DELAYED PUSHING
Most laboring women are actively coached to push, push, push! But could there be some instances when it’s best to relax, relax, relax? Delayed pushing means resisting the urge to push while allowing the fetus to passively descend past the pelvic supports. Waiting for fetal descent is also sometimes called laboring down. Medical literature dating back to the 1950s suggested that normal first deliveries require no encouragement to push, and that non-pushers appeared to have a lower risk of forceps delivery and injury to the perineum. After years of attracting little research interest, the issue of labor pushing has been recently readdressed. One multicenter study was performed at twelve locations throughout Canada, Switzerland, and the United States to investigate whether a delayed pushing strategy could benefit mothers during the first birth. A total of 1,862 women agreed to be randomized to either immediate pushing once fully dilated, or to wait for two hours before pushing if possible. The women were, on average, twenty-eight years old, and all received epidural pain control. Difficult deliveries were less likely among women in the delayed pushing group, and forceps assistance was necessary less often.
The benefits of delayed pushing appeared to be greatest for women whose fetus was still relatively high in the pelvis, or not yet turned to the facedown position, at the time of full cervical dilation. Slightly higher rates of maternal fever were associated with the delayed strategy, but no increased maternal or neonatal complications were seen. A 2002 study reported that women randomly assigned to delayed pushing benefited from a decreased overall average pushing time, less maternal fatigue, and fewer cases of a slowed fetal heart rate.
In each of these studies, all participants received epidurals. No research to date has assessed the strategy of delayed pushing in patients without pain control. Without an epidural, the natural urge to start pushing—and the difficulty in keeping the pelvic muscles relaxed—would make this labor approach infinitely more difficult. However, based on the evidence, delayed pushing may well be a worthwhile labor-room option for women choosing an epidural. A few tips might increase your odds of success.
Breathing exercises and relaxation techniques. Delayed pushing works best when you’re relaxed, mentally and physically. Try slow, focused breathing in between contractions. Rapid and deep breathing (huffing and puffing) and shallow panting may help you cope with contractions while resisting the urge to push. Punctuate these with long, deep breaths at each contraction’s end. If you’ve learned Lamaze, or an alternative relaxation/breathing technique, give it a try.
Pain control. Severe pain can completely prevent relaxation of the pelvic floor, slowing the progress of labor and making it impossible to labor down. An epidural can allow you to remain fully alert while laboring down more comfortably. Although the risks of an epidural are relatively small, always discuss them with the anesthesiologist and make an informed choice.
Positions. Alternating between the labor positions discussed earlier in the chapter may provide distraction and help the baby to navigate the pelvic anatomy most effectively. Labor nurses, doctors, and midwives are almost always open to Mom’s preferences unless specific safety issues arise.
PHYSIOLOGIC (SPONTANEOUS) PUSHING
The physiologic, or spontaneous, approach is a type of delayed pushing that entails waiting to push until you feel the natural overwhelming urge to do so, following the lead of your physical sensations rather than the direction of a coach or a predetermined schedule. One 1984 study suggested that perineal injury was less likely if women pushed only in response to strong involuntary urges (spontaneous pushing) rather than when they were coached to do so. A 1999 University of Michigan survey compared spontaneous to directed pushing and found that spontaneous pushers were less likely to have advanced perineal lacerations and more likely to have an intact perineum after delivery. Another study concluded that active pushing for over an hour caused more injury to the pudendal nerve, whereas extended periods of passive laboring after full dilation (relaxation during contractions rather than pushing) seemed to avoid this risk. Interestingly, spontaneous pushing does not seem to prolong the overall duration of the second stage. At the very least, it may decrease your level of exhaustion throughout the delivery process.
