Episode 6.5 How to Deliver A Baby (an evidence based approach)

In this episode we discuss the evolution and evidence behind vaginal delivery techniques. Plus, we discuss the importance of the golden hour after birth for the mother and baby.

00:00:02 Golden Hour Care After Birth

00:09:23 Traditional Practices in Vaginal Deliveries

00:20:54 Optimal Practices for Labor Management

00:26:10 Monitoring and Positions in Labor

00:30:52 Labor Positions and Pushing Techniques

00:36:30 Episiotomy and Preventing Perineal Tears

00:49:54 Third Stage and Cord Clamping Guidelines

Links Discussed

Providing Evidence-Based Care During the Golden Hour

Incremental risk of clinical chorioamnionitis associated with cervical examination

Effect of sterile vs clean gloves for cervical checks in labor on maternal infection at term: a randomized trial

Maternal positions and mobility during first stage labour

Evidence-based labor management: second stage of labor

Approaches to Limit Intervention During Labor and Birth

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial – the EOLE study

Pushing method in the expulsive phase of labor. A randomized trial

Selective episiotomy vs. implementation of a non-episiotomy protocol: a randomized clinical trial

Four Tips for Preventing Perineal Trauma: The Grip

Manœuvre de Couder. Connaissances et pratiques dans une maternité universitaire française

Somersault Maneuver Demo

A Case of Severe Infant-to-Placenta Hemorrhage in Association with Prolonged Delayed Cord Clamping

Evidence-based labor management: second stage of labor

Transcript

Howard 00:17

Antonia.

Antonia 00:18

Howard.

Howard 00:19

What are we thinking about on today’s episode?

Antonia 00:21

Well, we’re going to talk about what an obstetrician does during a regular vaginal delivery. And well, an obstetrician or any other kind of birth attendant for that matter that’s crazy right.

Howard 00:31

Yeah, birth, normal birth, huh.

Antonia 00:33

Yeah, I noticed something that some of our most recent episodes are fully transcribed on the web.

Howard 00:39

Yes, so yeah, so folks may want to know that, starting with season six, episode one, there are now full transcriptions and they’re not absolutely perfect, but they’re 99% perfect. So thank you artificial intelligence, but it will actually help folks find stuff they’re looking for, or some people prefer to read some of the things we said or any of the help search engines find some of the things we talk about. So that’s exciting change for the podcast website.

Antonia 01:04

Yeah, so if you hear something and you want to just review it later for some reason, then you can do a word search on our website. Crazy.

Howard 01:12

right, yeah, that’s right. You can find the things better to include in your hate letters to us with specific quotes.

Antonia 01:19

So that’s why you did it, that’s why I did it, okay, okay. Well, what’s the thing we do for no reason?

Howard 01:24

Well, how about rushing the baby off to the bassinet after delivery? Since we’re going to talk about delivery, let’s talk about the few moments after delivery.

Antonia 01:30

Okay, yeah, so we’re staying on topic today. So that has been custom for a long time, at least in the past, to take the baby right after delivery, usually right after immediate cord clamp, and cut to the baby warmer. Sometimes I remember in training we would joke that once the baby touches my hands, I want it out of my hands as soon as possible.

Howard 01:51

We’re not pediatricians.

Antonia 01:53

Well, yeah, we’re not, that’s not our expertise. But then they would get handed off, taken to the bassinet, get dried off, diapered, maybe clothed, weighed, get their Apgars assigned, and then often they might just stay and hang out under the warmer for a while longer to help maintain their body temperature while the mom is getting stitched up or whatever else is still going on over there. And of course, we will rush a baby to the warmer if they need resuscitation, because that’s where they need to be, so that the team can surround them and have appropriate access to them. But what we’re talking about here with this segment is a healthy, screaming baby at term. That really doesn’t need any extra help, and rushing them off to the bassinet certainly is not what we encourage anymore, but I’m sure it still happens in some places today.

Howard 02:41

Yeah, we definitely want to encourage evidence-based care during the so-called golden hour, which is the first 60 minutes after birth. This is when the newborns’ pulmonary, circulatory and metabolic systems are all adapting to neonatal life. So there are three key things we want to promote during that time. The first one is skin-to-skin contact with the mother, the next is delayed, or what we call optimal, cord clamping, and then the last is breastfeeding, all of which are associated with improved maternal and newborn outcomes, and anything that encourages taking the baby away to the bassinet in that first hour will be counterproductive, obviously, to all three of those efforts.

Antonia 03:17

Yeah, and I think anyone who goes through different types of resuscitation courses, especially ACLS or ATLS, might recognize the term golden hour from other fields. And that actually comes from the field of trauma and it refers to the care that’s received during the first hour of a traumatic event, and that first hour is the most critical for having good outcomes. It was Dr Adams Cowley, actually, who is a trauma researcher, in the 60s, and he created this concept to highlight the reduced mortality and improved health outcomes when there was a set of standardized care protocols that was utilized aggressively within that first hour of a traumatic event, where the care team was paying close attention to the clock and making sure certain things got done. So then in the 1970s, the French borrowed this idea of the golden hour in trauma for newborns too, not necessarily because they thought birth was some kind of inherent medical trauma Sometimes it is but they borrowed it because it.

04:24

Birth does cause some very sudden and major physiologic adaptations that have to happen for the baby to survive, and they recognize that there are certain things that we do in the delivery room that either can make those adaptations easier or make them, conversely, more difficult, for both the mom and baby, if everything in our bodies are working as they should be in the mom’s physiology and also the baby’s then actually very minimal and focused interventions are best during that golden hour rather than a bunch of extraneous stuff, including rushing them to the bassinet.

