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Ornament

Pushing

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Food For Thought: It is not typically the practice at a homebirth to assess a woman's pulse during the pushing stage if it was assessed shortly before pushing began.  In my training, the standard of care was to check the woman's temp., pulse, B/P every 4 hours during active labor and pushing, and to check the B/P more often postpartum.  However, if it is looking like the pushing stage may be longer than 10 minutes or so, it might be a good idea to check the mom's pulse at about that time.  Then you'll have a good heads up if the baby's heart rate starts overlapping with the mom's pulse range.



What is the Evidence for Pushing Positions? from Evidence Based Birth

Best Practices in Perinatal Nursing Implementing Safe and Effective Practices for Second-Stage Labor by Laura R. Mahlmeister, PhD, RN [July - Sept., 2008]

For nearly 60 years, women who reach the second stage of labor have been exhorted to push hard and push long during your contraction while I count to 10. This drill is commonly referred to as purple pushing because the mother's face becomes increasingly engorged with blood during sustained, closed-glottis, bearing-down efforts. The practice became standardized in virtually all labor and delivery settings in the United States and Canada by the mid-1960s. The ritual of immediate, forceful, closed-glottis pushing is attributed in part to medical literature published in the 1950s, reporting a relationship between prolonged second-stage labor and maternal-neonatal morbidity. However, subsequent studies have not consistently found a relationship between longer second-stage labors and adverse outcomes. Immediate, closed-glottis pushing has also been sustained in part by the establishment of arbitrary timelines for the duration of second-stage labor.


Prolonged second stage of labor and risk of adverse maternal and perinatal outcomes: a systematic review.
Altman MR, Lydon-Rochelle MT.
Birth. 2006 Dec;33(4):315-22.

CONCLUSIONS: The primary findings of our review indicated that most of the studies are flawed and do not answer the important questions for maternity caregivers to safely manage prolonged second stage. Meanwhile, approaches for promoting a normal second stage of labor are available to caregivers, such as maternal positioning and pain relief measures and also promoting effective pushing technique.


A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function.
Schaffer JI, Bloom SL, Casey BM, McIntire DD, Nihira MA, Leveno KJ.
Am J Obstet Gynecol. 2005 May;192(5):1692-6.

CONCLUSION: Coached pushing in the second stage of labor significantly affected urodynamic indices, and was associated with a trend towards increased detrusor overactivity.


This article was "Received 9 February 2005; received in revised form 29 April 2005; accepted 3 June 2005".  It involves the same cast of characters as the above article, but a slightly larger group of women in the study.

Notice that the May, 2005, version suggests that coached pushing may be harmful, whereas the revised abstract is sanitized to suggest that coached pushing is better because it facilitates a faster birth, which is assumed to be superior.  They gloss over the increased meconium, ignore the detrusor overactivity, and as far as the abstracts go, nobody bothered to ask the moms which they preferred.  I guess this isn't considered "clinically significant".

A randomized trial of coached versus uncoached maternal pushing during the second stage of labor.
Bloom SL, Casey BM, Schaffer JI, McIntire DD, Leveno KJ.
Am J Obstet Gynecol. 2006 Jan;194(1):10-3.

CONCLUSION: Although associated with a slightly shorter second stage, coached maternal pushing confers no other advantages and withholding such coaching is not harmful. [Ed.: Their previous article clearly stated that coached pushing is harmful, but they ignore that here.]


Don't Push Your Baby Out! from Dr. Mercola


Pushing for Primips - by Gloria Lemay


Ink Birth - Saturday, November 1, 2008 - fabulous photos of the pushing stage!


Honoring Body Wisdom by Pamela Hines-Powell, CPM, LM - about pushing and tear prevention


Second Stage Labor: You Don't Have To Push By Nancy Tatje-Broussard a must-read! From Mothering Magazine


Rebozo Technique - using a rebozo as something for the mom to pull on while pushing.


Pushing Techniques: Laboring down, pushing effectively and the best positions to use during the pushing stage from pregnancychildbirth.suite101.com

[NOTE - This article opens with the observation that women are often quite tired when they get to the pushing stage.  This is a normal physiological hormonal response to the transition from the first stage of labor (the opening of the cervix) to the second stage of labor (the pushing stage).  Even if a woman has had a one-hour, easy labor, she will often experience a sudden, overwhelming fatigue at this point.  The sensible approach is to help her rest while her body successfully completes the shift to the pushing stage.  You'll know when that's happened because the birthing woman will start pushing . . . it's almost like a miracle!]


When I was a student nearly 20 years ago, in the eastern part of Norway, my favorite midwifery wisdom gleaned from the older midwives on the ward, was the concept that the active phase of second stage begins when there is fetal hair on view at the introitus, not retreating between contractions.  Very rare to need intervention for prolonged second stage if you start that clock during crowning.


Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: a randomized clinical trial.
Simpson KR, James DC.
Nurs Res. 2005 May-Jun;54(3):149-57.

RESULTS: There was a significant difference between groups in fetal oxygen desaturation during the second stage (immediate: M = 12.5; delayed: M = 4.6) F(1, 43) = 12.24, p = .001, and in the number of > or =2-min epochs of fetal oxygen saturation <30% (immediate: M = 7.9; delayed: M = 2.7), F(1, 43) = 6.23, p = .02. There were more variable decelerations of the fetal heart rate in the immediate pushing group (immediate: M = 22.4; delayed: M = 15.6) F(1, 43) = 5.92, p = .02. There were no differences in length of labor, method of birth, Apgar scores, or umbilical cord blood gases. Women who pushed immediately had more perineal lacerations (immediate: n = 13; delayed: n = 5) chi(1, N = 45) = 6.54, p = .01.

DISCUSSION: Delayed pushing results in less fetal oxygen desaturation and less > or =2-min epochs of fetal oxygen saturation <30% during second-stage labor than the immediate pushing method; thus, delayed pushing is more favorable for fetal well-being as measured by fetal oxygen saturation.



Pushing and Birthing Positions



Comparison of the maternal experience and duration of labour in two upright delivery positions—a randomised controlled trial
I Ragnar, D Altman, T Tydén, S-E Olsson
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 113 Page 165  - February 2006
doi:10.1111/j.1471-0528.2005.00824.x

Conclusions Kneeling and sitting upright during the second stage of labour do not significantly differ from one another in duration of the second stage of labour. In healthy primiparous women, a kneeling position was associated with a more favourable maternal experience and less pain compared with a sitting position.


Upright Pushing Not an Independent Risk Factor for Increased Bleeding

If you have read the 'research' stating that upright birthing position increases the risk of blood loss >500 ml, and were curious as to why, here is the answer.

Harmful intervention seems to be a likely culprit not physiological positioning.

Sitting during labor not independent risk factor for blood loss
19 February 2007
BJOG: An International Journal of Obstetrics and Gynaecology 2007; 114: 349-55

Sitting down or partially sitting down while giving birth only increases blood loss in women with perineal damage, say Dutch scientists.
Their research contradicts the general supposition that women lose more blood during labor when they sit upright compared with other positions.
A Jonge (University Medical Center St Radboud, Nijkgemen, The Netherlands) and team measured the amount of blood lost when 1646 women gave birth vaginally in a variety of positions.
Mean total blood loss greater than 500 ml and 1000 ml occurred more often when women took up semi-sitting or sitting positions during labor.
However, these positions were only significant risk factors for extreme blood loss among women with perineal damage.
No association was found between sitting during labor and excessive blood loss in women with an intact perineum.
The scientists say their data support the idea that blood loss in sitting or semi-sitting birthing positions originates from perineal, not uterine, trauma.
They add that obstetricians should adopt a "restricted" rather than a "routine" use of episotomies during labor, to reduce perineal damage.
"Regardless of the birthing position, restricting the use of an episotomy to medical indications may reduce the number of women with severe blood loss, " conclude Jonge et al.


[Editor's Note - I am just dumbfounded that anybody would cut an episiotomy in an upright position. What the heck would they be thinking?  Oh, that's right . . . babies won't come out unless you cut them out one way or the other. :-(  Grrrrrrrrrrrrr!

