The Big Push

Does Coaching Help Labor Progress?

By Alexandria Powell
We've all seen it in the movies: The man in blue hospital scrubs holding his wife's hand in
the delivery room telling her to push. But does this really help labor along or just give the
nervous dad-to-be something to do?
In a study published in the January 2006 edition of the
American Journal of Obstetrics and Gynecology,
researchers found that women who were told to "push"
during contractions didn't birth much faster than
women who just did what their bodies told them.
Babies in the group that was coached to push made
their appearances on average only 13 minutes earlier
than babies in the uncoached group, and no other
differences or benefits were noted in the coached
group. Could "push, push, push" soon be a passe
phrase in the labor and delivery room?
Is Coaching Necessary?
Researchers at the University of Texas Southwestern Medical Center in Dallas looked at 320
women who were giving birth for the first time. None had complicated pregnancies, none
received an epidural and they were randomly assigned. The 163 women in the "coached"
group were told to push for 10 seconds during a contraction, while the 157 women in the
"uncoached" group were told to "do what comes naturally."
"Aside from a 13-minute shorter second stage of labor, we found no other benefits in the
coached group, including no difference in route of delivery (C-section, forceps, vaginal) or
episiotomy/lacerations," says Dr. Steven Bloom, professor and chairman of obstetrics and
gynecology at University of Texas Southwestern Medical Center. There were no differences
in outcome for the newborns of the two groups either.
In addition, an earlier study of this same group of women showed that three months
postpartum, women in the coached group had smaller bladder capacity and a decreased
"first urge to void" (the point at which they wanted to pass urine). Of course, this was only
one study, and bladder function can return to normal over time. It's far too early to tell if
coached pushing is associated with clinically significant injury to the pelvic floor, Dr. Bloom
says.
Modern Times
Coached pushing is something that many moms, especially in the United States, are familiar
with and have come to expect, says Deborah Lindemann, a registered nurse and professor
of obstetrics and pediatrics at Life Chiropractic College West in California. But coaching
during the second stage of labor – the point at which the cervix is fully dilated and the baby
is ready to start moving through the birth canal – is a relatively recent concept.
"This was not a factor, say, in the Middle Ages," Lindemann says. "But
back then, [humans] were so much more in tune with our bodies – we
were out there working and walking."
Even as recently as the 1940s and early 1950s, coached pushing wasn't
common, Lindemann says. In fact, women were often completely
unconscious during the entire birth due to pain relief methods used at the
time.
Lindemann feels coached pushing came into its own around the early
1970s. "Epidurals were just becoming more common then, and with that
type of anesthesia, you often have to do the coached pushing," she says.
Use of an epidural can make it hard for a woman to respond to her body's
urge to push.
Women who are told to simply respond to the needs of their body during birth push
differently that women who are coached, Lindemann says. The pushes tend to be more
controlled and shorter. In coached pushing deliveries she has seen, women were told to
push as many as four times during a contraction, to start pushing before the contraction had
reached its peak and to keep pushing even though the contraction was mostly over.
"I don't think a lot of people, even people in the medical field, know that there are options
[besides coached pushing]," Lindemann says.
Lindemann says the key thing is education. "It's really on the expectant parent to do the
research, find out about as much as they possibly can about the whole birth experience,
then interview birth practitioners and find someone you have confidence in, and that you
feel you have a good working relationship with," she says.
What Women Want
Heather Cook is a mom of two who experienced coached pushing with her first birth and
uncoached pushing with her second. Both births took place in a hospital. In her first, Cook, of
Calgary, Alberta, Canada, pushed for two hours. In her second, she pushed for an hour and a
half.
"[During my first birth experience], I had a very wise
nurse with me who helped me maintain my energy
levels, did perineum compresses and generally
supported me during the labor," Cook says. "I did have
coached pushing for part of it because I was physically
very tired and needed the encouragement. I'm a
structured kind of person and I really hung on to that
during labor."
Cook's second experience was with a midwife. During
her second stage, she was told only to do what her
body wanted. "Amazingly, I felt much more in control,"
Cook says. It wasn't that I felt out of control the first time, but this time I felt as thought
everyone in the room had confidence in my ability and so I had confidence in my ability."
The verdict is still out on coached pushing. Overall, opinions among moms seem to be
similar to Cook's. "Both times I felt very satisfied with the experience," Cook says. "My
second birth I felt even more competent and able – it had been all me – no coaching, just
encouragement and support."
http://www.dadstoday.com/articles/birth-procedures/the-big-push-4334/

