Benefits of Breastfeeding

Through your pregnancy, your body has done some amazing things to nourish and to nurture your growing and developing infant. The day is soon approaching when you will deliver your precious baby, and the care, the nourishing and the nurturing, will take place in your arms rather than your womb.

“The newborn baby has only three demands. They are warmth in the arms of [his] mother, food from her breasts and security in the knowledge of her presences. Breastfeeding satisfies all three.” Grantly Dick-Read, MD from Childbirth Without Fear, 1955.

You and your body are all your baby needs for nourishment, protection and nurturing. You can meet your newborn’s need for warmth, comfort, security, love and food through breastfeeding.

Your breasts have grown larger and changed in preparation for the feeding and the nourishment of your newborn. A mother’s milk is a baby’s normal food. No replacement or formula can even come close to matching breast milk. The milk that your body produces has every vitamin, mineral and other essential nutritional elements that your baby’s body needs to continue to grow and to develop through her first year of life.

In fact, breast milk meets your baby’s needs so well that it adapts and changes to meet her specific nutritional and caloric requirements through an individual meal, over the course of a day and through the entire year. Your baby will “design” his meals to suit his needs. If your newborn takes more breast milk at a meal, then more will be available at the next feeding. If your infant is simply thirsty, then he will nurse for a shorter period of time allowing him to get the thirst quenching lower fat milk. If he is hungry, then the longer nursing time accesses the satiating higher fat globules.

As your baby gets healthy nourishing meals, she also is getting protection from infection. Your first milk, called colostrum, is like liquid gold. It is produced in small amounts for the first couple of days after your baby is born, but it is super packed with concentrated immunological properties that are your sweet infant’s first protection against germs.

With your mature milk coming in, the gains to your newborn’s immune system do not stop. In fact, the breastfed baby enjoys an immune system that is nearly as strong as his mother’s. The living cells within your milk inhibit the growth of viruses and bacteria in your baby’s system. That means there is less risk and fewer illnesses such as ear infections, intestinal upsets, respiratory bugs or allergies.

Breastfeeding Image

Breastfeeding also lends itself to a deep nurturing attachment with your baby. The hormonal surge each time you nurse her leads to maternal feelings of well-being, love and contentment. The necessary skin-to-skin contact of breastfeeding fosters a strong emotional connection.

Science keeps finding new ways that breastfeeding helps your baby thrive physically and emotionally. Breastfeeding can soothe just about any of your baby’s needs from hunger and thirst to tiredness and fear, and even simply the need to snuggle. It provides comfort and creates an exceptional bond between mother and child. From birth through his first year, your breast milk is your baby’s best source of nourishment, protection and nurturing.


Don’t Forget Your Doula

I traveled to Florida a couple of weeks ago to be a part of a Childbirth Educator workshop. I arrived early enough to do some sightseeing and exploring with Bailey, my 14-year-old daughter.

I had my trusty GPS plugged into our rental car. I had Google searched some possible fun places to stop to observe manatees and to collect Gulf Coast shells. With directions and addresses written down, we set off from the airport.

My pre-planning  was only so good. The manatee park was without manatees. The GPS couldn’t warn me of the $6 toll to cross a bridge.  My directions didn’t alert me to an overflowing parking lot at the beach.

A quick stop at the Tourist center connected us with a lovely woman who pointed us in the right direction to a public beach with, what we hoped would be, ample parking.  Of course, she couldn’t accompany us, so we carefully tried to remember her instructions.

Bailey and I finally made it successfully to a great location and settled in for a fantastic afternoon together enjoying sea shells, wildlife, warm sun and sand between our toes.

During the drive, we never could really let down our guard and enjoy the scenes passing by. I was not familiar enough with the area.  Maps, GPS, directions could only take me so far. Even though we had a wonderful mom and daughter bonding day, I couldn’t help but think that I had wasted a good bit of time and gasoline.

As a first-time expectant mother, I gathered in books and articles to educate myself about pregnancy and childbirth. I read about breastfeeding and parenting. I attended prepared childbirth classes at the hospital.

