WASHINGTON (Reuters) - Pregnant women coached through their first delivery do not fare much better than those who just do what feels natural, according to a study released on Friday.
Researchers at the University of Texas Southwestern found that women who were told to push 10 minutes for every contraction gave birth 13 minutes faster than those who were not given specific instructions.
But they said the difference has little impact on the overall birth, which experts say can take up to 14 hours on average.
I must admit being inactive the past 6 years, in the prepared childbirth, L&D arenas, and being ill the past 2 years, and now being in my 70th (one only has so long a lifespan) year has distanced me from my earlier work. I wonder if Elizabeth Bing the New York pioneer, felt that way.
It seems that the high cost of research lowers n, in a way that, while not negating the studies you gave (fabulous eye openers), certainly points to the need for increasing n to at least 1500 participants in one study, with an equal control group. Unfortunately the largest studies were randomized.
Unfortunately the last resource you gave, by Yildirim G, Beji seemed biased to me, although consistent in its purpose. The "open glottis", it would seem is definitely necessary in 2nd stage pushing, as a closed one inhibits the flow of air (O2). It is assumed that all Valsalva pushing occurs with a closed glottis, yet it is not evaluated scientifically by checking neonate and - (not too costly) mom's O2 sats. The instruction the women were given in the first stage of labor, miraculously transferred to the 2nd, with "support". What that support is, for both groupos of 50 women, is not outlined
I didn't go into the techniques I taught, that I learned from the French Childbirth Educator (Christianne, in Los Angeles) during my (36 year old) pregnancy. They included positioning the head in a jaw forward position (which the coach assured happened) that opens the glottis (as CPR taught us). Also, the height of the head of the bed was not over 30 degrees (I would demonstrate sitting upright as 90 degrees, half that, lighing down further, 45 degrees, with 30 degree lower than that and the coccyx flattened, if they were in lithotomy (?if? WHEN, as you explained). I also taught them to practice the techniques in a squat, suggesting that they suggest that they would want that option, with their physician at an office visit.
Not many other instructors wanted to teach such a complicated method, when I explained it to them so only the 700+ women I trained afterward and Chritianne's small classes learned it. In the early '70s, research grants weren't available as they might be now, for that sort of thing. However, more highly educated women are expecting babies (a guess, due to the "baby boom"), who might press for the needed money to determine the benefits of unconventional (different than valsalva) pushing methods Also, the resistance of coaches to allay their high anticipation, and stay with the program, being supported and
encouraged to maintain their proactive roles, despite their fatigue. Perhaps auxilliary "pushing" coaches could take over, due to the alienation to the partner that transition can evoke. I would like to be around in another 50 years, to see that happen.........
The newer "birthing tables" were designed to allow pushing and birth in the squatting position, or "all 4s" and on the side, with the table elevated for "access" if necessary. However the comfort level and resistance to change most OB staffs exhibit (nurses and MDs) has kept the incidence of anything but lithotomy very low.
It takes midwives, nurses such as you, to try everything. The figure of
1 1/2 hours for pushing AFTER complete dilation has been achieved hasn't been researched adequately, but is a commonly used parameter. Charting for the 2nd stage is less than scientific. Usually once pushing begins, it is assumed that the patient's use of it is appropriate. A lot of thge time, it isn't, which adds to the long stage 2 reports. I've even seen 12 hours!]quote
Designed tables rubish - nothing to do with the woman and labour all to do with the care giver- Evidence showes that mobile women labor faster. It is wrong for you to tell familes that attend your classes that after pushing for 1 1/2 to expect a LSCS- completly wrong its not evidence backed information. But you should be telling them about is the latent phase - so when they turn up for a labour check and 2cms and are not in established labor they are confident to go home untill labour is established - this information is supported by evidence. Also about tranistion and everything that brings.
You've reminded me of the time I went to a conference in San Diego, CA where Sheila Kitzinger (auther of many childbirth books and manuals, from England) demonstrated how orangutans give birth "on the run", while tilting their pelvises (?Pelvi?) News cameras recorded her demonstration of that for posterity! It was hilarious!!! (I have mentioned that in the classes I taught, and occasionally upon considerable urging, repeated the demonstration, but told the participants they would not be expected to do that (if allowed).
