Face-off

Should laboring women be coached to push?

Should laboring women be coached to push?

No says urogynecologist Joseph Schaffer, M.D., associate professor of obstetrics and gynecology at University of Texas Southwestern Medical Center in Dallas.

The more vaginal deliveries a woman has, the more likely she is to have incontinence problems later in life, many studies show. Yet unless you are a strict proponent of scheduled Cesarean sections--which I'm not--there is very little doctors and pregnant women can do to decrease the risk of pelvic-floor dysfunction later in life. After all, we can't change the size of the baby, and we can't change the size of the mother. But how and when a woman pushes during labor is something that can be modified.

Two recent studies by colleagues and myself compared labor, delivery and pelvic-floor function of two groups of low-risk laboring women who did not receive epidural anesthesia. Those who were coached--or instructed to hold their breath and push through contractions for 10 seconds, then repeat--showed some decreased bladder capacity three months later, which we didn't see among the women who were told to simply do what comes naturally. Other outcomes, such as C-section, forceps or episiotomy rate, were the same.

I realize that three months is not a very long follow-up, and that the coached women's bladder strength may have improved. But since our and other studies have not identified any maternal or fetal advantages to coached pushing, it seems prudent to recommend that it be limited to specific situations, such as prolonged labor or a nonreassuring fetal heart rate.

Yes says Stephen F. Thung, M.D., assistant professor of obstetrics, gynecology and reproductive medicine at Yale University School of Medicine in New Haven, Conn.

The recent study by Joseph Schaffer and colleagues found that in women without epidurals, this technique could shave 13 minutes off labor's second stage, which averages 40 minutes in first-time mothers. To male researchers such as myself, 13 minutes may not sound like a lot, but you might want to check with some new moms about this. They may say they'd do anything and everything to shorten that uncomfortable stage.

As for the link between incontinence and coached pushing, the other study by Schaffer looked at women a mere 90 days after labor and found a slight decrease in bladder capacity, with no difference in actual stress incontinence in the coached mothers. There is no comment on long-term bladder function, making this a weak argument for stopping coached pushing. Some pushing is almost always required while giving birth without the aid of forceps or vacuum, and women who have epidurals may never feel a strong urge to push on their own.

For women who receive epidurals, the current debate is whether coached pushing should occur when the cervix is fully dilated or if it should be delayed--not whether it should occur at all. Unless research demonstrates significant additional benefits to uncoached pushing or significant long-term problems with coached pushing, I do not see any compelling reason to stop this common practice.

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