When to push with epidural?

  1. Hi Everyone! I am a labor and delivery nurse in a rural hospital seeking information from all of you experienced L & D nurses out there....

    Please speak to the concept of when pushing should start with a dense block from an epidural.

    Many of our physicians want the woman to start pushing as soon as complete dilation is achieved.

    Other nurses that I have worked with have a belief that if you place the woman in a very high fowlers position, with her knees below her pelvis, or a sitting squat, that the contractions will help facilitate descent of the fetus and thus accomplishing many things:
    1) saving time and energy on the part of the woman-she will push less if the contractions do some of the work with descent
    2) less labial edema from prolonged pushing
    3) less chance of an acynclitic descent of the fetus

    Please offer your insights on this matter. I am seeking an ongoing communication regarding this matter and will check back frequently.....THANKS IN ADVANCE!
    Alisa, RN
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  2. 17 Comments

  3. by   AlisaL&D
    kday

    Thanks for your great reply....I know some nurses that place the mother in a very high fowler's and drop the knees down to pelvis level...do you find that left lie works better for descent or are you choosing this position for it being the best for fetal 02 flow and mother's BP?

    Also, even if you had a perfectly functioning epidural, at what fetal station does the mother feel the urge to push....+1 or so....so we still need the head down there to get that sensation, yes? or am i missing something? Thanks so much for writing! Alisa
  4. by   at your cervix
    In my experience, I have found that even pts with a dense block will feel SOMETHING before the baby comes out. I usually let primips sit at complete for an hour (assuming that the baby still looks good on the monitor). If they don't feel pressure after an hour, I recheck them, if the baby is +1 or lower, I start pushing. If it is higher, I do a test push or two to see how well she will bring it down. If there is no descent, I usually let them labor down for another half hour or so as long as the baby is tolerating it. If she does bring it down well, I keep pushing her. (having pushed for three hours with my first baby, I know that anything to cut down on pushing is a good thing!!!!) Multips are a different story. I have found that once they are complete, they can usually push it out fairly quickly (as long as the baby is not OP). Laboring down can also help turn an OP baby and not exhaust the mom!!! The physicians that want you to push as soon as they are complete are a problem if they check the pt themselves, however, if you are doing the VE's, your pt's can stay "9 cm" for an extra hour (ha!ha!)
  5. by   AlisaL&D
    You lie-ing nurses! I love it! What a great idea....up til now, I only lied about her being 4 cm so she could get her epidural....now I will do more!! Thanks....Great advice....Anything more from you out there about positions for "laboring down?" Thanks in advance! Alisa
  6. by   bbnurse
    We call laboring down--when you just allow the position and the contractions to move the infant down in the pelvis. Letting nature take its' course and letting force of gravity work, so to speak.
    Is that what YOU others mean????
  7. by   HazeK
    with a heavy motor blockage from an epidural, about 75% of our docs prefer a "passive 2nd stage" until +2 station....on dayshift, while they are so busy in the offices! About 25% are still "old school" & want us to push when pt is complete. Suggestion: When you can, avoid lying...or you'll get a reputation for it! Instead, I just don't check "heavy epi" patients after 8-9 cms until pt c/o strong pelvic pressure or I see small var decels w/ each contraction...usually are +1 or+2 by then!

    Also, having done OB x 19 years in a unit w/ high epidural rate...must suggest you weigh each patient's need for an epi BEFORE 4 cms very carefully!!! You stated "up til now, I only lied about her being 4 cm so she could get her epidural.." I must suggest that in many cases giving an "early" epi is not in the patient's best interest! The pre-epi bolus is going to slow down her labor all by itself...then the heavy epi may slow it down even more! I HAVE given early blocks on very special occasions (PIH, "sh_tty tracings", very young teens who are frightend) but would suggest that active labor is NOT even well established until the pt is 4 cms! How about a nice HEAVY dose of narcotics instead? We often use Stadol 2mg+Phenergan 25 mg IVP for the "writhing, screaming" 2-3 cm patients!

    hope this helps!

    ------------------
  8. by   Q.
    I've let my patients push when they feel pressure, or when the infant is +2 or more. We also let our patients labor down as much as possible - and let the uterus do the work while they sleep!

    If an anterior lip is the problem, try positioning the patient on her side in which the lip is felt - it will often disappear. There is also the option of having her push through the lip while you simultaneously push the lip up and over the fetus's head. This has worked quite well for me.

    I want to agree with the above poster - in regards to epidurals before 4cm. I was shocked to read that you may "fib" about a woman's cervical check to get her an epidural. Aside from being "fraud" (not to sound like some staunch hard a**hole) it is definitely not always in the pt's best interest, as stated. Epidurals slow down labor, especially if given too early - and now you may have committed your patient to more interventions - pitocin, arrest of labor, causing a possile operative delivery of some sort, along with all the other risks of induction. Yikes! The best labor is one that is allowed to progress as naturally as possible.
  9. by   rdhdnrs
    Many of my patients have problems getting rid of that anterior lip, also, and golly-gee, you just don't want to try to push through and risk lacerating that cervix! And you don't want a resident or doc in there pushing them anyway, the tension level goes up exponentially. I've gotten to where if it's a normal delivery I just keep completeness to myself and call the doc when she's crowning!!
  10. by   amberm72
    HI Alisa--

    It appears as if you could be under some scrutiny regarding your "practice" at work. Lying to phsicians is an absolute no-no and one you will be caught and punished harshly. It looks like you work at Pullman hospital on the WSU campus---I know who your manager is and will be contacting them soon. I hope you can clean up your act!
  11. by   OBNURSEHEATHER
    WOW amberm72! This BB is a place for us nurses to talk to each other in confidence. It looks to me by your number of postings (1) that you registered at this site just to threaten! I guess we'll all have to start being careful about what we say in case someone we know is lurking in the darkness reading our posts waiting to narc on us!

