Beneficial Pushing During Birth
A comprehensive review of the best available scientific evidence supports delayed and nondirected pushing rather than directed pushing during birth. Unfortunately, the later is still a common practice. Women are still being directed to hold their breath and push as hard as they can with every contraction, often even before the urge to push is felt, to ensure that the second stage of labor is not prolonged. However, studies have shown that there is no significant difference in the length of second stage labor based on type of pushing. A recent study published in the American Journal of Obstetrics & Gynecology found that labor was only 13 minutes shorter for women who were directed to push during contractions compared to those who were encouraged to do what feels natural. Strong evidence supports that spontaneous pushing enhances the well-being of the woman and fetus without prolonging the length of second stage labor.
An evidence-based clinical practice guideline can be found on management of the second stage of labor in the National Guideline Clearinghouse (www.guideline.gov). The guideline recommends that women delay pushing until the urge to push is felt. Delayed pushing is also appropriate for women with epidural anesthesia/analgesia who do not feel the urge to push. Uterine contractions provide the primary power that facilitates the descent of the fetus through the pelvis. When women feel the urge to push, they naturally exhale while pushing, sometimes evidenced by a grunting vocalization. A basic exercise principle is to exhale with effort, not to hold your breath. Exhaling while pushing prevents detrimental cardiopulmonary effects that can result from prolonged breath holding. When the urge to push is felt, women can slowly and calmly exhale through slightly lowered jaw and open mouth, with their arms comfortably at their side rather than pulling on their legs. The only muscles they need to contract are the abdominal muscles. This decreases the total muscular effort, reducing the risks of extreme maternal fatigue and metabolic acidosis. In addition, relaxed pelvic floor muscles facilitate descent and rotation of the fetal head.
The guideline discourages prolonged breath holding pushing. Directed breath holding pushing can lead to increased intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting blood flow to the uterus and the placenta. Furthermore, prolonged bearing-down effort (more than 5-7 seconds) with breath holding decreases the oxygen content in the blood that reaches the placenta and reduces oxygen to the fetus. Additionally, sustained directed breath holding pushing tightens the pelvic floor muscles, leading to possible interference with descent and rotation of the fetus, and can lead to extreme maternal fatigue and metabolic acidosis with resultant fetal distress, which may increase the need for cesarean birth. Based on the scientific evidence, women are encouraged to talk with their health care provider about the benefits of delayed and nondirected pushing. Include this in your birth plan. The goal is to promote optimum maternal and newborn outcomes and increased satisfaction with the birthing experience.
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