How do you hold legs while pushing?

[Selke]

Good morning everyone. I have another question for your collective wisdom.

How do you all hold a woman's legs while she's pushing? I hear/observe different things and wonder what you all do.

I was told once to hold a woman's legs and push back (if she's not holding them herself) from behind the thigh, by the knee, and to not push back on the foot.

Other nurses/midwives will push back on the feet as far back as they can (I'm not speaking in terms of a McRoberts Maneuver for shoulder dystocia, just ordinary pushing). I've been told by some to push straight back on the feet, knees bent sort of at 90 degrees (can't explain this, sorry). Others will splay out a woman's feet pretty far, legs not straight but more like 120 degrees, and held way out from her body, and push back that way (sorry, can't explain this either!) --

I like having a woman bring her feet together, bring her arms together in front of her and grab her ankles, if she's able to do this. This opens up the pelvis quite a bit.

What do you all do? Do you have resources that address this? Thanks!

[Selke]

I just transferred to L&D at a large teaching hospital with a top notch NICU. However, for all the deliveries I've been in the room for, mom's had a heavy-duty epidural and couldn't really feel to push. In addition to that, when mom's pushing, the nurses I'm precepting with lower the head to almost flat (translation, lithotomy). I'm not especially fond of it, but I am the new girl on the block. I don't like the idea of just sucking it up and staying quiet about it when I know that position has been repeatedly proven to be the worst. But, I don't know how to bring it up to the very experienced nurses I'm with...:chair:

The staff at the nice natural-birth hospital in CA I learned labor support from said to put the head of the bed pretty flat when mom's pushing, too. I thought that was a bad thing to do, lithotomy position and all that. They told me it helps the baby's head make the bend around the pubic bone (extension). I'm too busy to look it up right now, but I think I saw in a book a reason why this might work -- keeping the small of mom's back flatter helps the baby's head and body align better with her longitudinal axis; this is more like the position a mom will take if she's squatting. But ... it's the lithotomy position. I'll put a pillow under her hip for uterine displacement and sometimes other nurses will yank it out. I need to investigate this more. I'd love to take a seminar from somebody to learn more about labor support and optimal fetal positioning, now that I've been doing them awhile and have questions.

Pushing with a lady with a dense epidural is one of the most frustrating things about the job ...

[PegRNBSN]

I never hold legs while pushing. Had a seminar by a physical therapist who specializes in maternal health and she talked about the damage you can do to your neck and back over time holding legs. If mom can't support her legs, epidural or not, I use the stirrups or help her find a better position. As far as the head being down or not, one midwife whom I respect alot told me it's better to be flat than semifowlers if you think about what happens to the pelvic position. She usually has her patients squat or side lying for those with epis. Seems to work well.

[MissJoRN, RN]

Wanna be freaked out? That was our C/SECTION RATE. Our epidural rate? Ninety-frickin-five percent. Now, the C/S rate is partially explained by the large number of high-risk antepartum patients. But still.

And in re my back and joints: yeah, that's what I keep saying. But years of ballet and gymnastics and cheerleading disagree with us. And possibly something rheumatic, that's being looked into right now. So I work in the NICU. If I can lift a patient with one hand, and spend quite a lot of the day sitting down, I can get by on NSAIDs instead of a narc, which is better for everyone.

Uggg... I hear you... the hospital I'm delivering at has a 90-frickin-5 % epidural rate, too. I'm not too happy about that! 8 weeks to go and I still consider backing out of the hospital and practice and finding a better alternative. Quite a few of the nurses are pro-NCB, though, so I know I'll have some support, and they'll know with me, I don't care if they handle my care and don't call the MD in for everything... not like those pts who don't understand nursing and demand to know where their Dr is for checks, etc!

One of the RNs there demonstrated squating, ankle holding, and the ankle holding reclined position for me (and just for me, LOL, she knows I'm the only one in class doing exercises on home, on the ball, etc, and the only one hoping for no epidural.)

Professionally, I've mostly done couplet care/ post partum, but was called in to help out sometimes in deliveries. Our hospital had a lower epi rate but we did rather old-fashioned leg holding. Hips and knees both about at a 90 degree angle... kind of like an Allen (OR) boot stirrup in a high position. Of course, I was never called in for midwife deliveries so I'm sure they didn't use that type of hold! I would have loved to attend more of their births but they're so low-key any one extra would have been noticed, and most of them had a different routine for newborn care that I wasn't oriented to so I never even got to be "NRP-girl"

[elizabells, BSN, RN]

pts who don't understand nursing and demand to know where their Dr is for checks, etc!

At the hopital of which I've spoken, the docs DID do all the checks. I'm not sure if the nurses weren't allowed to, or what, but I never saw anyone but an MD do a vag exam...

[SmilingBluEyes]

IN teaching hospitals, often, the residents or doctors do all cervical checks...

In smaller ones like mine, the nurses more directly manage labor/delivery.

If a labor is natural, I tend to do what the mom wants, labor on the toilet, squatting, walking, in shower, whatever. I love to see her be able to choose what works and support that for her.

If there is an epidural (as in the majority of patients where I work) less choice is possible. These ladies can't kneel or squat at all. And I won't generally hold legs, unless the p atient is rather small. I have only ONE back. Our beds do have built-in stirrups we can use for this purpose, and I do use them if need be. Or I let family members hold their legs, if they choose and are healthy. I personally love to see patients push on one side or the other, esp if baby is OP----this works like a charm to help the baby turn to OA and come on down.