In a lying-down position, the weight of the baby's head probably staunches the bleeding, whereas there is more free bleeding if the weight is more towards the pubic bone, as in an upright position.

Sheesh! you would really have to be an IDIOT to cut an episiotomy in an upright position.  And how do they DO IT anyway?  I mean, really, how do you reach all the way around the baby's head to cut it.  OH! I get it . . . they probably also cut the episiotomy EARLIER since it's more difficult as the head comes down.  Maybe it's the increased time between cutting the episiotomy and the birth that increases the amount of bleeding.

Sometimes you really have to wonder . . .]



Preventing Pelvic Floor Damage



Less Pelvic Floor Damage Associated With Uncoached Than Coached Pushing During Labor [Aug. 2, 2004] — Pelvic floor injury is less likely to follow the second stage of labor if women are allowed to push in the manner that feels most natural and comfortable to them, according to investigators here at the joint meeting of the American Urogynecologic Society and the Society of Gynecologic Surgeons. [Medscape registration is free]



Pelvimetry - Pelvic Diameters



Research into pelvic size and shape was done by Caldwell, Moloy and D'Esopo 1940. The more recent conceptions of the pelvic
architecture. In American Journal of  Obstetrics and Gynecology. Vol 40  pp558-565 This study looked at differences in pelvic size and shape and identified the four (sic) standard shapes of pelvis. This has not been replicated (as far as I am aware), so changes caused by diet and ethnic influences are not known.

Another article is Russell JGB 1969. Moulding of the pelvic Outlet. in Journal of Obstetrics and Gynaecology of the British Commonwealth (!!!) Vol 76 pp817-820

In this study Russell took x-ray plates of women both at the end of pregnancy and the day following birth, in two positions--lying down and sitting up but leaning forward. He measured the distance between the spines (bispinous diameter) and found a mean increase of about 7mm when women were sitting.


NORMAL PELVIC DIMENSIONS FOR SAUDI ARABIAN WOMEN IN TABUK OBTAINED BY COMPUTED TOMOGRAPHY PELVIMETRY

James English, MRCOG; Khawla Alcoair, MB,BS


Perhaps the premier expert on pelvic architecture is Todd Gastaldo, D.C., who is famous for his campaign against routine fetal skull squashing.



Pushing Before Complete Dilation



I had to chuckle at "I remember reading a surprising statement that allowing women to push before they were fully dilated caused no harm! This has actually been studied with research data to support it."  Years ago, AFTER the women I serve taught me this and I shared the information with my other laboring women who LOVED bearing down, then I shared this information at one of our state midwife meetings.  I got hammered at the suggestion of it!  I was told absolutely not!!!  I shut my mouth and just went on 'allowing' these ladies to do what they felt to do.  Eventually, I began to suggest it more & more to the ladies and again, it worked.  That is my research~the one I trust the most :0).

As for swollen cervixes, I seldom see it.  When I do see a swollen cervix at full dilation I just push that thing up as the mother is pushing and out comes baby.  I never let a swollen cervix be there for any length of time.

Oh, and with all this being said, the first timers usually don't bear down.  But if they do, again, I let them.

I had one lady, years ago, that was 3 cms when I arrived and she was constantly pushing (this was her 4th).  I told her to stop and she nicely ignored me.  She had the baby 1 hour later.

If a  mom doesn't push until she HAS to, then it's probably a good idea to let her do what her body is telling her to do --- even if we checked and found the cervix still had a bit to go. If she really has to push -- she probably should do it.

Unless I truly feel that a woman is working against herself, I will not interfere with what she is doing.



Decrease in Contractions Upon Complete Dilation - The Lull



Some years ago I read an excellent article called (something like) the Foetus (?Fetus) Ejection reflex. It described how the uterus can seem to go on strike at the very point when everyone is gathered around and everything is set up for the birth. I have looked up computers in good libraries and tried search services but cannot find it. Could anyone help with this, or with references to similar articles, please?


In UK literature this is referred to as the Ferguson reflex.

The best reference I can come up with is: Goodfellow et al. Oxytocin deficiency at delivery with epidural analgesia. Br J. Obstet. Gynaecol 1983;90:214-219

You could also see: Johnson et al. Effect of pudendal, spinal ... Am J O&G 1972;113:166-173


Respecting the Lull Between Complete and Pushing

One of our local hospitals, Georgia Baptist Medical Center is conducting a study. I don't know if it's just this hospital's own study, or if they are part of a larger study. I heard about it from a student last night, who was given information about it by her doctor's office.

The study is focusing on the "resting phase." The time after complete dilation, but before the urge to push. They are supposedly trying to see which is better: allowing the woman to rest (but only for an hour) as long as the baby is not in distress; or having her go ahead and push, even though she's not feeling the urge. They're looking for which women feel better after the birth, length of pushing, effect on baby, etc. To me this just does not seem to take much thinking! I mean, who do they think will do better? The women who have been through a long, long labor and are exhausted and are then forced to push, even though their bodies aren't ready? Or the ones who have had a rest, regained their strength and are working with their bodies timing? :)

I don't yet have all the facts about this study, but will definitely be checking into it! I am just so excited that this TEACHING hospital (lots of residents/interns) is actually recognizing that there IS such a thing as a resting phase! I definitely teach about it in my classes, and no one so far has ever heard of it, and their dr's tell them things like "oh it only lasts 5 minutes, you won't even notice it" or "well if you have an epidural it won't matter if you have it or not as we'll tell you when to push anyways" (I tell them that even with an epidural you can wait to push until you have a contraction - and the resting phase gives your epidural time to wear off so you can feel to push). It really blows the women's minds when I tell them that the resting phase can even last hours.... long enough to take a nap! I must say, I didn't know that though until it was recently discussed on one of these lists.



Urge to Push



[from ob-gyn-l]


My understanding was that Ferguson postulated a reflex which occurs at full dilatation with the presenting part distending the birth canal, which produces expulsive contractions. This reflex is said to be attenuated by effective epidural anaesthesia and supplementation with Oxytocic may overcome the deficit. No-one has ever worked out the anatomy of this nervous reflex.


This utero-pituitary reflex became known as the "Ferguson reflex" and retains its clinical relevance in modern obstetrics when epidural anaesthesia blocks the reflex, stopping the normal physiological increase in oxytocin release during the second stage of labour.'



Lack of Urge to Push



I hear from midwives all the time that we should wait for an urge to push. I agree with this most of the time but what about the first timers who never get an urge? I have had three first timers in a row who don't want to push. Not only do they not have an urge but they flat do not want to push. I try to help by applying a little pressure with my fingers, ( always worked in the past) but two of these ladies cried and got upset. So I sit back and wait and watch her get worn out. I have never had such a stubborn group of clients as I have in the last few months. I wonder if you have any ideas about helping the pushing stage for those moms who really hate it. I have counseled about sexual abuse and I have been successful with those ladies. But with these women it seemed like they had never done anything hard before and they just were not prepared for the hard work of getting a baby out. They were babied by their mothers and spouses and I was the one looking like a big meanie. The last birth we sat at 10 for 2.5 hours with this mom contracting every 2 min, giving these pitiful pushes & just wearing herself out. Then when she finally realized there was no way out she gave a good push about every third one. Total pushing time was 4.5 hours, with actual pushing about 1.5 hours. She was exhausted, baby was a little worn out and dad was saying how awful that was for her. I am a get it over with kinda girl. If I have to do something hard I just want to get in there and give it my all until it is done. Pushing was the easiest part of labor for me. I have had great success with women with emotional issues during labor. I have unlimited patience with that kind of stuff but I seem to have a block when it comes to the helpless personality. I get so annoyed with the woman that whines and wants someone to do it for her. I feel guilty because I think I should treat it like any other block but it just gets me. Does anyone have any helpful hints for these type women. 


