By Horatio Daub MD, MPH and Cathy Daub PT, CCE and CD(BWI)
A recent study in the Journal of American Medical Association1, October 9, 2018, found that delaying pushing once full cervical dilatation is reached for 60 minutes vs. immediate pushing had no significant effect on the rate of spontaneous vaginal delivery (85.9 % in the immediate group vs. 86.5% in the delayed group). However there were significant differences in the incidence of postpartum hemorrhages (2.3% in the immediate pushing group vs. 4.0% in the delayed pushing group) and chorioamnionitis (6.7% in the in the immediate pushing group vs. 9.1% in the delayed pushing group).
This contradicts the previously held beliefs that delayed pushing results in a better chance of having a spontaneous vaginal delivery and is safer for the mother and baby. In fact, the study was stopped early because of lack of effect of the delayed pushing on the percentage of spontaneous vaginal births and the significantly increased morbidity from higher rates of postpartum hemorrhage and increased rates of chorioamnionitis increasing the morbidity for mothers and babies. The new recommendation to not delay pushing once full cervical dilatation is achieved is supported by the findings of this study because of the significantly decreased morbidity for mothers and babies with immediate pushing.
There are some important points to consider:
- First, regional anesthesia would confine women in labor to beds and not allow them to walk & move their bodies thus allowing easier movement of the baby down the birth canal assisted by gravity rather than fighting it when they are confined to bed in a supine position.
- Second, this study assumes that the experience and outcomes of birth are improved with regional anesthesia numbing them to the experience of birth. There are no studies to support this hypothesis.
- Third, the study ignores evidence that using non-pharmacological comfort measures in place of regional anesthesia reduces cesarean sections in birthing women when they are mobile, upright and free to labor in whatever place and position, works for them.
- Fourth, the study assumes women with partially paralyzed, desensitized abdominal muscles can effectively push a baby out of the birth canal. Birthing women are basically being set up for failure by being anesthetized and partially paralyzed and being confined to the “stranded beetle” position hindering the natural progression of labor and delivery. In addition, with regional anesthesia, both motor and sensory nerves are blocked, making it impossible for her to walk or use her legs to change her position.
But what if women learn that positioning themselves in such a way that they are working with gravity instead of against it, only bearing down slightly when their body demands it at the top of a contraction, to be a less stressful and easier way to birth their babies? Then they don’t need as much power from their abdominal muscles and they can more gently birth their babies. They instinctively follow the cardinal movement of their babies moving and rotating through the pelvis to be born.
Reducing unnecessary cesarean sections was the topic of the recently published “Non-clinical interventions to reduce unnecessary caesarean sections by the World Health Organization (WHO). (Read more in our upcoming November Enews). These recommendations target women, health-care professionals, and health organizations, facilities or systems. For women it addresses what they call “Psychoeducation” where childbirth preparation can help address fear of pain and labor, and explain stages of labor, hospital routines, the birth process, and pain relief among other topics. Their recommendations include nurse-led applied relaxation training programs, and normalization of individual reactions.
Today, too few pregnant women are receiving comprehensive childbirth preparation for their upcoming births. In BirthWorks, we advocate birth education to be very early in pregnancy or even before pregnancy. Our program is comprehensive and integrates the mind, body, and spirit through the practice of human values. Working with the mind means helping women to release fears and feel safe having women choose the people & environment for her birth. For the body, it means finding optimal pelvic positions that ease movement of the baby through the birth canal, the value of mother/baby skin-to-skin contact, the physiology of birth, and more. For the spirit, it means knowing that all women are born with the knowledge about how to give birth, believing it, and having patience.
Non-pharmacologic methods to ease labor pain and reduce cesarean section are well known but underutilized. These include relaxing in warm water, moving in labor, keeping upright positions as much as possible, having the presence of a doula to help a woman in labor to feel safe, and having early childbirth preparation. The way to decrease cesarean sections is not to have women lying on their backs with regional anesthesia, unable to move out of bed, but rather allowing women to move and assume the positions that work for their birth.
Why not concentrate instead on ways to help pregnant women develop a new paradigm about birth- one that includes being upright, walking, having comprehensive childbirth preparation that offers both an academic and emotional preparation for birth, finding a safe place to birth, and the value of a doula.
Given the fact that most women in the USA give birth with epidural anesthesia, the researchers were trying to develop strategies to improve the percentage of spontaneous vaginal birth . Not surprisingly, they found no improvement with pushing early or late in labor in this outcome. They did find that immediate pushing decreased postpartum bleeding and infections. In order to make significant decreases in cesarean section and instrumental deliveries, we believe the logical conclusion is to decrease the numbers of women who are anesthetized for their births in the first place.
We recommend that allowing women to use movement and gravity to assist their births along with other non-pharmacologic measures, is what will improve outcomes for women and babies and decrease cesarean rates the most effectively.
- Sperling JD, Gossett DR. Immediate vs Delayed PushingDuring the Second Stage of Labor. JAMA. 2018 Oct 9;320(14):1439-1440. doi: 10.1001/jama.2018.12877. No abstract available. PMID:30304414