An audit of primary post partum hemorrhage.

Bibi S, Danish N, Fawad A, Jamil M.
Department of Obstetrics & Gynaecology, Ayub Medical College, Abbottabad, Pakistan.
BACKGROUND: Postpartum haemorrhage (PPH) is one of the leading causes of maternal
morbidity and mortality. Its causes & risk factors are important for its prevention and
management. Poor, unhealthy, high parity women delivering away from health facility are
usual victims. The purpose of this study is to determine causes of PPH, risk factors,
preventable factors and to assess treatment measures adopted.
METHODS: This retrospective study is carried out in Gynaecology 'B' unit of Ayub Teaching
Hospital Abbottabad. All patients admitted with PPH or developed PPH within hospital from
1st Jan-31st Dec 2006 are included.
Exclusion criteria were patients with bleeding disorders and on anticoagulants. Records of
admissions, deliveries, caesareans, major & minor procedures and history charts were
thoroughly evaluated for details. Details included age, parity, socioeconomic status,
transportation facility, distance from hospital, onset of labours, birth attendant
skilled/unskilled, evaluation of risk factors, duration of labour and mode of delivery. Patient's
general health, anaemia, shock, abdominal and pelvic examination and laboratory findings
were also taken in to account. Treatment measures including medical, surgical, blood
transfusions were evaluated.
RESULTS: The most important cause was uterine atony, 96 (70.5%) and traumatic lesions of
genital tract, 40 (29.4%). Factors causing uterine atony were augmented labour 20 (20.9%),
prolonged labour 21 (21.9%), retained placental tissues, 11 (12.5%), retained placenta, 11
(11.4%) Couvelliar uterus, 10 (10.4%), placenta preavia, 8 (8.3%), placenta increta, 7
(7.3%), chorioamnionitis 5 (5.2%), and multiple pregnancy, 2 (2.1%). Risk factors, grand
multiparity 70 (51.5%), antepartum haemorrhage 12 (8.9%), instrumental delivery 10
(7.3%), previous PPH, 6 (4.5%), choreoamnionitis, 5 (3.6%), multiple pregnancy, 2 (1.5%), no
risk factor, 21 (15.4%). Socioeconomic status was poor (75) & lower middle class (61).
Induced labour, 33 (24.3%), augmented labour 62 (45.5%).Uterotonics used for prophylaxis
in 30 (22%), for treatment of PPH, 106 (78%). Patients delivered by traditional birth
attendants 70 (51.4%), lady health workers 40 (29.4%) & doctors 26 (19.2%).Uterine
massage performed in 30 (22%), minor surgical procedures 33 (24.3%), manual removal of
retained placenta, 11 (8%), hysterectomy, 50 (36.7%), & compression sutures were applied
in 3 (2.2%). Maternal deaths due to PPH were 6 (40%).
CONCLUSIONS: PPH can be prevented by avoiding unnecessary inductions/augmentations of
labour, risk factors assessment and active management of 3rd stage of labour. It needs
critical judgment, early referral and early resuscitation by birth attendant. There is room for
temponade and compression sutures. Hysterectomy should be the last option.
PMID: 18693611 [PubMed - in process

http://www.ncbi.nlm.nih.gov/pubmed/18693611?
ordinalpos=19&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_Defaul
tReportPanel.Pubmed_RVDocSum