I was lucky enough to have the nurse who taught our class working a double shift when I went into labor.  She was terrific, but could only spend portions of her time with me to quickly point me in the right direction.

My super supportive husband, Todd, and I eventually reached our destination as I delivered a healthy baby boy after over 36 hours of labor.

Similar to our travels, we enjoyed our destination, but some of the driving was more stressful, not having a guide in our car who had been there. Without a guide, we didn’t adjust as well to changes in our plans. We covered more distance than we needed to and missed some opportunities.

When a couple decides to hire me as their doula, I see them, almost visibly, relax. I see her husband able to focus more on meeting his wife’s emotional needs during this process. The stress levels decreases since they won’t simply have to rely on “directions and maps.”

I will be there for them. I will be there with them. I have been there.

There is a tremendous amount of joy in this journey to parenthood and to meeting a new baby.  A doula serves as a guide providing continuous support through labor and delivery.  Having a guide who is completely focused on one mother is a great way to improve the birthing experience.

Gestational Diabetes

The following is a research paper that I wrote for my doula training.  I realize that the issue of Gestational Diabetes is not simple.  I hope that this is helpful to bring greater clarity to the purposes of screenings & most importantly, what are the key issues for moms to improve their own health & the health of their babies.  

Gestational Diabetes

A sweet syrupy beverage, an hour wait and a blood draw have become a rite of passage for pregnant women between week 24-28 of pregnancy. Although the Glucose Challenge Test and the follow-up Glucose Tolerance Test could be useful as indicators of risk for Gestational Diabetes Mellitus (GDM), the lack of a gold standard for diagnosis is problematic. In addition, questions remain in regards to whether or not identification and treatment of women with GDM will prevent some of the associated adverse perinatal outcomes, and if there is enough evidence to support wide screening for GDM in low risk, asymptomatic mothers.

Not until 1973 was an attempt made to link an abnormal glucose tolerance test with the absence of overt disease to perinatal outcomes. Though the correlation was tenuous, it gave rise to GDM as a disease entity to be searched for and treated

From the concept of prediabetes, GDM evolved as a pathology in blood glucose absorption and insulin resistance before an individual is truly insulin dependent. The Glucose Challenge Test purports to uncover a defect in the glucose balance which is then to be confirmed with a Glucose Tolerance Test to officially diagnose GDM.

Abnormally high levels of glucose in the blood are used to identify GDM. GDM is defined as an impaired glucose tolerance with the onset or first recognition during pregnancy. Therefore, a woman with no diabetes before pregnancy who presents with high blood glucose levels during pregnancy, following a Glucose Challenge Test and a follow-up Glucose Tolerance Test, is diagnosed as having GDM.

GDM affects how the cells in a woman’s body during pregnancy use glucose. Although the cause is not firmly agreed on, there are clues to why a woman’s body during pregnancy becomes unable to make and utilize all the insulin it needs.

Even with conservative estimates, GDM affects almost 1 in 20 pregnancies. Some cite impaired glucose tolerance in as many as one-third of women. Data, according to the Centers for Disease Control, suggest a prevalence of GDM in 2010 was between 4.6% to 9.2%, depending on the diagnostic criteria used, of all pregnancies.

Although the true prevalence of GDM is unknown, impaired glucose tolerance and insulin resistance can result in excessively high glucose levels for expectant mothers and their developing babies. The challenge in determining the prevalence of GDM is that the prevalence percentages are very sensitive to the diagnostic criteria used. The criteria has changed and continues to change mainly due to a lack of consensus resulting in the absence of a gold standard of blood glucose levels for the diagnosis of GDM.

During regular digestion in a non-diabetic individual, the breakdown of food leads to glucose entering the blood stream. The pancreas produces insulin to meet the load of glucose in the blood stream. The insulin serves as a key to the cells, moving glucose from the blood to the cells to be used as energy.

