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.