Don't push! The pushing stage of birth is coached in most hospitals and involves the attendants telling the birthing woman when her cervix is fully open (dilated) and encouraging her to give long, strong pushes with each contraction.
Previous research shows that coached pushing does not improve the short-term outcome for mothers and babies, except when the baby needs to be born as soon as possible.
This study, conducted by Schaffer and colleagues at the University of Texas Southwestern Medical Center and published in the American Journal of Obstetrics and Gynecology, May 2005, randomized 325 women giving birth to coached or uncoached pushing.
Three months later, they measured the pelvic floor and bladder function of 128 of these new mothers.1
Results Showed:
Women in the coached group had decreased bladder capacity and less urge to empty their bladder. They were more likely to have an overactive bladder muscle, and to have stress incontinence, on testing.
Researchers commented, "With uncoached pushing, bearing down does not occur until uterine contractions are well established and the urge to push is present. There are normally several short bearing down efforts per contraction with breath holding for 5 to 6 seconds."
In contrast, "In coached pushing, the mother is alerted to begin pushing as soon as a contraction is noted, and she is encouraged to push for 10 seconds, take a deep breath, and push again. Coached pushing could potentially increase the amount of pressure on the pelvic floor with subsequent deleterious effects."
Birth attendants have suspected, for many years, that damage to the pelvic floor is worse during a medically-managed birth. These same researchers have also shown that use of forceps, pitocin, and episiotomy also increase the likelihood of pelvic floor damage.2 Now we are getting evidence that coaching the woman to push against her instincts may also be harmful.
These results support the ideas of UK obstetrician Constance Beynon, who studied women's natural pushing during birth in the 1950s. She concluded, "... an entirely spontaneous second [pushing] stage is the ideal mode of delivery ..."3
Her theory, supported by this study, is that the early part of the contraction acts to pull the woman's tissues tight, which protects her when she starts to push. The baby can then descend without damage as the woman pushes during the second part of her contraction.
Coached pushing also involves breath-holding (so-called 'purple pushing'), which is very tiring and can increase the chances of tearing. Purple pushing can also reduce the oxygen levels in mother and baby at this critical time.
Note that the mothers in this U.S. study were all lying on a bed, which is not a position that birthing women will naturally adopt. Lying down (or even being propped up) makes birth harder by immobilizing the sacrum, reducing the diameter of the birth outlet, and disallowing gravity to help the baby to come down.
Many doctors are now advocating a cesarean to avoid pelvic floor damage, although this benefit does not seem to persist in the long-term.4 Cesareans carry other risks for mothers and babies, including:
More newborn health problems, higher risk of maternal death and life-threatening problems in subsequent pregnancies, including placenta previa, placental abruption, placenta accreta, unexplained stillbirth, and postpartum hysterectomy for catastrophic bleeding.5
There are many other reasons why cesareans are not the best option.
This study adds more useful information for women who want to give birth normally and also care for their pelvic floor.
References:
1. Schaffer JI, et al. A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. Am J Obstet Gynecol 2005;192(5):1692-6.
2. Casey BM, et al. Obstetric antecedents for postpartum pelvic floor dysfunction. Am J Obstet Gynecol 2005;192(5):1655-62.
3. Beynon CL. The normal second stage of labour; a plea for reform in its conduct. J Obstet Gynaecol Br Emp 1957;64(6):815-20.
4. McKinnie V, et al. The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. Am J Obstet Gynecol 2005;193(2):512-7; discussion 517-8.
5. Buckley SJ. Caesareans- the facts. In: Gentle Birth, Gentle Mothering: The wisdom and science of gentle choices in pregnancy, birth and parenting. (In press) Brisbane: One Moon Press, 2005.www.sarahjbuckley.com
For more about protecting the pelvic floor during birth, see the maternitywise Web site.
Sarah J. Buckley, MD is a writer on pregnancy, birth and parenting.