04:59

So this newborn golden hour emphasizes early skin-to-skin contact, drying but not fully clothing the newborn and then putting them directly on the mother’s chest and abdomen. They also emphasize delayed cord clamping and no routine bulb suctioning, as we’ve talked about before, and abiding by that certainly gives more room for all of the other I’d say more just emotional aspects of birth as well. It’s a life-changing event and people want to have good memories of it. And if you’re following that and a mom gets to see and hold her baby as they take their first breaths and they first look around and see light for the first time and stuff, then that’s pretty special. So if we’re instead needlessly robbing them of that experience by rushing them off to the bassinet and not letting them touch the baby for who knows how long, then they may remember that forever and feel like they’ve missed out on something important. It’s physically important, but also important in other ways, I think.

Howard 06:00

Well, this does require a shift, I think, in the mindset of newborn attendants, if they’re not used to doing this already. And before the 1970s most obstetricians absolutely were not they had been taught to sedate the mother. This was before epidurals were commonplace and then, since she couldn’t really push while she was sedated, they would cut a huge episiotomy, pull the baby out with forceps and then they would do their repair, oftentimes an extensive third or fourth degree laceration repair, ideally while she was still sedated, of course, and the nurses would tidy up the baby during this time. And often the baby was also maybe a little sedated from the drugs that had been given to the mother for sedation. So, depending on which regimen was used, they wanted to avoid overstimulating the baby before in that era when they deep-suctioned out any fluid or meconium. So obviously things like immediate skin-to-skin didn’t fit into this process and although we’ve done away with basically everything I just mentioned for routine deliveries, as we’ll talk about in this episode, it was a gradual process over the years and some parts of that mindset have just lingered, I think so, for example, some delivery teams may still fill an urgency to perform routine neonatal assessments as soon as possible and uninterrupted by the mother’s contact and the mother participating, I suppose.

07:11

But these can and should be done on the mother’s abdomen, taking care to cause the least interruption possible to the mother and baby dad and many less urgent things like weighing the baby or bathing the newborn, that can be deferred well after the first hour of life.

07:26

It doesn’t matter how much the baby weighs. I do feel like sometimes we’ve become obsessed with getting the work done, like the required charting and assessments, so we can finally go attend maybe to the next patient or sit down for a minute or even end your shift. So in that mindset it’s easier to take the newborn to the bassinet where there’s a timer and you’ve got all your equipment and you can just be efficient and you can weigh it and you can chart everything and measure it and do all that. But that all comes at the expense of optimal thermal regulation. Perhaps delayed cord clamping, maternal neonatal bonding and even breastfeeding. Success rates are acutely tied into this and so the babies will have more hypoglycemia because of less successful breastfeeding and body thermal regulation and things like that and other negative outcomes. So the golden hour is what we’re trying to promote.

Antonia 08:12

All right, well, with that, let’s get into our main topic. So this should seem pretty straightforward and maybe something that most obese and perhaps midwives also take for granted, which is how do you do, what do you do in a vaginal delivery? And I think anyone who’s ever spent probably more than one week catching babies, so to speak, at routine and uncomplicated deliveries probably doesn’t give this too much thought, and they probably just do their part in whatever manner they were taught to do, or at least in the most typical way that they saw during their training. But we’ve pointed out a few things previously on this podcast that often were done, or maybe still are done at the time of delivery that are not evidence-based. So here we’re going to try to pull all those things together and highlight what practices are the most evidence-based.

Howard 09:03

We’ve definitely talked about different parts of delivery in the evidence or, in some cases, lack thereof for some of those things in the last couple of years. So if we’ve talked about optimal cord or delayed cord clamping quite a bit, but also things like how to manage a nickel cord, whether or not to bulb suction, the newborn we talked about recently and, obviously, whether or not to cut an episiotomy, the answer’s no.

Antonia 09:23

Yeah, there’s still definitely a lot of tradition in how vaginal deliveries are taught and it’s not too far off from how you just described earlier, how it was being done. In the 70s I got to watch an actual training video that pretty much outlined that. It was kind of humorous, but I know you wrote a Howardism post a few years ago now that went into even more detail about how vaginal deliveries used to be classically done by obstetricians.

Howard 09:52

I mentioned just from older textbooks and older articles some of the things that were commonly done. And mothers would routinely get shaved. They would have vaginal cleansing with Lysol early in their labor, a soap enema, they’d get a full body shower this was all just done by the nurses a vulvar scrub with iodine Most of the cervical exams would actually be through the rectum and only after the doctor had done a full sterile surgical scrub, following them donning sterile gloves and gowns, and then they would routinely do things like a Ritgen maneuver at every birth. And all those things made a lot of sense to them at the time, but we would never do them today. And of course you know all the other things too, like episiotomies and unnecessary forceps.

Antonia 10:32

Many times Now I have to try to not imagine rectal exams during labor.

Howard 10:38

Yeah, well, especially in the pre-antibiotic era, if you already had ruptured membranes, they felt that doing a rectal exam of the cervix was less likely to cause infection. So they would do a transrectal exam and then they could fill the station at the head and usually the more advanced dilation of the cervix through the thin membrane between the vagina and the rectum.

Antonia 10:57

I guess that makes sense in a way, because even today we do try to avoid direct cervical exams completely. We don’t replace them with rectal exams. But we just avoid doing digital cervix exams in certain situations like, for example, preterm pre-labor membrane rupture, because we know that each exam increases the risk of infection. But I bet that back then they did these routine rectal exams without any anesthesia or other pain medication.

