Open glottis pushing & Perineal massage

RNKitty · Jan 26, 2005

There is a lot to be said for letting the patient with and epidural "labor down", or let the contractions bring the baby to at least +2. Just tell the Doctor that she is 9cm, and you buy yourself a good hour. Then, allow her to push and don't call the doctor until you really want them to catch the baby - most docs don't have the patience to push more than 10 minutes before they cut an epis. That also gives you control of the pushing in the room and allows you to let the patient try open-glottis pushing. Depending on the woman and the scenario, it is a great method if you want an oxygenated baby.

BETSRN · Jan 26, 2005

Smilingblueyes and others... I noticed in one of your posts mention of open-glottis pushing and decreased manipulation of the perineal body. Could you please ellaborate on this. I hate to admit it... but I was taught the hold your breath for 10-seconds and push in the lithotomy position method. I have read a lot to the contrary, but all of the nurses I work with do it that way. Of course, that doesn't make it right. I'm interested in learning more about better ways. First... Can someone please describe open-glottis pushing for me. How have you seen this benefit the patient? Do you push for a lot longer? Nearly ALL of our patients get epidurals... and they are dosed so heavily that I'm not sure if any amount of waiting time would elicit the desire to push. More times than not, my patients do not feel as if they need to push. I would like to say here... go easy on me guys. I'm a victim of the culture that exists within my hospital. I have been an OB nurse for just over a year now and am beginning to get the confidence to do my own thing as opposed to exactly what I have been taught. Also... we are victims of the M.D.s who want you pushing ASAP! What can you do to help women feel the urge, so to speak? I know that women tend to push so much better when they have the desire from my experience. Any ideas on position variations for 2nd stage with epidurals.
And... why decreased perineal manipulation. I was under the impression that perineal massage helps the perineum to stretch. Share please.
Thanks in Advance for all your insight

The longer you keep the doc out of the room, the better the mother will be. With less manipulation of the perineum (by docs fingers) there will be less liklihood of bleeding and unnecessary tearing or cutting prematurly.

Relaxing the facial muscles (when pushing), meaning no clenching the teeth with bearing down, will relax the perineum. meaniong when you tighten your facial muscles you are tightening the perineum as well.

Nurses do it the old way because they have never been shown differently. Lithotomy is the WORST way to push because you are totally working against nature.

BTW, perineal massage is totally different that perineal manipulation when the doc has hands on the perineum trying to stretch things when it isn't time for that area to stretch. BIG DIFFERENCE!!

SmilingBluEyes · Jan 26, 2005

Betsy said it well. But many don't know this cause it's still considered "best" to have a person "push til 10", holding her breath the whole time, (purple pushing I call it), and stretching the perineum ("ironing" it's often called) are used all the time. Both practices are being questioned these days for the reasons already stated. Pushing to 10 tires a mom out and reduces oxygen available to the baby. It's very, very strenuous and a person can only do this so long before becoming exhausted. And her baby needs all the oxygen he/she can get in labor as the stress of labor will reduce oxygen available to him/her just in the contractions it produces.

If a person chooses to be coached to push, and wants someone to count, I usually only have them push to 6 or 7, not 10. Also, stretching the perineum can be harmful and create inflammation, making it subject to tearing. It's far better to let the baby come down slowly, letting nature stretch the perineum gradually. Applying heated compresses to the perineum is often helpful and can feel VERY good to the mother. Some midwives like to use warmed olive oil for this purpose, or warm, wet washcloths, like we use at the hospital.

Betsy is right--- the longer we keep the doctor out of the room, the less manipulation to "hurry things along" there likely will be. I wait with primips to get the doctor over until the baby is nearly crowning usually (the doctors are at home at night). And with multips, have the doctor aware they might want to come in, when they are about 8cm if they are moving fast. Then, I tell them when they get to the hospital, I will call them in when they are needed and equipment is ready. Usually, they are happy to rest in the lounge or watch TV until that time (it is night shift and that is a distinct advantage we have at night). The doctors do not want to sit thru extended pushing either, where I work.

