Second stage: pushing naturally

When a woman’s cervix has opened to around 10 cm, her body starts transitioning into the pushing stage of labour. I say “around” 10 cm because I don’t advocate routine vaginal exams on mothers in labour, and I’m sure that some cervixes only open to 9 cm, and that’s enough, and some open bigger than 10...it’s all going to depend on what the baby needs to come out. I feel that the interference of making moms recline in order to check for full dilatation is unwarranted, causes discomfort at this important time in birth, and leads to more coached second stages. Instead, we need to trust that the mother will not harm herself by pushing as her body wants to.
Classic signs of transition, such as shaking and close, hard contractions, can help us to anticipate that a mom might start pushing soon. After this point, some mothers have a rest and their contractions space out for a little while. I find that most moms who have a physiological second stage have a short time of crisis just before their body starts its expulsive urges. They say things like, “I can’t do this” and “I don’t know what to do”. Sometimes they ask us to tell them what to do. I think the most appropriate thing to say to a mother at this point is, “I am here for you. You will figure it out.” If she can get through a couple of contractions like this, and surrender to the process, she’ll be pushing soon.
Some moms scream through their pushing, which is counter-intuitive to those of us who learned that moms must hold their breath and push in order to avoid “wasting” energy. I’ve learned that most moms who have a physiological third stage are loud, that they don’t put their chins to their chest but sometimes look like they are trying to pull themselves away. These are all things that the traditional medical community discourages or looks upon as unproductive, but again, if you leave these mothers alone and just BE PRESENT with them, they often push out their babies efficiently.
Some midwives advocate having mothers “breathe through” contractions as the baby crowns, in order to avoid tears. At my local hospital, the nurses encourage the mom to keep pushing through the burning. I think both approaches are harmful. Again, we need to allow the mom to do what her body is telling her. Trust me, most moms automatically slow down as the baby crowns, then get frustrated and push through the burning. I think it’s better for the mom to do what she feels like and that we need to let go of our thinking that we can, in all cases, prevent tears and perineal damage. Some moms are going to tear, but if we let the mom follow her body, I suggest we will see less tearing.
To sum it up, it’s important at this point to be hands-off and allow the mom to figure it out. If she’s looking to you for direction, she’s likely going to miss the subtle cues her body is giving her to help her baby descend and rotate. If she knows you trust her and her body, your presence will reassure her and let her surrender to her experience. It is a powerful feeling, pushing one’s baby into the world, and it’s made all the better by attendants who respect the amazing strength and ability of mothers.

For some great discussion of physiological second stages, please see the following:

Honoring Body Wisdom by Pamela Hines-Powell
Pushing for First Time Moms by Gloria Lemay
The "Rule of 10" Versus Women's Primal Wisdom by Lydi Owen
Michel Odent on the "fetus ejection reflex"
Pushing- leave it to the experts at Midwife Thinking's blog