Less Pelvic Floor Damage Associated With Uncoached Than Coached Pushing During Labor

Paula Moyer, MA

August 02, 2004

Aug. 2, 2004 (San Diego) — Pelvic floor injury is less likely to follow the second stage of labor if women are allowed to push in the manner that feels most natural and comfortable to them, according to investigators here at the joint meeting of the American Urogynecologic Society and the Society of Gynecologic Surgeons.

Conversely, the conventional style of coached pushing, ubiquitous in American delivery settings, is more likely to cause such injuries. In coached pushing, the practitioner and others in the delivery room urge the woman to take a deep breath, hold it, and push as forcefully and long as possible with each contraction. Therefore, more force is applied to the pelvic floor.

"We wanted to study the effects of coached pushing because some of the midwifery literature had suggested some benefits to delayed pushing," Joseph I. Schaffer, MD, who presented the findings, told Medscape in an interview. "Coached pushing is a modifiable practice. Everyone uses coached pushing, but it has no known maternal or fetal benefits, and we found that it was associated with negative effects on several urodynamic indices. Our findings suggest that physicians may want to reconsider routine coached pushing." Dr. Schaffer is the director of the division of urogynecology and reconstructive surgery at the University of Texas Southwestern Medical Center in Dallas.

The investigators randomized nulliparous women with uncomplicated term pregnancies who presented to the hospital in spontaneous active labor to receive either coached pushing during the second stage of labor or to push without coaching. In the coached group, each woman was coached by a certified nurse-midwife. In the uncoached group, women were told to just push in the way that felt natural. Neither group was more susceptible to prolonged second-stage labor, defined as longer than two hours, Dr. Schaffer told Medscape.

The investigators excluded women who had symptoms of pelvic floor dysfunction prior to pregnancy. They also excluded women who had received either augmentation with oxytocin or epidural anesthesia during the first stage of labor.

At three months postpartum all women underwent standardized testing that consisted of uroflowmetry, multichannel filling and voiding cystometry, urethral pressure profilometry, pelvic organ prolapse-Q (POPQ) examination, and pelvic floor neuromuscular assessment. The examiners did not know whether the women were in the coached or uncoached groups. The study was powered to detect a 10 cm H 2O difference in average maximum urethral closure pressure (MUCP) between the two groups.

Of the 325 women randomized to coached or uncoached groups, 128 returned for follow-up (67 in the coached group and 61 in the uncoached group). All women had delivered vaginally with cephalic presentations. The women were an average age of 21.2 years and their average body mass index was 28.5 kg/m 2. The infants weighed an average of 3,307 g at birth. Among these women, 94% were Hispanic, 4% were African American, and 2% were white. The groups were otherwise similar demographically.

The average MUCP was 83 cm H 2O in the coached group and 90 cm H 2O in the uncoached group ( P = .15). Cystometrogram in the coached group showed that 11 women (16%) had detrusor overactivity compared with five women (8%) in the uncoached group ( P = .16). Urodynamic stress incontinence was present in 11 women (16%) in the coached group and in seven women (12%) in the uncoached group ( P = .42).

The two groups' postpartum POPQ evaluations were similar, as were the digital assessments of their levator ani tone and contraction. There was also no significant difference between the groups' anal sphincter tone, contraction and integrity, or their bulbocavernosus and anal wink reflexes.

AUGS/SGS 2004 Joint Scientific Meeting: Abstract 14. Presented July 30, 2004.

Reviewed by Gary D. Vogin, MD

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