Looking at the Evidence for Birthing Your Baby: Self-directed vs Coached pushing?

As you approach the end of your pregnancy, it is normal to think about and even worry about giving birth. It is normal to have some apprehension in these last few days, even if you have given birth before or are looking forward to your birth day!

“On my first baby I was really anxious leading up to the birth as I didn’t know what to expect and it felt like a trip into the unknown. Would I be able to cope? On my second and third babies I knew what to expect and I was really looking forward to giving birth, but I still got a little episode of the wobbles just before I gave birth – almost like stage fright!! But once I was in the moment, that all melts away.”

Stages of Labour

Labour is broken into three stages. During the first stage of labour, your body prepares for the birth of your baby by softening and opening your cervix. This is also called effacement and dilation. Your cervix hangs low into your vaginal cavity during pregnancy, but during effacement, it slowly softens and draws up towards the neck of the womb and begins to open. Your cervix opens from zero to 10cm during the first stage of labour. During the first stage of labour you may experience bloody show, back ache, and contractions.

dilation

The second stage of labour is when you are fully dilated to 10cm and it is time to give birth to your baby. During this time, your contractions may become less frequent and you may notice a difference in how they feel different. Many women experience a ‘lull’ of contractions before the second stage of labour begins, earning the nickname of the “rest and be thankful” stage! The third stage of labour is the birth of the placenta.

“Surges were every minute and I could feel them starting to change from strong surges to open, to more spaced surges which pushed downwards.”  ~ A woman describing the changes in contractions between the 1st and 2nd stages of labour: excerpt from a 42 weeks positive Irish Birth story

Birthing Your Baby – Who is the Expert?

There are several schools of thought on the most effective way for a woman to give birth. This varies from self directed pushing, to coached pushing, and purple pushing. Self directed pushing follows the idea that women are the experts of how they are feeling and their own births – a woman should follow her feelings during birth. Coached pushing is based on the belief that women need assistance from health care professionals on how and when to birth their baby.

Self Directed Pushing is when women are encouraged to follow their own instincts on how to birth their baby and when. Women are encouraged to move into the position which they feel most comfortable in. The entire effort of pushing, bearing down, or breathing down the baby for birth should be self directed by the birthing woman. Women are given adequate time to birth their baby. If the woman has had an epidural, it may be turned down before the start of the second stage in order for women to feel the urge to bear down.

Coached Pushing or Purple Pushing is when women are coached by a health care provider on when and how to push her baby. Women may be asked to take a certain position, usually on their back or side, and are instructed on when to begin to push and for how long: “keep it coming”. Often, women are instructed to put their chin to their chest, to hold their breath for a count of 10 seconds, and push as hard as they can several times over the space of a contraction. Women receive coached pushing with and without an epidural. Women are often on a time limit for the second stage of labour before intervention is expected. In some hospitals, women are asked to push with or without an urge to push as soon as they reach full dilation. Remember the rest and be thankful stage?

Birth Photography

What Women Say:

“On my first labour I had an epidural around 5cm and the midwife told me at 10cm that she was turning the epidural down in order to help with the pushing. She then said they would leave it an hour before we started to push to let the baby come down. An hour later and I was getting strong pressure during contractions and felt like I wanted to push. I wasn’t in pain as the epi was still working but it was down enough to feel the pressure. I gave birth in 15 minutes with only a small tear. The midwife did give me some instructions on the first push, saying that a contraction was starting to build and would I like to give pushing a go. She told me to push down into my bum like I was having a poo for that first contraction and then the rest of the time said nothing but the progress of seeing hair or that I was pushing like a pro! I was on my side but I did have the epi so wasn’t too fussed. My next baby I didn’t have the epi and gave birth on all 4’s”

And:

“I only have one child but the pushing bit was quite hard for me. I had a brilliant midwife my entire labour but found she totally changed during the pushing bit. I was on my back with feet in stirrups and it was like military precision of when and how I pushed. The lovely midwife turning into a drill sergeant screaming really low and loud to push and get angry at my baby and body. I hated every second of it. It made me feel really stressed and like a total failure. I pushed for an hour and a half before the doctor came in and sent me for a section.”

And:

” I was told to hold my breath and push for a count of ten. I pushed so hard I burst blood vessels around my eyes.”

And:

“I got to 10cm and had no urge to push as the baby was still a bit high. This wasn’t my first baby so I knew that I just needed a bit of time, but the staff were quite uncomfortable with that and wanted to intervene. I found a position that I felt really comfortable in and laboured for a further hour before I started to feel an urge to bear down. I was well over the hospital time limits but didn’t care as myself and the baby were both doing fine. Time was all I needed  as I got a strong urge to bear down and on that contraction the baby was born. Its terrifying that they would have intervened had I not insisted otherwise!”

