Do you count?

[ayndim]

I am a pre-nursing student and l&d is a particular interest of mine. Maybe because I have had 3 little ones. Anyway, I watch these shows on the discovery channel and I hear the nurses counting. To me it is just plain annoying. And when I was delivering I think I would have told off anyone who did. Well with #1 my hubby did try to count but the CNM told him I knew when to push and for how long before I got the chance. So do you count when your moms are pushing? If so do any of your moms ask you not to? If you don't do any drs/cnm's want you to?

Just curious.

Thanks

[Zhlake]

I never ever count for moms that have not had medication or very little of it. Their bodies know how to push better than I can teach them.

For moms with epidurals I do usually count since they can't feel much.

Studies have shown that the long sustained pushing is not as good for the baby has the shorter "grunting" pushes that is more natural.

[lisamc1RN, LPN]

I have always found those baby shows to be annoying and to not be very realistic in their representation of what goes down at birth. They condense so much. They also seem to do what is "expected" , like counting. I can understand if a mother is having difficulty concentrating that it might be helpful, but otherwise, it's distracting and annoying. I have had 4 babies and always knew when to push. My husband started counting for me, with my first. We went to classes that told him to do it that way. I told him to shut up and let me do this! :chuckle He hasn't counted since!

[Dayray, RN]

it depends on the patient.

I don't ask them I just explain how to push and then see if they pick up on the timing. I give them pretty general instructions and then see how much of it they pick up on their own. If after a few pushes if they seem to be pushing too long or too short I count but I base the pace on their pushes and how starved they look for a breath. If they are pushing effectivily and are'nt tireing themselves out by pushing too long I'll let them do what ever the heck they want. If they need counting I make that Dad's job as I generally have to give other directions.

it's all bout what works for them. I dislike loud shouting or aggressive coaching but I have seen a few patients that needed it. You just have to figure out what works for them.

[Zhlake]

Here are some articles to read on directed pushing:

"Women will be encouraged to use exhalatory open glottis pushing versus forced pushing or Valsalva maneuver and discouraged from using prolonged closed glottis pushing (Mayberry, Hammer et al., 1999: Evidence Rating: I) (Parnell et al., 1993: Evidence Rating: II) (Sampselle & Hines, 1999: Evidence Rating: III)."

***Evidence-based clinical practice guideline. Nursing management of the second stage of labor.

http://www.guideline.gov/summary/summary.aspx?doc_id=2926

***Reconsideration of 'purple pushing' urged - Labor and Delivery

http://articles.findarticles.com/p/articles/mi_m0CYD/is_6_38/ai_99376501

***http://www.birthsource.com/proarticlefile/proarticle120.html

***http://articles.findarticles.com/p/articles/mi_m0CYD/is_3_37/ai_82879211

"There's also no need for women to routinely try pushing for a count to 10. When allowed to push on their own, they tend to push about three to five times each contraction, and they tend to push for about 4-6 seconds, Ms. Zottoli said. "If we let [the mother] go with her instinct, she's going to do a much better job of coordinating her intraabdominal and intrathoracic pressures to make a more forceful push."

Open-glottis pushing, rather than bearing down while holding the breath, also should be encouraged. When the mother bears down while holding her breath, she's increasing her intrathoracic pressure and decreasing her cardiac output and blood pressure. This results in a diminished blood flow to the fetus and an increased risk of hypoxia, Ms. Zottoli said."

[Dayray, RN]

Here are some articles to read on directed pushing:

"Women will be encouraged to use exhalatory open glottis pushing versus forced pushing or Valsalva maneuver and discouraged from using prolonged closed glottis pushing (Mayberry, Hammer et al., 1999: Evidence Rating: I) (Parnell et al., 1993: Evidence Rating: II) (Sampselle & Hines, 1999: Evidence Rating: III)."

***Evidence-based clinical practice guideline. Nursing management of the second stage of labor.

http://www.guideline.gov/summary/summary.aspx?doc_id=2926

***Reconsideration of 'purple pushing' urged - Labor and Delivery

http://articles.findarticles.com/p/articles/mi_m0CYD/is_6_38/ai_99376501

***http://www.birthsource.com/proarticlefile/proarticle120.html

***http://articles.findarticles.com/p/articles/mi_m0CYD/is_3_37/ai_82879211

"There's also no need for women to routinely try pushing for a count to 10. When allowed to push on their own, they tend to push about three to five times each contraction, and they tend to push for about 4-6 seconds, Ms. Zottoli said. "If we let [the mother] go with her instinct, she's going to do a much better job of coordinating her intraabdominal and intrathoracic pressures to make a more forceful push."

