The Push Paradox

When it comes to pushing during labor, more isn’t better.

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Conventional medical wisdom says the best way to send your baby out of the womb and into the world is with “coached” pushing: When your birth attendant announces it’s time, you tuck in your chin, tighten your abs, pull back your knees, take a deep breath, hold it and push for a count of 10, bearing down in this manner two or three times during each contraction. But a growing body of research suggests the conventional wisdom may be wrong, and that the healthier strategy is to follow your body’s cues and push spontaneously rather than following a coach’s count.

“Plain and simple, coached pushing, especially with the woman on her back, can harm mothers and babies,” says Amy Romano, C.N.M., a Connecticut nurse-midwife who contributed to the Lamaze International guidelines on care during the pushing stage of labor.

Several studies on coached pushing have been conducted in the past few years. Although not all reach the same conclusions, they suggest that the practice is more likely than spontaneous pushing to tire a laboring woman and make her less satisfied with her birth experience. The excess force of directed pushing may raise the risk of vaginal lacerations and episiotomies, as well as pelvic-floor weakness, which can lead to incontinence and sexual dysfunction. Pushing on command may also contribute to fetal heart rate abnormalities, lower blood oxygen levels in babies and an increased need for such medical interventions as instrument-assisted delivery. (It can be helpful if you’ve had an epidural, however.)

A new take on pushing
If coached pushing is potentially harmful, why do as many as 80 percent of hospitals and obstetricians continue to rely on it? “I think that a lot of what happens in the second stage of labor has been based more on tradition than on evidence,” says Edmund Funai, M.D., professor of obstetrics and gynecology at Yale University School of Medicine. “But where we’re heading now is to have women push when they feel like pushing.”

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February/March 2010

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