I think you referred to the occasion of my daughter's admission to hospital at 2cm. She was having monitor documented contractions of considerable length (45 sec.) and strength then, that were 2-3 minutes apart. (I peeked at her chart when I finally got there). That continued until she was given Demerol to get "a break", at 3-4cm. There was no one there trained to give epidurals.
I once lost a job teaching at a small city's only hospital, when a student repeated to her physician the information I'd given in class of the reality that emergency surgery or something else might delay the arrival of an anaesthetist to her side (OBs didn't give them there) - in an attempt to disuade them of the concept many women like, that an epidural will be given upon admission to the labour suite - way before 4 cm - and continued until post partum relief - if not voiding - has been attained....... The OB manager told me that the physician (who happened to be the chief MD of OB) went ballistic in her office, and there was no other choice. Well, maybe they hired extra anaesthesiologists to take my place.
Thanks for the resources on knowledgeable support during labor, and its part in reducing the need for C/Ss.
In the 35 years I spent preparing expectant women for childbirth, and working L&D, it was impossible to rid most L&D Nursers of their wish that it doesn't work, and only their intervention does. They were only too happy when a labor partner became tired/befuddled, and needed their input.
Doctors appreciated the preparation more than Nurses, as they were called in at the appropriate time for prepared couples, and fairly often misinterpreted monitor strips caused too early a call for them. And yes, occasionally a mom wasn't examined in time for the doctor to get there, as she was laboring so quietly, seemed in control, or her pushing was more effective than a L&D Nurse would have thought, for a primip.........
Then lots of resentment occurs, as the paper work for a Nurse delivery is more extensive, and doctors blame them for missing clear signals of the 2nd stage beginning; yet they left the order to "call when she's pushing".
All I can say is that if someone were instructing me as I tried to squeeze a watermelon out of my patoot he'd feel impact, all right, when my palm connected with his face.
What made me more pro C/S, was working as Pediatric Nurse Consultant at a Regional Center, visiting many CP children/teens.
I told my former OB supervisor, that I was seeing the results of our mistakes, and she said, "Oh, I couldn't do that!"
It turned my viewpoint completely around, as it often seemed that an
earlier C/S would have saved the child, family, and community so much misery!
Never again could I watch a woman start pushing earlier than complete dilation, because "she wanted to", causing the cervix to swell, and disabling complete dilation.
Never again could I stand by when the Doctor lets someone push beyond 2 hours without a C/S or consultation with a neonatologist. I'd have the studies of the incidence of severe consequences there, and if the OB wasn't impressed, then I'd call the Chief of OB, and on up the chain, directly to the legal department, if necessary!
What made me more pro C/S, was working as Pediatric Nurse Consultant at a Regional Center, visiting many CP children/teens.
!
Actually according to current research, fewer than 10% of CP cases are caused by birth asphyxia. Most are by causes earlier in pregnancy or postnatally. I don't have time right now to find many sources but here is one: http://www.emedicinehealth.com/cerebral_palsy/page2_em.htm
actually according to current research, fewer than 10% of cp cases are caused by birth asphyxia. most are by causes earlier in pregnancy or postnatally. i don't have time right now to find many sources but here is one: http://www.emedicinehealth.com/cerebral_palsy/page2_em.htm
the following is a direct copy of the material found in the above website, and the source of the information isn't mentioned, nor are the numbers of cases in (hopefully) the studies represented by the "new" figures.
i will continue to research newer studies that may offer better news, but i truly believe, based on my experience reviewing hundreds of cp cases that were definitely linked to oxygen deprivation at some point during neonatality, that the euphamistic thinking reflected in the sited article, is slanted (possibly to prevent future law suits).
it vcertainly makes l&d personnel feel vindicated, but i have to say, and those of you who work there too, know how it goes, when situations are dire, and someone states (soto voce), "we may get this kid through the pelvis, but will he/she get through kindergarten?"
now i do know of one "anecdotal" case of cp which may have been caused by inadequate postpartum nursing care, in the '90s. the baby was born with high apgars, seemed perfectly "normal", nursed well, and went to sleep afterward during the first hour of her life. dad went out for a bite to eat, and mom slept too, with the baby in her bassinette beside her. the nurse responsible for their care must have been lulled into a false sense of security, and didn't take the last b.p. for the mom. during that period of time, the baby may have seized, may have been choking - no one knows, but dad returned to the horror of his apneic daughter. cpr ++ revived her, and she is now 17 +/-, aphasic, unable to walk or socialize, and was taken to chico for treatment in the oxygen chamber there. she is adorable, and will forever be a child, this cousin of mine.
