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A Randomized Trial of the Effects of Coached vs. Uncoached Maternal Pushing During the Second Stage of Labor on Postpartum Pelvic Floor Structure and Function
Journal article

A Randomized Trial of the Effects of Coached vs. Uncoached Maternal Pushing During the Second Stage of Labor on Postpartum Pelvic Floor Structure and Function

J I. Schaffer, S L. Bloom, B M. Casey, D D. McIntire, M Nihira and K J. Leveno
Journal of pelvic medicine and surgery, v 10, pp S18-S19
2004
DOI: https://doi.org/10.1097/01.spv.0000134014.71099.f9

Abstract

OBJECTIVE: To determine if refraining from coached pushing during the second stage of labor in nulliparous women decreases childbirth related pelvic floor injury. METHODS: Nulliparous women with uncomplicated term pregnancies who presented to a county hospital in spontaneous active labor were randomized to certified nurse-midwife coached pushing during the second stage of labor versus uncoached pushing. Women with symptoms of pelvic floor dysfunction prior to pregnancy were excluded. At 3 months postpartum all women underwent standardized testing including uroflowmetry, multichannel filling and voiding cystometry, urethral pressure profilometry, POPQ examination and pelvic floor neuromuscular assessment. Examiners were blinded to the obstetric management. The study was powered to detect a 10cm/H20 difference in mean maximum urethral closure pressure (MUCP) between the two groups. RESULTS: One hundred and twenty eight nulliparous women were randomized to coached (n=67) vs. non-coached pushing (n=61) and underwent testing. All women delivered vaginally in cephalic presentation. Mean age was 21.2 +/− 3.6 years, BMI was 28.5 +/− 3.9, and birth weight was 3307 +/− 361 grams. Ninety four percent were Hispanic, 4% African American and 2% Caucasian. There were no statistically significant demographic differences between the groups. Mean MUCP in the coached and uncoached groups were 83 and 90cm/H20, respectively (p=0.15). Cystometrogram in the coached group showed 11/67 (16%) with detrusor overactivity vs. 5/61 (8%) in the uncoached group (p= 0.16). Urodynamic stress incontinence was present in the coached group in 11/67 (16%) vs. 7/61 (12%) in the uncoached group (p=0.42). Postpartum POPQ evaluation did not reveal significant differences between the 2 groups. Digital assessment of levator ani tone and contraction, anal sphincter tone, contraction and integrity, as well as bulbocavernosus and anal wink reflexes, also showed no differences between groups. CONCLUSIONS: A potentially modifiable obstetric practice affecting virtually all American women delivering vaginally is the practice of actively coaching expulsive efforts during the second stage of labor. In this randomized, controlled trial, no significant differences in postpartum pelvic floor structure and function were identified between the coached and uncoached groups. However, a trend toward increased detrusor overactivity and urodynamic stress incontinence was identified in women who were coached. A larger study would be necessary to determine if these outcomes are significantly related to the management of the second stage of labor.

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