I generally use positioning - either good deep squatting or toilet, which helps trigger an urge that leads to at least some good involuntary pushing. I've also been known to just leave the room and have women call me when they're ready to push the baby out.  Sometimes it just takes awhile for women to get into a space in their heads to "let go" and bring that baby out.  It feels kind of gutsy to walk away from a woman who is completely dilated, and I've found that the support system gets a bit panicky about that - usually I kick them out, too (except one main support person).  If the baby is okay and I know that it will fit through the pelvis (or at least am pretty sure it will fit), I allow lots of time to do second stage, if needed, especially for those primips. 


Well, I'm not sure what was  going on with each of these women, but you did mention sexual abuse issues.  Is it possible they had that as a background, and just couldn't stand the feeling of that HUGE baby (you know how gigantic it feels) pushing its way through?

I've had some success with warm compresses to give something that feels good to work towards.  I've gotten in their faces and shown them exactly what kind of grunting (deep, long, throaty, kind of work) I want to hear until they do it.  You might try water submersion with the ones who are open to a waterbirth-if you are-it's far easier for a woman to make the subtle pelvic moves that will assist through the pushing stage, which makes her feel more powerful and a bit less "victimized" by the sensation.  And, you are free to try the technique I made up for myself with my last birth-my midwife used it on some of her clients immediately afterwards, with great success-I just visualized all the overwhelming sensation, pain, and fear that I was feeling (I, too, tend to find pushing easy, but this time it HURT LIKE H--L) becoming a tiny ball of intense light.  It was like seeing my situation in the perspective of the entire universe.  I then imagined pushing that tiny ball of pain and light and fear through the center of my being and out, knowing that as soon as I got it out, the pain would stop.  I said "center, center, center" over and over again as my mantra.  It worked.  And, the baby's head was transverse, nose to my thigh, and a bit asynclitic-hence the grinding pain.

Also, positioning.  Getting them in a supported squat or hands and knees, or as I said, in water in a squat, will open things up and make it really hard for them to resist the urge.

Otherwise, perhaps it is a good idea to work more on preparation for this part with the primips.  Then they will know that it will hurt, but it will be movement, it will be very full, it will feel like splitting in two, and you will expect them to work hard to get the baby out.  Whatever.  If they know what to expect, it will be more likely they will be able to handle it rather than fighting it.

Finally, LAUGHTER!  Just try holding your butt tight while you are engaged in a belly laugh!  I've actually seen a woman push her baby out with deliberate laughs.  Brush up on your standup comic routine for when it gets serious.

All of these are just suggestions, but ones that I've seen work in various situations. 


Are these ladies in bed?  If so, get them moving!  I have luck with the ones who "can't/won't" push with sitting on the toilet, slow dancing (actually I had one lady showing me how to do the "achy breaky" a few years ago. Miraculous!) or with the towel trick.  As a last resort, I have left the room, telling her that I needed to get a drink etc., and that she should call me when she wanted to push.  Even the most stubborn have changed their tune pretty quick with the prospect of me leaving.  Too much "mothering the mother" seems to bring on helplessness in some women.  It is really doing them a favor to get them out of that nowhere rut. 


 The only thing I have seen work so far with these mums who just will not push is directed Valsalva pushing . However this has always been in hospital.---A couple of times when I was doula-ing, ran out of tricks, and the bored docs were muttering CPD and C/S.--- Twice after transport for pain relief after being complete and +1 for hours with refusal to push and growing inability to cope with contractions.  Exhaustion starts to set in and her pain threshold drops, dad gives up, hospital sounds easy.  Although I have a real problem with Valsalva pushing that is how the hospital nurses got the job done. So probably next time we might try it before we end up with a transport.  Thinking back my instinct would be to have the direction calmed down for crowning and then the birthing gentled back down again. But so far I have to keep my mouth shut in the hospital, and the nurses have become carried away with the cheer leading making the mum purple push through the burn. Oh well.  Another thought I had was maybe to have the mum go sit on the "potty" with the door closed for a little while to try to work things out for herself. More ladylike, maybe. 


I often tell them to get in the shower and not to get out until they have to push.  Works often.  I love the toilet, too.  When they say they feel like they have to have a bowel movement, I will often tell them to go try, rather than telling them it is the baby.  They get in there, in private, and often really start pushing. 


I really agree about the privacy issue.  For most of us, it is not a pleasant prospect to have a BM with an audience, especially in bed with your legs apart.  And we have to be honest, that is what it feels like - esp. to a primigravida.  Alone, or at least without a crowd, in the shower or on the toilet, seems to alleviate some of their fears of embarrassment.  So many of mine want reassurance that they are not going to "poop," if they are on the toilet it doesn't matter. 


Which is why enemas aren't always such a bad thing.


Some moms just don't' get an urge to push but the baby keeps coming down anyway and eventually the urge clicks in when the kid gets really low. That's Ok if mom isn't fighting things..

But the mom who is fighting things is a different case. I've had the best success giving them privacy --- usually recommending they go the toilet and spend time alone in the bathroom. Sitting on the pot gives a lot of them the emotional space they need; I think it helps the baby descend; and I think it helps open the way for them.

But it doesn't help to send a crowd in with her. Invite her to be alone -- or if she needs one person, maybe. But privacy is the key for them. It gives them time to work things out in their heads....  And they ALWAYS let us know in plenty of time when the baby starts to come! (We can hear those sounds!)


A gloved and lubricated 'baby' finger in the rectum will often produce an immediate push urge, but if you are considerate enough to ask the mom's permission first you probably won't get it. in a pinch i'd just do it. 


If my midwife did this to me I would either kick her in the head or never speak to her again.


Mom having a first baby had absolutely no urge to push. Even with the baby finally crowning! She would give a tiny 1 second 'uuh' only when we asked, which we only did maybe 3 times. She did eventually give 2 really good pushes, again, on direction and not from her own urge.  We just waited and waited. It really wasn't all that long- maybe 2-    2 1/2 hours after getting complete.  I haven't seen that before.....does that happen fairly often?


Happens often.  Unless she is in a standing position, most women will NOT get an urge to push.  That is why they depend on our direction and encouragement.  That being said, most women get the 'urge' BEFORE full dilation, but they are told not to push.  Too bad.  Because that is the bearing down urge which will automatically go into the pushing urge.


You know what just drives me crazy... walking through the L&D unit hearing them holler "PUSHPUSHPUSHPUSHPUSH!" If someone did that to me while I was birthing I think I'd have their heads.


Don't get me wrong here.....I NEVER TELL a woman to PUSH!PUSH! or push at all, even. In my limited experience, I have had to help women slow it down, breathe the baby out, listen to their bodies, BE EASIER. It seems more like learning to sacrifice and release, breathing the baby out can be a huge lesson in surrender.

I have never seen a woman have absolutely no urge -strong 'need'- to push before, and it was quite amazing to me. I have birthed a couple of babies myself, and remember that 'I want this baby out NOW, I GOTTA PUSH' feeling, and had to work at easing up. It seems like most ladies are this way, don't you think?


I see a total lack of urge to push every once in a while.  I think it happens to mothers in my practice more often now than it did in my earlier midwifery years (back when  did a LOT more telling the mother what to do).  I no longer believe in encouraging pushing, if anything, I may softly whisper a suggestion that the mom is doing the perfect nice, slow, gentle easing of her baby through its birth.  I have nothing but admiration for these kinds of births, the babies always come out with perfect apgars, and they hardly ever make any noises, they seem so alert and unafraid.  I think this is actually the REAL way they are supposed to come.  We probably got the PUSH idea from the man in charge of our mothers birth who was so afraid of birth he had to get it over with fast.  (I mean, if you watch other mammals do it, they don't waste a lot of energy in the effort, they seem to just "allow" the baby to slip out.  I love that.


I too would rather that mom "ooze" the baby out and refrain from pushing if at all possible.  Do lots of big babies with mom on her left side or hands and knees, or in the water....  I encourage the mom to work with her body and gauge her pushing reflex by the way her body is reacting to the baby moving down and out.



Helping Moms with Pushing



Balloons are valuable labor support tools! - neri lifshits has a nice blog about having moms blow up balloons as part of a pushing effort - interesting!

