“Time to Push!” Reconciling the Research When Supporting Our Clients

The birthing person is the decider. We hear this said at doula and childbirth educator trainings time and time again. But what does this actually mean if the information given is conflicting or confusing?

In the last few weeks, a couple of scientific studies on birth topics have raised questions in the birthing community. The first is a study which states that inducing at 39 weeks lowers the risk of Cesarean as well as the risk of some scary newborn outcomes. The second study states that in labors with epidurals, “laboring down,” or waiting longer until after full dilation has occurred to begin pushing, does not improve outcomes. I’m going to point out a few of the questions I have about these studies and then offer a few tips on how you could navigate this information with your clients.

In the 39-week study, one major takeaway is that while newborn complications were lower in the 39-week group, they were only slightly lower and not considered to be statistically significant. As for the risk of Cesarean, we don’t know which people from the “expectant management” (waiting for labor) group were also induced for one reason or another by the end of the study. So the comparison was done between a group of people who were definitely going to be induced at 39 weeks and a group of people who were not planning to be induced, some of whom birthed spontaneously, and some of whom were induced at 39 or 40 weeks, and up to 40 weeks 5 days. (No one in the study continued waiting beyond that.)

So when you say that the expectant management group had a higher Cesarean rate than the group that was induced at 39 weeks, we don’t actually know for sure if it was the timing of the induction which ultimately made the difference.

If we took a group of let’s say, 500 people giving birth at home and compared that with a group of 500 people who were induced at 39 weeks, I’d be willing to bet the Cesarean rate in the home birth group would be much lower. Granted, I do not have a scientific study in front of me to prove this, only the ancient tradition of midwifery and my intuition. And what of other outcomes in my imaginary study? This I don’t know either. But for now let’s stick to the subject and I’ll return to the factor of intuition a little later.

To make this information useful, here’s a sample script you could use when speaking to your client about the 39-week induction study:

Client: “I have to be induced at 39 weeks.”
Doula: “How do you feel about that?”
Client: “My doctor said it lowers my risk of C-section, so I feel like it’s what I need to do.”
Doula: “That makes sense. Do you have any questions about it?”
Client: “Not really. I’m not sure what I would ask.”
Doula: “Would you like me to suggest a few questions you could ask at your next appointment?”
Client: “Yes, that would be great!”
Doula: “You could ask:

Do you have any concerns about my pregnancy today?
What are the risks of induction during a healthy pregnancy?
Ideally what cervical dilation do you prefer that I have before inducing me?”

Remind your client that if it’s not an emergency situation, asking questions and asking for more time is always an option. Reassure your client that your support remains the same whether their pregnancy continues or whether they decide to be induced. Validate their feelings. You could say: “This is hard choice. I am with you and I support your decision.”

The main question I have about the “laboring down” study is: how did they know when someone was exactly 10 cm / fully dilated? This is supposed to be the exact moment, according to the study, that someone began pushing. Currently with the laboring down protocol, we wait until the birthing person begins to feel more constant pressure to have the provider check to see where the baby’s head is located in the pelvis. Waiting until the baby’s head is very low seems to work SO well, saving the birthing person’s energy and effort and making pushing more effective. I have some concerns about taking that option away based on what appears to be incomplete information.

For instance, was Pitocin used? We don’t know. Pitocin can affect postpartum bleeding, which was one of the outcomes they said was better / more favorable with immediate pushing. The rate of infection was also lower. But what if providers simply made a recommendation on when to start pushing based on whether the birthing person was showing signs of infection? Wouldn’t that make more sense? I’ve always gone by what a perinatologist once told me: “You’re not high risk unless you are.”

The third benefit to pushing right away was that the pushing stage was faster than for those who didn’t wait. But what does this really mean? Were forceps or vacuum extraction used? Did any of the birthing people have a Cesarean? What positions were used? Did they have peanut balls? How are they measuring the pushing time exactly? Each finding brings up more questions, none of which were specifically addressed.

Doulas in the birth room could use the following script in this scenario:

Provider: “You’re fully dilated! We need to start pushing right now to reduce your risk of complications.”
Doula to client: “Client, we had talked about laboring down with an epidural. Is that something you are still interested in? Do you have any questions for Dr. Smith?”
Client: “Which complications am I specifically at risk for? It’s really important to me to participate in pushing and respond to what I’m feeling and I’m not feeling an urge to push right now. What options do I have?”
Provider: “You aren’t showing any signs of infection and your baby is tolerating labor well. Would you be open to having some Pitocin started once we start pushing to help control any bleeding that could occur?”

This is of course an ideal response to this scenario and unfortunately, not very common, but with the doula participating actively, we can often get closer to informed consent. Helping our clients during pregnancy understand their provider’s practice style and how that could play out in the birthing room remains of utmost importance. Taking informed consent a step further, help your clients to distinguish the difference between being given permission to choose something and being given the full autonomy to make a choice, even if the provider disagrees.

Doulas and childbirth educators: We are childbirth experts! No, we do not hold medical degrees and we don’t know everything. But we know a lot about our clients’ preferences. We know everyone wants to have what they consider to be a safe and positive birth.

Of course we encourage clients and students to seek medical advice only from their providers. But it’s also normal for providers to hold differing opinions and interpretations of the research. As childbirth experts, it’s also acceptable for us to think critically and to weigh in. In fact, our clients depend on us for it.

We can do that by using the right language and following these steps:

  1. Look at things objectively.
  2. Continually examine your bias.
  3. Ask questions. Seek the truth.
  4. Always put the birthing person at the center of the conversation.

We are most effective when our clients understand that we support their expressed wishes, transforming the misconception of “following a doula’s advice” into “making my own decision with the support of my doula.”

It’s OK for your clients to change their minds and their plans. It’s OK to use medical tools and it’s OK to decline them. Either way, the decision cannot be the result of persuasion by us. There’s a big difference between persuading and providing supportive facts.

Medical research is one tool we have to learn about birth but it doesn’t always tell us the whole story. Remember that patient / client preference, intuition, experience, and medical recommendations can all intermingle in a healthy way. When used together, these elements have a more positive impact than when used separately. Encourage a well-rounded, informed approach, without attaching any feelings to the ultimate decision your client makes.

Keep reading, keep questioning, and keep doula-ing!

Jenny Bennett is DTI’s Director of Online Programming and works as a doula and childbirth educator with her company, Expecting the Best, in the DC metro-area.