Cervix stretching..dense epidurals - advice?

  1. Hi, I've been working as a labor and delivery nurse for about 8 months at a private hospital. Before that I worked labor and delivery, off and on, for 5 years at various facilities. I work with a nurse who has 17 years of labor and delivery experience and prides herself in getting woman delivered vs. going to the OR for c-sections. One of her methods is "stretching the cervix." She tells me that she often goes and "stretches" the cervix and throughout labor checks her patients often and proceeds to "stretch" them. For example, her patient yesterday had been on pitocin all day on the 7-3 shift and at 3 pm was 1 cm. During report, we were told that this patient would most likely be going to the OR and my co-worker told the day-shift that she would show them how it's done. The MD did an AROM, placed an IUPC and my coworker went into the room quite a bit, "stretching" the cervix at intervals. The patient delivered vaginally 6-7 hours later. A 6 pound baby. Ok - Here's my question..Is this stretching causing damage? I thought that this may cause trauma to the cervix so have not done it. I thought that nature should take it's course...but how can nature take it's course when 99.9% of our patients here get epidurals so dense you could drop an anvil on their legs and they wouldn't feel it?

    One thing I have noticed here and it's quite frustrating is that the epidurals that are given are so dense that oftentimes patient's can't even move their legs after they're given the epidural for hours and hours. Sometimes they can't walk for a couple of hours AFTER the delivery. Yesterday I got a 38 +3, gravida 1 patient at 3 pm and in report was told the was 9.5 cm and 1+ station. She had arrived last night ruptured. (1230 in am.) Pitocin at 5 mu/min and contracting q 2-3 min. I was delighted! Easy. In a little while she should start complaining of pressure and we could proceed. I assessed her and everything WNL except urine coming out of foley was cranberry colored and that she couldn't move her legs due to her epidural. Everything looks good so tell her to let me know when she's feeling pressure so I can check her and we can start pushing. Well, 30 minutes later she' starts complaining about pressure. She states she feels her contractions although they don't hurt. (She accurately tells me each time she's contracting.) I check her and she's complete and I put her numb legs into stir-ups to start pushing. We push for 3 hours...baby barely moves down 1 cm. Ends up a c-section at 7:30 pm and I feel like a complete failure. The entire time we pushed I only felt occasional pressure from her when she pushed. Methods I tried: sitting her up more...lying her back down...I tried the towel pull and she wouldn't pull. At one point, near the end, my experienced co-worker came in and proceeded to "iron" the perineum and told me that she got the baby to move down. This made me feel quite relieved...until I checked the patient after my co-worker finished whatever she was doing down there to cause quite a bit of bleeding...and didn't notice any difference in station at all. In the beginning I had the epidural turned down...finally, after the 1st hour I clipped it off for a while. Pt started complaining of pain and pushing didn't improve. NOTHING I did work. The MD came in after 3 hours, pt at this point states she wants a c-section, checked the patient, stated he did not feel comfortable with vacuum and due to to infant starting to get tachy (170-180), pt spiking fever (ruptured for 17 hours at this point) we proceeded to c-section. Outcome - 9/10 Apgars, ph 7.3, 7 pound 14 oz girl.....I still feel like a failure as a labor and delivery nurse today. I need advice on what to do to help my patients.
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  2. 11 Comments

  3. by   SmilingBluEyes
    I have some thoughts here, but unfortunately, I just got home from work, so I won't be quite coherent. LET ME JUST SAY:

    YOU ARE NOT A FAILURE!!!! We have all been where you are...self-doubting.....hang in there.

    Back later w/more.
  4. by   Dayray
    I wonder if we work at the same place =P

    I got my initial training at a place that didn't have many epidurals but where I work now we have a 95% epidural rate and they are fairly dense.

    So I see a few issues here, Ill try to address them all.

    #1- cervix stretching- where I work this is common practice by MD's and nurses. I have searched for some information about negative effects of this but have not been able to find any. I have however seen good results from gentle stretching. Some nurses will really stretch and roto rooter. I don't feel comfortable doing that and although (as I said) I have not found information saying that it is harmful, I wont stretch the cervix past what it will go to easily.

    So here is what I do and it does seem to progress labor. Now I don't do this as a rule and not every patient needs it done but if they are moving slowly or have scar tissue I will stretch a bit. I will check a patient, note their dilation and then stretch. If you have ever striped membranes, it's exactly like that. It's a circular motion and very gentle, with your finger bent slightly inside of the cervix. I don't stretch if I feel resistance. It shouldn't feel like tissue is stretching but rather like the folds around the Os are unfolding. Usually this will cause them to dilate 1/2 - 1 cm if they are in true labor. You should not have to put the strength of your arm into it, only your index or middle fingers. You shouldn't cause new bleeding by stretching. If the patient doesn't have an epidural the stretching shouldn't cause them horrible pain (unless they are in horrible pain just from an exam). Now in the case of scar tissue and a patient that has obviously been laboring but not changing their cervix, you may cause some bleeding but it still shouldn't require much effort (if it does you need to wait until the patient labors and effaces more). Some times with scar tissue all you need is to apply slight pressure with the pad of your finger to the outside of the Os.

