September 2010

My post Cervix Lingo: Effacement what? Dilation who? is far and away the most popular post on this blog. So when I found a birth animation that includes dilation and effacement in action I had to share. Effacement, in particular, can be such a strange thing to visualize, so I think this is really great. Also note the amazing choreography that the baby does to get out. That is part of why it is important that mama is mobile during labor and able to push in the way and position that feels instinctive.

This video shows birth again, but with an additional view of baby moving through the pelvis. You see that there are natural pauses as baby changes positions. These position changes are called the seven cardinal movements of labor–in case you’re curious the seven are: engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion–each of with ensures a safe passage through the birth canal and into the world. Sometimes in hospitals I see mamas coached to just, pardon my language, push like hell and keep on doing it in one specific way, for each and every contraction. As you can imagine after seeing this animation, there is a rhythm to labor and birth, it is not just one speed all the time.

Here in New York City, the non-midwife providers I have personally observed (with the exception of one) subscribe to the idea that birth is best accomplished by coached pushing. The alternative, and what many midwives use, is called physiologic pushing, in which a woman pushes the way her body guides her to. A good question to ask when you’re selecting a provider (which I suggest you do before you even get pregnant) is “what are your thoughts on pushing during labor for a natural vaginal birth?” Unless the provider specifically mentions physioligic pushing, and if this is important to you, you should seek another provider. I wouldn’t delay this conversation either. I have rarely seen a provider practice in a way that is not their normal standard, to meet a patient’s request.

The most current evidence is that coached pushing not only does not confer benefits, but has potential harms. If you’re a sciency-type like me, you may find this research on the matter of coached pushing interesting:

Research summary by Amy M. Romano, MSN, CNM of Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., & Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194, 10–13. {Scroll down a bit when you click through to find the summary}

Coached pushing provided no clinically important benefits in this well designed trial. Previous research has suggested that coached pushing may be harmful to the woman’s pelvic-floor muscles and may be associated with adverse neonatal outcomes. The widespread use of coached pushing undermines woman’s intrinsic knowledge of how to give birth safely and gently. In the absence of evidence that this practice is beneficial and with mounting evidence that it may contribute to poor perinatal outcomes, routine use of coached pushing should be abandoned.

Less Pelvic Floor Damage Associated With Uncoached Than Coached Pushing During Labor

“We wanted to study the effects of coached pushing because some of the midwifery literature had suggested some benefits to delayed pushing,” Joseph I. Schaffer, MD, who presented the findings, told Medscape in an interview. “Coached pushing is a modifiable practice. Everyone uses coached pushing, but it has no known maternal or fetal benefits, and we found that it was associated with negative effects on several urodynamic indices. Our findings suggest that physicians may want to reconsider routine coached pushing.” Dr. Schaffer is the director of the division of urogynecology and reconstructive surgery at the University of Texas Southwestern Medical Center in Dallas.

So ladies, please choose your provider wisely, and partner with someone who practices the art and science of pregnancy and birth the way you believe is best for you and your little one. Choosing someone who does not, and then trying to negotiate with them to do things a different way, is like hiring an impressionist to paint you an abstract mural. It simply isn’t going to turn out as well as it could, and you’ll buy yourself a whole bunch of frustration you might as well skip. Working with someone who’s philosophy is in alignment with yours, and who is a true partner, is a gift that will pay off a million times over.

Lamaze Healthy Birth Practice #5 is Avoid Pushing On Your Back and Follow the Body’s Urges to Push. Click the link for tons of great (evidence based!) information on the topic.

Here is an interesting perspective from Gloria Lemay, published in the journal Midwifery Today: Pushing for First-Time Moms

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