Using the Valsalva technique during the second stage of labour

History of the Valsalva technique

The technique of deep breath-holding and then forceful pushing against a closed glottis during the expulsive phase of labour is widely known as the Valsalva technique, after the 18th-century doctor Antonia Valsalva who first described it (Perez-Botella and Downe, 2006). Hollins-Martin (2009) further describes the technique as ‘purple pushing’, presumably because with prolonged breath-holding the small blood capillaries in the cheek and face burst, giving a purple tinge to the face. Way (1991) describes a similar technique to increase pressure in the Eustachian tube and, as a result, reduce blockage in the inner ear. Other terms describing this particular style of second stage management include directed, coached and closed glottis pushing (Kopas, 2014).

The Valsalva style of pushing is in direct contrast to spontaneous, physiological pushing when the woman responds to her own instinctive urge to bear down, known as Ferguson's reflex (Bosomworth and Bettany-Saltikov, 2006). This reflex is initiated as the fetal presenting part moves down the birth canal and stimulates the stretch receptors situated in the posterior vaginal wall. This, in turn, leads to an increase in oxytocin production, which stimulates Ferguson's reflex and eventually leads to the woman experiencing an involuntary urge to push (Roberts, 2002). When a woman feels this involuntary expulsive urge, a health professional who is aware of the physiology underpinning this response can be assured that the fetus is in an optimum position in the birth canal and that further progress and spontaneous birth is likely. However, if a woman is extolled to push before she feels the involuntary urge to do so, obstetric conditions may not be optimal and so extra, strenuous pushing efforts may be required in order to achieve a vaginal delivery. This may lead to exhaustion and additional stress for the woman and her fetus.

Despite this, since at least the beginning of the 20th century, many women in the Western world have been asked to follow specific instructions on pushing during the second stage (Thomson, 1993; Hanson, 2009). Historically, these instructions were described extensively in the medical, obstetric and midwifery literature (Myles, 1964; Reeder et al, 1980) where women are advised to take a deep breath and hold it for as long as possible and then push down into the rectum as though opening their bowels. The usual aim would seem to be for the woman to fit in three strong pushes with each contraction (Bosomworth and Bettany-Saltikov, 2006).

The ‘pushing’ mantra, familiar to midwives, is described as such by Cooke (2010: 76):

As Perez-Botella and Downe (2006) highlight, it is unclear how the Valsalva technique became associated with women in childbirth. It has been suggested that a possible reason for its use was the perception that directed pushing led to a shorter second stage of labour (Bosomworth and Bettany-Saltikov, 2006). A prolonged second stage (longer than 2–3 hours) was considered particularly hazardous for the fetus, leading to increased perinatal mortality and morbidity (Rossi and Lindell, 1986). Early studies on the use of Valsalva pushing did appear to indicate that it led to a shorter second stage (e.g. Barnett and Humenick, 1982) and so it was considered the safest way to manage the second stage of labour.

Anecdotally, use of the Valsalva technique appears to have become widespread in modern midwifery and obstetric practice (Royal College of Midwives (RCM), 2007; Hanson, 2009; Cooke, 2010) despite a lack of evidence to support its routine use. There is, however, very little published research into the practices undertaken by midwives during the second stage of labour, so evidence around how often Valsalva is recommended in modern midwifery care is lacking.

Research

The accompanying physiological changes in a labouring woman's body while undertaking the Valsalva technique have also been described widely in the literature. Some research has suggested that the use of this technique, although introduced to reduce the length of the second stage and the perceived associated hazards (Barnett and Humenick, 1982), may actually have a detrimental effect on the woman and her fetus (Caldeyro-Barcia et al, 1981; Yeates and Roberts, 1984). A more recent, albeit relatively small, randomised controlled trial (RCT) involving 100 primigravid Turkish women without access to epidural anaesthesia found that women using a Valsalva-style pushing technique—as opposed to spontaneous pushing—experienced a significantly longer second stage of labour, a longer duration of active pushing and less reported satisfaction with their overall birth experience (Yildirim and Beji, 2008). Another small quasi-experimental study undertaken by Chang et al (2011) in a maternity unit in Taiwan compared the experiences of 66 women allocated to two groups. One group was assigned to ‘usual care’ (supine position, directed pushing and the Valsalva technique encouraged) and the other to the experimental group (women supported to push spontaneously in an upright position). Results showed that women reported greater satisfaction with their birth and less pain and tiredness in the spontaneous pushing group. The duration of the second stage was also significantly shorter in the spontaneous pushing group, with no difference in the Apgar scores of babies born in each group. As in the previous study, the results are limited as the sample size was small and included only primigravid women, with no randomisation in the study design.