    With that I offer a disclaimer, practices very from area to area and hospital to hospital. Some nurses are not going to feel at all comfortable with doing this. However at my facility given the epidural rate, density of epidural, the amount of chryo and LEEP we see, the standard practice of RN's in my unit and expectations of MD's I feel comfortable doing this (in some cases). In my state if you are accused of practicing out of your scope, you are brought before a board of your peers and it is judged by them weather or not you were out of your scope. The standard of practice at your facility is also considered. That being the case I believe that this is within the scope for an RN at my facility and other high volume L&D's in the city.

    #2 dense epidural, ours can be fairly dense too. Some nurse turn off or down epidural and that does seem to help but IMO it's kinda mean. So I only turn them down if nothing else works. First off you need to let pirmips labor down (passive decent) before pushing. Wait at least an hour after they are complete before pushing. In the case you offer above your patient was uncomfortable and that's why you pushed. In that case I would try a few practice pushes and if I didn't feel decent I would stop and make them wait, even if they are uncomfortable. If after an hour of passive decent and a few of the pushing tricks you tried, I would have them turn down or off the epidural. I hate turning down epidural but for most patients it is preferable to a C/S or silastic.

    #3 "Ironing out the vagina" = doesn't work. I have never seen it work and even our midwives use this one. It does make them bleed and can even cause swelling and worse tears but doesn't help with delivery. I was trained to do this and have all but completely abandoned it. I will sometimes gently massage a fold to help it get behind the head if I think it's going to tear.


    #4 please don't beat your self up. Patients choose epidural and it is well documented that they increase risk of a c/s . The way I look at it the things you do in an attempt to avoid a c/s are "extra" they really are above and beyond, so those that you do help to do a vag delivery are a victory but those that you cannot are not a failure. Most nurses at a hospital with dense epidural just expect their patient to have a c/s. You are doing a great thing for your patients by trying to get them to have a vag delivery and you are doing more then many of your peers would. You have to realize that it is the patient's choice to get an epidural and even though you can try to help them deliver vaginaly you can't make it happen. Patients chose epidural and they are warned about a higher incidence of c/s, they chose to take that risk and patients should be able to make informed choices.
  5. by   RNnL&D
    I totally agree with Dayray.

    A primip should labor down before pushing, especially with an epidural. I let all my pts with epidurals labor down until they are feeling significant pressure. Not "Um, I think I feel a little pressure." Of course, I work nights which makes it alot easier because the docs aren't hovering around to get their pts delivered.

    Decreasing or turning off the epidural is another option that does seem to help especially if pt can not feel well enough to push effectively. If you are adjusting the rate though, you should consult with the doc or anesthesia, jmo.

    This just happened to me last weekend. I had a pt who was scared to get an epidural because she knew the risk for CS and didn't want surgery. She did consent for an epidural at 4 cm, after AROM when the pain became unbearable. A few hours later, she was complete and -1. We pushed for 20 minutes with very little effect. So, since she was comfortable with her epidural, I encouraged her to sleep until she felt more pressure. Two hours later, after flipping from side to side, we started pushing again at +1 station. An hour later, the doc came in, turned off the epidural and we pushed for another hour and ended up with a vag delivery.

    I think, if your pt is comfortable, then by all means, let them rest until feeling more pressure. Once pushing, if it doesn't feel like she is pushing effectively, then something should be done with the epidural so she has enough feeling to tell what she is doing.

    About cervical stretching, I don't do it. The closest thing I do, is trying to push a cervical rim back while pushing if Mom is really wanting to push. During labor, nope.
  6. by   SierraN
    SmilingblueEyes: Thank you so much for your response! Thanks for telling me to hang in there. It really does make me feel better!

    Dayray: Thanks for your response. I too intially trained in a hospital that did not have as many epidurals, nor where they as dense, so it's a whole new ballgame. I appreciate the time you took to answer my question. I've heard of the "stripping membranes" and never had a clue as to what they were talking about because everyone always assumes you know what that means. I'm still a little confused - Ive heard other nurses say, "Oh, he must have stripped her membranes in the office today.." I just nod knowingly but if I was a cartoon I'd have a blank air bubble above my head when they tell me that! So thanks for explaining it.

    RNNL&D _ thank you for your advice also! With this patient, she did complain of pressure for approx. 30-40 minutes and told me that she was feeling a lot of pressure - when I checked her before putting her up to push I asked her to push and could have sworn I felt the head come down. Next time I will take my time and really be sure about this. There was a lot going on - The MD kept asking if I was putting her up to push yet, the 100 or so family members were pressuring me every time I walked into the room...it was just one of those messed up situations...The patient go her epidural at 2 cm...

    One option I bounced around in my head was the one you mentioned about just giving it a rest after the first hour...but the MD didn't want me to do that and wanted the epidural turned down or off because he said, "She's not pushing worth a damn."