I wanted to share with all of you my latest blog post ; Inflate the Balloons during Birth, They are Not Only for Birthdays!
It's a cool and fun post declaring balloons as labor support tools! While balloons are everyday sight in mother & baby rooms, and will often welcome the mother and her newborn when they arrive home, no one talks about the value of balloons during childbirth. I recently gave a presentation to a local group of OBGYN's and gave each and every one of them a new balloon to inflate, demonstrating the value of it for moms who are struggling with pushing. However, I realized that there is so much more that I was doing with balloons in my years of practicing as a doula, so I set down to write this blog post. Enjoy!  



How do you encourage/ describe to your mothers to push?

My text suggests encouraging a laboring woman to "push towards the end of the bed" or "Mentally guide the baby under your pelvic bone and out of your body" instead of "bear down like you are having a BM". Their rationale states that those mothers who are shy/don't want to loose control of their bowels, encouraging them to push "like a BM" may cause ineffective pushing or not pushing at all.


I never thought of the shy woman, too shy to have a BM in public. I like that rationale. I won't use that anymore. Nor do I like everyone shouting PUSH PUSH. Because I'm not prone to the shouting thing, my teachers thought I wasn't taking charge of the room. So in school, I became a shouter. I hated it. Now, whenever a family, or nurse, or whoever, start shouting, I get their attention, and tell them, that if it is helping the mother, fine, but when I call for their attention, they MUST fall silent, since it is MY hands down there doing my best to preserve the perineum, and it should be my voice and only my voice the mother hears at that point. I don't want any gung-ho cheerleaders drowning out my "just a little grunt, cough", whatever and encouraging the mother to explode the head out. I find that when a mother extends a tiny MLE, or has a bad lac, it is when her cheerleaders have encouraged such explosive pushing, or when a huge baby with football pad shoulders does it all on his own, in spite of all the support I can give.

When a mother can't quite 'get it', and is pushing ineffectively, I usually just put one or two fingers into the vagina, push down gently, and say "Can you feel that?" when she says yes, I say, "just push my fingers out." It works every time. Don't have to traumatize the tissue either, just a gentle pressure is enough to focus her in the right direction. Once she has it, I find I usually don't have to repeat it, either.


A couple of times, I've seen moms who had to push to the point of exhaustion have nasty tears. It seems like by the time she gets baby around the pubic bone, the mom is just about done in, and you wonder if she will actually ever get that baby OUT. Then, she makes one huge last efforts and pushes the baby straight through the perineum.

Can you risk trying for a slower birth of the head when it seems a miracle that she gets it out at all?

By the way, I'm thinking of two births that I've seen like this, both with the same midwife, both with strong directed pushing.

I'm liking directed pushing less and less. When I was interning, women didn't push until they couldn't stand not to, and I didn't see one prolonged second stage. My partner almost NEVER directs pushing efforts whatsoever and has very few or small tears and much, much, less hemorrhaging than I have seen with births where second stage was directed. I am especially impressed by the virtually bloodless births.

What do all of you think - esp. about the first issue?

It's kind of funny, I was taught to coach pushing, rectal pressure, etc. I don't do it that way. I was also taught to deliver the placenta a certain way, and I don't do it


I've seen several labors where a mother "failed" to bring a head down. They were excused from further pushing, and stopped, were epiduralized for C-section, and delivered vaginally while the OR was being prepared. So instead of worrying about "risking" a slower birth, I think the question is, when things aren't going well, can you risk the "directed pushing."

I think "directed pushing" causes a large number of problems, including failure to progress, as noted above. I think it is the largest cause of fetal distress in the second stage, also, and is therefore the greatest reason for our National C-Section Surplus. I hate it. I hate it. I hate it.

From a biological point of view, can anyone explain to me why "directed pushing" makes more sense during second stage than it does during first stage? In either case I'm convinced it represents the same thing--impatience.


I also detest directed pushing for the most part...and it got me in some trouble when I was an L&D nurse. Particularly when it was getting to the morning and the end of my shift...I would be telling the mom to listen to her body, and push the pain away, to breathe as needed...and in would come the day shift, bright eyed and with fresh make-up on, and get in the mom's face 'hold your breath, count to ten', etc. One of the nice things about being the midwife is being "the authority" in a hospital hierarchy (at least until the consultant walks into the room!). Having said that, I do believe there is a place for directed pushing and the full armamentarium of positions, including on occasion the dreaded lithotomy position. The wisdom and judgment is in knowing when to intervene, and when to be hands off. And a lot of the time I may be wrong, at least when viewed through the retrospectroscope.

Does anyone here remember the comments Brigitte Jordon made about pushing in "Birth in Four Cultures"? I am referring to the practice of having moms start pushing from the beginning of labor. I am also interested in how necessary is it really to wait for the cervix to be completely gone before 'allowing' a mom with an overwhelming urge to push her baby down. My experience and gut feeling is that we often play labor as a numbers game, and have all these rules that interfere with the mom's ability to trust her own body's messages. Comments?


Perhaps we would see less intensively coached pushing if our medical culture were better informed of the health risks of directed pushing.

Guide To Effective Care (pg 228) reads

In all the published controlled trials comparing different approaches to bearing down in which cord umbilical arterial pH assessments were available, mean cord umbilical arterial pH was lower in the group in which sustained or early bearing down had been encouraged. Sustained bearing down efforts also appear to predispose to abnormalities of the fetal heart rate and depressed Apgar scores.
I think many folks are unaware that coached pushing may be harmful to the baby.

I think some women- not most, but definitely some- NEED directed pushing. I am talking in particular about those who have had epidurals and have no sensation or very little sensation below the waist. My method is to let the contractions/uterus get the baby as far down as possible and to have them push at the last. If they have such a "good" epidural, there is no use to wasting it and the mothers strength and energy as long as mom and baby are doing well. I personally will ask to have the continuous pump turned off or down so we can begin pushing. Sadly however, many docs want the woman to start pushing as soon as the nurse or(or the doc) find she is "complete". With the high rates of epidurals in the hospitals, many nurses are used to doing "directed pushing" more out of habit I think than anything else.

There are times too when the mother can use a little "re-direction" to regain focus and control. This is usually only a transient period though- not through the entire second stage.


well, sure. Each women is unique and there will certainly arise some situations where directed pushing is of aid.

But re epidural use. From appx 1925 till the mid 70s the majority of US women were delivered under general anesthetic. They did NOT push since they were unconscious (or close to it). Their babies were often born through uterine contractions alone -- though some docs were fond of "prophylactic forceps" and fundal pressure.

Even with a good epidural I would expect most babies to be born without maternal pushing efforts.

I worked with a group of midwives years back who did not allow maternal pushing. Ever! Their moms were trained in pregnancy to breathe with contractions and NEVER, NEVER to push! We spent a lot of our time coaching, panting, breathing with her to help her resist pushing.

Surprisingly, the births seemed to take about as long as other births!

The midwives felt that forbidding pushing would reduce tears. The moms seemed to tear about as often as other moms, though.


You have made a good point. One of the problems in many hospitals though is the never ending (it seems) "system". A woman has to be checked every two hours to assure progress- by doc, (attendings or residents), nurses , or the midwife. Once you hit that magic "ten / 100% / " mark, the clock starts ticking. It ticks sooner if there has been "no progress", causing the use of IUPC's, pitocin etc. Many docs and many protocols call for starting pit even in second stage if it is going "too slow". The back up physician on call and the nurses on duty influence this process a great deal. That is why many women are started on pushing.... to try and avoid a C/S ultimately. It is a judgment call to be made depending on the situation at hand.

Would be much nicer if we could just let nature take its course!


I was taught in my homebirth practice, never to let mom push before she reached ten cms. Then, after many years, where I have transported, I see CNMs having people push past 8 or 9 cms, or then myself having to hold ant. lips back and have mom push around them, I see that there is no fast rule. I like having the woman push when she feels the very strong urge now, as long as she's not 6cms. And some women never get that urge, so you just say go for it. I agree with your "numbers game" assessment, constantly watching the numbers on the EFM, dilation....where did watching and listening to the mom go???