In contrast, a larger RCT (Schaffer et al, 2005) including 320 primigravid women randomised to either a coached Valsalva pushing group or an uncoached, spontaneous pushing group found that the Valsalva group did have a slightly shorter second stage than did the spontaneous pushing group, but there was no increased incidence of prolonged second stage of labour in the spontaneous pushing group. In addition, there were no significant differences between the two groups in terms of spontaneous or assisted birth, perineal trauma or condition of the baby at birth. However, when a subset of 128 women from this study agreed to have their pelvic floor and urinary function tested postnatally (Schaffer et al, 2005), a significant number of women in the Valsalva pushing group demonstrated decreased bladder capacity and increased pelvic floor descent 3 months following birth compared with participants allocated to the spontaneous pushing group. Conversely, a later RCT (Low et al, 2013) found that spontaneous pushing did not reduce the incidence of postpartum urinary incontinence at 1 year following birth. It is worth noting, however, that these researchers identified various limitations to their study, including a high attrition rate and a high rate of crossover between the randomisation groups.

Physiology

A description of what occurs physiologically in the body during Valsalva pushing may help to explain why directed, forceful pushing may affect some women in an adverse way. During Valsalva pushing, as the initial deep breath is taken and then held, the intrathoracic pressure in the woman's body increases and her blood pressure rises. After forceful pushing is instigated, the intrathoracic pressure rises above that of the blood vessels returning blood to the heart, and this leads to a fall in the woman's blood pressure and a subsequent reduction in cardiac return and output (Barnett and Humenick, 1982; Enkin et al, 2000). As a result, there is a reduced supply of blood to the placenta and consequently less oxygen getting through to the fetus (Caldeyro-Barcia et al, 1981; Aldrich et al, 1995). The woman may then feel dizzy and give a reflex gasp, leading to a sudden increase in blood to her heart. Rebound hypertension ensues, which may increase over the duration of her labour (Yeates and Roberts, 1984).

Shaffer et al (2005) argue that the reduced bladder capacity and increased pelvic floor damage seen in the Valsalva group of their RCT could be due to the fact that in directed pushing there is a potential increase in the amount of pressure on the pelvic floor. This is because women are encouraged to push as soon as the contraction begins and to keep pushing for the duration of the contraction. Research has shown that women left to follow their instincts demonstrate a very different style of pushing to that directed in the Valsalva technique (Roberts et al, 1987; Thomson 1995). For example, they do not take a deep breath at the start of a push, they do not start pushing as soon as they feel a contraction and they tend to use a combination of both open and closed glottis pushing (Thomson, 1995). Prolonged breath-holding during a contraction is not the norm in physiological pushing. Instead, women tend to undertake a number of short, strong pushes during each contraction, with a deep breath prior to each effort (Roberts et al, 1987).

It is apparent that instinctive, spontaneous pushing bears little resemblance to the highly directive approach of the Valsalva technique. Sampselle et al (2005) further argue that birth attendants giving such detailed direction during the second stage of labour discount the woman's own innate and rhythmic imperative, which may lead to her losing confidence in her body's ability to give birth.

Birthing position

Valsalva pushing is associated not only with a specific breathing technique, but also with a specific position for the woman to adopt. In 1970, recommendations in the Peel Report (Department of Health and Social Security, 1970) led to a policy advocating that 100% of births should take place in hospital. Since this time, when hospital birth became the norm, most women in the UK give birth in a semi-recumbent position in bed (RCM, 2007). This position is the most convenient for Valsalva pushing, as it means that the birth attendant is able to view the fetal head clearly and assess descent while directing the woman to push. A semi-recumbent position, however, also stops the coccyx moving backwards and invariably leads to the woman slipping down in the bed into a supine position (Downe, 2009). A labouring woman adopting a supine position means that the full weight of the gravid uterus causes compression of the vena cava, which in turn leads to a fall in the woman's blood pressure, reduced perfusion of the placenta and reduced oxygen flow to the fetus (Humphrey et al, 1974; Johnstone et al, 1987).

As with use of the Valsalva technique, if left to follow their own instincts, very few women would chose to give birth in a supine position. As Gupta et al (2012) highlight, women select a number of different positions while giving birth and may choose to change position frequently. This systematic review around positions for second stage of labour highlighted a number of benefits for women of pushing in an upright posture, including reduction in the length of time of the second stage of labour, fewer fetal heart rate abnormalities and fewer instrumental deliveries.

