Natural or Directed pushing

[Bazooka]

I have just finished my OB clinical rotations at a hospital that uses midwives. I loved being at this hospital because the midwife and nurse were with the patient the whole time while she was pushing (encouraging her), and the baby came out in about 25 minutes. This patient had an epidural, but the nurse wasn't standing there counting to ten the whole time, etc. It was a beautiful delivery.

I work at another hospital as a professional student nurse, and I had the wonderful opportunity to transfer into the OB department. At this hospital, there are not any Nurse practitioners or midwives working in the OB/neonatal departments. I was able to observe/assist with a delivery, and it was a completely different experience. Here, the nurse was counting to ten 3x during each contraction when it came time to push. The baby wasn't descending easily, and the patient was pushing for over an hour. Finally, the nurse said she would stop counting and let the patient push with each contraction. We were afraid the baby was getting a lot of caput. The OB came in, and the nurse explained that she was no longer going to count with the patient. Then the OB starts counting! The patient delivered after 2 hours of pushing.

I have only seen 3 deliveries in my life, but I am really wanting to be an OB nurse. Is it pretty standard for all the nurses to do the same thing per hospital or unit protocol? I am going to ask them more about this when I get to know the nurses on the unit a little better. What are your thoughts on pushing techniques, and does it seem like the hospitals/OB's/midwives determine the protocol or the nurses at the bedside. I was thinking that the patient should be the one to decide how she would like her labor experience to be, but sometimes 1st time moms don't know what to expect. They just do what they are told....Thoughts?

[CEG]

The literature is very clear: directed pushing is bad for mom and baby. It results in worse cord pH, lower APGARS, more fetal distress, increased fetal distress, increased perineal injury... and it goes on.

The issue is that many OB units do not provide good evidence-based care. Midwives are often known for their emphasis on evidence based care, but it's not universally the case.

Moms trust their healthcare provider to do what is best for them. If they don't research things for themselves, or even if they do and their provider tells them they are wrong, they typically go along with whatever they are told.

It's reasonable to believe that your health care provider has your best interest in mind, but sadly they do not always use best practice. I just came from a unit that was cutting edge in terms of implementing evidence based practice to one that is dinosaur age. Hard to deal with!

[klone, MSN, RN]

Once in a while, if the mom has a heavy epidural and simply cannot feel contractions at all, directed pushing is helpful. Most of the time, IMO, the woman should be allowed to push how it feels right, and only coached on it if she's using the wrong muscles.

[Bazooka]

Thank you for your responses! We were taught in school to go with evidenced based care, and let the mother push the baby out with the urge. We were told it was best to use the most natural techniques possible, unless the woman had a heavy epidural or didn't know how to push. I was surprised to see how it was done at the other hospital....the counting and direction didn't seem to be effective. I know everyone is different with labor, but it's no wonder there are so many c-sections. I am curious if this was just a unique case for the hospital or if all the births are done like this (it seemed standard with the particular nurse I was with). Who knows, maybe if I precept with a different nurse it will be different. Thanks again for responding.

[klone, MSN, RN]

It is different with different nurses. Counting is kind of a pet peeve of mine, and I don't count unless the doctor makes a stink about it.

[redbeads]

I agree with the evidence based care of non-directed pushing...it totally makes sense, especially regarding cord pH and utero-placental blood flow to the baby. I also do not count for my patients except for the rare time that the patient requests this b/c it helps her focus. That said, I have to point out that every delivery is different, and the fact that the non-directed pushing woman delivered faster than the woman who had directed pushing could very well be just coincidence....or it could have been due to epidural, gravida para, size of baby, size of pelvis, position of mom, position of baby...in other words, non-directed or directed pushing aside, there are a multitude of factors that determine how long a woman pushes. I am all for women doing exhale pushing (non-directed pushing) and pushing when they feel the urge, but with the high epidural rate that I work with, this is not always possible. I try it more and more b/c I know it is the "right" thing to do, but it is very hard to get a woman with a dense epidural to push effectively using exhale, or non-directed pushing. Very recently, I had a patient who was a multip with a dense epidural, who just could not get the baby to move, no matter what we tried (and believe me, I nearly exhausted my bag of tricks). Finally, with a C/S as the alternative, we turned off her epidural. After two hours, she finally felt a mild urge to push and I let her push how she wanted (interestingly, she pushed holding her breath). After 45 minutes of this, she finally delivered a 7lb baby in the occiput posterior position.