OPEN-GLOTTIS PUSHING
This involves breathing or making noise while pushing, rather than keeping quiet, holding your breath, and bearing down. Although most women in the United States bear down silently, open glottis is the standard custom within many other cultures. The mellifluous ululation and high-pitched chants of Haitian and Caribbean women are well known to most labor-room nurses and always leave medical students amazed when hearing them for the first time. Because it’s virtually impossible to bear down as strongly while laboring with the open-glottis technique (try straining while holding your breath, then again while allowing it to escape), it seems quite possible that the pelvic floor might be exposed to less stress over the course of a long labor. Whether this could ultimately reduce the odds of pelvic-floor injury and subsequent symptoms remains unknown. More research is needed to understand the pros and cons of the technique.
FACTORING FETAL POSITION
The position of the baby relative to your pelvic bones is a major determinant of how difficult a delivery might be. Although few specifics regarding the effect of fetal position on the maternal pelvic floor are known, the basics of normal and abnormal positions are useful to understand.
Occiput anterior. Most babies deliver in this facedown position, with the baby facing the mother’s backside. It is the easiest and most biologically correct way in terms of delivery.
Occiput posterior. In this position, the baby comes out faceup, or “sunny-side up,” as some labor nurses are known to say. It’s been long observed that these deliveries may be more prolonged, with increased discomfort and pain focused in the lower back. A recent study from Ireland documented these observations by analyzing a large number of deliveries and comparing babies who descended in the occiput posterior and occiput anterior positions. Posterior deliveries were associated with markedly different outcomes, including a sevenfold increase in anal sphincter injuries, and higher rates of delivery by cesarean and forceps. Fewer than half of them achieved spontaneous vaginal birth. As mentioned earlier in this chapter, certain labor positions (for example, hands and knees) may help the baby to turn from the posterior position before maternal pushing begins.
Transverse. When the baby fails to complete even its first requisite turn in Mom’s pelvis, it becomes stuck in the transverse (side-facing) position. Forceps were often used to rotate the baby’s head in this situation, allowing its descent; today that approach is less common, since the overall risks associated with forceps are more widely appreciated. If the second stage of labor begins with a fetus in the transverse position, cesarean may be the best choice, since for some women, the odds of a long and difficult push, or needing operative assistance (forceps or vacuum) are quite high.
Breech. When the baby’s feet or buttocks come out first. To deliver vaginally, the fetus must be fairly small compared with Mom’s pelvic opening. Certain types of breech presentations are far more likely than others to succeed with a vaginal birth. Unless forceps assistance is used, vaginal breech in itself poses no known increased risk to the pelvic floor. But the overall risks of attempting a breech delivery are complex and far beyond the scope of this book.
Brow and face. The brow position, in which the baby’s forehead presents first, is uncommon. It often requires a cesarean, because the broadest part of the baby’s head may have trouble clearing the pelvic bones. The face position looks like it sounds—the baby’s face, rather than the top of its head, presents itself first. Certain types of face positions are compatible with vaginal birth, and others are not. Neither the brow nor the face position poses any specific risk of injury to the pelvic floor.
LENGTH OF PUSHING: HOW LONG IS TOO LONG?
There was once a time when prolonged labor meant a truly epic and dangerous struggl
e for Mom, often lasting for several days. That period of time, we came to understand, was too long, since truly obstructed labors caused a handful of problems, including, on the maternal end, fistulas—abnormal openings between the vagina and bladder, urethra, or bowel after prolonged compression against the fetal head. But even today, the true limits of normal labor remain unclear. A first stage (from the beginning of regular contractions to full dilation) longer than fifteen hours may begin to raise valid suspicion about successful delivery. For the second stage (from full dilation to delivery), the American College of Obstetricians and Gynecologists defines the normal limits as not exceeding three hours for a woman’s first delivery, and two hours for those who have previously given birth. Yet in actual practice, some women—especially those who are comfortable with epidurals—will be encouraged to persevere through second stages lasting many hours more. After all, large studies have shown that with vigilance and modern obstetrical monitoring, long labors pose no specific risk to the newborn. But aside from the fetal perspective, other questions are less commonly addressed: could the length of your labor influence the function of your postreproductive body later on?