    It's busy body snitches like you that give nurses a bad name!

    Heather
  12. by   Q.
    I have to agree with OBNurse Heather. Threats like yours are very unprofessional to say the least.
  13. by   jamistlc
    Originally posted by HazeK:
    <STRONG>with a heavy motor blockage from an epidural, about 75% of our docs prefer a "passive 2nd stage" until +2 station....on dayshift, while they are so busy in the offices! About 25% are still "old school" & want us to push when pt is complete. Suggestion: When you can, avoid lying...or you'll get a reputation for it! Instead, I just don't check "heavy epi" patients after 8-9 cms until pt c/o strong pelvic pressure or I see small var decels w/ each contraction...usually are +1 or+2 by then!

    Also, having done OB x 19 years in a unit w/ high epidural rate...must suggest you weigh each patient's need for an epi BEFORE 4 cms very carefully!!! You stated "up til now, I only lied about her being 4 cm so she could get her epidural.." I must suggest that in many cases giving an "early" epi is not in the patient's best interest! The pre-epi bolus is going to slow down her labor all by itself...then the heavy epi may slow it down even more! I HAVE given early blocks on very special occasions (PIH, "sh_tty tracings", very young teens who are frightend) but would suggest that active labor is NOT even well established until the pt is 4 cms! How about a nice HEAVY dose of narcotics instead? We often use Stadol 2mg+Phenergan 25 mg IVP for the "writhing, screaming" 2-3 cm patients!

    hope this helps!

    </STRONG>
    Greetings All Nurses,

    I have to agree with Hazel on all points! I am an advocate for "Natural Childbirth" and as such I think epi's only set the client up for a C-Section. But I have as a Doula suggested a analgesic like "Nubain". I like Nubain becuase it does not have the respitory depression like narcotic analgesics, as Nubain is a narcotic antagonist, in the same classification as Narcon, yet has analgesic properties. As a Natural Childbirth advoacte I want the client to take as many breaths as possible to evacuate built up lactic acid from the muscles, especially from these under used muscle groups, LOL. KEGAL, KEAGAL, KEGAL!

    Originally posted by amberm72:
    <STRONG>

    HI Alisa--
    It appears as if you could be under some scrutiny regarding your "practice" at work. Lying to phsicians is an absolute no-no and one you will be caught and punished harshly. It looks like you work at Pullman hospital on the WSU campus---I know who your manager is and will be contacting them soon. I hope you can clean up your act! </STRONG>
    I have my thoughts on this post too. First of all this person is new to the board and may not know it's purpose or the ethics. Geezzz this was her first post, Welcome amberm72! I think we as a group need to ethically realize this is bullentin board's purpose is to share in safe place, information, strength, hopes, and dreams. It is not a place to "lurk" or gather information against other nurses. But amberm72 has a valid point it just her methods are in error! She IMHO should have PM'd (Private Messaged) Alisha rather than make a threat! There is two sides to this coin. We want autonomy as a Professional group, we must also except part of this is the ability to discapline our members! The only process I know of is the Board and that is not really what am talking about. What I am talking about is peer/professional review. Since I do not know of a method to address this type of issue, I think amberm72 is only saying what she knows to do. It is wrong (unethical) practice to lie to get an order! It is also unethical to use this forum for the purpose of catching nurses doing short cuts or similar things! So we as a group (call it the bullentin board nurses group) should form a committee for this issue and send our suggestion to the board of nursing in each of our states, so that we can do our own peer review without fear of loss of licensure, LOL


    Peace,
    Have a Blessed Day,
    Jami




    [ May 19, 2001: Message edited by: jamistlc ]
  14. by   amberm72
    So now that everyone thinks I'm a narc--there are some issues I should clarify. I know my sweet Alisa personally and have worked with her closely for awhile now. It's true that I am new to the board and stumbled on my dear friends board and I thought I would rib her a little and give her heck for saying that she lies to physicians. Alisa is a very ethical and loyal person and nurse and at no time would she ever compromise pt. care with lying etc... to get what she wanted. There is one nurse anesthetist in particular that refuses to give epidurals to women that are not a good 4 cms and complains when the doctors "make" her do it because the patient is out of control. It is my fault for falsely posting false information intentionally to give Alisa a bad time and therefore misleading all of you. To be honest, I didn't think that anyone would respond--boy was I wrong. I would never "narc" anyone out unless I thought someones life was at steak. My goal is to keep my own patients safe and practice nursing ethically while being a patient advocate--I don't want to have to worry about how my fellow nurses practice as well, I just want to be able to communicate and bounce ideas off my fellow co-workers and hopefully better the nursing practice as a whole. I hope this clarifies this issue for you all. Please forgive my for misleading you all. I will humbly leave my honest opinion from now on. Please respond--comments are welcome

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