    Ok...I'm going to let it go...I just want to keep improving. I think that with so many experience levels here there is so much to learn from each other.
    Last edit by SierraN on Nov 12, '05
  7. by   heartICU
    Quote from SierraN
    The patient go her epidural at 2 cm...
    Do your patients usually get their epidurals this early? I am a CRNA student finishing up my OB rotation, and for primips, they usually wait until they get to about 4cm before placing the epidural. Also - what drugs are used in the infusion?
  8. by   Dayray
    Quote from heartICU
    Do your patients usually get their epidurals this early? I am a CRNA student finishing up my OB rotation, and for primips, they usually wait until they get to about 4cm before placing the epidural. Also - what drugs are used in the infusion?
    I wish I could find the article that was published in many newspapers a few months back. It's been researched and proven that rules about 4cm or 5 cm before getting an epidural don't decrease the risks of C/S, failure to progess or fetal distress.

    If patients have some cervical change, regular contx that are painful they can probebly get an epidural and not have to wait until they get to xxcm.

    Our doc's leave it up to the nurses discreation when the patient can have an epidural. The reason that some doc's write orders to wait until 4 or 5 cm is because they don't trust the nurses to make the call for an epidural. In cases like that I just say the patient is 4cm even if they are 2cm.

    our hospial uses ropivicane and fentinal in their epidural drips.
  9. by   Newbie Nurse SMP
    Can someone tell me what exactly "ironing out the vagina" is?:imbar
  10. by   Spidey's mom
    Quote from *SMP* FUTURE RN
    Can someone tell me what exactly "ironing out the vagina" is?:imbar
    Yeah, me too and I'm an OB nurse!!!


    Well, I never stretch the cervix or strip membranes -

    steph
  11. by   Dayray
    Quote from *SMP* FUTURE RN
    Can someone tell me what exactly "ironing out the vagina" is?:imbar
    So, okay first you need a really hot iron.....

    no not really,

    It's when you take the index and midle finger of both or either hand and gently iron out the pelvic floor. Its suposed to help the baby move down and relax the pelvic floor but all it really does is cuase swelling and bleeding.

    It's a competly different thing to use a variation of this to help the patient feel the right point to push or to oreient them to their pelvic floor.
  12. by   SierraN
    Quote from Dayray
    I wish I could find the article that was published in many newspapers a few months back. It's been researched and proven that rules about 4cm or 5 cm before getting an epidural don't decrease the risks of C/S, failure to progess or fetal distress..
    I find that very interesting. I will look for that research when I have time. If our patients are 3-4 cm and contracting every 2-3 minutes, they're going to get an epidural. If our patient's are 2 cm and the doctor orders it, they're going to get an epidural. Each doctor is differant and there are very few hard and fast rules. There are numerous factors that we take into consideration.

    My biggest complaint with the epidurals is that there are just too dense and I hate that these patients are so numb they can't even move their legs! Sometimes it's just perfect - the patient isn't really hurting but they can feel contractions and move their legs...but for the most part they end up not feeling a thing and then when it comes time to push, especially if they are a gravida 1, it's a pain in the butt. Laboring down helps to an extent, but if it's a big baby, you're gonna have to PUUUUUSSSSHHHH! Most patients here would rather gamble with an increased risk for c-section then hurt...and I don't judge that decision. I did have my one and only child without an epidural...notice how I never did it again after that!!!

    As far as ironing goes, I have not done that either...I hate ironing of any kind. Some people say it works...some people say it does not...that's one thing I'm trying to learn more about. I don't want to be responsible for causing damage, but if there's more I can do to help, I want to learn about it. Yesterday, my patient's doctor was pushing with the patient (this is very rare - she is a female doctor that is partnered with another female and they actually push with their patients..the more experienced nurses HATE it, but I'm always hoping I can watch and learn instead of trying to figure what works and what doesnt by trying this or that. Anyway the doctor basically had her fingers inside of the vagina, rotating completely around the baby's head with lots of gel and ironing (as Dayray described) every time the patient pushed...I really don't know if it made a differance in speeding up delivery...I do know the patient was extremely swollen afterwards. I suppose it made a differance...it looked like it would...why else would she do it?
  13. by   alohanursejenn
    Just a reply.. I have worked L&D in 6 states, mostly in high risk L&D and am now finishing my CNM. It may be textbook to make someone wait until 4 cm to recieve an epidural, but it can be mean. I know many many physicians and CNM's who let their patients have an epidural earlier (2-3 cm) as long as they are laboring, especially if they are having an induction with pitocin or the provider performed AROM.
    I know this subject has been researched.. if it is evidenced based or not and further research needs to be done.

    Many of the epidurals in the North West facilities have fentanyl. One high risk facility I work at does spinal epidurals and the patients have good relief with leg movement.
    I have worked at facilities who give epidurals that are very very dense and where women are unable to push.
    Good luck with your CRNA!

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