During pregnancy, however, there are normal changes in glucose metabolism that are necessary to promote the baby’s growth. Human Placental Lactogen and other placental hormones diminish the effect of insulin in the mother’s body with the key purpose of allowing more glucose to cross the placenta to nourish the baby. The placental hormones support the baby’s development, but also block the action of the mother’s insulin creating insulin resistance. The action of the placental hormones causes the mother’s body to increase insulin production in order to deliver blood glucose to her own cells to be used for energy. A modest elevation in blood glucose following meals is normal during pregnancy.

Although normal in a healthy pregnancy for maternal cells to be less responsive to insulin, if the pancreas cannot keep up with the load of blood glucose, blood sugar levels will rise too high. At that point, as the pancreas works overtime to produce insulin, the blood glucose levels continue to remain high. Without enough insulin, the key to opening the mother’s cells, the glucose cannot leave the blood and be changed into energy.

GDM generally affects mothers late in pregnancy after the baby’s body has been formed, but while the baby is still busy growing. As the baby grows, the placenta produces increasingly more insulin blocking hormones. Glucose builds up in the blood at high levels that can affect the growth and welfare of the baby.

Insulin from the mother does not cross the placenta; however, blood glucose does. The increased amount of blood glucose available to the baby as it crosses the placenta forces the baby’s pancreas to react by increasing insulin production. The high blood glucose delivers more energy than the baby needs often leading to excessive growth or a large size. Uncontrolled GDM has risks and concerns about the baby’s size, an increased risk of cesarean section, low blood glucose levels for the baby at birth and respiratory distress at birth. Also cited in literature are the possible long term adverse outcomes such as an increased risk of obesity and development of Type 2 Diabetes (Non-Insulin Dependent Diabetes Mellitus or NIDDM).

The current standard of care for expectant mothers includes a routine screening for GDM. The initial Glucose Challenge Test protocol requires the mother to drink a sugary solution. Blood is drawn at one hour. If the blood glucose is less than 130-140 mg/dL, it is considered normal. However, if the blood glucose is higher, it means that the mother is at a higher risk for GDM.

With a high blood glucose measure on the one hour Glucose Challenge Test, the mother is then referred for a follow-up Glucose Tolerance Test. The mother is expected to fast overnight. First, a fasting blood glucose blood draw is taken. Next the mother drinks another sugary solution, but this time with a higher concentration of glucose. Her blood glucose is then checked every hour for three hours. If at least two of her blood glucose results are higher than normal, she is formally diagnosed with GDM.

The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study was a response to the need for an internationally agreed upon diagnostic criteria for GDM based upon their value for predicting adverse outcomes in pregnancy. The primary criteria used in the United States are the National Diabetes Data Group (NDDG), The Carpenter and Coustan Criteria (CC) and the International Association of Diabetes and Pregnancy Study Groups (IADPSG). The NDDG and CC are recommended by the American Congress of Obstetricians and Gynecologists (ACOG) and when applied result in GDM diagnosis in about 5-6% of pregnancies. The American Diabetes Association (ADA) recommends IADPSG resulting in a prevalence of 18-20% of pregnancies. Medical experts do not agree on a single set of screening guidelines for GDM.

There is, however, agreement that mothers are at a high risk for GDM if their Body Mass Index (BMI) is greater than 30, if they previously had GDM, and if there is a strong family history of diabetes. In addition, advanced maternal age, higher parity, nonwhite race and overweight correlate with an increased risk of GDM. The increase in perinatal mortality associated with an abnormal Glucose Tolerance Test can already be predicted as much by the indications for testing such as obesity, large fetus or a previous stillbirth.

The adverse outcomes most commonly associated with GDM are fetal macrosomia (birth weight greater than 90th percentile for gestational age), increased rates of cesarean delivery, shoulder dystocia and birth trauma. A baby may be too large to enter the birth canal or the head may enter, but the shoulders may become stuck. Evidence does support a positive association between an abnormal Glucose Tolerance Test, increasing blood glucose levels and macrosomia; although, the majority of macrosomic infants are born to moms who have normal Glucose Tolerance Tests.

Severe GDM can result in stillbirth. There is also an increased risk of preeclampsia and hypertensive disorders. Indeed, there are direct risks to the baby, as he may experience newborn hypoglycemia, jaundice, lung immaturity and breathing difficulties.