"at one time, problems during birth, usually inadequate oxygen, were blamed for cerebral palsy.
we now know that fewer than 10% of cases of cerebral palsy begin during birth (perinatal). {what study, on how many cases revealed that?}
in fact, current thinking is that at least 70-80% of cases of cerebral palsy begin before birth (prenatal). (again, what was the methodology and numbers of cases involved that reversed these stats?}
some cases begin after birth (postnatal). {has anyone broached what that may be, or showed proof of it?}
in all likelihood, many cases of cerebral palsy are a result of a combination of prenatal, perinatal, and postnatal factors. {aha! a supposition arises - from what? but if we know that, what is being done to identify/prevent it?}
risk factors linked with cerebral palsy include the following:
infection, seizure disorder, thyroid disorder, and/or other medical problems in the mother {we do know those situations predispose ptl
but how did the statement arise that oxygen deprivation or anything else occurred that caused cp?}
birth defects, especially those affecting the brain, spinal cord, head, face, lungs, or metabolism {certainly s/s similar to cp are evident in many genetic syndromes, but how can we leap to cp in those situations?}
rh factor incompatibility, a difference in the blood between mother and fetus that can cause brain damage in the fetus (fortunately, this is almost always detected and treated in women who receive proper prenatal medical care.) {exactly!}
please be sure that nih, acog apa, and other bonafide organizations surveilled/approved the material/studies responsible for any change in etiology/thinking about something.
i recall being stunned when the information i was told to give expectant mothers, by the largest healthcare insurance company, was totally unfounded! yet they hire registered nurses to read from :"healthwise", "web md" and a newer prenatal book, rather than give facts from their training and experience.
the web is a marvelous source of information, but before quoting anything you read, be sure of its veracity by acknowledged leaders in healthcare education. it's always great to be the first one to proclaim news, but be careful, it can bite you (wikipedia being one example).:typing
The web is a marvelous source of information, but before quoting anything you read, be sure of its veracity by acknowledged leaders in healthcare education. It's always great to be the first one to proclaim news, but be careful, it can bite you (Wikipedia being one example).:typing
Sorry, I realize that the site I posted was not an academic paper but a general information website. I was actually under the impression that it was common knowledge that most CP cases do not occur in the intrapartum. That is what I was taught in nursing school and the knowledge that my coworkers and myself operate under. I just wanted to quickly find a reference that backed up what I was saying. I don't think there is really any question at this point in time as to whether this is the case. I think you will find the same from a lit review.
(different source- discussion of same original article from the Green Journal)
I looked all the way through this thread, and didn't see your reference, or I would have responded to it sooner.
First comment: There's pushing ..... - and then, there's more pushing, and then there's "conditioned" (practiced) pushing.
Second Comment: Although researchers attempted a double blind study, the "n" was very small, and no reference was made as to how the expectant mothers pushed, whether they were primips, multips, attended classes and practised the technique, whether they were all completely dilated when pushing began, and most importantly, how long their first stage of labor was, as their ability to push hinges on the fatigue factor, as well as their physical shape antipartum.
Third Comment: I never trust a study done with "n" less than 1,000, and having some description of who was involved in the study, and their teaching background. There's the "Greek chorus" type of pushing, with exhortations of "keep pushing, keep pushing" with no suggestions of how to breathe before breath holding pushing. There's "slow controlled pushing", which must be practised for at least 2 weeks on a daily basis before it's utilized, with the mother quite informed about the necessity of not "blurting" the baby out suddenly, which causes excessive tearing. Personally, I taught a technique straight from the clinic where Dr. Lamaze worked, that Dr. LeBoyer administered. It was lengthy, complex, and difficult for L&D nurses who hadn't been thoroughly indoctrinated, to comprehend much less coach. It was taught gradually in 3 classes, involved slow pelvic tilting as the head crowned, and slow blowing without retaining air (hyperventilating) as the shoulders were eased slowly out.
So I believe the term "coached" pushing is a misnomer, meant to distract
readers from knowing that extensive training is necessary for effective coached deliveries, wherein doctors can expect women to stop pushing on their direction, to avoid too hasty and damaging a birth.