Howard 11:25

Well, of course, in neither kind of exam is that comfortable, but I can only imagine a rectal cervical exam is probably worse than a vaginal cervical exam. And when it came time for delivery, they would use anesthesia for quote unruly patients, and then prep and position the patient in a completely aseptic manner and then, as the fetus was crowning, most of the women were given a deep sedation with scopolamine plus an narcotic, and then later they were given a gas inhalant in the 1970s instead of that, but still the effect was to knock them out. And then after that you cut your episiotomy, pull the baby out with forceps. If she happened to somehow deliver without forceps, then you would use a Ritgen maneuver where you stuck your fingers in the rectum to flex the head out. And of course, in all this the father’s in the waiting room, nowhere near to be found, and then the doctor would come out and announce the birth while the mother’s still unconscious.

Antonia 12:11

Yeah, so that describes what has been called the twilight births of the mid 1900s, not like Twilight, the vampire movie, but didn’t exist. Yeah, but it was women who were having normal vaginal deliveries were made unconscious during birth with, I think, some kind of narcotic or scopolamine or something in the vast majority of cases.

Howard 12:33

Yeah. And as soon as the head was delivered you’d stop, reduce a nuke cord suction the mouth before the nose, before the baby took a breath and if there was a condom, you’d pass a deep deli suction device down below the vocal cords to aspirate meconium stained the fluid and then in many cases, you’d wait for the shoulders to auto-restitute before proceeding on with the delivery. And as soon as the baby was delivered, you’d hold its head down below the body, below the level of the placenta, but still clamp the cord immediately as fast you can god forbid any blood get in there. And then you would manually extract the the placenta by sticking your hand up inside the uterus and pull it out and then sew up your fourth degree proctoepisiotomy.

Antonia 13:11

That sounds painful. I know that pain relief in labor was a big advance at the time, but it seems like in this context it was it’s almost like it was more being used for the doctor’s convenience and the nurse’s convenience and not for the mother’s comfort. And of course back then, especially without epidurals, I’m sure everyone thought if you want the pain relief and other benefits, maybe like maybe they were thinking about the infection risk too then this is the only way you achieve. That is with this whole package deal of the twilight birth, and you had also written in your post that in in those times it was thought incorrectly. But it was thought that cerebral palsy came from the baby’s head being somehow excessively compressed, I guess, by the natural labor process and passing through the birth canal. And so that’s why they were favoring the use of forceps, which they thought was protecting the baby’s head from the mother’s body, and they were rescuing the baby from that little tunnel of pressure and getting them out as soon as possible and not allowing a long second stage.

Howard 14:17

Yeah, another, of course completely baseless theory that people just accepted in practice for decades. It actually started with Sigmund Freud. He wrote a tract called . You know how Freud was right about everything right and that’s actually why they would really start cutting their routine episiotomies. It wasn’t just to make room for forceps or to speed things up, but they thought that they were eliminating the pressure or the pounding against the baby’s head during pushing by cutting the perineum, and of course none of that had any effect on cerebral palsy.

Antonia 14:47

But then they still used their own hands through the mother’s rectum to then push on the baby. But I guess that’s okay if they’re pushing on the chin and not the top of the head. I guess maybe that’s their logic. I don’t know if it’s even possible to medicalize birth anymore than what it was back then.

Howard 15:05

C-section.

Antonia 15:06

Well, okay, sure, or yeah, maybe, if you keep all of those same things, the whole twilight birth thing, and then also connect the mom to the wired fetal heart rate monitor, uterine monitors scalpel electrode yeah, bunch of IVs. Draw labs from her multiple times, tell her you can’t eat, you can’t move out of bed, you can’t lay sideways. That might be potentially the most medical birth possible. No husband, no support person, right?

Howard 15:32

yeah, and I think this is why we have the reactionary I’ll say reactionary natural birth movement. That kind of the pendulum swings in many cases the other way, because this did create that movement, a writer named Ashley Montague that’s a male, a famous man in the 1950s and 60s, famous for some good reasons and some not so good reasons, but he wrote an article in the Ladies Home Journal in the mid-1950s basically arguing what that? What we just said, was this utterly absurd thing and that women would be better served by having their babies at home. And so the natural home birth movement grew out of a response to all of those things.

16:10

Now, that being said, it’s tough because a lot of the stuff we just listed, well, they can be medically indicated in certain situations. If the mother has preeclampsia, for example, with severe features or some other indication, she may benefit from some of these interventions. Or if there’s fetal distress, shortening the second stage, there are reasons why a lot of those things might make sense, but women, increasingly, are conflating these interventions with the Twilight Birth Procedures we listed earlier that were never actually indicated based on any good evidence there was. You know, the Freud was wrong, and so that’s part of this pushback, I think today, against any intervention at all, is because it’s all just been bundled. We just gone from one extreme to the other.

Antonia 16:49

Yeah, I’ve actually had patients who developed help syndrome and we needed some labs, we needed to give magnesium, and these patients to the patient and her friends blamed her help on the medical environment and on the things we were doing, like we were also giving oxytocin to induce delivery, and they were saying, well, the oxytocin caused this help. I would never have had it if you hadn’t done this. But that might be a more extreme example. But I’ve seen kind of a lot of very anti-medical attitudes, and right along with frequent requests for no IVs at all, no fetal monitoring, are also requests for more reasonable things, like they don’t want pain meds, they don’t want an episiotomy, they want immediate skin to skin. So I think all available modern interventions are definitely getting lumped together also with a lot of outdated interventions and they’re all getting lumped into this bad category.

