Delayed pushing versus Instructed pushing

Delayed pushing versus Instructed pushing

Link: http://digitalcommons.cedarville.edu/cgi/viewcontent.cgi?article=1069&context=pharmacy_nursing_poster_session

Delayed pushing versus Instructed pushing

By Chien-Yueh Lee, Kristen Mohre, and Jessica Wall

In the recent past, there have been several concerns as pertaining the entire process of labor. One of the key aims within the maternity has been the elimination of perineal lacerations and the prevention of prolonged labor. With this in mind, there have been several strategies put in place to ensure that labor is a transition process that doesn’t give the mothers more complications than there should be. Vaginal and perineal tears at large commonly occur during delivery because of the forces brought about in the process of delivery. It had previously been documented that 18% of the total obstetric procedures are often laceration repairs.

Perineal tears also have several complications and associating factors including severe pain, risks of infection and even maternal psychological depression. For prolonged labor, the risk of developing Vesicovaginal fistulas and other forms of fistulas are even higher. It is for this reasons and several others that perineal tears and prolonged labor should be avoided at all costs. This study sort to compare the effect of spontaneous pushing and instructed pushing and how these affect the total outcome and the sustaining of perineal tears in the second stage of labor. There are two main types of pushing in the 2nd stage of labor, delayed pushing and instructed pushing. Delayed pushing refers to the attempt to let down in a mother who is in labor during the process of giving birth and not pushing initially. Delayed pushing is when the woman is given instructions to avoid pushing until the urge to push is irresistible or until the baby has descended to the perineum.

Instructed or coached pushing refers to the process when women are trained by a medical personnel on how to push and let down the baby. Pushing is done during the second stage of labor, after full dilatation of the cervix at ten centimeters.Delayed pushing entails whereby the mother takes time before attempting to apply muscular force with the help of the abdominal muscles. The uterus contracts in sequences and applies force to aid the baby to come out. In the meantime, the mother is stimulate to apply Valsalva maneuvers in order to try and add to the effort of giving birth. In delayed pushing, the mother awaits for some period of time before starting to push and giving the Valsalva maneuvers. The delayed pushing might be done with or without epidural method of anesthesia.

Instructed pushing can also be described as whereby the pregnant woman is asked to lie in specific positions and taught by the medical personnel or trainer on how to push and for how long to push. The assistant gives the mother moral support to continue pushing when required. Normally, the women are taught to put their chin to their chest, holding their breath for a count of 10 seconds and pushing as hard as they can several times during contractions. The women are trained and coached with or without the help of epidural anesthesia. The training is usually on a time limit because too much laboring on second stage of laboring might cause complications.

In this study, the population of study was the women in the 2nd stage of labor. The intervention was spontaneous pushing with the comparison being instructed pushing. The outcome to be evaluated in both cases was the presence of perineal lacerations and the entire length of the 2nd stage of labor. From the study, it was realized that there was very little evidence relating the direct influence of the pushing methods on perineal lacerations. However, there was a study that had a direct statistical difference between the pushing type and the presence of lacerations (Balogoch et al., 2012).

Despite all this, a relationship between the rate of perineal tears and the length of the 2nd stage of labor was found to exist. It should be noted that the risk of attaining a perineal laceration increases when the duration of the second stage of labor increases (Aiken et al., 2015, Frey et al., 2012, Landy et al., 2011). Also, it was realized in the study that the duration of the 2nd stage is significantly increased in women who push spontaneously (Funai et al, 2015, Frey et al., 2012). It was therefore concluded that spontaneous pushing possibly increases the entire rate of formation of the perineal lacerations. It was therefore concluded in this study that, although unclear, during the 2nd stage of labor, spontaneous pushing may decrease perineal lacerations. However, spontaneous pushing does cause a subsequent increase in the length of the 2nd stage of labor, which increases laceration incidence. Therefore, spontaneous pushing may indirectly affect the total laceration rate.

A review of other randomized clinical trials concluded that coached pushing, as a method of giving birth is not recommended. The review recommended that supporting spontaneous pushing and encouraging women to decide on what method of pushing they prefer was the best clinical practice during the stages of labor. Evidence also showed that it was better to delay pushing for several hours than to put the mother under training of coached pushing. It was encouraged that it was better for the mother to delay until the urge to push and let down is felt. Delayed pushing was not associated with demonstrable complications despite the second stage of labor going on up to 4.9 hours. In select patients, such delay may be beneficial.

In terms of amount of time a woman pushes, coached pushing shows slight reduction compared to delayed pushing. However, coached pushing causes increased stress on the baby and increases incidents of late decelerations in the baby’s heart rates. Coached pushing also causes the baby to receive low oxygen levels and it increases fatigue in mothers. There is increased organ injury to the baby and low Apgar score for babies with coached pushing. Coached pushing causes great discomfort and pain to mothers. Delayed pushing was associated with increased time during the second stage of labor. Delayed pushing reduced incidents of organ injury and it helped the mother to give birth in their most favorable position with reduced pain of contractions. Delayed pushing was associated with reduced perineum injury and reduced pelvic floor injury.

From reviews of a total of 20 included studies by Cochrane, with studies of mixed methodology, in terms of perineal lacerations, there was no difference between delayed and coached pushing. There was also no difference in the incidences of episiotomy. However, there is insufficient evidence to conclude and justify the routine use of a certain or specific timing of pushing, this is because the benefits arising from the various kinds of pushing and the adverse effects are not well established and concluded therein.

Authors

Chien-Yueh Lee

Cedarville University School of Nursing

Kristen Mohre

Cedarville University School of Nursing

Jessica Wall

Cedarville University School of Nursing