And yes, "laboring down" is invaluable. Especially in the presence of epidural anesthesia, the uterus can push that baby down all by itself with no effort from mom, conserving her energy and oxygen for baby. I always let a mom labor down unless a baby is in trouble, at which point, the doctor will be called in to assess the situation. Leave her alone! Let her rest til the baby is nearly ready to crown and she will THANK YOU! Believe me.

A mom without anesthesia will "feel" what is right to do, if we let her. She can tell us what she needs to do, more often than not. She will "grunt" and "groan" her contractions, (in the transition and final phases) gently pushing the baby down with these efforts. Almost NO mom will naturally push, holding her breath to a count of ten, to get her baby out. She will more likely push in spurts, to relieve the tremendous pressure she feels during each contraction. This is a good thing! Seems nature has a way of taking over and they just do what comes to them, and all I do is keep them focused and reassure them what they are feeling is normal and ok. I listen to them, keeping my mouth SHUT unless they NEED me to intervene. The baby will come down faster and better if they are sitting, squatting, standing, anything but laying on their backs. I have them sit on the toilet or chair more often than not to help them with this and sometimes, babies literally FLY down as they squat. This is truly amazing to behold.

Hope all this helps you. The more we let nature take its course, the less likely tearing and instrumental intervention will be needed, most of the time.

lifeLONGstudent · Jan 26, 2005

smilingblueyes - you are a great teacher! thanks for taking the time to be so in-depth and detailed!

lifelongstudent

SmilingBluEyes · Jan 27, 2005

wow that is HIGH praise indeed. Thank you lifelong!

SheaTab · Jan 27, 2005

Thanks so much for all of your insight. Can any of you offer some alternative positons for 2nd stage with the anesthetized patient? Thanks!

SmilingBluEyes · Jan 27, 2005

you can have them push on their sides....first one then the other. This works amazingly well for OP babies.

RNKitty · Jan 27, 2005

My hospital has a 90% epidural rate (and the way we are going, soon we will have a 90% C/S rate too :chuckle ). However, these aren't the blocks of the early 90's. My patients can usually move around in bed, use squat bars on the birthing beds, sometimes even push on their hands and knees (also great for OP babies). About once every three months I get a gal who does a wonderful natural birth, and that keeps me going through all the crap for another 3 months.

BETSRN · Jan 27, 2005

Thanks so much for all of your insight. Can any of you offer some alternative positons for 2nd stage with the anesthetized patient? Thanks!

Beside pushing on the side, sitting them straight up and/or using the squat bar works great. Using nature is a great thing. They don't teach that to docs in school: nor do they teach patience. If you have the standard birthing beds, put the foot of the bed down and have them turn around and kneel on the foot part and lean forward on the other part.

We also use the squat bar as a foot rest. Then we tie a sheet around the middle of bar and have the mom pull on it (like a rope) instead of using the bed handles, which are often not in the right spot for her arm length. Mom can focus her energy better that way. That's the best trick.

BabyGuide · Jan 27, 2005

it's great that evidence is now revealing the best practices for helping women with second stage labor! a really helpful, evidence-based clinical practice guideline for managing women's second stage of labor was issued in 2000 by the association of women's health, obstetric and neonatal nurses (awhonn). it is based on the highest-quality research and expert recommentations. here's a quote from the summary:

"women should be encouraged to push for 4 to 6 seconds with a slight exhale for approximately five to six pushes per contraction or as tolerated by the woman and fetus. traditional breath holding for 10 seconds should be discouraged (thomson, 1995: evidence rating: i) (roberts & woolley, 1996: evidence rating: iii)...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)."

it also suggests that women be allowed to rest as needed, rather than being required to push with every contraction.

title: "evidence-based clinical practice guideline. nursing management of the second stage of labor." (monograph). washington (dc): association of women's health, obstetric and neonatal nurses (awhonn), 2000 jan. 27.

the complete guideline can be ordered from awhonn (www.awhonn.org):

you can take a look at the summary of its recommendations --->

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

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WhatToDo · Jan 27, 2005

Sorry for the ignorance, I'm not yet a nurse. But I am realyl astonished at how crappy docs can make this whole process. I'll be sure to have a midwife when I have a baby!

I had no idea that the uterus can actually push the baby all the way out without pushing. I always thought that at some point, women get the urge to push and that pushing is necessary. Do women only get the urge to push becuase that is what they see on TV, what the docs says etc.?