A recent initiative at Medway Hospital in Kent, U.K. found that the incidence of perinatal tearing was reduced by 85% when they changed the instructions to women about pushing during the second stage of labor. Instead of encouraging women to lie on their backs, hold their breath, and push harder, women were told to slow down, assume a variety of positions during pushing, and breathe during contractions. Providers used perineal support and did not pull babies by the shoulders. When women respond to their natural urge to push, expel air during pushing (open glottis), and assume comfortable, natural positions (squatting, kneeling, holding the squat bar, etc.) they can put less strain on the perineal tissue. We know that “purple pushing”: holding the breath for a count of 10 while mom is in the lithotomy position (on her back with legs in stirrups) can cause a drop in blood pressure and fetal heart rate. Yet old school providers were taught to “deliver” babies this way. The American College of Obstetricians and Gynecologists issued a new Committee Opinion this week on Approaches to Limit Interventions During Labor and Birth. In this document they admit that women should be free to assume a variety of positions during the first and second stages of labor and push any way they want! Of course midwives have known this for ages. Be sure to talk to your provider about his/her approach to the second stage of labor. Fortunately the rate of episiotomies has dropped to 17% in the U.S. (from a high of 56% in the 1990s). Episiotomies are rarely justified; they are associated with severe perinatal lacerations and research shows they have no beneficial effect on neonatal outcomes (Goer & Romano, 2012). To reduce the risk of perineal trauma, take your time with pushing, try gravity-neutral positions, “nudge” your baby down, and have your provider brace your perineum with a wet washcloth. Be sure to practice “candle blowing” breathing so you are ready to slow down when your baby’s head crowns. Remember YOU are giving birth. You got this!