17:49

Yeah, so if a woman thinks that she’s going to walk onto the labor and delivery ward and immediately get overstated, strapped down to the bed, have her pelvic floor just butchered and then have her baby yanked out, whisked out of sight right away, that, if she thinks that, then you can’t blame her for wanting to run as far away from all that it’s possible and seeking out the opposite of that and saying I want a natural birth. But just to reiterate, none of those things like the routine episiotomies and the taking a baby away immediately have a role in modern obstetrics and routine care. But it does take a long time for different practices and attitudes to go away, even after the scientific evidence has shown they’re not helpful or even that they’re harmful. And even though we definitely do not do those twilight births anymore haven’t been doing them for at least a whole generation many women still can feel like whatever treatments they did get were just as invasive and paternalistic.

Howard 18:49

Yeah, and there’s a desire, obviously, to have control and a good desire to have control over the birthing experience, and so all of that took all of that away from women.

19:00

It was very paternalistic and directed and dictated towards them.

19:03

But again, don’t conflate being narced out with a narcotic and scopolamine and having conscious and normal mentation with an epidural that takes your pain away, and don’t just throw all those things and think of all of them in the same bucket. So we’ve seen a complete rebellion against this over medicalization of birth, and that’s good in a sense. It’s just a question of how far did we take it? And I would say that at the time those doctors thought they were doing something effective and beneficial. In the pre-antibiotic era they had seen a great reduction in the number of deaths from infection and pure apparel fever and things like that related to those, maybe to those rectal exams, for example, or all that over cleansing and things like that, many of those practices like sterile gowning and gloving and the vaginal rinses and avoidance of actual vaginal exams. They would argue and tell you to they were blue in the face, that women were dying less often because of them in the pre-antibiotic era, and there’s probably an element of truth in that, but it’s just not needed today.

Antonia 20:01

We probably can give them at least a little credit, because even now we still use clean hands and clean gloves for each check. We’re not using bare unwashed hands like they did back in the 1800s and overall we are aiming to eliminate extra cervix checks. So that’s an important lesson that we’ve carried over from all of those other unnecessary things. But I’m glad we’ve been able to eliminate at least eliminate the use of harsh chemical cleanses inside the vagina for normal labor and those other things we talked about. So let’s now just go through a regular vaginal birth, kind of talk through it and talk about the different decisions and options we have and what the evidence is for all of those and for certain things we’ve talked about before. We don’t have to completely repeat ourselves. We can just kind of refer back to those prior episodes.

Howard 20:52

All right, let’s do it All right.

Antonia 20:54

So let’s start out with some questions leading up to delivery. One of the traditional things you see, especially in training programs, is that women seem to be getting cervical exams every two hours. That seems to be the expectation and I suppose the reason is, so you can catch stalled labor progress or slow progress as soon as possible and intervene somehow. But this has got to promote some increased risk of infection, at least endometritis, which those rates have been reported to be higher in academic programs. So the question is how often does a woman need to have a cervix check during labor?

Howard 21:31

All right.

21:31

Well, it’s definitely true that more cervical exams equals an increased risk of infection, and I’ll put a link to a 2022 paper that shows that.

21:39

It also doesn’t matter whether you use clean or sterile gloves and sterile technique You’d washing your hands before and opening up daunting sterile gloves and sterile manner doesn’t make a difference and I’ll put a link to a 2023 paper that was actually a randomized controlled trial, essentially showing that sterile technique and sterile gloves don’t make a difference. It’s just a waste of time and money. Now, I’m unaware of any paper that specifically studies the optimal interval between checks, but I will say that every two hours comes from an era when we utilize the Friedman curve, where, in the active phase, we were looking for women to not change their cervix over a two hour period as a reason to do a cesarean or to intervene in some way. It’s probably also true that more frequent exams increase the risk of cesarean delivery because we’re creating impatient thresholds for women to arrive at and then intervening in some cases with a cesarean for no reason, whereas if you’ve been more patient and waited four hours, that wouldn’t have happened.

Antonia 22:34

Yeah, and I think this can result in.

22:36

This can be like sending a subliminal message to the patient, who then becomes the one that wants the cesarean.

22:42

If she’s constantly hearing her nurse or doctor check and they look disappointed and they’re saying things like, well, we’re moving pretty slowly because they’re checking every two hours, then the patient may get frustrated with the process and eventually request a cesarean, whereas just based on her progress, if nobody had ever raised the idea to begin with because they were only doing checks when it was actually indicated then she may have been happy to keep laboring for a lot longer and potentially have a normal vaginal delivery.

23:12

So it seems like it’s completely arbitrary to check the patient every two hours on the dot, especially in the latent phase of labor. So an educational model that promotes every two hour checks is teaching the wrong lesson, frankly. And if someone has a cervical ripening agent in, then they probably don’t need to be checked at all until there’s a change in their status or there’s a need for a new intervention, like maybe another dose of misoprostol, or maybe if their catheter, their Foley catheter, has come out and it’s time to look at starting oxytocin or something else. But for the most part, checking a patient should be based on her complaints and any clinical findings like changes in the fetal tracing and otherwise, probably no more often than every four hours.

Howard 23:59

Yeah, and by today’s labor guidelines, even in active labor. Well, we don’t do anything different unless there’s been no change for four hours in the active phase. So knowing what it is in between there isn’t meaningful, unless we think delivery is imminent or there’s fetal distress or something like that.

Antonia 24:14

Okay, so no arbitrary two hour cervical checks. Now the next question what about the mother’s position during the first stage of labor, before pushing begins?

Howard 24:24

Okay, so this is just while she’s laboring, while she’s contracting.