For the mother with GDM, even if blood glucose levels return to normal following pregnancy, she has an increased risk of developing NIDDM or Type 2 diabetes later in life. In addition, she risks GDM during subsequent pregnancies. There are also potential long term consequences of GDM for the baby as he grows up such as glucose intolerance and obesity.

GDM has a small, but important risk of adverse perinatal outcomes and also long term risks for mother and for child. Even with these positive associations, however, no clear threshold of blood glucose levels for increased risk has been found. Uncertainty remains as to the level of glucose impairment associated with adverse perinatal outcomes.

The cornerstone of treatment for mothers diagnosed with GDM is dietary and nutritional management. Blood glucose monitoring, exercise, medications and close monitoring of the baby to include fetal measurements also figure into most treatment plans. Through intervention and treatment, the risk of neonatal complications such fetal macrosomia, shoulder dystocia, cesarean section rate and hypertensive disorders may be decreased.

Different reviews of literature point to varying evidence of improved outcomes with treatment. The majority of studies appear to support the concept that treatment involving diet and blood glucose monitoring is not harmful to mother and baby and will more likely result in a baby that weighs less than 8 pounds 13 ounces.

Health outcomes of those with GDM as identified by screenings are still not solidly verified with or without treatment. The Glucose Tolerance Test results are not reproducible. A positive test may unduly label a pregnancy as “high risk” leading to extensive, expensive programs of tests and interventions with unproven benefit. Negative test results may be falsely reassuring that the risk has been removed. These issues certainly call into question the broad application of these screenings to all women, symptomatic or asymptomatic, at 24-28 weeks gestation.

Clinical judgment based on the assessment of pre-pregnancy weight, pregnancy weight gain and a pregnancy past 42 weeks gestation is more predictive of fetal macrosomia than the Glucose Tolerance Test. BMI, previous pregnancies with GDM and a family history of diabetes may be more predictive of impaired glucose tolerance and insulin resistance. If the wide application of the Glucose Challenge Test and the Glucose Tolerance Test have limited value, perhaps interventions to mitigate obesity and modify lifestyle would be a more effective treatment.

Preconception and early intervention in pregnancy in regards to body weight and lifestyle such as diet, activity and exercise, may result in improved glucose tolerance before the pancreas is overtaxed resulting in excessively high blood glucose that leads to adverse neonatal outcomes.

Researchers reported that women with a history of GDM who reach an ideal body weight after delivery decrease their risk of developing NIDDM or Type 2 diabetes. Those mothers with GDM who breastfed increased their postpartum weight loss which was also associated with a decreased risk of developing NIDDM.

With more than one-half of pregnant women considered overweight or obese according to ACOG, obesity associated GDM could potentially be prevented by targeting the risks and lifestyles of the women in that category with BMI 25-29.9 (overweight) and 30-34.9 (obese). Preventing obesity using healthy eating and regular exercise is the key component to women’s health care before and after conception. Eating healthy foods, keeping active and losing excess pounds, before pregnancy if possible, may be the best preventative care and treatment plan.

GDM, even with its lack of a gold standard of diagnostic blood glucose levels, is undeniably a risk for both mother and baby in the short term, pregnancy, and as well as long term, into the foreseeable future. Risk factors for GDM such as a high BMI, especially greater than 30, should be addressed early in pregnancy. If overt symptomatic diabetes is suspected, blood glucose testing should be done. However, the evidence does not support the broad net approach of screening utilizing the Glucose Challenge Test between 24-28 weeks gestation.

Works Cited

Buchanan, T. A., A. H. Xiang, and K. A. Page. “Gestational Diabetes Mellitus: Risks and Management During and After Pregnancy.” Nat Rev Endocrinol (2012): 639-49. Web.

Coustan, D. R., L. P. Lowe, B. E. Metzger, and A. R. Dyer. “The HAPO Study: Paving the Way for New Diagnostic Criteria for GDM.” Am J Obstet Gynecol (2010): n. pag. Web.