I am also interested in how necessary is it really to wait for the cervix to be completely gone before 'allowing' a mom with an overwhelming urge to push her baby down. My experience and gut feeling is that we often play labor as a numbers game, and have all these rules that interfere with the mom's ability to trust her own body's messages. Comments?


I agree - I haven't had a problem with the dreaded "swollen cervix" with early pushing unless there is something else going on (usually a malposition of the baby's head). I don't try to stop women from pushing early, but usually remind them that their uterus is doing most of the work, so they still can keep breathing through the contractions unless they really NEED to give a push, following the urge signaled by their body. This seems to work pretty well - keeps away from full-out pushing, but allows the woman to trust the body signals and not get the idea that she's somehow doing something wrong if she's pushing at 8 or 9 cm. I also check a bit more, though, to make sure that progress is being made and will manually reduce stubborn rims, if that seems appropriate.


i don't coach positions, and women give birth however they want to: but i really don't remember a mom arching her back.


I've found that by asking a woman to pretend she is blowing up a tight balloon, she gets a feel for what muscles to use when pushing.  Instead of presenting a balloon, I ask her to just stick the tip of her thumb in her mouth and pretend it is a tight balloon.  Usually, after just a few seconds of this, mom knows just which muscles to use.  (She doesn't have to do this the whole time pushing...it's more of "see how that feels those are the right muscles") It is very effective for moms who have had epidurals or just don't seem to get the "hang of it" for whatever reason.

A pillow case was used as a "tug of war" when mom was pushing.  Mom pushes while she is pulling on the end of the pillow case (mine is rolled and tied in a knot), someone else pulls the other end, like tug of war.  This works well with a rebozo or towel too, and I've heard that by wrapping a rolled sheet around the doulas body and having mom pull on both ends it works wonders too and is easier on the doula.


How Homebirth Mom Handled Long Pushing Stage



Towels for Leverage / Tug of War



The Labor Link is a rope device approximately three feet long that allows moms to pull while pushing.


During the pushing or second stage of labour it has been proven that pulling on something helps bring the baby down through the birth canal. The muscles used to pull with are the same ones that assist the uterus in pushing the baby down and out. This can be done various ways, such as hanging from a rope secured to the ceiling, pulling the handles of a birthing bed or pulling on the hands of another person. The "rebozo technique" uses this principal with a length of material, called a rebozo, where the labouring mother pulls on one end and an assistant pulls the other.


I've been told about the towel trick but can't seem to get the technique down in my mind.  Can anyone describe it to me.  Tell me what the midwife does, what the mom does, where does she sit, etc.  Isn't this good for posteriors, too??  Thanks.


Give mother one end of the towel, you take the other.  Have her brace her feet well.  when contraction starts, she begins pulling, it is a tug of war.  she is amazingly strong.  The labia pout and part and the latest generation peeks forth, you drop towel and catch baby.


I have a fourteenth century woodcut of a midwife at a birth which shows the midwife with a wide leather strap across her back.  I believe this is the precursor for the "towel trick" which does work so well at teaching the mother the appropriate direction to aim her pushing efforts.  Some moms tend to push all the energy out their legs or their arms, and have difficulty centering their efforts down their spine.  I have used a huge bath sheet, and had the mom grab both ends.  I find that the best position for the midwife or attendant to be is below the level of the mom's bottom.  So if mom is at the edge of the bed or on the birthing stool, midwife should be close to the floor or on the floor.  Personally, I prefer to have the mom to use both hands separately, although I have seen both hands used together to grab the same section of towel.  As the mom pushes, you attempt to direct her push by lowering the towel until she is pulling back on the towel (instead of her legs) at the appropriate angle to direct the push toward the sacrum. I have seen this work for posteriors, as well, but my favorite method for posteriors remains the pancake flip.  Two contractions on left side, two on right side, two on hands and knees, and two in knee-chest.  Rarely have I had to do more than two cycles of that to turn a posterior.  Turning a posterior with the mom on in an upright position is difficult because you lose the flexibility of the sacrum. The towel trick will often help if the mom has an epidural (for those who practice in the hospital).  Also I use a pushing position where the mom lies almost recumbent for two contractions, and grabs her ankles and pulls them toward her bottom to turn the posterior or correct a malpresentation. You have to be creative in the hospital setting, because often the logistics of the bed and any pain meds require different techniques.  OOH we can have the  mom assume different postures too.  Years ago, I saw a device that my grandmother, who was a midwife in WV, carried in her bag. It was a wide leather belt akin to the one in my picture, that went around her back and had a long rope handle attached on either side with a wooden handle threaded through the rope.  The birthing mom grabbed the rope handle and my grandmother leaned backward to counterbalance her weight, and the mom pulled the rope as she pushed.  It was apparently very successful, as my grandmother said she was on the fifth "harness" of her career. Interesting that what worked five hundred years ago, still is just as appropriate today, huh? 


I use the towel trick differently with different people.  I sometimes use shorter towels, sometimes longer, depending on the moms position.  I have friends who tie a sheet or towel around the top of the squat bar, but I, like Vicki, prefer that my hands are lower than the moms.  I have her grasp the towel with both hands, Thumbs POINTED TOWARD ME, and pull like tug of war (when I have used a longer towel and tried to have her pull both ends of the towel (one end in each hand), I haven't liked the results).  Sometimes I have them prop their feet up on something.  It is very important  that you don't encourage pushing, but just pulling on the towel.  It seems like they "forget" about their bottom, and can relax the legs.

It works super for people who are epiduralized.  I don't like it for OPs, since they have to be semisitting and I think that limits the amount of room in the sacrum.

It has been one of my most consistently effective "tricks of the trade." Hope it works for you.  Just try playing tug of war with your kids, you will see its effect on your bottom! 


Tugging on the other end of the towel make me feel light-headed, so now I try to get the dad to pull the other end. I wonder if it might work to have a little longer towel, have the mom put it around her feet with one hand on each end, and pull against herself.  Maybe I'll try it.  I also used a towel once in a mom pushing on her side.  We put the towel behind her upper knee.  She pulled on the inside end, someone else pulled on the outside end.  I think we liked it for awhile, but not so good if mom has varicosities! 


You can go to a pet store and buy a dog's pull toy (for large dogs like shepherds or labs.)  It has a large knot at one end to hold on to and a handle on the other end.


There's a "labor assist device" called the Pull-Ez Reclining Squatter, which is supposed to facilitate this sort of pushing with moms in reclining positions, such as with an epidural or in McRoberts.  Inquiries to:  Sylvest-Sarah, Inc., P.O. Box 21871, Greensboro, NC  27420, fax #336-274-2649.



Arched Backs While Pushing



Okay, I have a question. I keep seeing women point their chins at the ceiling when the baby starts to come through the cervix. Other midwives and drs have told them to put their chins down and push because they're holding their baby in. It's my belief (unsupported) that this is a normal reaction of the body to help slow the birth process so as to not have as many tears.

Do all of ya'll (or some or none) tell the moms to put their chins down on their chest when they push? Or do you just let the mom push which ever way is natural for her?


I've never seen this [chin pointing at ceiling] when the mom is in an upright, off the bed type position, only when moms are lying down or in a semi-recumbent. Moms seem to push more effectively in 'non-traditional' positions IMHO.


I can't remember the exact way it was put, or the mechanics, but I read or heard that when a woman arches her back she shortens the muscles in the back and actually puts more ooomph into the push. Why not just let her do what she wants unless she is making NO progress for a while. Remember, much of what we are taught about pushing comes from the original Lamaze instruction, which, among other things was designed to cooperate with the medical mode of delivery. Semi sitting, IMO, is merely a modified lithotomy position. I never willingly put a mother in that position.

I taught CBE for 10 years. Taught "chin down, elbows out, back round", until I became a midwife and found that I don't have to tell the average woman anything. She already knows how in her millions-of-years-old racial memory.