24:27

So I’ll put a link to the most recent Cochrane systematic review. But essentially, women, per this review, should be encouraged to be mobile and upright during the first stage of labor. This is associated with a higher chance of vaginal delivery and fewer overall interventions, including less need of an epidural, especially if that’s their desire. If a woman has an epidural then of course her mobility and positioning will naturally be restricted by the epidural, but at the same time mobility is not a reason to withhold an epidural. So you shouldn’t tell a woman not to get one so that she can remain more mobile.

Antonia 24:59

Yeah. So if you don’t have an epidural, then moving around and walking will likely help you be more comfortable, and it’s definitely better than just laying in bed without moving at all. So we’re still in the first stage of labor in this delivery we’re talking through. So what about fetal monitoring? Because it seems like most women are admitted and immediately put on continuous fetal monitoring for their entire labor but, as we’ve discussed before, that also is not evidence based.

Howard 25:26

Yeah, continuous electronic fetal monitoring is actually associated with an increased risk of cesarean, without an increased benefit to the newborn in most studies. So some studies have shown a slight improvements in rare outcome of fetal seizures, but overall, in low risk pregnancies at least, continuous fetal monitoring probably does more harm than good, particularly when you’re weighing C-section as a harm.

Antonia 25:49

So that would favor intermittent monitoring, in other words, heart tones every 15 minutes in the first stage of labor and then every five minutes in the second stage of labor, as long as the patient is low risk and it’s spontaneous labor and there’s no other new concerning issues going on.

Howard 26:06

Exactly, and I will say that when women are up and around and moving, unfortunately. It’s nice now that we have remote monitors and things like that, even now monitoring patches that don’t have to be moved, but that actually we need to solve the problem of how to do intermittent monitoring and use those devices, because we don’t want to see all that extra data.

Antonia 26:24

Yeah, knowing that intermittent monitoring is superior in low risk labors at least, it would be good to find a way to make it more feasible to do on a larger scale, because the classic intermittent monitoring, because of how frequent it is, it’s essentially like one-to-one nursing and I can’t say I’ve ever had a nurse volunteer to do this without at least the patient asking, if not the doctor, probably because of the workloads they already had, and I’ve never really had a patient push for it either.

Howard 26:55

You will.

Antonia 26:56

Yeah, yeah, we should just be ready for that. But, as you mentioned before, if those monitoring technologies improve, then maybe we should consider adopting that into routine practice. If we can’t now, then hopefully that’s something that we could in the foreseeable future.

Howard 27:11

Yeah, I don’t know how close it is to reality, but it’s theoretically possible and would eliminate the additional burden on nurses of intermittent monitoring. But let’s say in this hypothetical delivery that we have an appropriate patient and the nurse is able to do it, and so we’re just taking heart tones every 15 minutes during the first stage and every five minutes during the second stage.

Antonia 27:28

Okay, so let’s get to that second stage, which is after complete dilation until the infant is born. So first, should the mother begin pushing immediately as soon as we know she’s fully dilated, or should she labor down? We’ve discussed this before and at this point there’s no medical justification for laboring down. Essentially, women should begin to push once we know they’re completely dilated. But I know it’s a popular thing and one of the things natural birth people request is waiting to push until they feel the urge.

Howard 28:01

Yeah, it’s an interesting phrase that’s repeated a lot in the natural birth community this filling the urge to push and the idea is that a woman shouldn’t push until she feels the urge because otherwise she’ll wear herself out or she’ll push too soon or something. But I would point out first of all that women with epidurals may never feel an urge to push and, on the other hand, women without epidurals often don’t need specific coaching or instructions about what to do. Their body tells them. In many cases they may still not push immediately, even when they’re completely dilated because of pain during their contractions or on their pelvic floor, and pushing makes that pain worse. But that’ll pass in a few minutes and they’ll eventually start to push, and patients is definitely a virtue.

Antonia 28:40

Yeah, and in other situations I’ve seen a lot too, without epidurals the woman, her body, is just pushing. You can’t even tell her not to push, it’s just, it’s like this automatic thing and some women will actually say, oh fine, it feels better actually to push.

Howard 28:54

Interestingly enough, and unfortunately, they may start pushing when they’re eight centimeters. So that.

Antonia 28:59

Well, hopefully that just causes them to dilate and not to tear.

Howard 29:03

And if they’re paris, it’s usually okay.

Antonia 29:05

Yeah, yeah. Now it’s one thing to be in a place where you don’t really have access to an epidural, but in our practice settings, usually if a woman doesn’t have an epidural it’s not because she didn’t have access. Usually it’s because she deliberately chose not to get one, because she, whatever it is, she values it’s, she wants to either go through the process with full sensation or just wants to avoid the epidural. So, whether or not she has one, what is the best position for her to give birth in, to push in and then also, after the pushing, when the baby’s coming out, what’s the best position for that? Because we talked about this with breech deliveries and how squatting and supine and all floors have been studied and how the squatting actually made the pelvis unfavorable for vaginal birth and the all floors position let’s the fetus slide back upwards a little bit because of gravity, so it might slow the delivery.

Howard 30:00

Well, I think again, if a woman doesn’t have an epidural, she will find the positions that are most helpful to her for pain relief. So the all fours position may feel better for a while, since it, as you said, lets the baby kind of fall out of the pelvis and away from the cervix and pelvic floor and all that pressure. But eventually she is going to have to push through that and have the baby go through her pelvic muscles.

30:22

And it may take longer for that to happen in the all fours position than if she was in an upright position, but that’s okay. She may need that position to deal with the pain and again, like patients is okay because there’s no fetal distress. She should be allowed to be in the position that she feels most comfortable in.