Crowther, C., J. Hiller, J. Moss, A. McPhee, W. Jeffries, and J. Robinson. “Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes.” (2005): 352. Print.

Desisto, C. L., S. Y. Kim, and A. J. Sharma. “Prevalence Estimates of Gestational Diabetes Mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS) 2007-2010.” Preventing Chronic Disease (2014): n. pag. Web.

“Does Gestational Diabetes Always Mean a Big Baby & Induction?” Evidence Based Birth. N.p., 03 July 2012. Web. 10 Jan. 2015.

Enkin, Murray. A Guide to Effective Care in Pregnancy and Childbirth. Oxford: Oxford UP, 2000. Print.

“Gestational Diabetes: Causes, Diagnosis & Treatment | BabyCenter.” BabyCenter. N.p., n.d. Web. 10 Jan. 2015.

“Gestational Diabetes.” Definition. N.p., n.d. Web. 10 Jan. 2015.

Hartling, L., D. Dryden, A. Guthrie, M. Muise, B. Vandermeer, W. Aktary, D. Pasichnyk, J. Seida, and L. Donovan. “Screening and Diagnosing Gestational Diabetes Mellitus, Evidence Reports/Technology Assessment.” Agency for Healthcare Research and Quality (2012): n. pag. Print.

Hartling, L., D. M. Dryden, A. Guthrie, M. Muise, B. Vandermeer, and L. Donovan. “Benefits and Harms of Treating Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis for U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research.” Ann Intern Med (2013): 123-29. Print.

Hayes, C. “Long-term Prognostic Factors in the Diagnosis of Gestational Diabetes.” Br J Nurs (2009): 523+. Print.

“Hyperglycemia and Adverse Pregnancy Outcomes.” New England Journal of Medicine (2008): n. pag. Print.

Landon, M. B., C. Y. Song, E. Thom, and M. W. Carpenter. “A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes.” New England Journal of Medicine (2009): n. pag. Print.

Simkin, Penny. Pregnancy, Childbirth, and the Newborn: The Complete Guide. Minnetonka, MN: Meadowbrook, 2010. Print.

Walkinshaw, S. A. “Dietary Regulation for Gestational Diabetes.” (n.d.): n. pag. Web.

“What Is Gestational Diabetes.” American Diabetes Association. N.p., n.d. Web.

The Gate Theory for Labor Support

I wasn’t paying attention, and the indoor soccer ball slammed into my head. The impact threw my head against the wall. Ouch! Instantly my hand went up to rub the spot where the ball made contact with my head and where my head made contact with the wall.

Maybe this exact sequence hasn’t happened to you, but the attempt at pain relief sure is common. It has been termed the Gate Theory or the Gate Control Theory. It is a theory you already practice when you, like me, get hit by something or walk into something. You use touch, massage or pressure on the painful spot to relieve and control the pain.

It seems natural and instinctive, but there is real honest to goodness science behind it. The nerve impulses sending pain signals to your brain travel slowly. But the non-painful impulses travel more quickly, blocking some of the pain impulses from making it to the brain.

These large fast moving nerve impulses may be stimulated by touch, pressure and massage. As these large fiber impulses outrun the small fiber pain impulses, they can effectively shut the gate on the slow pain impulses. The sensation of pain is then decreased and diminished.
As I worked with athletes and students in the Sports Medicine clinic in college, we applied the Gate Theory by using various modalities to help with pain relief and, ultimately, to lead to healing and rehabilitation. I was excited to see the Gate Theory pop up again in my doula training for labor support and comfort measures.

Through my doula training, I am learning additional techniques that stimulate the fast large non-pain nerve fibers to provide comfort to laboring mamas. My goal, with continuous labor support, is to utilize moist heat, pressure, touch and massage to send fast impulses racing ahead of the painful impulses and to close the gate on the slow pain fibers’ messages to the brain.

As a doula, I can help a laboring mama decrease her pain in childbirth. That decrease in pain may lead to fewer interventions and fewer complications for both mama and baby, and a more satisfying birth experience.

