the problem and what you guys are asking about, we will have people say, Oh my gosh, I feel like I need to pull They're like, No, no, no, no, no, don't you push, don't you push you hold that we got to call the doctor. And I'm like, What is your body telling you? Don't stop that. Listen to that, right? If we have an obvious problem, we should be picking it up on monitors probably, the likelihood that a problem arises, when you're found the urge to push is so low, it's so low, we're more likely to encounter a problem. If we stop that person from pushing when their body is trying to naturally expel that baby, what we really run the risk of is shutting that birth down completely. And we can't get those contractions back. And then we never have that urge to push ever come back.

Well, the other thing we're doing is robbing women of their own instincts, because we can give them the impression that like, Don't listen to what every cell in your body is telling you to do right now. It's like, hold on the timing isn't right, the right person isn't here that this that? And I mean, I don't know if there's ever a stronger urge in our lives than that urge to give birth when it's the moment of giving birth. And what a thing like what a thing to do to another human being to say, No, your instinct is wrong. Follow my instruction.

So I was talking to a doctor friend of mine yesterday. And we were actually both kind of complaining about the god complex that gets in the way. And I think this is sometimes where we see it rears its ugly head is when providers feel like they knew better than you. And your body's literally telling you what to do. We see it pop up in the pushing, we see it pop up in positions, we see it pop up in, you know your instincts around induction. Once we kind of start an induction, we're a little bit stuck there, especially depending on the methods that you choose, right. But cancel your induction and have a frank conversation with your provider about, Look, my instincts are really telling me something here. And I just want to make sure if I'm going to be induced, I'm 100% confident in that choice. And if you're not, then it's not the right choice for you right there in that moment, right doesn't mean it's not the right choice for you. It means right then in that moment, you just need to take a pause and say I think I need something 10 minutes more research another conversation.

A few days, if something doesn't feel right to us, I mean, what better thing to teach your child then if you have a moment in life where something doesn't feel right to listen to that moment.

That's usually when we're seeing the women switch to another provider, because usually when they have that conversation, it's not well received.

Yep. And that makes safe that makes you feel like wow, I am not safe in your care. You do not respect what I'm trying to say, or what I am sharing about what I'm feeling or about my goals and my birth. And that is really hard.

He he we know you wanted to share some information about preventing tearing. So what do you have to say about that?

Yeah, so I think the first thing to know is, you know, we just talked about one step versus two step delivery, if you can really advocate for kind of a hands off delivery. That's your first step of taking control while your body do it. Right. The second thing is about your baby's positioning shoulder dystocia is a large reason we're why we see tearing. But if we didn't have people on their backs for birth, maybe we wouldn't see as high of a number of shoulder dystocia. To get off of your back is my second thing. My third thing is going to be labor in the water, if you can labor and water and provide your body with that hydration and that wants and just the relaxation, even if your mind can't necessarily relax in the tub, or you don't think it will be able to your body physically will be able to relax in the tub. And so your body will be you know, much more plasticky, you'll be able to stretch a lot better. And so I think if you can labor in the tub, honestly, maybe if you labor into the tub until you are that plus two and you're finding that urge to push doesn't go away. If your hospital doesn't allow waterbirth which I hear so many of you say your other alternative if you don't want to make it to the bed which respect to you your burden of AV you don't have to walk all the way to the bed, stand up, mash the drain on the tub. And as the tub is draining that appeases the no water birthing for your providers. And you're standing up to give birth to your baby and you catch your baby or your partner catches your baby and your providers there and great. Now everyone's appeased, we didn't have a waterbirth I didn't have to get on the bed. I didn't tear my baby slipped right out also standing up so we did not have the opportunity for my provider to put their hands on my baby and do one step delivery. So I got my two step delivery as well. Bada bing, bada boom, I was all that easy.

Another thing that I always advise women to do or try to help them with is in that moment when the baby's head is crowning, and they're feeling that intensity of Ring of Fire is to just resist the urge to blow right through that because a lot of times, women really do just want that over so fast and it's just like, I'm gonna just expel this baby in the next, you know, next urge. But if you can slow that process, if you can breathe through it and take your time and allow that stretching to happen, you definitely reduce your risk of tearing because that muscle is designed to stretch like that. Right? And I think we would just be so remiss if we didn't mention this. We talked about a PCR dummies but not only is that parent am designed to stretch but it does know where to tear in the best place. It's designed like that it will tear where it will naturally be able to heal back the best. So, kind of hands off there. Trust your parents. You don't have to push on your back. You don't have to wait for a provider to give you a cervical check to know that you're ready to push if your body is telling you to push. You don't have to push just because you're 10 centimeters and a provider has told you you're ready to push if you're not feeling the urge to push so you have total control over the way that you push your body will tell you when it's appropriate to push and all you have to do is listen to that urge.

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