Those of us who have been teaching for a REALLY long time remember the research of Dr. Roberto Caldeyro Barcia in the early 1980s on the dangers to the baby of directed pushing. Since that time, many childbirth educators have been teaching their students about the benefits to both the baby and the mother of physiological or spontaneous pushing. Finally the “party line” has caught up to Caldeyro Barcia’s pioneering research, but practice has not. Researchers at the University of Texas Southwestern Medical School (home of Williams Obstetrics) have published several studies recommending spontaneous pushing, and AWHONN has taken a strong stand urging nurses to use physiological pushing with their labor patients. But as I travel across the country teaching workshops, I am told over and over again that the admonition to push hard to a count of 10 is still being heard in labor rooms today.

Several studies published in nursing journals in the last three years address the issue of physiological pushing:

1. A meta-analysis of studies comparing passive descent to early pushing in women with epidurals was published in JOGNN in early 2008. Researchers concluded that passive descent should be used to safely and significantly increase spontaneous vaginal births, decrease instrument-assisted deliveries and shorten pushing time.

2. In an article published in the January-March 2009 issue of the Journal of Perinatal & Neonatal Nursing, Dr. Lisa Hanson, PhD and CNM, provides nurses with evidence-based recommendations for using spontaneous maternal bearing down even in challenging labors with slow labor progress and fetal heart rate abnormalities.

3.In a small RCT (randomized controlled trial) published in the March/April 2010 edition of MCN (Maternal Child Nursing), researchers compared the length of pushing between an immediate pushing group and a delayed pushing group of mothers who had epidural analgesia. They found that delaying the onset of immediate pushing for up to 90 minutes or until the mother felt an uncontrollable urge to push resulted in an almost 50% reduction in the length of time that the mother spent pushing.

If you are a labor and birth nurse and/or childbirth educator in a hospital where directed pushing is still used routinely, you may want to obtain copies of these three articles to share and discuss with the decision-makers on your unit.

Last week, news stories from Great Britain reported that a target to reduce the number of cesarean surgeries in the United Kingdom has been quietly dropped based on “new” recommendations from the World Health Organization. My first response was, “Oh no!” In the US, the March 2010 NIH VBAC Conference focused attention on the risks of multiple cesareans. The Joint Commission in their new perinatal quality measures and some OB leaders are calling for a reduction in the primary cesarean rate as the most obvious strategy to reduce the risks associated with multiple cesareans. To dig deeper into the UK news story, I googled the reference for the “new” WHO recommendation, Monitoring emergency obstetric care: a handbook (2009). I found what I was looking for on pages 25 to 26. The “new” recommendation was taken out of context. Here is the complete paragraph from the booklet:

“Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for cesarean section. Although WHO has recommended since 1985 that the rate not exceed 10-15% (125), there is no empirical evidence for an optimum percentage or range of percentages, despite a growing body of research that shows a negative effect of high rates (126-128). It should be noted that the proposed upper limit of 15% is not a target to be achieved but rather a threshold not to be exceeded. Nevertheless, the rates in most developed countries and in many urban areas of lesser-developed countries are above that threshold. Ultimately, what matters most is that all women who need caesarean sections actually receive them.”

Beyond a doubt, the World Health Organization is most concerned with the women in the least-developed countries of the world who are dying because cesarean surgery is not available. WHO cites an average cesarean rate of 3.5% in Africa. Efforts to increase the availability of life-saving cesarean surgery in those countries with rates under 5% will clearly improve maternal and newborn mortality rates. But WHO is also concerned about cesearan rates and maternal mortality in countries with high cesarean rates. From page 26 in the handbook,

“Many observers consider that we are experiencing a worldwide epidemic of overuse of caesarean section (131) and that the rates will continue to rise, in view of practitioners’ and administrators’ fear of litigation, local hospital culture and practitioner style as well as increasing pressure from women in highly industrialized countries to undergo cesarean sections for nonmedical reasons (132, 133). At the same time, evidence for the negative consequences of caesarean section is increasing: recent studies in countries with high rates suggest that caesarean section carries increased risks for maternal and neonatal morbidity and mortality (126-128.)”

Shame on all those who took words out of context to suggest that the World Health Organization has, in any way, backed off on their recommendation that cesarean rates in any part of the world not exceed 15%.

The July 2010 edition of Obstetrics and Gynecology has still another study (PubMed ID # 20567165) confirming that induction doubles the risk for cesarean surgery. I have been teaching long enough to remember when elective induction was an issue only in December – both for the convenience of the doctor and the family during the holiday season and for the tax benefit for the parents. As inductions increased in popularity, studies appeared in medical journals – almost all warning of the increased risk of cesarean with induction. At one local hospital, a nurse confided to me that so many women were being induced that it was unusual for the nurses to admit a woman in spontaneous labor. I don’t think that there is any doubt that the explosion in the number of inductions is closely tied to our skyrocketing cesarean rate.

With the growing research on the increased risks to late-preterm babies, there is finally accountability for elective inductions done before 39 weeks. In order to comply with the new Joint Commission perinatal quality measure (on elective births before 39 weeks), hospitals across the country are developing policies and protocols banning elective deliveries before 39 weeks. The NIH Conference on VBAC in March focused attention of the risks of multiple cesareans. Some OB leaders are calling for a decrease in the primary cesarean rate as the most obvious way to eliminate the risks of multiple cesareans. I am eagerly waiting the time when the obstetric profession takes the next step and reexamines the wisdom of performing elective inductions at all.

The newest induction study involved almost 8000 women who were induced both electively and for medical indications at a large community hospital (more than 7000 births each year). Researchers studied nulliparous women delivering a live, singleton, vertex pregnancy at term between May 2003 and December 2006. The obstetric staff included both teaching faculty and community providers. The researchers describe the patient population as reflecting the variability in race and ethnicity as well as socioeconomic diversity seen in the United States overall. Therefore, the patients studied approximate a population-based cohort. Although recently guidelines have been put in place at this hospital to eliminate elective induction before 39 weeks, during the time of this study, no such guidelines existed. Indications for induction were identified as fetal indications 13.6% of the cases, fetal macrosomia in 3.3%, maternal indications in 24.9%, postterm pregnancy less than 41 completed weeks of gestation in 14.3%, postterm pregnancy greater than 41 completed weeks of gestation in 18.3%, and 25.6% elective. The researchers combined elective with postterm pregnancy less than 41 weeks to come up with an overall elective rate of 39.9%. I would have also added in the inductions done for fetal macrosomia since that is not an indication recognized by ACOG (and not supported by any evidence) and since estimates of fetal weight at term are notoriously inaccurate. As in many other other studies, researchers found that the use of labor induction was associated with more than a two-fold increase in the odds of cesarean delivery.

In  conclusion, the authors wrote:

“This study has important implications for providers and their patients and emphasizes the need for women to be counseled about the potential risk of cesarean delivery with labor induction. It also predicts that efforts to reduce the use of elective labor induction might lead to a 20% decrease in the rates of cesarean delivery for a community-based population of nulliparous women.”

We agree, although we wonder if eliminating all unnecessary inductions might reduce the cesarean rate by more than 20%…