Directed pushing

[LauraLou]

I have a question about helping pts push. My preceptor has the pt hold her breath and push for a count of 10 x 3 per contraction, while we hold her legs. This is how I learned in nursing school and is the way I have always seen it done.

The internship class I am taking says not to do any of that. The legs should be down, have her breathe while pushing and don't count, let her push however long/little she wants during a contraction. (This class is not held at my hospital but is a consortium of several hospitals which hold a joint class.)

I can understand the not holding your breath while pushing, that makes sense to me. But I don't see how having the pt's legs down and not coaching her to push would work. Is it really more effective than the traditional way?

I want to use the most update practices but I would really need to see a nurse help a pt push the new way before I would be comfortable trying it myself. All the nurses on my unit push the old way. I have been using the count to 10 x 3 method because I am not sure how to use the new method and there is no one to show me.

What are your thoughts how to help a pt push and what method do you use? Thank you for your help!

[Dayray, RN]

The method you describe (not holding breath) is called open glottis pushing. There has been research that shows that it results in more blood flow and oxygen to the baby and that moms can push longer with less fatigue.

When I first read about it I immediately jumped on the bandwagon and started using it with my patients. The problem is that 95% of the patients at my hospital have epidurals. I quickly learned that open glottis pushing is much less effective then the old hold your breath till 10 method. So I don't use it. Even if there is more bloodflow to the baby if you consider the differences in the time it takes using the different methods. Both mom and baby will benefit from the shorter pushing period I have seen when using closed glottis pushing.

Mom's and babies often tire during pushing if mom is exhausted or if baby starts to have a bad FHR your patient will end up with assisted delivery. To me the risks of assisted delivery (although not horrible in and of them selves) are greater then the risks of closed glottis pushing.

As for the legs in any position, If we are talking about a patient with an epidural I would strongly disagree. Many of the supposed risks of epidural are myth. However one thing that is true, is that it takes longer to push with an epidural. Certain positions can help make the process go faster. The tried and true one is with legs pulled back, which is because that’s the closest a patient with an epidural can get to squatting.

I use directed pushing; my process is one of assessment. I offer what instructions are needed in the beginning, assess to see if they are working and if not I change the directions. I'll often ask the patient if there is a position or breathing technique she wants to use. If it works great, if not I explain what is happening and suggest that we change it. I don't count unless the patient asks for it. I just tell them to stop pushing when they need to take a breath. If they are not pushing long enough I talk them threw it. I know many people count but I find it annoying. Also many times I notice that the volume of the counter becomes higher and higher until they are shouting. The last thing I think I would want in labor would be someone yelling numbers at me.

A patient without an epidural doesn’t need the same kind of direction but still may need some. If you can help them with simple suggestions then why wouldn’t you? Mostly with natural patients the directions are aimed at coping and breathing as well as keeping them from running away when the baby crowns. Most natural patients don't need suggestions for position or open verses close glottis pushing.

[SmilingBluEyes]

All this long-drawn-out closed glottis pushing can be avoided in anesthesized women IF we let them "labor down". But getting dr's to cooperate, is hard. So I often "fudge" dilation to buy time. Laboring down is the way to go.

[elliebellie]

I am a total believer in open glottis pushing after an experience I had last week. Primip with epidural, pushing for 3 hours. She ended up with a c-section unfortunately but the OB doing the surgery told her "I can tell how hard you worked pushing because this kid's head is so molded".

But closed glottis is the way 99.9% of our docs tell patients to push.

I am generally a very mellow "director" in the room & use the cues from the patient for how much instruction & direction they need. If they have great urges we go with whatever their body says. If a dense epidural, I'll be more creative.

And I've been known to "fudge" on dilation as well if the doctor is known for pushing immediately at 10 cm;)

[SmilingBluEyes]

Molding is not caused by closed glottis pushing, necessarily. It can be caused by poor pelvic/fetal head proportion, acynclitic presentation, or simply the kid being "engaged" or very low in mom's pelvis for several days or weeks.

[elliebellie]

Molding is not caused by closed glottis pushing, necessarily. It can be caused by poor pelvic/fetal head proportion, acynclitic presentation, or simply the kid being "engaged" or very low in mom's pelvis for several days or weeks.

In this case the molding was from the great open glottis pushing she was doing with an asynclitic head. None when we started, lots when we stopped. It was the 1st time I really saw that open glottis was just as effective for her as closed glottis.

[kenni]

it sounds like your internship was with a nurse-midwife (not that anything is wrong with that). nurse-midwives tend to stress the importance of making the woman comfortable & letting her labor the way she wants to. most MDs & nurses get so caught up in "what we learned is best" that we tend to just go with the norm.

[SelectRN]

I heard about an interesting study in Europe that studied patients allowed to labor down with epidurals vs pushing. They reported that patients allowed to push got to the same result within 15 minutes of laboring down, so why not let them labor down.

For me, many times directed pushing just makes people hold their breath to the count of ten and not necessarily push effectively. I prefer to let the patient dictate their pushing, but as other people have said before, you have to individualize to each patient.

[Mugwump53]

The only time I haven't seen some type of pushing get a baby out is when they totally refused and just laid there. I have seen 2 C/S because of "lack of maternal effort." Even when there is a language barrier, a baby comes out eventually. Most of the time, the body will take over and do what is necessary. (13 years in the business!~)

[Pollyp]

The article on spontaneous pushing is in JOGNN Nov/Dec 2005, Vol 34, Number 6, 695-702 and is titled Provider Support of Spontaneous Pushing During the Second Stage and the authors are Carolyn Sampsellem Janis Miller, Yuwadee Luecha, Kathryn Fischer and Lisabeth Rosten

Conclusion:

The proportion of spontaneous pushig by the birthing woman was positively and significantly associated with the proportion of caregiver communication supporting and encouraging spontaneous pushig. Importantly, spontaneous pushig did not significantly lengthen the duration of second-stage labor or totlal time spent pushing.

[Mississippi_RN]

Body will most of the time know exactly what to do. Advising a mom to hold her breath and push is definitely not the way to do it. It cuts off continous oxygen circulation in the blood and the fetus has to rely on the "fetal reserves" in the placenta. However, if you have an "aged" placenta with any degree of uteroplacental insufficiency, then you can run in to trouble, like late decels.

Other than that... you may have to encourage the mom to push if they have had an epidural and absolutely can not recognize the urge.

[SmilingBluEyes]

That is, again, why I so love laboring down. Letting the uterus do its work til mom feels urge or the baby is very low, is THE way to go.

[riern]

I'm with SmilingBlueEyes! Nothing beats laboring down. It's better for mom and baby.

:)