What stimulates these fast moving non-pain nerve fibers?
Applying moist heat
Applying cold
Massaging the feet, hands & fingers, back
Holding hands
Applying lip balm
Being submerged in deep, warm tub

What do I have in my bag of tricks?
Tennis Balls
Pool Noodle
Rice Pack (moist heat)
Massage Oil

What can a mama pack in her hospital bag?
Lip Balm
Small Hand Held Massager
Vibration pillow

What’s for Dinner? Health, Food & Enzymes Essay

Our health and our food choices are undeniably intertwined. Many moms, responsible for the shopping and food preparation for their families, carefully consider the best ways to get the greatest nutritional bang for their hard earned bucks.

According to an article from USA Today’s web page (May 1, 2013), the average cost of feeding a family of four a healthy diet can range between $146 to $289 per week. Add in a booming supplement industry amounting to nearly $30 billion annually, and it can be challenging to determine the best cost effective ways to promote the health of our families utilizing food sources and nutritional science.

Putting our budgets and our taste preferences aside, we find that food is, at its base level, a combination of protein, carbohydrate, fiber, fat, vitamins and minerals. Food nourishes our bodies providing the essential substances that sustain growth, promote repair and provide energy.

The building materials that are found in food are essential to life. But simply having the building materials available does not do the actual work of building or repairing cells, tissues and organs. Food enzymes have the unique capability to do the work by utilizing the supply of essential nutrients, such as protein, carbohydrate, fat, vitamins and minerals.

Our food choices may include animal and plant derived items. These living food substances not only contain some combination of the basic essential nutrients, but also contain enzymes. These enzymes are responsible for the majority of biochemical reactions that bring food to maturity and ripeness. In addition, these enzymes digest food in which they are contained when the conditions are right. For example, enzymes in an apple are activated when you begin to chew it.

Although not officially considered an essential nutrient because our bodies can manufacture enzymes for digestion, enzymes can be used up, exhausting our supply and leading to deficiencies. In an effort to maintain balance and meet its digestive demands, the human body will rob other cells, tissues and organs for the necessary parts to make more enzymes. From that stand point, enzymes are essential for digestion and for the overall health of the individual.

Dr. Edward Howell, author of Enzyme Nutrition, proposed that enzymes completed the picture for nutrition and digestion, and believed that they also held the keys to understanding chronic degenerative diseases. He concluded that many degenerative diseases that lead to human suffering are caused by enzyme deficiencies. He pointed to cooked and processed foods as the culprit in enzyme deficiencies.

In the process of making food shelf stable and of cooking, food is heated to temperatures beyond 118 degrees Fahrenheit. At this threshold, the enzymes inherent in the food are destroyed. This enzyme destruction in the food source puts additional stress on the individual body to generate and produce sufficient digestive enzymes to meet the meal load.

Dr. Harold Loomis, Jr., author of Enzymes: The Key to Health, studying the teachings of Dr. Howell, recognized the nutritionally beneficial synergistic relationship found in whole raw foods. He, too, pointed to the chronic problems created in the human body by systematically removing enzymes from the diet through processing, canning and cooking.

The enzymes found in all raw foods are the workers that are responsible for the benefits derived from releasing the essential nutrients in digestion. Although both plant and animal sources contain enzymes, plant enzymes may be of greater benefit primarily because of their effectiveness in broader pH ranges allowing them to work earlier in the digestive process. In Dr. Loomis’ research, he recognized that the plant enzymes from raw food along with our own salivary enzymes allowed a process called predigestion.

In predigestion, the salivary enzymes and the food enzymes released through chewing begin the work of digestion in the mouth. Predigestion continues as food sits in the stomach for up to an hour while the acidity gradually increases. Working in concert with salivary enzymes, plant enzymes can pre-digest a large percentage of the carbohydrates in the meal and thus, limit the amount of additional enzymes needed to finish the job of digestion.

Each raw, uncooked fruit and vegetable contains the enzymes that will digest it and will assist with predigestion. When indigenous food enzymes are destroyed, the entire burden of digesting the food is on your body. The human organs are not large enough to produce all the enzymes needed to digest the average American diet.