Nerve function. Several studies have suggested that a longer pushing stage is associated with diminished pudendal nerve function afterward. As we’ve discussed, this type of injury may represent the first step toward postreproductive pelvic-floor disorders, including prolapse.
Anal function. A recent German study compared women whose second stage during their first delivery lasted less than two hours, to those with a second stage over three and a half hours. The long-labor group had a significantly higher rate of new-onset flatal incontinence (inability to control gas).
Bladder control. One study demonstrated that every additional twenty minutes of pushing time resulted in a 20 percent rise in the risk of bladder dysfunction. Other small studies have failed to demonstrate that a longer duration of pushing leads to a higher risk of incontinence. Definitive research on this question has yet to be done.
Operative deliveries. A very prolonged second stage of labor, especially with early and sustained bearing-down efforts, tends to exhaust Mom. In some cases, this may lead to a greater likelihood of forceps or vacuum assistance. These interventions, as you’ve already learned, substantially raise the risk of a pelvic-floor injury.
How long is too long for your lower body? The question may not have a simple answer, but it’s worth discussing with your provider. As future research unravels the questions surrounding labor’s second stage, the right approach will hopefully become clear.
WHEN CROWNING FINALLY OCCURS: THE FINAL PUSH
Crowning refers to that long-awaited final stage of labor when the baby’s head reaches the perineum and becomes visible through the vaginal opening. The perineal tissues stretch and bulge forward, and Mom usually experiences an overwhelming urge to push hard and finish the job. What’s your best strategy when this moment of truth for the perineum finally arrives?
Arrive prepared. Hopefully, perineal massage and pelvic-floor exercises during pregnancy have left you well toned and flexible, inside and out.
Relax and breathe. Rather than bearing down strongly, women are sometimes coached during the crowning stage to “puff out the birthday candles.” These short, shallow breaths allow the force of the uterine contraction alone to ease the baby’s head slowly past the perineal opening.
Control the speed of delivery. Doctors and midwives usually apply a bit of counterpressure against the fetal head to prevent it from delivering too quickly. Moms are sometimes shown how to help guide the baby out, and to control the speed of delivery, using their own hands. These maneuvers are meant to decrease the risk of perineal laceration.
Avoid traumatic positions. According to some physicians, pulling back the legs too much (hyperflexing) may increase the risk of a sudden laceration due to the baby’s head quickly popping past the perineum. As a result, it should be avoided during that final push. However, in certain emergency situations, this maneuver may become necessary.
Avoid fundal pressure. Fundal pressure refers to a simple push of the hand across the top of Mom’s uterus in an effort to push the baby down and expedite delivery. In some countries, this practice is common, but in most settings, it is reserved for emergency situations, specifically to help dislodge the baby’s shoulder when it becomes stuck behind the pubic bone. Although the physical effects of fundal pressure on Mom’s pelvis have not been studied, it’s probably safe to assume that stretching the uterine and pelvic supports when they are soft and vulnerable to injury may cause harm. It should be done only when it’s a necessity, and not as a routine procedure.
PUSHING FOR ANSWERS: CHALLENGING OUR CHILDBIRTH TRADITIONS
In 1997 a report from the University of British Columbia examined all of the existing studies on pushing styles and arrived at a few conclusions:
First, too few high-quality research studies have addressed this women’s-health issue. “The way physicians and midwives manage labour and delivery today,” the study concluded, “is based on opinion rather than scientific evidence.” Second, based on the few studies that do exist, the second stage of labor appears not to be prolonged by the relatively gentle open-glottis or physiologic pushing styles, even for a first pregnancy. Finally, less forceful pushing appears to be associated with lower risk of perineal injury.
