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Routine coached pushing may be harmful: when done in the second stage of labor, it adversely impacts bladder capacity, first urge to void, trial shows.

SAN DIEGO -- First urge to void and bladder capacity were negatively impacted by coached maternal pushing during the second stage of labor, compared with uncoached pushing, results from a randomized trial suggest.

In addition, a trend toward increased detrusor overactivity was seen in women randomized to coached pushing. Dr. Joseph Schaffer reported at the joint annual meeting of the American Urogynecologic Society and the Society of Gynecologic Surgeons.

These findings "suggest that routine coached pushing may have harmful effects and that uncoached pushing is not harmful," said Dr. Schaffer, who is chief of gynecology at the University of Texas Southwestern Medical Center at Dallas.

"Coached pushing is a modifiable obstetric practice without known maternal or fetal benefit. Strong consideration should be given to limiting coached pushing to specific indications such as prolonged second stage or nonreassuring fetal heart rate," he noted at the meeting.

For the study, which is the first of its kind, 128 nulliparous women with uncomplicated term pregnancies were randomized to coached or uncoached maternal pushing during the second stage of labor. Midwives supervised all labors. The 67 women in the coached protocol were told to take a deep breath and hold it during the peak of the contraction, then bear down and push for 10 seconds and repeat this as long as the contraction continued.

The 61 women randomized to the uncoached protocol were told to do "what comes natural or whatever the patient feels the urge to do," Dr. Schaffer said at the meeting.

At 3 months' postpartum, patients underwent uroflowmetry, multichannel filling and voiding cystometry, urethral pressure profilometry, Pelvic Organ Prolapse Quantification exam (POPQ), and pelvic floor neuromuscular exam.

The mean age of the patients was 21 years. Their mean BMI was 29 and the mean birth weight was 3,307 g.

No significant differences in postpartum pelvic floor structure and function were identified between the coached and the uncoached groups. However, the incidence of detrusor overactivity was twofold higher in the coached group (16% vs. 8%).

Women in the coached group had decreased bladder capacity (427 mL vs. 482 mL) and decreased first urge to void (160 mL vs. 202 mL), compared with women in the uncoached group. Urodynamic stress incontinence was diagnosed in 16% of the coached group vs. 12% of the uncoached group.

Mean maximum urethral closure pressure was 83 cm/[H.sub.2]0 in the coached group vs. 90 cm/[H.sub.2]0 in the uncoached group.

Postpartum POPQ evaluation did not reveal significant differences between the two groups except for point Bp, which was negatively impacted by coached pushing. (Bp is one of the six POPQ sites evaluated when a patient is straining. It is on the posterior vaginal wall.)


San Diego Bureau
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Title Annotation:Obstetrics
Author:Brunk, Doug
Publication:OB GYN News
Date:Oct 1, 2004
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