And:

“I don’t understand how women can ‘breath’ a baby out – to me the sensation to push was completely uncontrollable! I couldn’t have stopped it if I tried!”

And:

” I had felt really out of control when I tried to push myself. I felt like I wasn’t getting anywhere and was getting really upset. I asked the midwife to help and immediately felt more effective.”

Birth Photography

Self Directed or Coached Pushing: What Does the Evidence Say?

A review of randomised clinical trials concluded that while more evidence is recommended, the conclusions were that coached pushing is not the recommended method of giving birth. The review recommends, “supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.” BMJ, 2010

Evidence also suggests that it is better to delay pushing for several hours, until a woman has the urge to push, than to engage in coached pushing as soon as a woman has completed dilation.

“Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit.” Hansen

Your care team should go through all the benefits (the advantages of coached pushing vs self directed pushing), the risks (the disadvantages of coached pushing vs self directed pushing), implications (associated risks of coached pushing vs self directed pushing) and possible future consequences, in order for you to make an informed decision. Labour is not necessarily the best time to hear this information for the first time, so it is recommended you discuss birthing options, and any questions or concerns, with your care team at your ante-natal appointments. A birth plan can be an excellent way to initiate this discussion. You might also ask what your local maternity hospital’s policy is on the second stage of labour – options, birthing positions, time limits that you should be aware of, as well as the beliefs of specific individuals in your care (private consultant or SECM). Remember, just because your local maternity unit may have certain preferences or policies on how women birth, the decision is ultimately yours.

Here are some of the advantages and disadvantages of coached pushing vs self directed pushing to help you make the best decisions for you and your baby.

Advantages of Coached Pushing:

– some research shows that there is a slight reduction in the amount of time a woman pushes for if coached pushing is involved

– some women prefer coached pushing or may need the reassurance of being instructed on what to do

– in units with time limits, it may prevent surgical birth

Disadvantages of Coached Pushing:

– increases stress on your baby

– some research has shown that coached pushing increases incidents of late decelerations in baby’s heart rates

– lower apgar scores than babies born with self directed pushing

– increases risk of lower oxygen levels on your baby

– increases risk of fatigue in mums

– increased risk of injury (urinary system, pelvic floor, perineum)

– there are often time limits associated with coached pushing

– you cannot choose the position you give birth in

– positions you are in may increase discomfort and pain

 

“Women should be informed that in the second stage they should be guided by their own urge to push. If pushing is ineffective or if requested by the woman, strategies to assist birth can be used, such as support, change of position, emptying of the bladder and encouragement.” NICE guideline to Intrapartum care

Disadvantages of Self Directed Pushing

– self directed pushing is associated with a slightly longer duration than coached pushing

– some women prefer the controlled aspect of coached pushing

Advantages of Self Directed Pushing

– babies born after self directed pushing have higher apgar scores at 1 and 5 minutes than babies born following coached pushing

– reduced incidents of urinary system injury

– reduced incidents of pelvic floor damage

– reduced incidents of perineum damage

– you may choose the position you feel most comfortable to give birth in

– choosing the position you give birth in may reduce pain of contractions and discomfort

 

42 weeks AIMS Ireland

A woman gives birth on all fours from the 42 weeks gallery

Pushing with an Epidural

A Cochrane Review found that women are more likely to have shorter first stages of labour (when contractions dilate the cervix) and less likely to have an epidural if they stay in an upright position. Upright positions include standing, walking, kneeling, rather than lying in a bed.

If you decide to have an epidural, speak to your care team about ways in which you can benefit from the advantages of keeping upright with an epidural. An epidural means that you will be restricted to a bed, however, this does not mean you must stay on your back. With the support of your partner and care team you can use upright positions with an epidural.

Positions to try:

* side lying position

* jack-knife position

* supported kneeling position over the back of the bed

You might also discuss turning the epidural down for the pushing phase in order to have self directed pushing. It is possible to turn it down to enable pressure for bearing down, while still having adequate pain relief.

One study showed that when women were in control of the amount of epidural they used, they used 30% less than the standard dose. The study also showed these women had similar satisfaction ratings but less assisted deliveries than the group using a standard dose.

For more information on the epidural and for videos on positions for labouring and birthing with the epidural please see our previous article from 42 weeks Epidural, Is it right for You? 

For more information or to access AIMS Ireland support services, please contact support@aimsireland.com

If you have a positive epidural story you would like to share, please send it to 42weeks@gmail.com

Resources:

NICE Guideline for Intrapartum Care

Hansen: Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial.

Simpson: Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: a randomized clinical trial

When and How to Push: Providing the Most Current Information About Second-Stage Labor to Women During Childbirth Education

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