This is an interesting set of conclusions, and a stark contrast to the obstetrical styles you’ll find advocated in many labor rooms. Even more remarkable is the fact that such basic women’s health questions remain unanswered. Do you think if men were faced with the biological task of expelling a tennis ball through their urethra that the least harmful strategy wouldn’t have been thoroughly researched? It’s time the physical efforts of motherhood are acknowledged, not as an inevitable sacrifice but as a challenge to be solved.
Cesareans, Forceps, Epidurals, Etc.
KEY OBSTETRICAL CHOICES AND THEIR POTENTIAL PHYSICAL EFFECTS
Regardless of the technology, engineering, and modern conveniences that have entered today’s labor room, one simple fact remains: there are just two ways for a baby to be delivered—vaginally or by cesarean, from below or from above. Even a perfectly routine natural vaginal delivery, as we’ve discussed, can have detrimental implications for future pelvic-floor function, even when the birth itself appears uneventful.
But what about when the birth becomes more interventional?
In some cases, operative techniques, such as cesarean delivery, forceps, or vacuum devices, may be used to achieve vaginal delivery. Do these interventions increase or decrease the risk of future pelvic trouble? Or do they affect that risk at all? Let’s take a look at a few of the most important obstetrical interventions and choices you might face in the labor room.
Forceps and Vacuum and the Pelvic Floor
Forceps look something like oversize salad spoons, and they are used for two basic purposes—either to help the baby pass through the vaginal canal, or to rotate its head and enable vaginal delivery. Two basic types of forceps deliveries are in use today. Outlet, or low, forceps refers to their use after the baby’s head has reached the pelvic floor and is visible at the vaginal opening; midforceps refers to applying the device to a fetal head higher in the pelvis.
Before addressing the rather strained relationship between forceps and your body, let’s make one historical point clear: forceps have probably saved more lives, maternal and fetal, than any other obstetrical device. Back when obstructed labors commonly led to maternal death, these instruments were often the only way out. Vacuum and forceps procedures still play a truly valuable role in obstetrical care, under a number of circumstances. For instance, when the baby is close to delivery and develops an abnormal heartbeat, or when Mom is simply too exhausted to keep pushing, these two devices can facilitate the safest birth for both you and your baby.
But it’s equally safe to say that forceps have been the most overutilized devices in the labor room. As the p
endulum of medicalized childbirth took a rather wide swing around eighty years ago, women were commonly sedated, then etherized, during the second stage of labor. An episiotomy was then cut, and forceps were used to deliver the fetus. Many obstetricians believed that this liberal use of forceps could reduce the risk of pelvic injury by resulting in a more controlled delivery, with less pressure against perineum as the fetal head was lifted out. Forceps and episiotomy together, it was felt, offered the best protection against pelvic injury for some women.
But that was then, and this is now. What is known today about the pros and cons of this procedure when it comes to your postreproductive body? And how about the pros and cons of the vacuum—a suction-cup device applied to the baby’s head, an increasingly common alternative to forceps.
FORCEPS AND VACUUMS TODAY
There’s no question that both forceps delivery and, to a lesser degree, vacuum devices, increase the risk of injury to your perineum. Episiotomies are often cut to make room for the placement of these instruments around the baby’s head, and we’ve already discussed the potential effects of this “little cut.” But even without an episiotomy, the risk of injury during a forceps delivery, to the perineum and elsewhere, is high. One study concluded that of all women with tears into or through the anal sphincter following childbirth, up to 50 percent had either a forceps or vacuum-assisted birth. A landmark British study revealed that 80 percent of women who underwent forceps delivery experienced tearing of the anal sphincter that could be seen by ultrasound. Another report from Australia, involving more than three hundred women, concluded that women with prior forceps deliveries were up to ten times more likely to experience urinary incontinence after later deliveries. One recent study found that the odds of having stress incontinence seven years after a first childbirth was roughly ten times higher among women who had undergone a forceps delivery. And from Great Britain, it was reported that forceps delivery more than doubled the frequency and quantity of urinary leakage, compared with normal birth, at six months postpartum.
Ever Since I Had My Baby Page 10