Maybe it is a population-specific thing, but I sometimes see moms arching their backs a lot. I think it is an instinctual way to get the baby past a prominent sacral promintory (arching the back results in the sacral promintory moving posteriorly). In my experience, we should encourage the mom to push in a way that works. Although this may be anathema to many, I often keep my fingers in the vagina as the woman pushes. In this way, I can give feed back as to which pushing efforts seem to work. Please note that this is not forced pushing...it just helps me to identify for that particular woman which pushing maneuvers are the most effective. Because I sometimes do this, I have identified women whose back arching results in the best descent.


it just occurred to me to wonder if we all mean the same when we say "arch" the back. I'm understanding it to mean "to make the back hollow - swaybacked -- if on hands and knees, to slump the back downward with shoulders and hips higher than the middle of the back". DO others mean to "make an arch of the back" --like a cat when it's alarmed?


Good point. In the context of my original post, when I said I often saw women instinctively arching when the baby was trying to get past the sacral promontory, I meant that they had their spine in hyperextension, not flexion. Swaybacked, if you will. But when I referred to arching, I was referring to moms on their backs, or semi recumbent.

Conversely, when women are on H-K, I think of arching as flexing the spine....ie like an angry cat...to make an arch. I guess my use of the term arching to refer to women in a dorsal recumbent position was incorrect, or at least, confusing. Thanks for pointing this out. To be more precise, I see women who are trying to get the fetus past a prominent sacrum , when they are recumbent or semirecumbent, keep their heads and hips on the bed, and point their bellies up towards the ceiling (hyperextension). This position, at least to my interpretation, points the pelvis posteriorly and pulls the sacral promontory away from the presenting part. (At least in my non-spatially oriented mind!!)


This is an interesting conversation. I was at a birth yesterday where the mom had a great deal of second stage pain though she otherwise had just breezed thru the rest of labor. The only way she seemed to be able to progress when she pushed is when she arched back (hyperextended her spine) and I quit telling her to put her chin on her chest when I realized this. This state of affairs continued until the baby had negotiated the curve and was fully on the perineum, then she stopped arching. Another interesting thing is baby had started out ROA, and we felt this kiddo rotate from transverse or oblique to OA and then back again several times in the course of early pushing! Baby had a nuchal hand, so maybe it was hard for her to negotiate her way down. Mom finally gave birth to her over an intact perineum about one and a half hours after the onset of effective pushing.


Finally realized what you guys are talking about. With my second baby and first HB, the baby was OP, no back labor thank you, my midwife said to arch my back when I started pushing in order to rotate the baby, he did and delivered but felt strange.


Dr. Odent talks about women in the last pushes suddenly reaching up (they generally delivered in a standing or supported squat) and grabbing something with both hands, arching backwards a little. I had a powerful example of this myself at our homebirth. For the last push (was a precip--I think there were only 5 pushes) I just had to reach up and grab something, arching myself backwards slightly.


I've heard that arching a back during pushing can be an instinctive response to a posterior baby.



Preventing Hemorrhoids While Pushing



In labor-by the way, most of my books believe that hemorrhoids are started by constipation during pregnancy and aggravated by the pushing stage..so prevention could be the key-a gentle pushing stage in positions that keep you off of your back and your bottom from being compressed between the bed and the baby's head can help. Some suggestions were kneeling, all fours, squatting, side lying, and standing. Your anus will distend no matter what you do, but true hemorrhoids will stay "out" long after the birth, be swollen and hot, and uncomfortable. Kegeling is supposed to help as is sitting on hard level surfaces...tub baths...witch hazel pads, and, of course, eating a diet high in fiber and drinking lots of water.


I like to have all women deliver on their left side, do not insist on it but that way I can put aloe for sunburn (contains lidocaine and can be purchased at any drug/grocery store suntan counter) on a paper towel (prefer Viva because they are so soft). I use the heel of my left hand to gently counter pressure as the mom pushes and this, even with the largest hemorrhoids will keep them from swelling too much as babe descends. Immediately after the birth any external bulges that will retract should be pushed into the rectum beyond the sphincter muscle. I use the same aloe gel which numbs and makes it easier. Bring the legs down and put ice (Condom 1/2 filled, frozen wrapped in another paper towel works well) on. Mom should retract them when she goes to the bathroom each time till they no longer bother. If left out the sphincter acts like a rubber band around them and they get even more swollen. If clots form - a homeopathic remedy Bothrops 30x works miracles. It is taken a pellet or two at a time when pain occurs. At first it may be every ten minutes, then spaced out as the clot disintegrates. If an MD insists on removing the clot (the only method they know) make sure he goes up into the varicosed vessel (that's what a hemorrhoid is) and removes any small clots or they will continue to happen. Know this from personal experience before I knew anything about homeopathy. Had a clot happen routinely about every six months. The last one, went to a new MD, was instructing another MD (at my embarrassed expense) while lancing a thumb-sized clot. He told him that the small ones up inside would continue to descend and like snowballs making bigger ones if not removed. He showed me what he had gotten out when he was through. Sure enough there was the thumb sized one that was causing the pain and along with it 5 or 6 small ones.



Pushing with Vulvar Varicosities



See also: Vulvar Varicosities


Encourage the woman to push as slowly as possible so that the perineum distends slowly.


I cared for a woman last yr with the most appalling varicosities, so much so that when she thought she had ruptured her membranes, I found it impossible to pass a speculum because of the oedema. She did a lot of yoga antenatally, basically bottom in the air!  Our plan was to use water and to get into a position which may reduce the pressure. She used water for much of her labour but got out to give birth on all fours and pushed/ breathed out a 4.8kg baby with an intact perineum! She had had a PPH with her previous birth (no varicosities then) but no probs this time.


I have personal experience of vulval varicosities in my second pregnancy. Apart from them being pretty painful, especially when standing up, they caused me no problems at all.  I gave birth at home and was fine  - although I did have to reassure the community midwife that I wouldn't have to go into hospital!  She was quite concerned.


My (limited) experience is that as the perineum extends, the varicosities stretch and flatten out and are less of a problem in second stage than at other times.  You could always offer to hold a pad to support them as she pushes.  I have recently been at a homebirth with a similar woman her varicosities were fine, I just suggested she birth on her hands and knees to reduce the congestion in perineum/vulval area (as I would for any birth to promote an intact perineum and SLOW stretching)


I have just looked at the ARM website - they have a good archive section on varicosities, people sharing their experiences.


My (limited) experience is that as the perineum extends, the varicosities stretch and flatten out and are less of a problem in second stage than at other times.  You could always offer to hold a pad to support them as she pushes.  I have recently been at a homebirth with a similar woman her varicosities were fine, I just suggested she birth on her hands and knees to reduce the congestion in perineum/vulval area (as I would for any birth to promote an intact perineum and SLOW stretching) " 


One of the most unfortunate things that can happen to a woman with varicosities of the vulva is having an episiotomy.  Imagine trying to approximate wound edges during the repair and what that will mean for the resolution of the varicosities, not to mention the potential for blood loss.  It is amazing how the varicosities disappear as the head distends the perineum, and then just stay gone thereafter.  If they have been disrupted by a previous episiotomy, it might not work that way; I don't know.  But the idea of recommending CS to a multiparous woman because of vulvar varicosities is drastic, to say the least.  Sounds like the practitioner didn't have any experience with them, and they do look like an absolute hindrance to a normal birth if you don't know better.  Women with varicosities seem to be stretchier than average too - lucky thing!



As a homebirth midwife of many years I was always gratified to find that the varicosities ironed out as the perineum stretched. I imagine it would be a problem if an episiotomy was cut. It would seem very odd to me to plan a hospital admission instead of a homebirth for vulval varicosities. They look awful before the birth and I have had a few and never had a problem.

This is the only evidence I have and someone out there may in fact have seen a problem with them?



Pubic Lift



I was in Boston also for the ACNM convention- my 1st! I met a lot of friends etc. The session I attended which was most interesting was called 'PUBIC LIFT Technique'. This is a technique used by the speaker-as well as other midwives, to increase the pelvic diameter to facilitate delivery esp. in OP presentations- Presenter said that using technique can help rotate the OP to OA or may just allow delivery in OP position.

