Last winter a patient of mine, who we’ll call Sarah, shared her birth story with me. She was in the hospital laboring with her first child and everything was progressing as planned. Sarah started to develop strong urges to push and instinctively started to bear-down. The nurse in the room noticed what she was doing and told her to stop. She wanted the doctor to be present for the delivery. Unfortunately, the doctor was not close by and Sarah ended up suppressing her urge to push and waiting almost 20 minutes for the doctor to arrive. When the doctor arrived, he then coached her on when to push. Happily, Sarah delivered a healthy baby.
The thought of Sarah not being allowed to push when she had a strong instinct to sounded peculiar to me. I decided to do some research and look into the literature to find out what the best practices are with regards to coached pushing and uncoached maternal pushing.
As mentioned in Melinda Fontaine’s blog on labor and delivery, the second stage of labor is the time between complete cervical dilation and the birth of the baby. It is accompanied by frequent and regular contractions with an urge to push. There are two approaches the medical team can take at this point, coached pushing or maternal pushing.
1) Coached pushing is when the medical team “coaches” the mother on both when to push and how to push. Commonly in the USA, once full cervical dilation is reached, the woman is instructed to lie on her back and to immediately begin pushing. She is coached to take a deep breath at the onset of a contraction and to hold it while bearing down as strongly as she can for approximately 10 seconds.1 This is repeated with each contraction until the baby is born.
2) Maternal pushing, also known as “uncoached pushing,” is when the woman is encouraged to wait until she feels an urge to push before initiating bearing-down efforts. This urge may not be immediate after full cervical dilation is reached as it can take up to 1-2 hours before the woman feels an urge.1 Only when she does feel an urge to push is she encouraged to bear down. She is not instructed to take a deep breath and hold it while bearing down. Maternal pushing promotes the woman’s spontaneous urge to push; the medical team is there for support rather than direction.
To understand the relative merits of these two approaches, it is important to understand what is actually happening in the second stage of labor. It turns out that there are two phases in this stage. The first phase is called the “latent” phase and it lasts from complete cervical dilation until the woman begins active pushing.1 During the latent phase the fetus passively descends the birth canal. Women may not feel an urge to push during this phase and in the maternal pushing approach they are encouraged to rest and conserve their energy instead. Pushing right away, which is what happens in the coached pushing approach, does not allow the fetus to passively descend, nor does it give the woman time to rest and conserve energy. The second phase is called the “active” phase. As the baby’s head reaches the pelvic floor muscles, a reflex is triggered and the woman starts to feel an urge to bear down, actively pushing the baby out.1 However, not all women will feel this urge, and so the beginning of the active phase can also be recognized from when the baby’s head becomes visible at the vaginal entrance.1
From this, it seems as though the latent phase could be an important part of the birthing process. Research on what happens during “spontaneous” delivery provides more information about the physiology of natural childbirth. For example, in spontaneous deliveries, women tend to choose up-right positions for giving birth, instead of lying on their backs.1 When these women have an urge to push, they tend to wait for the contraction to build to a threshold of uterine pressure ≥ 30 mmHg before initiating pushing.2 They then tend to push approximately 3-4 times during a contraction for an average of 5 seconds, followed by several breaths for approximately 2 seconds each. The women in the study did not choose to hold their breath while pushing.1 It was also found that women do not always bear down with each contraction and the intensity of bearing-down varied. As the second stage of labor progressed, the intensity of bearing-down increased.2 This is very different from routine coached pushing, which includes breath-holding and bearing-down as hard as the woman can for 10 seconds.
So, coached pushing involves encouraging the woman to behave differently from how they would have in a spontaneous delivery – but is this a bad thing? The research mentioned above goes on to suggest that holding the breath and bearing-down for 10 seconds can contribute towards short- and long-term pelvic floor and urogynecological impairments.1 Delaying pushing efforts until the active phase begins (as in maternal pushing) results in optimal use of the woman’s energy, has no detrimental effects towards the woman, results in improved fetal oxygenation, and can reduce the incidence of C-section births.1 Lying flat on the back and hold the breath while pushing can cause a decrease in the baby’s heart rate, resulting in decreased oxygenation.1
They conclude that while coached pushing may result in a shorter second stage of labor, the benefits of maternal pushing may outweigh this time saving.
Given this research, why do women continue to be coached in the USA? There are multiple barriers with instituting maternal pushing throughout the country. The main obstacles include nurses’ lack of trust in the evidence presented, resorting to old habits by the medical team, and physician resistance to new protocols – but also the patients’ desire to deliver the same way as they did with previous births.1
Sarah plans to have more children, however after discussing the literature findings with her, I doubt she will deliver the same as she did the first time.
Please feel free to share your birth story or delivery tips in the comment section below.
- Osborne, Kathryn, and Lisa Hanson. “Labor Down Or Bear Down.” The Journal of Perinatal & Neonatal Nursing 28.2 (2014): 117–126.
- Roberts, J, and L Hanson. “Best Practices In Second Stage Labor Care: Maternal Bearing Down and Positioning.” Journal of Midwifery & Women’s Health 52.3 (2007): 238–245.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Wow, I was told to do the same thing. Not push until they could find the doctor. I have to wonder what effects that had on me and my child. It seemed to me then to be instinctively wrong. That was 23 years ago.
I’ve birthed four times–thrice at home and once in hospital. My third home birth was unassisted. My labors have been short and uncomplicated, ranging from eight to two hours. All of my pushing has been maternal.
I’ve never understood the coached approach, because twice my pushing has been reflexive and involuntary, not instinctive. During my first labor, I pushed reflecively, but ineffectively. My son back-tracked between contractions, so my midwife coached me on effective pushing–what muscles to focus on–but did not instruct me when to push, for how long, or when to breathe. That lesson was well learned, and I have applied it in subsequent labors.
With my other three labors, which have been less intense, and I have been able to focus on the baby’s movements during and between contractions. Being able to track the baby has guided me in pushing. If I had been attended by people coaching my pushing, I would have been focused outward and not inward. Focusing inward has been incredibly useful in the birthing process, and interruptions while birthing for other purposes have indeed distracted me, drawing my focus from the task at hand towards how to respond effectively to the other person.
My suspicion, although I have no evidence to back it up, is that coached pushing arose from women being to heavily medicated during labor to respond to contractions meaningfully. Under such circumstances, it would make sense to coach a woman to push methodically. Outside of those circumstances, I think it makes more sense to instruct the woman ahead of time in effective pushing and on how to pay attention to the baby’s movements.
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