Directed pushing

  1. 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!
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    Joined: Oct '02; Posts: 549; Likes: 19

    32 Comments

  3. by   Jolie
    The "hold your breath and count to 10" method seems to be the old stand-by, and may have some value for patients who have "heavy" epidurals and can't feel anything to guide their pushing.

    I have no research to back me up, but I believe the other method to be more productive for most patients, as they are able to work with their own bodies to bring about effective pushing without exhausting themselves, and stressing their babies.

    I also believe that allowing the patient to position her legs comfortably makes much more sense than holding them up (exhausting the nurse and the SO), or using stirrups, which are terribly uncomfortable and unnatural.
  4. by   JeanettePNP
    Just curious - if a woman in labor said she was more comfortable pushing in a different position than the one you were taught, would you let her do her thing or insist that "this is the way it's always been done"?

    My opinion is that a mother in labor RULES. Whatever she feels comfortable with is what should be done. No questions asked.
  5. by   topamicha
    When I was laboring, I definitely felt the urge to push. I couldn't resist it, it was so strong. I didn't need anyone to tell me to push! But, I can see how someone with an epidural might need coaching.
  6. by   SmilingBluEyes
    with natural labor, there is no need to tell a woman to push or how, I have learned. Labor under anesthesia, well that is quite a different thing. Sometimes, this MUST be coached to get anyplace at all.
  7. by   ladybugsea
    I'm an advocate for natural birth as well as active birth and hope to eventually become a CNM. I'm a pre-nursing student, starting clinicals this fall. Is my maternity clinical going to be a huge problem for me?
  8. by   NurseNora
    Sometimes I use directed pushing, sometimes not. I just play it by ear. A patient will start pushing on her own when she gets the urge. Many of our clients are so used to being told what to do that they don't know they can do what works for them. I tell them to do whatever their body is telling them to do. Usually they will start out with short, tentative pushes and then move into longer, stronger pushes as the baby moves down and the stimulus gets stronger. Give lots of support that whatever they are doing is right.

    Just because someone is 10cm dilated does not mean that they are ready to push. The baby will move down with uterine contractions alone to a level where the urge to push takes over. Change her position frequently so the fetal head is in the best position and it will happen.

    That said, sometimes I direct the pushing: if the baby isn't moving after a reasonable period of time (very subjective on my part), with stong epidurals, if the patient just isn't tuned into her body and is panicing and fighting her labor.
  9. by   SC RN
    JOGNN had a great article on this ... I believe it was the Nov/Dec 2005 issue but I can't seem to find it in all of my piles of magazines right now! It was titled something like "Spontaneous Vs. Directed Pushing" ... fantastic idea ... now if we could only get our docs to read the article and go along with it! :roll
  10. by   SmilingBluEyes
    Quote from ladybugsea
    I'm an advocate for natural birth as well as active birth and hope to eventually become a CNM. I'm a pre-nursing student, starting clinicals this fall. Is my maternity clinical going to be a huge problem for me?

    Depends on your attitude. Go with the intention to learn some things (which you will)--- while keeping your values intact. You will do ok.
  11. by   beckinben
    Quote from SmilingBluEyes
    Depends on your attitude. Go with the intention to learn some things (which you will)--- while keeping your values intact. You will do ok.
    Second this. You will learn things, and you will change your mind about things. But, speaking from a similar perspective (SNM in a very medicalized setting who has strong beliefs about the naturalness of childbirth), you will also learn to nod you head and go with the flow, knowing full well that when you get out of school, you'll have a greater capacity to be able to practice in a setting more to you liking with a style more to your liking.

    I directed push and have legs back with the strong epidurals, not with the rest, unless it's going not so well for some reason.

    Becki, SNM (graduating Aug 2006)
  12. by   kids
    Quote from SC RN
    JOGNN had a great article on this ... I believe it was the Nov/Dec 2005 issue but I can't seem to find it in all of my piles of magazines right now! It was titled something like "Spontaneous Vs. Directed Pushing" ... fantastic idea ... now if we could only get our docs to read the article and go along with it! :roll
    Could you possibly mean "A randomized trial of coached versus uncoached maternal pushing during the second stage of labor" by Bloom et al that was published in the January 2006 issue of AJOG?
    If so PubMed has the abstract with links to the full text (for a cost). http://www.ncbi.nlm.nih.gov/entrez/q...89004&query_hl

    MedPage Today has a teaching brief that discusses it. http://www.medpagetoday.com/OBGYN/Pregnancy/tb/2408

    And Nursing Center has a CE on the topic
    Last edit by kids on Feb 15, '06
  13. by   beckinben
    Quote from SC RN
    JOGNN had a great article on this ... I believe it was the Nov/Dec 2005 issue but I can't seem to find it in all of my piles of magazines right now! It was titled something like "Spontaneous Vs. Directed Pushing" ... fantastic idea ... now if we could only get our docs to read the article and go along with it! :roll
    I think this is the one:

    Sampselle CM. Miller JM. Luecha Y. Fischer K. Rosten L. Provider support of spontaneous pushing during the second stage of labor. JOGNN - Journal of Obstetric, Gynecologic, & Neonatal Nursing. 34(6):695-702, 2005 Nov-Dec.

    Becki
  14. by   Dayray
    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.
    Last edit by Dayray on Feb 16, '06

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