I will try to describe the technique- Please bear with me-

The technique (used in 2nd stage) done during a vaginal exam-with mom in dorsal position -during ctx - place examining fingers under pubic bone- pads up, avoiding the urethral meatus, apply firm traction upwards on pubic bone while mom bears down. Technique may be repeated with ctx until successful in turning or bring head down and under pubic bone.

The technique is suggested for use when other more generally used techniques such as position changes etc. have been tried but have not been successful.

Other midwives spoke up saying they have also used technique in semi-sitting position. One said she has noticed an increase in shoulder dystocia with use of technique.


I use the pubic lift technique when mom is exhausted and I am desperate! It is not particularly comfortable, but it does work well. Have not seen any increased in shoulder dystocia. I think it is the same principle as the two-handed squeeze...open up that pelvis to get a little more room.


This is one of those things I have done for a long time but until today, didn't know I was doing it. Generally have done it when there is an anterior lip that I have been holding back. Pushing it in and lifting at the same time. Seems to give the mom a bigger push, and often see descent improve. Just now put it all together! Now I will have to really watch and see what happens the next time.



Chinning



Chinning is difficult to describe in writing one needs to really demonstrate.  It is/was a method of "delivering" a baby where the head is on the perineum for A-G-E-S and there is a need, e.g. concern about the baby to expedite the birth, or the Mum is just getting past it and asks for a bit of help.  In hospital the Ventouse would be used.  However if one does not have access to the ventouse it is worth trying "chinning" Ask mum to lie in Left Lateral position, put the first three fingers of R. hand over the occiput of fetal head which will be  emerging under the SP every time she pushes and has been doing that for A-G-E-S and going back between contractions. Now flex the fingers of your L hand onto the palm of your Lhand and pad your knuckles with either a thin ST or a clean flannel and feel for the chin/face of the baby which can be felt between the anus and the coccyx.  During a contraction put pressure on the chin through your L hand and if you have it, you can feel that you can hold the head between your R.hand fingers on the occiput and your left knuckles on the chin through the maternal structure just posterior to the gaping anus.  If the anus isn't gaping there isn't enough descent and you can't do it. The pressure you exert is difficult to describe but what you are trying to do is hold that head down and stop it going back between contractions.   Flexing the fetal head with your R hand fingers and pushing on the chin to assist descent with your L hand.  It is not a nice thing to do to a woman but they amazingly seem to know what you are trying to do and between you, that baby's birth can be achieved in a two or three contractions.  I hope that is clearer than mud but it really is hard to describe but easy to show.  If you have a mature, i.e. nearing retirement midwife around ask her.  She may well know the trick and show you.



Finger Forceps



Finger forceps is when you cross your hands and then use your index finger to stretch the internal tissue.  You can reach as far as the ischial spines sometimes (not that u can feel them) technically not 'forceps in that you get the babies head but you do try and minimise tissue resistance and widen the exit. It is certainly invasive but no more so than ventouse/episiotomy and in many cases because it can be done without a hooha of calling doc I think I'd prefer to try before going for a 'lift out' even without an episiotomy.


I'm a "do nothing" till nothing the mom does is working. Then I use the 4-fingered-braced-backs-of-hands pry to open the pelvis a little more. Is that what you mean, by 2-handed squeeze?


I agree with "do nothing" til it's absolutely necessary. What I mean by two handed squeeze is standing behind mom, one hand on each of her hips (iliac crest) and push in towards the middle. [This is also called the pelvic press in Heart and Hands.] Is this what you mean by the 4-fingered-braced-backs-of-hands pry?


Nope. I mean a pelvic spread done vaginally, fingers pushing out on the pubic arch at about 2 & 10 o'clock positions. Probably has the same effect as the pubic lift. Have sometimes done just 1 side - side w/ occiput or frontal bone against it if head hasn't been making descent and head is still not OA or OP.


I hate coached pushing and valsalva pushing, the methods hospital birthing still holds sacred.



Pelvic Press



Well, Ina May showed us all how to do a pelvic press, first of all.  It turned out many of us were doing it wrong enough so that it didn't do enough.

She had us practice on each other - let me see if I can translate the physical learning experience into words.

Mom is standing in between two support people, who are at her sides facing each other.  Each person finds mom's iliac crest,  the large flared out part on the top of the innominate bone, and just below and behind it is that natural indentation, into which you put the heel of your hand.
Gently push at first while asking mom if both support people are in the same place on her hips, then they push directly towards each other (not up) as hard as they can, putting their weight into it.  IM had to tell us repeatedly "You can't hurt her by pushing too hard!"

You have to make sure you push at the same time and with relatively equal pressure on both sides so mom doesn't fall down.  While the press can be done with mom supine in bed (if she has an epi or something) it should preferably be done with mom standing up resting her hands on something to steady herself.  Press for the full length of the contraction while mom bears down.  Do for 5 full ctx, repeat once or twice if needed.  If that fails, baby won't come down and a section is warranted. (This is the point where IM said she hasn't had to go for a section for OP for 10 years, since she started doing this press.)

I did many a pelvic press before but only for one ctx, or by myself, or between ctx.  If you practice this with two colleagues, like we all did, you can really feel how this opens up your sacrum!



Rigid Perineum



Occasionally, a woman's perineum will be so tough that it simply will not tear, or she's so exhausted that her pushing efforts aren't strong enough to push through them, even if they won't stretch.  At one such birth, the OB made a comment that the superficial muscles of the pelvic floor are notoriously tough in women from cultures that squat a lot.

What are ways of stretching the perineum to avoid episiotomy in a case like this?


Well, ideally, you might have noticed this at an initial physical exam so she could have started perineal stretching prenatally.  In particular, The EPI-NO Childbirth and Pelvic Floor Trainer might actually be ideal for women with a rigid perineum.

Once you get to the point where you have a baby on the perineum, and it just isn't stretching, you don't have a lot of options.  You can try to relax the muscles with your hands, but it's going to have to be very gentle pressure so as not to harm the other tissues, and because too much pressure could increase the muscular resistance.

You can try lobelia, a very powerful herbal muscle relaxant, but you have to be very careful, one drop at a time over time.

Lots of warmth on the perineum might help relax the muscle - being in a birthing tub might be ideal, or lots and lots of warm compresses.

I think there are some homeopathics for a rigid perineum, but can't think of them offhand.



Ring of Fire



I use Cetacaine gel for the ring of fire, and women really appreciate it!


I did have some of the gel for a while and it did seem to work real well for the crowning/stinging burning end of pushing. I think it helped gets a few primips over-the-hump -- just something to take the edge off the last little bit of crowning.



Fundal Pressure



I learned how to do fundal pressure during second stage last year while interning. I have kept the knowledge stored in the back of my brain for total way out emergency situations. I am shocked to read how many in-hospital providers use fundal pressure.


An old book lists potential trauma from fundal pressure: "rupture of the uterus, bruising of the muscle and peritoneum- inviting sepsis and embolism - abruption placenta, injury to the abdominal viscera".


[from ob-gyn-l]


About six weeks ago, I was assisting a CNM with the delivery of a G3P2 who was pooped and not pushing well. The CNM does not have privileges for vacuum extraction (vtx at +2) so I placed it. After one contraction, there was little progress, so I asked the L&D nurse for fundal pressure. She flatly refused (in front of the patient) stating the L&D staff had recently attended a conference where they were advised it was "contraindicated" to provide fundal pressure. As I picked my jaw off the floor and tried to decide if there was something wrong with my hearing, the CNM quickly assisted me and we completed the delivery uneventfully.

At the ob-gyn department meeting in my hospital today, the incident was discussed. The notes of the conference the L&D nurse attended were distributed and it became apparent that the prohibition on fundal pressure was meant to apply to shoulder dystocia. Obviously, suprapubic, not fundal, pressure is the maneuver for a shoulder dystocia, since fundal pressure will only further impact the shoulder. But the nursing administration maintained they had done a survey of many other hospitals within our state, and NONE of them allowed the nurses to apply fundal pressure.