Antonia 30:38

Okay, so it sounds like we can allow it. That’s fine, but we shouldn’t be explicitly recommending it. If she’s not in that position, be like no, you need to get on all fours, since it doesn’t have any advantage.

Howard 30:50

Yeah, it’s not a better way to have a baby.

30:52

I will say that one of the positions or one of the benefits of being in the dorsal lathotomy position is just management of emergencies like shoulder dystocia.

31:01

But apart from that, there’s certainly been women that I’m worried about that I will ask to go on their back because I’m maybe anticipating a shoulder dystocia, but for the most part it doesn’t matter ultimately which way, and squatting is not a better position either.

31:15

We know that women who deliver in the kneeling or squatting or standing positions, they actually have higher risks of perineal lacerations and a higher estimated blood loss, probably because the third stage of labor isn’t managed in a proactive way. So both of those make sense. We’re not able to control the head as it comes out, and so they may be more likely to tear. And then, like I said, if we’re not pulling on the cord and actively managing a placenta, then she’s more likely to lose blood. But essentially, barring those things, women should be allowed to push in any position that they like, which includes the back, the side, the hands and knees, standing, squatting, if you’re just asking the question scientifically, what’s the most physically advantageous way? An upright or lateral position for delivery is better than all fours, and if you can avoid squatting or standing, you’ll have less severe tears and you’ll have less blood loss.

Antonia 32:04

Okay, so that’s positioning. Another choice we have to consider then is when pushing, should the woman do it with an open glottis or closed? So closed glottis is essentially the Valsalva maneuver, where usually you take a deep breath and then hold it and then bear down, and I think that’s the traditional way most women in the hospital setting our coach to push and their nurses are counting to 10. Whereas with an open glottis they may be bearing down but they’re breathing out during that push, which means it means by definition, they’re not maintaining the Valsalva maneuver, and it is possible to push that way, but the effort feels maybe more focused to the core muscles rather than the entire val salva kind of feels like it’s your whole body pushing, and so it can feel less exhausting to push.

32:53

When you’re allowed to exhale, we’ve traditionally thought of the val salva as being more powerful than the exhale, and often a lot of nurses will even discourage exhaling with pushes for that reason A lot of nurses I’ve seen. I don’t think that there’s been studies measuring the intraabdominal pressure with comparing both types of pushing, but clinical studies have shown no consistent differences in any birth outcomes like the fetal well-being or the mother’s risk of laceration, episiotomy, operative delivery or even total duration of pushing. Now there is a ACOC committee opinion on limiting labor interventions that does reference a meta analysis of which method of pushing women used and it found that with the Valsalva, so holding the breath and bearing down, they pushed for an average of 19 minutes less than the women who exhaled while they were pushing.

Howard 33:49

Yeah, the Valsalva probably does generate more force than open glottis exhale pushing and that’s what that 19 minutes is about, but in the absence of a true clinical benefit of one method over the other, this is another area where women should be encouraged to do what they want to do, and we shouldn’t be too dogmatic about it.

34:06

So if asked what the best way is, I would say closed glottis pushing appears to be the best, but also wouldn’t deliberately offer that commentary to a woman who’s pushing with an open glottis, Unless there was a reason. I’m worried about fetal distress or decelerations or something like that, and I want to shorten the second stage. I might do some deliberate coaching to make her pushes a little bit better and deliver the baby a little bit faster. I’ll put a link to an article from the journal Midwifery in 2020, where I think the authors intended to show because this is another one of those things that people think must be better they intended to show that open glottis pushing was better, but accidentally showed the opposite effect, and that’s been, as you said in that Cochrane review. That’s been what people have found over the years.

34:47

So they concluded then that either method was okay. There was an older trial in 1993 that showed that it didn’t make a difference one way or the other. But the infants in the open glottis group were smaller than those in the closed glottis group, so that might have been a confounder. It’s obviously not that which way you pushed made the baby all of a sudden bigger or smaller. But if you’re pushing out a group of smaller babies then it might be easier to do that.

35:12

So you might not see a time and delivery. It’s interesting because I’ve seen another couple of recent articles that talk about size of baby, with things that you might not think would affect the size of the baby. It’s just a thing that they pull out of the chart and then run the software on.

35:25

So, you better think about confounders like that when you see them. In this case it might have made a difference. It might also make a difference in things like delay cord clamping, where babies may weigh more because they have more blood volume, things like that. So you do see that a lot of times in these sorts of studies.

Antonia 35:39

Okay, so we’ve determined whichever method of pushing in a normal labor is fine. But now what about, regardless of which method, getting coached on that pushing or even just the breathing between pushes, because I’ve seen a lot of birth plans that strictly forbid any kind of coaching either.

Howard 35:55

Yeah, yeah, I think there’s no right or wrong answer to this question either. Some women do their best in silence, with no coaching or very minimal feedback, and other women, particularly those with very dense epidurals they need some feedback in order to figure out how to push. They need some coaching and encouragement. So this should very much be individualized to the patient and her needs. I do believe that if you’re coaching, letting her know when she’s doing it well and giving her feedback again, particularly with a very dense epidural, it can be helpful, and doing so in a positive way and encouraging way is obviously the goal, but this is up to the patient.

Antonia 36:28

Okay, well, let’s move on. I don’t think we really need to talk about episiotomy here. Surely our audience doesn’t believe for even a second that we recommend them. But I do have to say they are still being cut. I know they are Universal. Episiotomy was fairly standard probably about 40 years ago, but in the 1980s a study showed that they did more harm than good. A practice of more limited episiotomy became commonplace. So, for example, it became restricted, instead of to all moms, only to first-time moms, plus any other women that the midwife or OB just felt might benefit from it per their judgment. But even that limited practice still needed to be reined in even more, because there’s simply no evidence that first-time moms routinely should get those cut and overall the use of episiotomy. It may be necessary in some rare emergencies, but should really occur way less than 1% of the time.

