Those of us who have been teaching for a REALLY long time remember the research of Dr. Roberto Caldeyro Barcia in the early 1980s on the dangers to the baby of directed pushing. Since that time, many childbirth educators have been teaching their students about the benefits to both the baby and the mother of physiological or spontaneous pushing. Finally the “party line” has caught up to Caldeyro Barcia’s pioneering research, but practice has not. Researchers at the University of Texas Southwestern Medical School (home of Williams Obstetrics) have published several studies recommending spontaneous pushing, and AWHONN has taken a strong stand urging nurses to use physiological pushing with their labor patients. But as I travel across the country teaching workshops, I am told over and over again that the admonition to push hard to a count of 10 is still being heard in labor rooms today.
Several studies published in nursing journals in the last three years address the issue of physiological pushing:
1. A meta-analysis of studies comparing passive descent to early pushing in women with epidurals was published in JOGNN in early 2008. Researchers concluded that passive descent should be used to safely and significantly increase spontaneous vaginal births, decrease instrument-assisted deliveries and shorten pushing time.
2. In an article published in the January-March 2009 issue of the Journal of Perinatal & Neonatal Nursing, Dr. Lisa Hanson, PhD and CNM, provides nurses with evidence-based recommendations for using spontaneous maternal bearing down even in challenging labors with slow labor progress and fetal heart rate abnormalities.
3.In a small RCT (randomized controlled trial) published in the March/April 2010 edition of MCN (Maternal Child Nursing), researchers compared the length of pushing between an immediate pushing group and a delayed pushing group of mothers who had epidural analgesia. They found that delaying the onset of immediate pushing for up to 90 minutes or until the mother felt an uncontrollable urge to push resulted in an almost 50% reduction in the length of time that the mother spent pushing.
If you are a labor and birth nurse and/or childbirth educator in a hospital where directed pushing is still used routinely, you may want to obtain copies of these three articles to share and discuss with the decision-makers on your unit.