Pushing Instructions

[aunttae]

This might be a silly question, but how do you educate/instruct your pts. on pushing? I have been on L&D for a year and I still feel like I could say things differently. I work at a rural hospital where most have epidurals, legs in stirrups... etc. The dr. comes in for the last few pushes saying "push down like you are constipated" One Dr. hinted that I could be more clear in my pushing instructions (which I would agree) but left it at that. Any suggestions???

[theamberdawns]

Instruct patient put chin to her chest, take a deep breath and hold while pushing, to grab under thighs and pull legs toward abdomen curling around her belly, to RELAX LEGS and push. I tend to give a lot of supports/cheer patients on!!:typing

[HappyNurse2005, RN]

If they DO NOT have an epidural, i say "do what your body tells you to do. bear down when you need to" and they do what is needed. This is why no epidurals are wonderful!! occasionally, they are freaking out and need guidance, and then i try to calm them down, and encourage them to push/bear down.

If the DO have an epidural-

first of all, i skip the stirrups-they suck. foot pedals. i say "take a deep breath, and bear down into your bottom. when you have to, take a breath and do it again." also, show them where to hold their legs (behind legs or on top of knees) or, if they are on their side, or squatting wiht the bar, etc-it varies depending on where they are laying/sitting). refine instructions based on how they push.

i dont count to ten b/c some ppl can't hold it that long. or can hold it longer. no need to make someone feel bad b/c htey can only hold their breath til 7. plus, hearing 1, 2, 3, 4, 5, 6, 7, 8, 9, 10! 3 times a contraction, ctx q3min for 3 hours-BORING! and annoying. while she's pushing i'll say "good job, Jane! keep going you're doing great, right into your bottom, a little more ifyou can" etc etc etc just encouragement.

i'll ask her if she thinks she is pushing well, and give her help that she needs.

[HappyNurse2005, RN]

oh yeah, i tell them to tuck their chin down "curl up on that baby like a tube of toothpaste" then they tend to laugh. so i say, hey, when you curl up the end of hte toothpaste, the toothpaste does shoot out the end, right? lol. i try to be humorous and encouraging!

[RNBelle]

I love it when women don't have epidurals. If they do not have an epidural tell them they don't have to hold their breath, just follow what their body tells them to do. Sometimes they get a little freaked and need to be calmed done and focused. Now if they have an epidural I have them tuck their chin to their chest and take a deep breath in and push. And then encourage as necesary.

[NurseNora, BSN, RN]

AWHONN discourages directed pushing and when a patient doesn't have an epidural, it's wonderful to be able to tell them to listen to their bodies and just do what their bodies tell them to do. If the patient does have an epidural and you do have to do directed pushing they should not push to the count of 10 and they should push no more than 3 times per contraction.

If pulling on knees or thighs, be sure her elbows are out "like you're rowing a boat". I don't know why the elbow position should make a difference, but it does. Remind her to exhale before taking the next big breath as often she will try to inhale on already full lungs. Curl up around the baby, push the baby toward the ceiling (if she's on her back with her legs in stirrups).

If she has an epidural, let her labor down for a while. It's amazing how much the baby will come down with just the action of the uterus alone. Often she will spontaneously labor down until she feels pushing pressure even with a good epidural. Once she feels the pressure, you don't have to give her as much direction.

One thing I've done to help a woman feel the right place to push is to have her exhale forcefully against the back of her hand held against her mouth. Try it, you'll feel the pressure in your bottom. I have no problem with noisy pushes. Grunting is very effective and is less stressful for mother and baby both. Prolonged closed glottis pushing leads to decreased maternal cardiac output and therefore decreased uteroplacental perfusion. So let her grunt and groan if she wants. If she"s making high pitched screaming sounds, she's not pushing effectively. You know what the difference sounds like.

[CEG]

AWHONN also discourages the use of stirrups and encourages a supported squat position. Seems to depend on the hospital though whether stirrups are used widely.

I usually start out with my patients pushing spontaneously, since typically I do not check them until they report feeling pressure or pushing urges. Typically if they need instructions I tell them to take a big breath after the next contraction has started to build and push.

I really do not get into directed pushing or counting if at all possible- it is actually shown to result in lower apgars and poor cord gases.

Occasionally if a patient is really not pushing effectively I will provide a little perineal pressure, but I try to stay out of the lady parts as I feel too much mucking around down there increases swelling and tearing (and evidence agrees).

I always feel telling a woman that pushing is like having a bowel movement is somewhat demeaning and inappropriate. Many women are embarassed by the possibility of having a bowel movement while pushing and I think it is really unhelpful to describe it that way. At least from my own experience of pushing out three babies, it isn't pushing like having a bowel movement, it's pushing like having a baby:) But just a personal preference.

I try to change positions fairly often because I find that there is often a magic position that zooms that baby right down. My epidural patients rarely have any problem doing side lying, supported squat, or hands and knees. My natural patients will push standing up, in the toilet, leaning over the bed, etc.

[anggelRN]

Wonderful article on pushing:wink2:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1948091