Coached Breathing Doesn't Work During Pushing

Reuters reported today what many birth professionals have long known, "Pregnant women coached through their first delivery do not fare much better than those who just do what feels natural." The study, published today in the Gray Journal (American Journal of Obstetrics and Gynecology) found "the difference has little impact on the overall birth, which experts say can take up to 14 hours on average" when "women who were told to push 10 minutes for every contraction gave birth 13 minutes faster than those who were not given specific instructions."

While I doubt that this study will suddenly stop all of the nurses from yelling pushing instructions at mothers who suddenly are found to be at the magical 10 cms dilation, it is important that this information is available for professionals and expectant parents. This procedure of coaching mothers to attempt to forcibly exhale with the nose and mouth closed to the count of 10, taking a deep breath and doing it again is called the Valsalva maneuver. Named after Dr. Antonio Valsalva (1666-1723), the Valsalva maneuver was an original method of inflating the middle ear which is still practiced today. It is also used as a diagnostic tool to evaluate the condition of the heart and is sometimes done as a treatment to correct abnormal heart rhythms or relieve chest pain. Its use in obstetrics started when heavily medicated mothers couldn't feel the urge to push and it was believed the Valsalva maneuver would speed descent of the baby and hasten delivery.

The World Health Organization's Care in Normal Birth, Chapter 4 explains the risks. The practice of encouraging sustained, directed (Valsalva) bearing down efforts during the second stage of labour is widely advocated in many delivery wards. The alternative is supporting the women's spontaneous pattern of expulsive efforts (exhalatory bearing down efforts). These two practices have been compared in several trials (Barnett and Humenick 1982, Knauth and Haloburdo 1986, Parnell et al 1993, Thomson 1993). The spontaneous pushing resulted in three to five relatively brief (4-6 seconds) bearing-down efforts with each contraction, compared with the 10-30 second duration of sustained bearing-down efforts, accompanied by breath holding. The latter method results in somewhat shorter second stages of labour, but may cause respiratory-induced alterations in heart rate and stroke volume. If the woman is lying flat on her back, it may be associated with compression of the aorta and reduced blood flow to the uterus. In the published trials mean umbilical artery pH was lower in the groups with sustained bearing down, and Apgar scores tended to be depressed. The available evidence is limited, but the pattern emerges that sustained and early bearing-down efforts result in a modest decrease in the duration of the second stage, but this does not appear to confer any benefit; it seems to compromise maternal-fetal gas exchange. The shorter spontaneous pushing efforts seem to be superior (Sleep et al 1989). It goes on to state in Chapter 6, under Practices which are Clearly Harmful or Ineffective and Should be Eliminated, "Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour (4.4)."

Getting back to today's article, "Women in both groups experienced about the same number of forceps use, Caesarean deliveries and skin tears, among other complications. Less clear was whether extra pushing encouraged by a coach could lead to bladder trouble. In an earlier study, the researchers tested bladder function in 128 of the mothers three months later. While such problems usually resolve on their own over time, women who had been coached had a smaller bladder capacity and felt the urge to urinate more often, they previously found." I also question if Valsalva pushing can also be implicated in causing or aggrivating hemorrhoids. We have all seen mothers with broken blood vessels in her eyes and face from pushing wrongly, universally a result of coached pushing.

The argument for Valsalva pushing is that a mother with a complete epidural and/or intrathecal block cannot feel the urge to push. Certainly her uterus will continue to contract and bring her baby down, but the effects are much more muted when not accompanied by the spontaneous bearing down women's bodies were designed to bring baby into the world most efficiently with. This begs the question, will staff have the patience to allow fetal descent before Valsalva or at least allow a more physiological second stage with open glottis pushing in shorter stints? Rarely in my experience. Turning over patients is always a priority in modern day obstetrics and with high epidural rates, rarely is a woman allowed to "labour down" as we have come to call the time from full dilation until crowning after an epidural placement where the mother is left alone to let her uterus bring baby down. Instead mothers are made to push for hours, exhausted and shaking, while her baby's heart rate dips ever lower because of the lack of oxygen caused by the unnatural pushing efforts of coached breathing. I hope we learn from this that normal physiological second stages work and do not need to be fixed by clocks and coached breathing.