If health professionals recommend that a woman uses the Valsalva technique during the second stage, they are also advocating that she adopts a specific position while giving birth. It would appear from the literature available that neither approach—in terms of pushing or position for birth—are ones that a woman left to her own devices would instinctively adopt.

A systematic review into the use of spontaneous vs Valsalva pushing during the second stage of labour (Prins et al, 2011) highlights that good quality RCTs investigating this topic are sparse and limited in generalisability, with findings that often appear to be conflicting and ambiguous. This review focused on RCTs, the aim being to compare the outcomes of women who were randomised to push using the Valsalva technique or left to their own devices to push spontaneously.

Another recently published systematic review into pushing methods for the second stage of labour (which included women who had received epidural anaesthesia) gave similar results (Lemos et al, 2015). Seven RCTS including 815 women comparing types of pushing with or without epidural analgesia were reviewed. As previously, there was no significant difference found in the length of the second stage of labour, duration of pushing, perineal damage or use of episiotomy between the two groups, and no difference in type of birth (spontaneous vaginal birth, instrumental birth or caesarean section). In addition, the authors of the review reported that potential adverse effects of pushing technique on the pelvic floor remain unclear.

A major limitation of any RCT in this area is the fact that there can be no blinding of health professionals or participants with regard to the group to which the participant is allocated, which could lead to bias. A high attrition rate and crossover between groups—because participants may use a combination of pushing techniques—could also be considered major limitations to some of these studies. There is also a lack of qualitative research in this area exploring what women want to do and how they feel during the second stage, or asking midwives about their decision-making processes and why they care for women during the second stage in the way that they do.

It is clear that there is no strong evidence to support the idea that directing women to push strenuously during the second stage of labour is best practice. More high-quality research is required and, until this is forthcoming, the recommendation is that women should be encouraged to follow their instinctive urges and push spontaneously during the second stage of labour (RCM, 2012; National Institute for Health and Care Excellence (NICE), 2014; Lemos et al, 2015) without forceful direction from health professionals. The NICE (2014) guidelines further recommend that, if pushing is ineffective or if the woman requests help, further support can be offered and strategies such as emptying the bladder, changing the woman's position and extra encouragement should be considered ahead of directed pushing.

It has been recommended that further research into various aspects of intrapartum care is required. This includes the way in which care during labour is provided by midwives practising in the UK, how the quality of care may be improved and how different approaches to midwifery care may impact on outcomes for women and babies (RCM, 2012). For example, an American study (Borders et al, 2013) used an observational methodology to explore how midwives offer verbal support to women during the second stage of labour. Interestingly, in this study, researchers noted a range of verbal support strategies used by midwives, with highly directive support being relatively uncommon. The authors accept that their small qualitative study is not intended to be generalised to larger populations, but it does raise awareness for other practitioners of types of support that are not always directive, such as affirmation, information-sharing and specific talk around the baby as a being in its own right. Similarly, Kopas (2014) ends her review of practices during the second stage by recommending that practitioners observe the practices of their colleagues with low rates of perineal trauma as a proactive strategy to improve their own outcomes.

Summary

Walsh (2007) argues that directing the second stage of labour in a manner such as the Valsalva technique is a prime example of the potentially disempowering impact of a biomedical model of childbirth, where women are made to doubt their ability to instinctively give birth without professional guidance. The practice also highlights the social construction of birth in the Western world, where the technical knowledge of doctors and midwives who ‘manage’ birth is seen as more relevant than the experiential knowledge of the women who are actually giving birth (Rothman, 1982; Bergstrom et al, 1997; Davis-Floyd, 2004). Jordan (1997) highlights the continuing power of authoritative knowledge in childbirth. It would appear that a hierarchy of control continues to exist in maternity care, where professional interpretations of what constitutes the ‘best’ in childbirth practices conflict with women's personal interpretations of what they want from the experience and their own instinctive knowledge of what feels right (Downe, 2010).

As argued by Bosomworth and Bettany-Saltikov (2006), because directed pushing requires the birthing woman to ignore her bodily instincts, it actually involves a transfer of control from herself to her caregivers. There is, therefore, a professional and ethical responsibility to ensure that its continued use is solidly based on up-to-date research evidence.

It is argued that care of women during the second stage of labour care should be guided by the health practitioner's professional judgement, informed by the latest available evidence and taking the woman's individual needs, risk factors and preferences into full consideration (Kopas, 2014). Ongoing assessment of the progress of labour and the wellbeing of the woman and her baby are fundamental to intrapartum care.

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