Not sure how to word this - fingers in while pushing

**canoehead, BSN, RN** · Jul 2, 2005

I always thought that was something I wouldn't want done as a patient. Never seen it make much difference (we must be doing it wrong :) )

SmilingBluEyes · Jul 2, 2005

I prefer to let patients labor down until they feel pressure and/or a desire to push.No need to stick my fingers in there this way at all.

amber1142 · Jul 2, 2005

Ok, I'll try to word this as well as I can. You know how you can "help" epidural pts push by putting your fingers in the birth canal and creating pressure on the posterior wall? I was taught just to push your fingers down to "show" them where to push. I've seen RNs and MDs do it different ways, like just pushing and also stretching (moving the fingers in a sweeping motion). I always just push down when I do it, bc I don't want to cause too much swelling.

Sounds like they're stretching the perineum at the same time. Might as well kill two birds with one stone as long as you have your fingers there.

SmilingBluEyes · Jul 2, 2005

I would caution: too much manipulation of the perineal body may cause swelling and inflammation, leading to tearing and/or injury. Many do not recommend perineal "ironing" or "stretching" anymore.

Rather, use warm moist compresses and let the body do its work stretching the perineum naturally as fetal descent progresses.

allnurses Guide · Jul 2, 2005

I've never done either . . . the doc does it sometimes as the patient pushes. Both ways.

steph

amber1142 · Jul 2, 2005

I would caution: too much manipulation of the perineal body may cause swelling and inflammation, leading to tearing and/or injury. Many do not recommend perineal "ironing" or "stretching" anymore.
Rather, use warm moist compresses and let the body do its work stretching the perineum naturally as fetal descent progresses.

It wasn't a recommendation; it's a comment on the possible rationale. We all know that evidence based practice in obstetrics is as rare as hen's teeth.

USA987, MSN, RN, NP · Jul 5, 2005

I had it done with my second delivery...I hated it! I wanted to scream at the L&D nurse to get her hand out of there. Even though I had an adequate epidural I felt all of it.

I have seen docs do it both ways as well.

I, too, am a big proponent of laboring down...just wish I could convince all my docs of that! :rolleyes:

pebbles1977 · Jul 5, 2005

I had it done with my second delivery...I hated it! I wanted to scream at the L&D nurse to get her hand out of there. Even though I had an adequate epidural I felt all of it.
I have seen docs do it both ways as well.
I, too, am a big proponent of laboring down...just wish I could convince all my docs of that!

Here's the thing: most everyone (MDs and RNs) on my unit does this. I've had several pts tell me how helpful it is (those with the epidurals). Those that don't have them, I try to only put my fingers in there sparingly, as the MDs will want a progress update. We're taught to pretty much check the pushing status regularly (although you can tell eventually how well they're pushing, right?), and if it goes over and hour with pushing, the MDs are in there wondering what's going on. If it's an epidural pt (even with a reassuring strip) pushing for 3 hours; she's automatically going to get a VE.

But I digress... my original point was to ask (since this is an expected and routine practice at my hospital) which method was more used, if any. It's good to know that a lot of people don't do it at all. But for me, God forbid the attending (or resident even) walks in and I can't automatically report the station. Then again, even if I can, there fingers are in there going, Push here! Push here!

SmilingBluEyes · Jul 5, 2005

It wasn't a recommendation; it's a comment on the possible rationale. We all know that evidence based practice in obstetrics is as rare as hen's teeth.

depends on where you work, and who your work with, I would say. :) I have found in places where most of the staff are members of AWHONN and other such organizations, and subscribe to journals and read a lot regarding best-evidence practice, evidence-based practices are more common. I also find having the priveledge of working with midwives enormously helpful in this area, as well. :)

But there is always room for improvement for us, isnt' there?

BETSRN · Jul 5, 2005

Sounds like they're stretching the perineum at the same time. Might as well kill two birds with one stone as long as you have your fingers there.

Ever heard the phrase "too many cooks spoil the broth"? Well, too many fingers in the lady parts can cause excess bleeding. One can damage the perineum wtih too much roto rooting....... The less you manipulate the better. Let the patient wait to push until she has the urge. It's much less work that way. No need to rush...........Warm compresses to the perineum aid in stretching and are much nicer.

Dayray, RN · Jul 5, 2005

Like so many things I think this question depends allot on the situation.

There are allot of different reasons to "put you fingers in there" and one thing I'll say in regards to all of them is that as little as necessary is best.

That being said there are allot of variables that will influence how much is necessary.

Firstly epidurals are very very different from hospital to hospital and doc to doc and patient to patient. With some epidurals a patient can void in a bedpan others can get up to the BR and still others need to have a foley because they can't feel their bladder at all. It depends on the meds, how much of the meds and what kind of injection as well as allot of other stuff. So in some hospitals your patients don't need "help" at all. However in my hospital most of the patients do need that help because no matter how much time they have to labor down they won't feel the urge to push. I always start out with pressure on the posterior wall and if the patient gets the hang of it I stop and just check progress every so often. However there are those that need that pressure to push against pretty much the whole time. You have to judge what is best for your patient based on how they do with or without it.

As for the swiping motion, I've wondered about this myself. I was trained to do it but now I usually don't do it. I think it can and does cause more swelling and damage. I do use it sometimes when there is a tight band of tissue that is likely to tear because I'd rather it not tear and often you can gently stretch it. There are studies that show that this really can cause allot of damage but I have also seen it work wonders for patients in some cases so again I think it depends on the patient and your assessment skills. Many times it's best to let the patients body do things on it's own yet there are times that a little intervention can help the patient do better.

I've heard the swiping motion refereed to as perennial massage but this is misleading. Perennial massage is talking about the area between the lady parts and the rectum. Here gentle massage does help a bit in preventing tears. If you do it to much it can cause swelling but if you do just a small amount it does soften and stretch out the tissue.

I would caution you in putting too much stock in resident's information. I often learn new things from residents at the same time I realize that much of what they know is from books and not personally tested. Also nursing and medicine are similar in some respects but very different disciplines. I don't blindly believe advise from anyone but I place allot more stock in what veteran nurses say then doctors or residents. Doctors really don't know all of what nurse's do just like nurses don't know all of what doctors do. If surgery needs to be done call a doctor, for questions on pushing call your veteran nurses.