Pressing Questions

Three delivery dilemmas explored


1) Should you wait to push? If asked whether they’d like to prolong labor, few pregnant women would say yes. But in some circumstances, waiting to push may be a wise thing to do. Women who receive epidurals may have less complicated deliveries if they delay pushing until after the cervix is completely dilated to 10 centimeters, research indicates. Here’s why: Waiting a few hours before pushing allows the continuing contractions to help propel the baby into the pelvis.

This technique, called “passive fetal descent” or “laboring down,” can prolong labor by three hours or more. But a Canadian study of 1,862 first-time mothers who’d had epidurals showed it also reduced by half the number of expected difficult deliveries (those requiring forceps, vacuum extraction or a Cesarean section) when babies were in unfavorable positions, says study leader William D. Fraser, M.D., M.Sc., chairman of the obstetrics and gynecology department at the University of Montreal. Such babies are head down but facing to one side (transverse) or toward the mother’s abdomen instead of her back (posterior).

However, a small study (this one of 202 women, also first-time mothers who’d had epidurals) found no significant benefits for women who waited to push. In fact, C-section rates were identical, and the women who waited to push required slightly more forceps deliveries. “Our study was relatively small and not [set up] to show a difference in C-section rates,” says study author Beth A. Plunkett, M.D., a high-risk-obstetrics fellow at the Northwestern University Feinberg School of Medicine in Chicago. “But there was no difference between the two groups in how satisfied the women were with their deliveries.”

Until more research is conducted, there is no way to know whether waiting to push will benefit all or even most women. But Fraser says that at least in certain instances, it probably will help. “A woman whose baby is in a transverse or posterior position is most likely to benefit from delayed pushing,” he says.

2) Can breech babies be turned? Ellen Bagnato was 36 weeks pregnant with a baby in a transverse breech (crosswise) position when she panicked and began culling the Internet for natural ways to turn her baby in utero. The Atlanta mom-to-be says she was terrified of undergoing a C-section or an external version—a sometimes-painful procedure in which an obstetrician attempts to physically turn the baby. “I was about to start doing handstands in a swimming pool when one of the other techniques I read about worked,” Bagnato says. “I propped an ironing board against my couch and lay on the board with my head at the floor for 15 minutes twice a day.” After she did this for a week, her baby turned head down and was later delivered vaginally.

Not everyone is so fortunate. (And in general, you should avoid inverted positions late in pregnancy; get your doctor’s OK before trying this maneuver.) But many women say they don’t mind trying natural ways to turn a baby in utero. These include prenatal yoga, walking, and swimming the crawl stroke to help lift the baby and give him room to move. Here’s what we know about some alternative choices:

Moxibustion An acupuncture method now gaining credibility in the West, moxibustion involves burning the herb Artemisia vulgaris, or mugwort, next to the outer corner of the small toenail. A clinical trial in China that was published in 1998 in the Journal of the American Medical Association showed an 81 percent success rate for women who underwent moxibustion twice a day for two weeks, and a 75 percent success rate for those who did so once a day for two weeks.

The Webster technique The thinking behind this method is that certain chiropractic adjustments can relax the ligaments and muscles supporting the uterus, easing pressure on the baby and allowing him to move. While the International Chiropractic Pediatric Association—whose founder designed the technique—claims a high success rate, no independent trials have been conducted. So if you want to try it, consult your obstetrician. “No good studies say it’s effective, but if a woman has a low-risk pregnancy, it couldn’t hurt to try,” says Catherine A. Buerchner, M.D., an obstetrician at the Scripps Clinic in San Diego. “However, I would advise against it for women who are experiencing bleeding or are pregnant with multiples or if the placenta is covering the cervix.” 3) Is your doula a dud? Birthing doulas—women whose function for centuries has been to provide emotional support to women during labor and delivery—now are commonplace in many delivery rooms. Unfortunately, a few doulas have created havoc, either by giving medical advice or by disregarding physicians’ or nurses’ orders. Such incidents have prompted some hospitals to be more careful about allowing just any doula to provide services. Santa Monica-UCLA Medical Center in California, for example, has a list of recommended doulas; other hospitals have doulas on staff. According to Lynn Sullivan, community program manager at Santa Monica-UCLA, some physicians and nurses are wary of using doulas because not all have undergone proper training.

But lack of formal training doesn’t necessarily mean a doula will pose a problem. Finding one you’re comfortable with and who gets along with your physician as well as labor-and-delivery nurses require more than reviewing a resume, however. You'll also need to meet with several candidates and ask specific questions (example: "If any of your previous clients had to have a C-section, how did you respond to her doctor when he said it was necessary?"). Check references and ask around at birthing classes and hospitals to learn what people say about a particular candidate.

It’s also important to ask a doula whether she has been trained to follow certain professional standards and protocols, says Ann Grauer, president of Doulas of North America, an organization that certifies and educates doulas, training them to provide only emotional support. But ultimately, paying attention to your gut feeling is the most important precaution. If you’re not comfortable with a doula in the interview, chances are you—and others—won’t feel at ease with her in the delivery room, either.