title: Pushing in labor: performance and not endurance.
abstract: OBJECTIVE
  It is believed that delivery is faster if women are instructed to voluntarily bear down in synchrony with their uterine contractions. Confronted by the large variance in the duration of the second stage of labor, many clinicians attribute a "fast" or a "short" expulsion time solely to the patient's willingness to cooperate or to the strength of epidural anesthesia if it is a factor. Yet, knowledge of pushing performance and the factors affecting it remain limited. We investigated the maternal, fetal, and labor characteristics that influence the maternal "pushing performance" and sought to design a predictive index that prospectively identified "high" versus "low" pushing performers.
  
  
  METHODS
  Intrauterine pressure (IP) was prospectively measured during the second stage of labor in 52 women recruited at one North American hospital. Recordings were begun after documentation of full cervical dilatation and descent of the fetal head to +2 station (on a -3/+3 scale). Each woman acted as her own control, received epidural anesthesia, and was alert and responsive throughout the study. Pushing (closed glottis technique) was performed in a standardized fashion. Multivariate analysis with linear regression was applied to identify significant associations between maternal, fetal, or labor characteristics as the independent variables and the percent increase in IP consequent to active pushing as the dependent variable.
  
  
  RESULTS
  Women in labor increase their IP 62% by actively pushing with a contraction during the second stage. A scattergram of the individual percent increase above the baseline IP integral revealed that for some women, pushing more readily increased their IP than it did for others (range, 0% to 192%). The percent increase was best calculated by a linear combination of myometrial thickness, estimated fetal weight, the maternal body mass index, and the obstetric need for labor augmentation (P =.007, r = 0.52, power = 0.975). A 66% change in IP provided the best separation between high and low pushing performance. Myometrial thickness provided the single strongest contribution to the regression equation's predictive value (P =.01, r = -0.36). A myometrial thickness of 6 mm had a specificity of 88% (but only 53% sensitivity) for the identification of women able to increase their IP by 66% over baseline.
  
  
  CONCLUSIONS
  In women in labor who have received epidural anesthesia, the efficiency with which maternal expulsive efforts are converted into increased IP is directly related to the patient's body mass index but inversely related to myometrial thickness, the sonographic estimate of fetal weight, and the need for labor augmentation.
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, the University of Maryland School of Medicine, Baltimore, USA.
authors.forename: Catalin S
authors.initials: CS
authors.lastname: Buhimschi
authors.forename: Irina A
authors.initials: IA
authors.lastname: Buhimschi
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Malinow
authors.forename: Jerome N
authors.initials: JN
authors.lastname: Kopelman
authors.forename: Carl P
authors.initials: CP
authors.lastname: Weiner
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural; D000773:Anesthesia, Obstetrical; D015992:Body Mass Index; D005260:Female; D005333:Fetus / Q000502:physiology; D006801:Humans; D007748:Labor Stage, Second / Q000502:physiology*; D009215:Myometrium / Q000033:anatomy & histology; D005082:Physical Exertion; D011237:Predictive Value of Tests; D011247:Pregnancy / Q000502:physiology; D011312:Pressure; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014590:Uterine Contraction / Q000502:physiology; D014599:Uterus / Q000502:physiology; D014636:Valsalva Maneuver / Q000502:physiology