Open-glottis pushing, rather than bearing down while holding the breath, also should be encouraged. When the mother bears down while holding her breath, she's increasing her intrathoracic pressure and decreasing her cardiac output and blood pressure. This results in a diminished blood flow to the fetus and an increased risk of hypoxia, Ms. Zottoli said."

What have you seen with open glottis pushing?

I've tried it a few times because of these articles and others like them. I like the idea of increasing maternal and fetal blood flow.

Maybe it's because I'm unfamiliar with the technique and could be doing something wrong but pushes don't seem to be nearly as effective with the technique. With my patients they seemed to get more tired because they were pushing more times per contraction and it was hard for them to get the feel of exhaling while pushing.

I have also tried it a few times when the strip wasn't looking hot.

If you have some real=life experiences I'd love to hear them.

[SmilingBluEyes]

that is the beauty of natural labor; pushing rarely has to be coached at all. The advent of epidural anesthesia has made it necessary for us to coach women to push. I too, have ready MANY articles about closed versus open-glottis pushing. I like them to push for shorter times, perhaps MORE pushes with each contraction. And women seem to last longer and do better when they do, also. If I have to count, I only have them pushing to 6 or 7, NOT 10. The babies seem to do better, as well. Also, controlled deep breathing between contractions is a MUST ,and more often THIS I have to coach the moms to do, more than the counting itself. They just need a reminder now and again, and tend to hyperventilate otherwise.

[mother/babyRN, RN]

Some people don't initially get the idea that you keep air in your lungs for the time to push so I ask them to imagine holding their breath as though they were going to dive into a pool....A person will let you know pretty quickly if counting helps or doesn't..Pretty much look at every situation differently or individually. A lot of people are in the zone and let their bodies take over so short pushes might help in their case and if so, I encourage them to do so as long as we see progress. For someone who is tired or hyperventilating, I gently ( or firmly depending upon the situation) ask them to look at me and tell them about square breathing ( which we probably already practiced in prodromal labor or during a labor check so they have some familiarity with it)...Take a deep breath into the count of four, hold it to the count of four, exhale to the count of four and then hold it to the count of four, like a square. For those who are really frightened or distracted I will gently draw their face my way and do the breathing with them so they can see and participate. Helps them calm down and stop hyperventilating....If the woman likes the counting thing, I usually have dad, significant other or friend do it because it helps them feel they are involved and doing something, as opposed to not being able to participate in a helpful way, often how their families feel....

[Zhlake]

Some people don't initially get the idea that you keep air in your lungs for the time to push so I ask them to imagine holding their breath as though they were going to dive into a pool.....

What I was trying to point out is that research shows that open glottis pushing is more effective and better for the mom and baby. There is no need to old your air in--this would be closed glottis pushing.

[mother/babyRN, RN]

Yep, we have people from classes who actually believe that until they get to the pushing phase....And, as one who pushed out a nine and a half pounder with no epidural I can tell you that for me ( and the majority of my patients of fifeteen years of delivery), holding the air in when you push by far surpasses the sort you suggest in the way of effectiveness, but hey, just a personal and professional observation. If someone is pushing effectively and happily the way you describe, I am all for it, despite the fact I totally disagree...

[Zhlake]

Yep, we have people from classes who actually believe that until they get to the pushing phase....And, as one who pushed out a nine and a half pounder with no epidural I can tell you that for me ( and the majority of my patients of fifeteen years of delivery), holding the air in when you push by far surpasses the sort you suggest in the way of effectiveness, but hey, just a personal and professional observation. If someone is pushing effectively and happily the way you describe, I am all for it, despite the fact I totally disagree...

I did use open glottis pushing when I pushed out Brenna (my 9 pounder) in March of this year. And my 9 pounder Gavin 3 yo ago now that I think about it! (Neither one with an epidural either)

I am just showing you the research here. Personal and professional observation are helpful....but evidence based practice is the key.

[L&D_RN_OH]

I try to discourage Moms from holding their breath while pushing. Rather, I tell them to take a deep breath to fill their lungs, then exhale slowly through pursed lips while pushing, kind of like slowly blowing up a balloon. Professionally, I don't think prolonged breath holding is good for Mom or baby.

As a side note, I walked into a delivery the other day where the nurse was counting. She was up to 14 and going......

[SmilingBluEyes]

14????????????????????????? who precepted this nurse?