Howard 37:26

Yeah, and a lot of people after the 1980s. They definitely spent a lot of time trying to prove some benefit from episiotomy just to justify their continued use in some of those patients. In those studies they’ve not been productive. I’ll put a link to a 2017 study which compared a limited use of episiotomy approach to a no episiotomy protocol and, of course, they found that the no episiotomy protocol was safer for the mother and the child and questioned whether there was any indication at all for the procedure.

Antonia 37:54

I definitely remember some more senior attendings in my training who would promote it to us, and one thing they’d say is it made the tears easier to repair because they have been cut in neat lines rather than sometimes a spontaneous tear becomes kind of jagged and uneven, and that happens when they don’t happen at episiotomy. So of course, the truth is that even with those jagged spontaneous tears, it’s less likely to be as extensive or to cause long lasting pelvic floor dysfunction compared to a tear that first was in a episiotomy and then extended from there. So that brings me to the next question, which is how to prevent tears, and on this one I think there’s a little bit more to discuss. A lot of studies have focused on hands-on versus hands-off approaches and also other things like warm compresses, perineal massage before delivery for a few weeks before delivery, and then we already mentioned that not being squatting also reduces the risk of those tears. So that’s the first thing perhaps is being in the right position. But what about the other things?

Howard 39:01

Well, I’ll put a link to an article I wrote about the finished grip and I think that that’s the answer overall right now in terms of the best way to reduce lacerations.

39:11

So I’ve been doing this for a number of years, even before I knew it was called the finished grip, and it’s unusual that I have significant lacerations, or really any laceration at all, in most women who give birth.

39:21

But even for first time moms, most of them do not tear. But you see a lot of studies and a lot of commentary on this that will focus on the hands-on versus the hands-off technique, because that’s where the academic interest has been for a number of years, and those studies have shown that the hands-off technique was more beneficial than the hands-on technique, which you might interpret as being saying the finished grip is bad. But the hands-on technique in those studies was essentially applying pressure in the middle of the perineal body to force flexion of the head, almost like a modified Ritgen maneuver, just against the transperineal approach instead of through the rectum. And many studies have looked at this comparison and found no difference in whether tears happened or not with either technique. They did find a higher rate of episiotomy with the hands-on technique, but also more first degree tears in the hands-off technique, which is an interesting observation.

Antonia 40:14

Yeah, because you would think that with the hands-on technique it would naturally lead to more intervention like episiotomy, and then you would think that that would lead to more tears, but it sounds like it should the opposite, as in there’s no real difference, while the hands-off technique then does lead to more at least first degree tears. So I wonder if the higher episiotomy rates with the hands-on technique makes up for what would otherwise have been less tears compared to the hands-off group, which would mean then that overall the hands-on technique could actually prevent tears if you have people do it and just not do an episiotomy.

Howard 40:54

Yeah, the harm from the hands-on technique comes from the tendency to cut a episiotomy in most of these studies there’s a ton of studies, but that seems to be the trend. So maybe if the doc is in the lounge and not paying attention, the woman’s less likely to get an episiotomy, I think might be the problem. So now, more importantly though too, I think that just pressing in the middle of the perineal body, well, it really doesn’t do much to prevent tears. If you think about the physics of it, other than maybe force some extension of the head and I’ll explain why the finish grip is, then, I think, better than this. What people have called hands-on support. But, yes, a weakness in these studies was always a high rate of episiotomy, where the hands-on group tended to have up to 15% risk of episiotomy, compared to less than 1% rate that we’re advocating for.

Antonia 41:40

Yeah, that’s quite a big difference, All right. Well, what about the worm compresses?

Howard 41:43

Well. So worm towels is another thing commonly brought up and in the same way they seem to be associated in some studies with fewer episiotomies and consequently lower tears and slightly better overall outcomes. So people have advocated these because they don’t cost anything, there’s no harm associated with it all that. But the worm towel is essentially placed along the distance of the perineum, with your hand pressing it on the perineum as the head comes out, In other words the finished grip. Except not done intentionally, so in these studies they start using it during the second stage, during pushing, and usually only when the head’s descended enough to distend the perineum. So I think that’s just a foreshadowing of what the finished grip is, in which you use a towel in the same manner but more consciously and for different purposes than introducing just warmth to the perineal body, which is thought to increase circulation and things like that, to maybe help it be more pliant.

Antonia 42:35

Yeah, really the only barrier I’ve seen to using this besides just that the team doesn’t know that it’s a good thing is that you can’t keep a worm towel warm. It’s going to cool off, and so then when it cools off someone has to go re-soak it in warm water or go get another warm one and just keep changing them out. And especially if you have to run the water for a while before it warms up because it always starts off cold, then it’s just another minor kind of delay and inconvenience. And I’ve actually heard of patients bringing in like a crock pot or something or a slow cooker and just setting it on warm and just keeping their own warm water ready to go. And I think then you just have to make sure you’re not overheating it because you don’t want to burn the perineum or the baby’s head. But even that is probably just another minor inconvenience for the patient, another thing they have to bring in and then remember to take home and clean it out, et cetera. So I think it might take a little bit of deliberate effort and change to make the worm compresses more widely used on a regular basis at any given facility, and ironically I don’t think I’ve really seen worm compresses in most birth plans.

