Description and Official Rationale
It is thought that the baby's head cannot pass through the mother's cervix until it reaches full dilation to 10 centimenters, and that if the woman begins to push before complete dilation, the baby's head will become "a battering ram," as it will be unnecessarily and harmfully smashed against the pelvic floor and the cervix may rip. Too early pushing can also cause the cervix to become swollen from the pressure of the baby's head, thus making complete dilation take longer and be more painful to achieve. Correspondingly, once the woman is fully dilated ("complete"), the baby can and therefore should be pushed through her cervix as quickly as possible, as the pushing stage is held to be hard on both mother and baby and should be expedited. Most hospital guidelines allow no more than a maximum of two hours for completion of the second (or pushing) stage of labor.
Thus, as soon as completion is announced, hospital personnel often immediately begin to exhort the laboring woman to push, whether she actually feels the urge to push, or not. But when the baby is near to being born, the woman must be transported to the delivery room. So that the baby will not be born en route, the laboring woman in transit will be exhorted not to push with as much vigor as she was previously commanded to push.
Physician Michelle Harrison (personal correspondence) states that the physician's basing of judgment concerning readiness to push on the arbitrary standard of full cervical dilation eliminates the more physiologically efficacious possibility of basing such judgment on the woman's urge to push. Harrison notes that she often allowed her home birth mothers to begin to push gently whenever they felt the urge, even if they were not completely dilated, and that this gentle pushing would serve to help, rather than hinder, the woman to achieve full cervical dilation (1982:98). Although it is sometimes true that hard and prolonged pushing before 10 centimeters dilation can have harmful effects, it is also true that pushing after dilation is complete, but before one has the actual urge to push, can be harmful as well. Many of the women in my study described long, discouraging, and exhausting pushing phases in which they were repeatedly yelled at to push because they had dilated to 10 centimeters, but their efforts seemed to be to no avail. Susan McKay reports that nurses, when asked why the two-hour rule exists, commonly responded that
it was learned as part of institutional norms, and that if the nurse doesn't urge and cajole the woman to push harder and faster in order to meet specified time limits, more intrusive intervention, such as forceps or vacuum extraction, may be used. The message can be imparted even more strongly as the birth attendant conducts frequent sterile vaginal exams to ascertain even the slightest evidence of progress of the descending fetus. This occurs despite no evidence that two hours of second stage is any safer than any other length of time providing the mother and the baby are in good health. Urging the mother to push harder and longer may, in fact, make things worse as the baby's head and umbilical cord are compressed through the mother's intensive effort, leading to [heart-rate] decelerations and fetal hypoxia [oxygen deprivation].
-McKay 1990 In Spiritual Midwifery, internationally renowned midwife Ina May Gaskin reports that home birth women, after reaching complete dilation, often experience a slowing or lessening of contractions, sometimes to the point where they can even rest for a while before actually feeling a pushing urge (1990:358). Midwife Jerianne Fairman explains that forcing the mother to push before she feels the urge to push usually accomplishes little more than to drain her energy:
Once the cervix is completely dilated and the baby's head has passed into the birth canal, the uterus, which had been tightly stretched around the baby, now fits flaccidly around the rest of its body. Because of this, uterine contractions do not yield sufficient pressure against the baby's bottom to assist the abdominal muscles in moving the baby down through the birth canal. As the uterus continues to contract during the resting phase, muscle fibers in the uterus gradually retract, reducing the uterus in size until it again fits snugly around its contents. Once the uterus has contracted sufficiently, contractions once again become effective; the baby's head descends lower into the birth canal and a bearing down reflex is simulated. The resting phase has ended. It may take anywhere from a few minutes to two or three hours. (Fairman 1990)
Midwives, after making sure that the mother's bladder is empty, and that her psychological condition and the position and heartrate of the baby are favorable, will encourage her to simply rest, sometimes even sleep, during this latent period of second stage labor, which Sheila Kitzinger has labeled the "rest and be thankful stage" (quoted in Fairman 1990:10). But this stage, although common, is largely unknown in the hospital, where it is rarely given time to occur naturally.
I became aware that I was indeed in the throes of transition. Contractions were inordinately forceful, were periodically back-to-back, and often appeared to have two peaks of intensity. I was extremely uncomfortable during contractions, experiencing considerable backache and intermittent urges to forcefully push near the end of the fifty minute transition phase. In light of this, the obstetrician reported that the cervix was fully dilated, and I should begin voluntary pushing with subsequent contractions. Shortly thereafter, though, I didn't perceive the contractions to be as intense as before, nor at the same rate, all of which was confirmed on the monitor. Having finally arrived at the second stage, it semed as though my uterus had suddenly tired! When the nurses in attendance noted a contraction building on the recorder, they instructed me to begin pushing, not waiting for the urge to push, so that by the time the urge pervaded, I invariably had no strength remaining but was left gasping, dizzy, and diaphoretic. The vertigo so alarmed me that I became reluctant to push firmly for any length of time, for fear that I would pass out. I felt suddenly depressed by the fact that labor, which had progressed so uneventfully up to this point, had now become unproductive.
-Merry Simpson, from her Lamaze story-report With the head crowning, it was decided to take me into delivery. I was feeling the urge to push. Blow, blow, blow. Anne asked me to move onto the delivery table, but as hard as I tried to summon all my muscles, I couldn't budge. They had to pick me up. Blow, blow, blow. I was becoming frantic and felt as though I was losing control. Where was the doctor, any doctor? You have to blow, Lee....I felt as though my whole pelvic area would explode if I didn't push. But I heard Anne (whose hand was my lifeline at that point) saying, "You can't push yet, Lee!"
-Lee Heit, from her Lamaze story-report In Merry's response, we can observe her internalization of the message that her machine was defective. She does not say "the nurses had me pushing too soon," but "my uterus had suddenly tired," and labor "had now become unproductive." And Lee, who according to a witness had been ready to push her baby out for half an hour before she was allowed to, gives us a fair idea of both the depth of her conviction that institutional orders are to be obeyed above bodily imperatives, and of the physical agony which her following those orders entailed.
Although babies' heads come in many different circumferences, standardization of production necessitates reliance on the arbitrary standard of 10 centimeters for every cervix, regardless of the size of the baby that must pass through it. If the birthing woman's body is a machine producing a product, then it makes perfect sense that once the production opening reaches the standard, the product should be immediately produced, given that time is of the essence if production schedules are to be maintained. And, given the constant danger of damage to the product from maternal mechanical malfunction, it seems in the product's best interests as well to get it out as soon as possible. To have a number of people continually exhorting and commanding her either to push or not to push constitutes a complete denial of the validity of the natural rhythmic imperatives of the laboring woman's body and intensifies the messages of the mechanicity of her labor and of her subordination to the institution's expectations and schedule.