What is an effective push during labor?

I got this comment recently on my blog about pushing:

"When I gave birth last year, my midwife kept telling me I was "wasting energy" by making noise while pushing. I was sure that I had read that this idea was untrue, but I was doubting myself. In the end, I couldn't figure out how to push without noise, so I just ignored the midwife! I am going to bookmark this post to read before I have another baby (God willing!). "

I felt like what we had going on this scenario was  a different idea of what an effective push was and what it means to "waste energy".

I'll start with the first term.  What is an effective push?  I don't think this has been explored by academia, but I think most medical professionals would argue that an effective push is one that pushes the baby out as hard and as fast as we can.  This is also deemed as the best way to go about birthing.   If that is the definition, than pushing as hard and as long as you can may indeed be the best way.  In general, the medical world tends to view birth as needing to happen fast and on track.

I would argue that effective pushing encompasses much more than that, and that pushing a baby out fast, is not really what is important unless it is medically necessary.  What we need to look at is the whole picture.  How is the woman coping during this stage?  What effect is the type of pushing having on the baby?  Is the noise of labor helping a woman to cope or not?  And, is the pushing helping the baby to move into a better position to be birthed? 

From one study we find this result:

"The baby fared better with spontaneous pushing, with higher 1- and 5-minute Apgar scores, and higher umbilical cord pH and Po(2) levels. After the birth, women expressed greater satisfaction with spontaneous pushing."

At a conference I went to at AWHONN, these ideas where also discussed.  I can't find the reference right now, it basically was showing more research than this to show that spontaneous pushing is better for both mom and baby on many different levels. 

So you can see that women feel better about spontaneous pushing, and the baby does better also.  One thing I have heard from women who grunt or make other noises during pushing is that it helped them to cope with the intense feelings during this stage. 

What we do need to be careful about, is making sure those noises are good noises vs those that indicate distress.  This takes an experienced ear and training.(Which goes back to my whole post on the need for medical professionals to get more training in normal physiological birth).  Once we can differentiate those two, we can decide if more medical or direct help with pushing is needed.  If a woman is more distressed with pushing she may need more directed coaching.  Again, though, that takes experience which is lacking by most people who help deliver babies.

Another research article sums this idea up well:

"It has become custom and practice within the midwifery and obstetric professions in the English-speaking western world for women to be required to follow very specific instructions on how to push in the second stage of labour. There is very little literature on the behaviour of women using spontaneous pushing in the second stage of labour. In a pilot study of a randomized controlled trial comparing spontaneous (n = 15) with directed (n = 17) pushing, the behaviour of the women was observed and recorded. The findings from the observational part of the study are reported in this paper. When pushing spontaneously women do not instinctively take a deep breath, they do not start expulsive effort with the commencement of the contraction, and they use both open and closed glottis pushing. In order to assist women in the second stage of labour, those caring for them should be aware of what is normal behaviour when women are using spontaneous expulsive effort."

From what I have personally observed from women who are not coached, is that they will sometimes push hard, sometimes not.  Sometimes they don't even push during a contraction.  Noises are usually normal(though for some it can be a sign of distress).  The most common noise that I hear is a low moan or grunt. 

Then we have to go back to the idea of "wasting energy".  I feel like that is a very subjective term, but I have heard it often.  Essentially it means the same thing as ineffective pushing....which means the mom is not pushing the baby down as fast as she can.  How would I answer?  "Is the mom coping well?  Is baby doing ok?  Is she making some progress(and that can be subjective also)?  Is she doing ok medically and psychologically?  If yes to all these questions, then how in the world is she wasting energy?"