What is the situation in your hospital? Do you folks use fundal pressure as part of your armamentarium?


We indeed use fundal pressure in the situation you describe. In our case with 1 or 2 residents and a medical student scrubbed and a faculty person in attendance for all deliveries, there is no question of asking a Nurse. We just do it. This is another situation where the Nurses have taken it upon themselves to contradict what we have learned in those 8 years above what they went to means nothing.


Yes we do. Not with shoulder dystocia, of course, although Hankins operative obstetrics does describe the theory that during a screw maneuver one should have some fundal present.


I thought this was used only after the shoulder has been released.


We do use it, even for breeches sometimes. Shoulder dystocia is another story.


Most of the time at our place we have to remind the nurses about the difference between fundal pressure and suprapubic pressure. If you ask for suprapubic, they often employ fundal. I don't seem to use fundal pressure much, but I can see where its useful and of course you hate having the co-professionals telling you how to take care of your own end of the stick.


I am an obstetrician who conduct all my deliveries assisted by my midwife and I do think that fundal pressure is very useful and it really reduced my rate of instrumental deliveries and sometimes even C-section.


At all of our hospitals in Austin, Texas, fundal pressure is used on a prn basis. In fact our better, more active nurses will often suggest or initiate it on their own.

Having been involved recently in a shoulder dystocia case from 17 years ago, I had reviewed the literature, and as so many of our colleagues have mentioned, the only time that the issue of fundal pressure comes up is if there is a bad outcome. As you know, shoulder dystocia is unpredictable, and it even happens without fundal pressure, macrosomia, etc.

Anyway, I find your nurses to be way out of line!! I would ask them for the clinical literature on which they are basing their refusal to apply fundal pressure. There may be some articles they will present if you follow warped, circuitous logic (as our legal colleagues often do ), but no truly valid literature.


The reference previously mentioned is J Nurse-Midwifery 41:334-337 (1996) entitled "Use of Fundal pressure during second-stage labor: pilot study" by Karen Cosner. A prior study in 1990 surveyed 250 OB units and 74 (30%) replied. Of these 62 (84%) indicated that the OB staff (all comers) used fundal pressure.


The first delivery I observed as a nurse (and new midwifery student) the OB asked for fundal pressure with vacuum assist on a 2nd twin. None of the nurses responded. He then turned to me, who he knew had been a" labor coach" for many years and whose youngest child he had delivered 6 months earlier, and asked for help, which I gave. After two more contractions without delivery and evident fetal distress, a much older, veteran OB nurse moved me aside and gave very much stronger pressure than I had dared. The twin was delivered with APGARs of 1 and 1 and , tragically, did not survive.

I later was told that other than the contraindication of shoulder dystocia and fear of liability, the primary reason nurses no longer perform fundal pressure is concern over injury---- to the person performing the procedure. If you look at the origins of the policy of the hospitals in your area you may find it is based on risk of job-related injury.

I guess I agree with Sita Bhateja's message "I have opted for attachment... and though it is at times unbearable, I will not change it and have no regrets" To refuse assistance better come with a real strong conviction that to do otherwise is to render greater harm. BTW, what does Medline have to say on current practice re fundal pressure?


The same policy has been enacted at one of the 2 hospitals to which I go. It is a large (11,000 deliveries annually) private one, and the nurses can opt not to give fundal pressure even if the doc asks for it.

Apparently, this is not as kosher as it used to be. BTW, I am 11 years out of training, and was raised not to ever use fundal pressure. When I first started in practice, I remember asking the nurses to stop giving fundal pressure when they did it automatically.


I am a RN in a mid size community hospital where fundal pressure is a hot topic right now. We are being asked by some physicians to do prolonged fundal pressure (>1/2-1 hr.) on some pts, sometimes w/ horrendous outcomes (we recently had a fetal death after prolonged fundal/vacuum). We know that this is not right & a committee has been set up to develop guidelines for "appropriate?" fundal. So far they have come up w/ 15 min. limit, vertex presentation, MD required to be in room. I have mixed feelings about this because there is no literature to support the use of fundal for any time period (or possibly at all). Needless to say, the docs that use this often are up in arms that the nurses are upset about this practice.


In my training, we used fundal pressure exactly in the situation you have described, sometimes it was given by the anesthesiologist who was attending the delivery to help us also, and during the delivery of 2nd twin too. In my practice (mostly military trained partners) they seem to have the notion that fundal pressure in ANY situation may cause uterine rupture if given in circumstances other than c-section. We tried to do a lit-search on this, very little info on giving fundal pressure. The CNMs in our hospital feel that fundal pressure is also contraindicated - according to their literature (I have yet to see them). I wonder if that's something that is clinically passed down to us from the old-timers that we didn't write about, or are there references to this?


Recently in a discussion with several ob/gyns and CNM this issue also raised questions. There is a publication concerning fundal pressure in the CNM literature recently; however, it said basically, what you said. The only times that the issue arises in a critical way is when an adverse outcome occurs and then analysis often shows/suggests that it was not appropriate. In circumstances such as the one described I think that if fundal pressure between contractions (Kristellar maneuver) shows easy descent then in the exhausted patient or the one impaired by an epidural block, the application of forceps or for those who like vacuum, should be able to negotiate delivery without a significant increased risk of adverse outcome. The application of fundal pressure to assist delivery should not be required. When it is, the question that should be asked is "Should I be doing this?" I do not like vacuum; therefore, my own prejudicial view is that for the patient described forceps alone would have been sufficient. By the way I looked at the first edition of William's trying to find either written or indexed referral to fundal pressure during the second stage. I could not find it. If someone does, please post it.



Fundal Pressure w/VBACs



Is fundal pressure used in VBACs? I've seen fundal pressure used almost routinely during second stage in hospitals, but there seems to be no official policy concerning its use. And I haven't been able to find a journal article on its use other than the survey in J. Nurse-Midwifery and a few articles specifically concerning fundal pressure in shoulder dystocia. Do you consider fundal pressure contraindicated with VBACs, or do you believe it would cause no harm?


I wish people would investigate the possible role of 2nd stage fundal pressure in uterine rupture. Two nurses at different institutions have told me that fundal pressure in 2nd stage is practically routine where they work, and done just as frequently in VBACs as other births. Doesn't it seem that fundal pressure could be dangerous for a scarred uterus? There's very little in the literature--nothing in the medical literature that I could find, and in the nursing literature, just one survey on the frequency of its use, a few articles on fundal pressure in shoulder dystocia, and one small study on the use of fundal pressure in second stage.
 
 

Use of Fundal Pressure During Second-Stage Labor

by Karen Cosner. Journal of Nurse-Midwifery. vol 41, no. 4, July/Aug. 1996. 334-337

Abstract: Fundal pressure is a controversial obstetric technique used by some practitioners in second-stage labor. In this preliminary study, 34 deliveries in which fundal pressure was used to expedite birth were matched with 34 deliveries that occurred spontaneously. Several parameters were compared between the two groups. In the group of women who were delivered with use of fundal pressure, second-stage labor was longer and a higher incidence of third- and fourth-degree perineal lacerations was observed compared with those women who delivered spontaneously. This article discusses the possible reasons for these findings, the reasons fundal pressure was used, and the controversial issues that surround this technique.
 
 

The use of fundal pressure during second stage of labor

Journal of Obstetric, Gynecologic and Neonatal Nursing 1990 19: 511-517

This study surveyed 250 obstetric units in the U.S., finding that 84% used 2nd stage fundal pressure



Misc



Descent vs Time to Mold
From: Gloria Lemay <gloria_lemay@ultranet.ca>

I wonder why people expect "descent" of the baby. What I notice is that babies need "time to mold" the head. They don't descend, their heads mold. Once that molding of the head takes place (gently), the head is suddenly visible. It may take hours of supposed "no progress" for this to happen in Nature's time. Gentle, physiologic pushing will not stress the infant while this happens.

 




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