As part of an examination into key areas of practice related to normal birth, Anna Byrom and Soo Downe consider the evidence for directed pushing in second stage labour and suggest that it may undermine physiological birth.
As part of an examination into key areas of practice related to normal birth, Anna Byrom and Soo Downe consider the evidence for directed pushing in second stage labour and suggest that it may undermine physiological birth.
Midwives magazine: April 2005
`Birth is an involuntary process, and, as such, cannot be managed' (Sutton, 2001).
Introduction
This article is written as one of an occasional series of short accounts linked to the activity of the RCM `Campaign for normal birth'. The steering group for the campaign made an early decision that it will examine two key areas of practice at a time, the first two being electronic fetal monitoring and directed pushing in second stage labour. This short article summarises some of the evidence relating to the second subject. We do not claim that it is an exhaustive systematic review and it is presented as an aid to debate and discussion.
Observations in practice
We start this article with a scenario. This is a stereotypical scene, taken from numerous personal clinical encounters experienced over the last ten years. The setting is a modern obstetric unit. Sarah is having her first baby. She is labouring in a pleasantly decorated room. She has been walking around, but is now on the comfortable labour bed. Her partner is with her and the labour is progressing well. The midwife has been supportive and caring. Sarah is beginning to feel pushing urges. The midwife checks the state of the cervix. Indeed, the cervix is fully dilated. Sarah begins to push, but there is little sign of progress.
At this point, there is a change in tempo. Maybe it is the midwife herself who begins to take control of the situation. Maybe it is Sarah's partner, eager to see the baby. Maybe it is the labour ward coordinator, who has a ward full of labouring women, and four more due in at any moment, who `pops' in to see how Sarah is doing.Whatever the scenario, suddenly one or more voices are saying to Sarah: `Now come on Sarah, let's get this baby out - put your hands behind your thighs and pull up your legs, take a deep breath in and PUSH... Push! Try to get three good pushes out of each pain' and Sarah pushes with all her might, going red in the face in the process, the midwife hears some fetal heart decelerations with her doptone, and there is a renewed effort to get Sarah to PUSH... Eventually, the baby is born (a little flat, but fine after a whiff of oxygen), the air of tension is defused, and everyone breathes a sigh of relief and congratulates red-faced, triumphant Sarah on her achievement.
Anna qualified as a midwife in the last year. As a student, she frequently observed this form of care, and was sometimes encouraged to become involved in it, despite hospital guidelines advising against it. It appears to be a practice that has become ingrained, and something some midwives find difficult to shake.
Evidence
Peterson et al (1997) distributed a questionnaire to birth attendants distributed throughout 68 maternity units in the US to assess their beliefs and practices. They found that 45.5% of respondents (n=691) directed women in the way they push. On the basis of our observations above, it seems that this practice is also still prevalent in the UK today. In contrast to this observation, the removal of directed pushing from practice internationally has been advocated by the World Health Organization (2003).
Given this variation between practice and authoritative guidelines, what is the evidence for midwifery practice in this area? In the absence of a systematic review in this area, an extensive traditional literature search on direct pushing was conducted. The results are outlined below. Evidence on length of labour One paper was found in this area (Thomson, 1993). The study was of low-risk women and the author controlled for confounding variables. She found that directed pushing may cause a modest decrease in the length of second stage. However, there was no reduction in maternal satisfaction and no increase in fetal or maternal morbidity for those women who pushed spontaneously. This suggests that the argument that spontaneous pushing affects the length of labour may be true, but that it is not clinically relevant. Fetal outcomes Aldrich et al (1995) performed a prospective study evaluating the outcomes of ten babies who had experienced directed pushing during the second stage. They found that this approach to bearing down causes significant fetal hypoxia. This finding is supported by an experimental study performed by Roberts et al (1995).
They compared a valsalva style of pushing with `mini pushes', characteristic of spontaneous pushing, and found that valsalva pushing increases fetal heart rate abnormalities. Maternal outcomes Half a century ago, Beynon (1957) conducted an experimental study comparing the outcomes of directed versus spontaneous pushing. She concluded that directed pushing increases damage to the muscles of the vagina and uterine support ligaments caused by premature bearing down before the peak of the contraction, creating increased friction between the fetal head and the cervix or posterior vaginal wall.
Yeates et al (1984) compared the outcomes of two groups of women who were allowed to choose their pushing style. They found that perineal trauma was increased in the group that chose to have directed pushing. In addition, Sampselle et al (1999), in their retrospective analysis, found that perineal trauma increased when women were directed in bearing down. It is important to highlight that the design of these studies may render generalisation unreliable. The only randomised trial located was that of Parnell et al (1993), undertaken with nulliparous, low-risk women. These authors reported an increase in perineal trauma in the directed pushing group, including a higher incidence of third degree tears.
Such an increase in maternal morbidity may well be correlated with maternal satisfaction. McKay et al (1990) in their qualitative research around women's views of the second stage of labour found that some respondents felt that midwives' instructions were out of synchrony with their physiological responses. They reported that the lack of control was uncomfortable, and they were dissatisfied. Maternal behaviour Thomson (1995) performed a small, randomised, controlled trial to assess maternal behaviour during the second stage of labour. The results of the study show that women use a mixture of breath-holding and exhalation when no direction is offered. The findings of the study indicate that the spontaneous maternal approach allows for appropriate maternal and fetal oxygenation, while promoting fetal descent and progress. Pushing in the context of epidural analgesia We are aware that most of the existing evidence in this area relates to practice in the last decade, or earlier. Rising rates of epidural analgesia pose a particular problem in this area.
There is very little evidence related to the early pushing urge in the context of epidural analgesia, or to the potential for spontaneous descent of the baby if a woman with a deep epidural block is not exposed to forced pushing in the second stage. This is work that is urgently needed.
Conclusion
In summary, it appears that directed pushing undermines physiological birth. In the absence of a systematic review in this area, the narrative review set out above indicates that, despite shortening the length of the second stage of labour slightly, directed pushing has been associated with increases in fetal and maternal morbidity. We believe that many midwives know that women can achieve birth with spontaneous bearingdown efforts. Given that, in the vast majority of cases where women are labouring normally, the midwife is in sole attendance, at least during the early part of the second stage of labour, there is no external pressure to encourage birth with forced pushing.
The way a woman is supported in her pushing efforts is up to the attending midwife - we are responsible for this. We hope that this article will encourage more midwives to work with women to birth their babies as physiologically as possible, especially in the context of second stage pushing.We look forward to studies in this area in future. This should involve qualitative and observational research, as well as rigorous systematic, multi-centred trials.
References
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