Health is dependent on the ability to digest, absorb, transport and utilize food. The enzymes found in raw food are an important part of this process. Cooked and processed food causes additional digestive stress, decreasing the ability of the body to release and absorb essential nutrients, and even forcing the body to steal from other cells, tissues and organs to manufacture sufficient digestive enzymes.

With the rising costs of food and the lure of a multi-billion dollar vitamin and mineral supplementation industry, it is important to understand how to provide the best health promoting foods and products for our families. Raw “living” foods, especially plant derived, provide essential nutrients packed with the proper enzymes to deliver the best nutritional bang for your buck.Fruit Heart

Valsalva Pushing versus Physiologic Pushing

A woman’s body was masterfully designed by her Creator to bring forth new life through labor and delivery. Until recent history, women were encouraged to follow their own body’s instincts in childbirth.

In the last few generations, our Western culture has responded to the laboring process as something to be managed rather than simply supporting a natural birth experience. Research is now confirming that the instincts a woman experiences in childbirth, including her urge to push spontaneously, provide the best outcomes for a mother and for her baby.

Coached, directed and Valsalva pushing are the terms used to describe the common medical practice of managing the second stage of labor. The rationale for directed pushing is to speed up the second stage of labor to deliver the baby more quickly.

In Valsalva pushing, the laboring mom is instructed to take a deep breath, hold the breath and push. When a contraction begins with full cervical dilation, a mother is asked to hold her breath while pushing for a count of ten. The expectation is to then repeat this cycle two to three times during the course of a single contraction until the baby is delivered.

Although directed pushing may shorten the second stage of labor, it creates problems for both mother and for baby with no clear advantages gained by speeding up delivery. Directed pushing is tiring and difficult for the mother. Valsalva pushing increases her fatigue. The forceful pushing also increases her risks for an episiotomy, tearing, trauma to the perineum and to the pelvic floor musculature.

The holding of her breath and the exertion of pushing (the Valsalva Maneuver) increases the blood flow and pressure, causing the stereotypical red face, head, arms and legs, which can lead to burst capillaries in the face, neck and eyes.

The mother’s blood pressure rises during the breath holding and exertion, then plummets when she breaks from the exertion of pushing. This cycle stresses her own cardiovascular system. Her breath holding lowers her oxygen levels while increasing her carbon dioxide levels.

As her body is responsible for nourishing her baby, this decreased oxygen leads to a decreased blood flow and oxygen traveling across the placenta. Changes in the baby’s heart rate pattern indicating distress are caused by Valsalva pushing.

The following vicious cycle can result.

Directed pushing=Hypoxic baby with an abnormal fetal heart rate=More urgent directed pushing=More fetal distress=Ob/Gyn Intervention such as forceps, vacuum extraction or c-section

It is normal for a laboring mother whose baby is ready to be born to feel a strong urge to bear down and push her baby out without anyone telling her how, when or what to do. Physiologic or spontaneous pushing encourages the laboring mom to trust her body and to follow her urge to push.

In her article for Midwifery Today entitled “Pushing for First-Time Moms,” Gloria Lemay explains that if the “Fetal Ejection Reflex” is there, the urge to push cannot be stopped. If it is not, then it cannot be forced.

An upright or gravity neutral position is safe for pushing and is often more comfortable. A mother following her own urge to push experiences a less stressful childbirth for both her and for her baby compared to directed pushing in the second stage of labor.

A woman following her own urge to push usually will wait for each contraction to build. She will then push for about 5 seconds, take a few short breaths and then push again. Physiologic pushing is generally easier. Even though it may take longer to deliver the baby, there is often less wasted energy.

The calm, unrushed environment of spontaneous pushing and a mom’s ability to breathe naturally result in more oxygen to the baby through the placenta. There is less chance of trauma to the perineum and to the pelvic floor muscles as physiologic pushing also allows more time for a gentler stretching of the perineum.

Laboring mothers are created to handle delivery without lots of input, tampering and interference. While directed pushing has clear risks for mother and for baby, research confirms that a woman’s own physiological urge to push leads to better outcomes for both the mother and for her baby.