Now "uncoached" pushing is the result of natural "going along with the flow" of crescendo-like contractions, and the direction of the push is often anal. Women don't know that they could stop pushing when the contraction ceases, to rest up for the next, and usually with one eye on the clock, staff usually want the birth to be speedy. Certainly Dr. Bradley's form of "Husband Coached Childbirth", which is based on Dr. Grantly Dick-Reed's efforts as the first person to take on teaching pregnant woman to help themselves through detailed preparation which was meant to eradicate fear. Unfortunately nor every doctor or nurse has the persuasive capabilities he had when he attended births, during which his mere presence was so reassuring (?hypnotic) that women responded only to him.
This comment is based on my need to know what outcome the researchers
thought/hoped would result from their study.
Were they adamant "naturalists" who believed nature would dictate the outcome regardless of coaching? Were they advocates of training for more participation/control during the second stage (never mind the other 2 stages)?
(different source- discussion of same original article from the Green Journal)
I looked all the way through this thread, and didn't see your reference, or I would have responded to it sooner.
First comment: There's pushing ..... - and then, there's more pushing, and then there's "conditioned" (practiced) pushing.
Second Comment: Although researchers attempted a double blind study, the "n" was very small, and no reference was made as to how the expectant mothers pushed, whether they were primips, multips, attended classes and practised the technique, whether they were all completely dilated when pushing began, and most importantly, how long their first stage of labor was, as their ability to push hinges on the fatigue factor, as well as their physical shape antipartum.
Third Comment: I never trust a study done with "n" less than 1,000, and having some description of who was involved in the study, and their teaching background. There's the "Greek chorus" type of pushing, with exhortations of "keep pushing, keep pushing" with no suggestions of how to breathe before breath holding pushing. There's "slow controlled pushing", which must be practised for at least 2 weeks on a daily basis before it's utilized, with the mother quite informed about the necessity of not "blurting" the baby out suddenly, which causes excessive tearing. Personally, I taught a technique straight from the clinic where Dr. Lamaze worked, that Dr. LeBoyer administered. It was lengthy, complex, and difficult for L&D nurses who hadn't been thoroughly indoctrinated, to comprehend much less coach. It was taught gradually in 3 classes, involved slow pelvic tilting as the head crowned, and slow blowing without retaining air (hyperventilating) as the shoulders were eased slowly out.
So I believe the term "coached" pushing is a misnomer in the study mentioned in 2005 by Texas practitioners, who meant to distract
readers from knowing that extensive training is necessary for effective coached deliveries, wherein doctors can expect women to stop pushing on their direction, to avoid too hasty and damaging a birth.
Now "uncoached" pushing is the result of natural "going along with the flow" of crescendo-like contractions, and the direction of the push is often anal, which can stall the second stage. Women don't know that they could stop pushing when the contraction ceases, to rest up for the next, and usually with one eye on the clock, staff usually want the birth to be speedy.
Certainly Dr. Bradley's form of "Husband Coached Childbirth", which is based on Dr. Grantly Dick-Reed's efforts as the first person to take on teaching pregnant woman to help themselves, during labor and birth through detailed preparation which was meant to eradicate fear, and wasn't about conditioning through repeated practise. Unfortunately not every doctor or nurse has the persuasive capabilities Dr. Reed had when he attended births, during which his mere presence was so reassuring (?hypnotic) that women responded only to his direction, and other doctors laughed his techniques off as ineffective when they tried to have their patients do them. You have to love women to take on such a time consuming pursuit. As we nurses realize, not all doctors love all women.
This comment is based on my need to know what outcome the researchers
thought/hoped would result from their study, and where their interests lay.
Were they adamant "naturalists" who believed nature would dictate the outcome regardless of support/coaching?
Were they advocates of training for more participation/control/family involvement during the second stage (never mind the other 2 stages)?
Were they interested in the best possible outcome for all participants of the second stage?