43:44

But this would be a great thing both for patients and for doctors to advocate more strongly, for I think I have heard of facilities implementing kind of multi-pronged programs to reduce perineal lacerations that also include additional things besides the things we’ve. Some of the things we’ve mentioned pushing with the hips extended and the legs straight out, and so the idea there is to cause less stretching laterally on the perineum while the baby’s head is still descending. I think actually for delivery you can’t just have the legs straight and closed, you still want to be able to rock the hips back a little bit to make the angle favorable for when the shoulder’s coming out. So this is more about the pushing, another pushing, position modification before delivery, and from what I can find, there is a current clinical trial comparing this to the traditional hips flex pushing, but there’s no results posted yet. So maybe we’ll see something about this in the future and then we’ll know is it useful or not.

44:40

But let’s, why don’t we go back to the grip? So this is from some midwives in Finland, I think, and in Finland the rates of severe perineal lacerations are only 1.2% on average, compared to 5.3% in their neighboring country, Sweden, which otherwise demographically is very similar. So it seems like that difference is primarily related to the method of delivery during vaginal delivery, and the article you wrote about this and posted on Howardisms has some pretty good illustrations, so we should just refer folks to that for the visual. It’s a little bit harder to describe.

Howard 45:16

Yeah, I’ll put a link to that with a full explanation of it. But essentially the grip is all about redistributing forces by deliberate flexion of the head upwards and redistributing the force the head puts against the perineal body away from the mid portion, which is the weakest spot near the perineal raphe, right in the middle, by using a towel to apply upwards pressure at the moment the head’s coming out and closing your hand a bit, which tends to protect the raphe and distribute those forces more evenly along the perineal body.

Antonia 45:47

Yeah, this is something I think a lot of people probably do intuitively if they haven’t grown up in the era of episiotomies, but it hasn’t been studied in the US. So we’re basically relying on basic science and physics and then clinical data from Finland and Sweden to make a guess about how effective this approach is, but it does appear to work well. So we just need studies from randomized controlled trials that look at it specifically.

Howard 46:16

Yeah, another problem is that sometimes the head delivers and the perineal body is intact at that moment and then the shoulders themselves cause a tear. So this is difficult to manage because if you’re busy guiding and supporting the baby out, there’s no way maybe that you can also protect the perineum with the grip. And I’ll admit that I often do this protection while my student delivers the baby and I probably prevent a lot of tears that otherwise would happen with the shoulders. But there’s another technique that has some evidence behind it that is definitely underutilized, at least in the United States. This is a French technique called Couture’s Maneuver and this simply consists of delivering the anterior arm of the fetus before delivering the trunk, which allows the fetal diameter to be reduced by about three centimeters and has been shown in France to be associated with fewer perineal lacerations and second-degree tears in particular that are probably caused by the shoulders.

Antonia 47:07

Yeah, we’re definitely not taught that in the US. We’d go as soon as the front shoulder is out. Then we go for the back shoulder and arm, but especially if it’s a larger baby, this probably makes a lot of sense and is a good opportunity to help even that mother have her baby without tears.

Howard 47:24

It’s almost a reverse delivery of the posterior arm.

Antonia 47:27

Yeah, exactly, deliver the anterior arm. So okay, now let’s say the head is delivered, the shoulders are not yet delivered and, like we’ve said before, we are not immediately bulb suctioning the mouth and nose, as was once tradition. We’re also not reducing a new chord, even if we see it. Instead, we’re going to do a somersault maneuver. But you said it was also tradition to allow the shoulders to restitute spontaneously, by which meaning we wait for the baby’s head to turn to one side or the other before we touch them or apply any traction. I know, historically, some people would even go further than that and they would wait for spontaneous shoulder delivery too, which some natural birth groups still promote. Now, that could be quite a while. It could be several minutes or more if you’re just waiting for the next contraction, rather than having the mom push between contractions. And, as a side note, I’ve never, thankfully, had a patient ask about this, let alone demand that. I have.

48:27

Wow. Well, I’ve actually I’ve seen stuff on YouTube, including a birth video, where they didn’t touch the baby. The head came out. They just let the head stay there and didn’t do anything, and then they waited and waited and then the next contraction came. It seemed like it forever, but I think it was less than a minute, honestly and then the whole baby just flew out. But Honestly, and in this video, the baby was fine, but I don’t think I could stand by in good conscience and just do nothing for however long three, four, five minutes or more while the baby’s head is just there and compromised circulation and everything like that.

Howard 49:03

Yeah, and there’s actually a Canadian obstetrician who’s written several letters to the editor who argues that shoulder dystocia is caused by us not waiting for this restitution, and he’s advocated for this practice, which used to be very common in even up into the 1950s and 60s. But if there’s going to be a shoulder dystocia and if there’s compression of the cord and the neck and things like that and you’re waiting two minutes to even identify that there’s going to be a shoulder dystocia, you’re going to have a seriously compromised newborn. Not a good idea. Now it’s amazing what you can find on YouTube.

Antonia 49:37

Yeah.

Howard 49:38

So I’ve got a little video here from YouTube though that I’ll put a link to of that somersault maneuver. We talked about it before, but this video will actually show you what it is if you’ve never done it. That’s for managing those new cord cords. But yes, those other things don’t make a lot of sense. They’re certainly not evidence based. Waiting for the shoulders to deliver on their own can be risky. It probably doesn’t matter in most babies. There’s probably something different about eventual shoulder dystocia and the compression on the cord and due to how big the baby is and things like that. But you don’t know that. Are you going to wait two minutes to figure that out and then realize, oh crap, I’ve got two minutes to deliver this baby. Well, I already spent those two minutes. So yeah.