Talk to me about spontaneous pushing

Specialties Ob/Gyn

Published

I am just coming to realize at the end of my orientation on L&D that I have not witnessed any RN's encouraging moms to spontaneously push when fully dilated. There's often a lot of teaching around trying to aim for 3-4 pushes for each contraction, each push more intense than the previous, enforcing chin to chest, don't use your voice or make noise (to contain energy within?) and lots of "PUSH, PUSH, PUSH" The thing is I've just come to the realization that I've been starting to do the same teaching (maybe without the intensity of some of the other nurses)? Reflecting on the theory I learned - spontaneous pushing is what should be encouraged (of course with an epidural some may need help directing their pushes)....I feel that by doing so I will be looked at like what the heck is she doing? I'm just curious what you L&D nurses do? I feel that I am on board with spontaneous pushing ( I know that's what I was encouraged to do with my first) but that it will almost be frowned upon by the other nurses...that I won't be "doing my job" per se. Thoughts?

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What is current evidence based best practice? If it's spontaneous pushing then encourage that. You do not want to lower your level of care to fit in, as hard as that may be, but your patients deserve the right to up to date care.

You might also want o discuss what kind of birthing experience the expectant mother thought of regarding pushing and encouragement - you'll be surprised how many have precise ideas.

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Specializes in Family NP, OB Nursing.

Spontaneous pushing is great...for patient's without epidurals. When a patient has an epidural they often don't feel enough to start pushing or need help finding the right muscles to push with since they have decreased mobility and sensation.

I'm all for letting an epidural labor down on their own, however. Once complete, put them upright, "frog-leg" them and let the contractions do their thing. Once the baby gets good and low they usually start feeling some urge to push. You might find that some of them still need some guidance as they may only feel "pushy" at the peak of the contraction.

Probably about 75% of my labor patients had epidurals. Out of the remaining 25%, half went so fast there only was spontaneous pushing as the baby was coming quickly...the other half, some needed some encouragement to push and some were great at doing it on their own.

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According to this systematic review, spontaneous pushing and/or having women use the method they prefer is the best approach. spontaneous pushing isn't as applicable if a woman has an epidural though.

http://www.ncbi.nlm.nih.gov/pubmed/21392242

http://www.medscape.com/viewarticle/558117_4

(disclaimer, I am only a pre-nursing student with interest in L&D medicine, but also a mom to twins born lady partslly at 40 weeks so I always read up on the recent evidence based recommendations)

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When I had my first child I had a nurse that was all about yelling PUSH! and having me push while she counted to ten...I wanted to yell "I cant hold my breath that long while exurting that much effort and I am trying to concentrate so SHUT UP!" But I was too distracted and exhausted to say anything. I feel like the nurse wanted to control what I was doing and wasn't paying attention to ME. I mean, I am there turning purple from trying to push for ten seconds and then gasping for breath and before I can even gasp twice she is yelling for me to push again, I mean seriously, this is not a race. And it didn't even help get the baby out I ended up needing the forceps after pushing for hours.

My second childs birth went so smoothly, my nurse was older, spoke calmly, was quick and efficient, really knew her stuff and I have to admit was one of only two nurses I HAVE EVER MET that spoke to me with a smile and not a ****** off "I have other things to do hurry up" attitude (and thats in all depts not just LD). It made such a difference. Anyhow, when they said push they let me push as I wanted and just gave murmurs of encouragement like "here he comes" and "oh your doing a great job" and guess what he popped out after only about 5-10 min of pushing.

Now I don't believe that the coaching during either births had anything to do with how fast the children came out (although it very well is possible) but the overall effect on me and my memories was enormous.

What I am trying to get at is why are you asking us? Ask the person who is important, you patient :) ! And be ready to switch it up if needed while she is in labor, maybe you can tell she needs a little more encouragement, maybe she just needs a little peace and quiet to concentrate lolo!

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

I disagree that spontaneous pushing doesn't work with an epidural. Where I currently work, the CRNAs/anesthesiologists are fabulous at being able to control pain, but not pressure, and many/most of the women I care for are still able to feel pressure, especially as the baby descends further.

I generally dislike "Push push push push!" or even counting, and I tend to not direct second stage. However, sometimes a woman does need that instruction, and I can recognize and jump in with it. I generally like to ask the woman what she prefers, though.

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Specializes in Family NP, OB Nursing.
I disagree that spontaneous pushing doesn't work with an epidural. Where I currently work, the CRNAs/anesthesiologists are fabulous at being able to control pain, but not pressure, and many/most of the women I care for are still able to feel pressure, especially as the baby descends further.

I generally dislike "Push push push push!" or even counting, and I tend to not direct second stage. However, sometimes a woman does need that instruction, and I can recognize and jump in with it. I generally like to ask the woman what she prefers, though.

I totally agree with you and did point out that some patient's with epidurals might need some guidance. I don't believe in "PUSH PUSH PUSH" count to ten either. Guidance is different than directed. Also, if you let them labor down you decrease the need for guidance as they can start to feel more the lower the baby gets.

Each patient needs assessed as an individual. Some people are great at doing it on their own, others may need some help. There are much better ways to help a patient push, if needed, than: "Take a big deep breath, blow it out, take another, hold it, chin to chest, curl up around baby and push 1, 2, 3..."

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