Reading the article gave me no clue as to the factors involved in "coaching" and "no coaching". Therefore the study seemed to me a waste of time and an exercise in futility that negated the work of Dr. Lamaze, who after all completed Dr. Reed's preliminary attempts for more humane birthing, by training paid labor coaches in France, who in America were translated to husbands, family members, or close friends. Their involvement built from attending classes together, to practising techniques daily at home, and then utilizing them from early to transition first stage labor, and by the second stage being the most trusted (albeit exhausted) person in whom the woman had total reliance for support, and acceptance of any digressions from her task. Her doctor became the director/expert who would deal with medical complications should they arise, and the nurse was a steady presence who could assist the coach by bringing additional pillows, ice, or be there when he/she needed a bathroom break (having become familiar with the techniques that were unique to them). The Nurse would also be able to administer smaller doses of analgesia to aid relaxation or call an obstetricasl anaesthesiologist should it become clear that control had been lost and intervention for pain relief was necessary.
I've never taught anyone that no medication was the objective of prepared childbirth, and always encouraged them to develop their own ideas of what experience of childbirth would be best for them; and to never think taking medication meant failure, or C/section avoidable, if only they'd practised enough. One does the best they can, and should not be faulted when plans change.
My experience of my son's birth 36 years ago contained altered plans, as I refused to push when the Nurse told me I was fully dilated. "I can't be", I exclaimed. "Why not?", she asked. "I haven't had medication yet!" I spluttered. Upon admission to the unit, I'd informed each Nurse who cared for me, that "just because I've taught childbirth classwes for 6 years, doesn't mean I won't take medication", so sure was I that I wouldn't cope without it. Then I asked incredulously if she thought I could do it, and her positive response was all I needed to perform the techniques I've outlined here, and when I tilted my pelvis, to assist in the rotation of my 8#12oz baby's round head, my OB practically applauded, saying "What do you need me for?" He had no extensive moulding of his head, and the episiotomy was quite small.
Not all childbirth educators teach the same way. We all have our individual trainings and experiences that lead us in the directions we take. However, the sole reason for our vocation, is to assist women to achieve their ultimate possibility during their invocation to parenthood.
I hope this lengthy dissertation has served to explain a philosophy of coached childbirth that may not have been readily apparant in the original referenced article.
lamazeteacher
2,170 Posts
WOW!!
Thank you, thank you, thank you CEG!!!!
I must admit being inactive the past 6 years, in the prepared childbirth, L&D arenas, and being ill the past 2 years, and now being in my 70th (one only has so long a lifespan) year has distanced me from my earlier work. I wonder if Elizabeth Bing the New York pioneer, felt that way.
It seems that the high cost of research lowers n, in a way that, while not negating the studies you gave (fabulous eye openers), certainly points to the need for increasing n to at least 1500 participants in one study, with an equal control group. Unfortunately the largest studies were randomized.
Unfortunately the last resource you gave, by Yildirim G, Beji seemed biased to me, although consistent in its purpose. The "open glottis", it would seem is definitely necessary in 2nd stage pushing, as a closed one inhibits the flow of air (O2). It is assumed that all Valsalva pushing occurs with a closed glottis, yet it is not evaluated scientifically by checking neonate and - (not too costly) mom's O2 sats. The instruction the women were given in the first stage of labor, miraculously transferred to the 2nd, with "support". What that support is, for both groupos of 50 women, is not outlined
I didn't go into the techniques I taught, that I learned from the French Childbirth Educator (Christianne, in Los Angeles) during my (36 year old) pregnancy. They included positioning the head in a jaw forward position (which the coach assured happened) that opens the glottis (as CPR taught us). Also, the height of the head of the bed was not over 30 degrees (I would demonstrate sitting upright as 90 degrees, half that, lighing down further, 45 degrees, with 30 degree lower than that and the coccyx flattened, if they were in lithotomy (?if? WHEN, as you explained). I also taught them to practice the techniques in a squat, suggesting that they suggest that they would want that option, with their physician at an office visit.
Not many other instructors wanted to teach such a complicated method, when I explained it to them so only the 700+ women I trained afterward and Chritianne's small classes learned it. In the early '70s, research grants weren't available as they might be now, for that sort of thing. However, more highly educated women are expecting babies (a guess, due to the "baby boom"), who might press for the needed money to determine the benefits of unconventional (different than valsalva) pushing methods Also, the resistance of coaches to allay their high anticipation, and stay with the program, being supported and
encouraged to maintain their proactive roles, despite their fatigue. Perhaps auxilliary "pushing" coaches could take over, due to the alienation to the partner that transition can evoke. I would like to be around in another 50 years, to see that happen.........