Answer: The Lamaze technique for second stage is not directed pushing. Second stage is normal and natural, just like the first stage of labor. Nature does an incredible job directing women's efforts to bear down and push their babies into the world. In Lamaze classes, women should be encouraged to listen to their bodies and trust their inherent ability to give birth. Tapping into inner wisdom requires feeling and responding to the pain and pressure of contractions. The process of feeling and responding to contractions promotes the progress of labor and protects mother and baby.

Lamaze childbirth preparation is not simply techniques (breathing and pushing and relaxing) to cope with labor. Lamaze is preparation for birth that acknowledges and appreciates the inherent wisdom that all women have as they give labor and birth. Lamaze preparation assists women to develop confidence in their own ability and trust their inner wisdom. It also helps women plan for the freedom they will need to respond to their contractions in any way that feels right throughout labor. And it helps them plan for the continuous support of family, friends, and professionals who will encourage and applaud their hard work.

Women who attend Lamaze classes understand the anatomy and physiology of giving birth naturally. They understand the value of movement to help ease the baby through the birth canal. They understand that during second stage their response to the pressure of contractions and the descending baby—moving, tightening and releasing vaginal and perineal muscles, moaning, occasional breath holding—protect the birth canal, the perineum, and the baby.

The Lamaze technique for pushing is following nature's lead. There is no need to interfere with nature's plan unless there is a specific problem with mother or baby. How is this different from directed pushing? There is no prescribed sustained breath-holding with contractions, although women will naturally hold their breath for up to 6 seconds as second stage progresses. There is no “right” position for pushing, although the upright position and movement facilitate rotation and descent. And, as long as mother and baby are doing well, there are no arbitrary time limits for second stage.

When my daughter Mary was told by her midwife to “push between contractions,” she looked at me with confusion and asked, “What do I do?” My reply was, “Your body is telling you what to do. Listen to that, not to us.” The hallmark of Lamaze is to trust the natural, normal process of birth. I could confidently convey this to my daughter not just because Lamaze says so, but because I know the physiology and anatomy of normal, natural birth and because I know the research that supports the wisdom of that process and the dangers inherent in interfering without just cause. And because, over and over again, women like Mary have taught me that they have within themselves everything they need to give birth.

Why are some childbirth educators teaching something quite different about pushing? Quite simply, they are teaching principles based upon what we in the United States knew about normal, natural birth 40 years ago, which was very little. During those 40 years, we have made great progress in reclaiming our knowledge, our wisdom, and our trust of birth. We have learned from several generations of women, including ourselves, who have given birth naturally. We continue to learn from an ever-increasing body of international research that provides more and more evidence that trusting nature's ways not only makes sense but is also safer for mother and baby. As is often the case when new information pops up, some of us never hear about it, some of us hear about it and change our practice, and some of us hear about it and keep teaching the way we always have.

How does the childbirth educator keep current, continue to learn, and know that she is really teaching Lamaze? What should we value as evidence as we add to our knowledge and contemplate changing our practice?

The most compelling evidence is probably historical—women giving birth across time and cultures. Modern science has not improved upon nature's design for labor and birth, although hygiene and nutrition have certainly improved outcomes by preventing infection and complications. And no one disputes medical science's successes when pregnancy or childbirth moves beyond the realm of normal. Listening to women, observing the natural process of labor and birth, and thoughtfully analyzing what we see and hear are important ways to learn about birth. Unfortunately, we do not usually see normal, natural births in the current hospital environment. Videos that tell the simple story of birth—for example, Celebrate Birth (2000), especially the “Everyday Miracles” segment—give powerful testimony to the inner wisdom of women as they give birth. Many collections of birth stories are well worth reading and analyzing. One of the best is Labor Day: Shared Experiences from the Delivery Room (Giglio, 1999). Another book worth reading is Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives (Davis-Floyd & Sargent, 1997), a collection of articles that examines childbirth across cultures. Talk to women who gave birth at home, recently or before technology became such a big part of modern birth. And attend as many normal, natural births as you can. Let women share their wisdom with you.

Research—especially randomized, controlled trials—provide knowledge of a different sort. A Guide to Effective Care in Pregnancy and Birth (Enkin, Keirse, Renfrew, & Neilson, 2000) is essential reading for the childbirth educator. The guide is a summary of the research to date on every issue of concern about birth, including pushing. The research team conducted randomized, controlled trials and reviewed and analyzed studies—published and unpublished—from around the world. The result is a set of recommendations for practice and further research, based on all the available evidence. Henci Goer's The Thinking Woman's Guide to a Better Birth (1999) is written for women in general, not just professionals, and is a wonderful resource for all of us. Goer presents the research and then moves the reader through a thoughtful discussion of the evidence and the implications of that evidence. Both Goer and Enkin's publications summarize the literature. You may find that you will want to take it a step further and read the original research reports. Lamaze International plans to feature important research about birth with commentary on its web page (http://www.lamaze.org). This will be an excellent resource in the future. The current Lamaze Childbirth Educator Study Guide (Lamaze International, 2000) is also an excellent resource and includes reprints of current, important research.

Ideally, as we observe and experience normal, natural births, listen to women who describe what they know about birth, and share scientific research with each other, we will be able to provide a body of evidence that advances our understanding of birth and informs our practice of childbirth education.