How to push during labor-what the current research says

I can not tell you how often doctors and other nurses would look at me strange when I would push with women during labor. Not only would I have them on their sides or sitting up(even with an epidural), but I very rarely encouraged women to take a deep breathe, count to 10 and push down as hard as they could. Why didn't I do this? Because most research I read showed that this was not the best way to deal with second stage labor(or the pushing stage). Instead, I would encourage them to go with their own natural urges. If they were using an epidural, I would still encourage this if they could feel anything. If they couldn't, I would encourage them to wait a little bit to push and then just push for as long as they wanted. They could even let their air out a little if they wanted. If they baby was having more problems, I would have them wait a few contractions to allow both them and the baby to take a break. This is all based off of current up to date research that showed that both babies and moms did better with this kind of pushing.

I did have some nurses tell my manager that I did not know how to deal with this stage of labor, and there were doctors that would not trust me alone in the room with their patient because of this. I had to laugh when I would see some doctors poke their heads through the door to make sure I was doing it the right way:) How could I do it their way, though, when I knew that there was nothing to back up how they did it. Here's an interesting excerpt that explains the dilemma as well as current research.


"Provider preferences and individual patient preferences also influence how successfully evidence is translated into practice. An example of how provider preferences may influence the implementation of evidence-based change into practice is open glottis pushing versus closed glottis pushing during second-stage labor.

Early research clearly demonstrated that closed glottis pushing compared with open glottis pushing caused detrimental hemodynamic changes.22 However, women in second-stage labor are still told by their labor nurses to "take a deep breath and push" as hard as they can and as long as they can. This closed glottis pushing using a Valsalva maneuver decreases oxygenation and is in part why limitations of 1 to 2 hours have been placed on the length of second-stage labor. In the late 1970s and early 1980s, there was a movement to change to the more natural open glottis pushing, in which women made noise while they were pushing. However, in an evidence-based practice demonstration, one barrier to changing from closed glottis to open glottis pushing was noted to be provider discomfort. With open glottis pushing, patients made guttural noises that sounded to some providers like the noises made during lovemaking or defecation and these noises made some providers uncomfortable."

http://www.nursingcenter.com/library/static.asp?pageid=1016650

with woman

"What does the term 'With Woman' mean to you? I've been thinking about this phrase quite a bit, and I'm curious what others may think. I know the etymologists definition of midwife is "With Woman", but I'm more interested in what that means to each of us individually. Any suggestions?"

This was a question that was posed on a forum I subscribe to, and I found it interesting. Midwife is defined as "with woman", and that definition has played a role in how midwifes view themselves nowadays. I thought I'd just respond to this by relaying a few experiences I've had.

I think one of the neatest experiences I've had in being "with woman", was when I was working with a hospital based midwife. She stayed with the mother the whole time. As the mother was having a natural birth, both of our attention was undeniably on the mother. We watched her movements, tried to understand her needs, and spoke with her where she was at emotionally and physically at that time. I have never before experienced such an intense feeling of teamwork. Not only did we focus on the moms emotional needs, but there was a keen awareness of the need to focus on how the baby was doing also. There was no tension over whether there were too many interventions or not, because we were all on the same page. There was a sense of trust. And while there were some issues that were worrisome, there was no feeling of fear or adrenaline rush. We simply did what we needed to do. I think a lot of this was due to the fact that the focus was on the woman.

The other time I think of, was when I was laboring with a woman who had intended on going natural She had become exhausted by the time she got to eight centimeters. A decision was made at that time to get an epidural. She wanted to just have a light one so that she could feel a little bit more when she was pushing. Well, it came down to pushing time, and she pushed and pushed but that little baby just did not want to make his way down. So, me being the natural minded nurse I am, decided that having her push on her back the way I was taught she should, was ridiculous. I knew she was able to move a little bit more and we had lots of help, so we had her role over on her hands and knees and with support she pushed more.

She eventually was able to push her baby out, but the thing that was most memorable for me, was how I loved working with her to decide how she might be able to push better. I loved supporting her in her desire to push the baby out, and in her desire to try different positions (we even had her squatting on the bed with some support). I loved being able to make sure that her new baby was still ok by holding on the monitor while she pushed instead of having it strapped to her. To me, supporting her in this way was one of the things I love the most about my job.

Being "with woman" is a very intense, emotional and physical job. It takes a lot of brain work, and emotional work to do. It is so much easier to not do it, really. I think if you can find a caretaker that takes this view on as part of their job description, you've found a gem.

So what position should I be in anyways?.....

This post comes from a question about positions during the pushing stage of labor. In one of my previous posts http://thebeginningofmotherhood.blogspot.com/2009/02/emergency-pain-control.html, I mentioned how you should not give birth laying on your back. So, if that's the case, what position can you push in? Answer: just about any position but that one:)

Here's the extended answer:)

It has been shown that being in an upright position helps to decrease the amount of pushing time, decrease the amount of tears, and decrease the amount of instrument deliveries. These positions include squatting, sitting, and on your hands and knees. There are good things and bad things about all of these. Obviously squatting would get tiresome, but if you have good help, they can help support you from behind. Hands and knees can also get tiresome, but it is one of the best positions to turning baby into the right position. You can also use a birthing stool to sit on, or if you are at the hospital, get the bed positioned to help support you sitting up. This is one of my favorite positions.

For those who have epidurals, or are just plain exhausted, the side-lying position has been shown to help. Essentially you have one leg raised while you are pushing on your side. With an epidural, you can also have the head of the bed raised to allow you to be more upright. Just make sure you are fully up and not just half way as this will decrease the space in your pelvis.

A good book to look at for positioning is Penny Simkins book, Labor Progress. She does a wonderful job of explaining different positions throughout the labor and why you would use them.

If you feel a need to be in any kind of position, I would stick with that. Many times, a woman's body can tell how they need to be to help move that baby down. Your biggest hindrance will be with medical staff that aren't used to these positions. I would make it clear from the get go that you want to push differently. Talk to your doctor about this also. Some are fine with doing whatever, and others are pretty stuck in the lying on the back mode.

I also had a question about doula's. First off, I'll say that I never had a doula, but probably could have used one. I have a wonderful supportive husband, but I feel like a doula who has been trained and been to many births, has experiences that neither I nor my husband had had at the time. Plus a doula allows the husband to take breaks when needed. A good doula will help the husband in his supportive role. I also think that there is something different about how men and women think, and having a women's support along with your husbands would make a difference.

Studies on doula's have shown that women who use doula's have shorter pushing times, less instrument deliveries, and breastfeed longer(Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN / NAACOG [J Obstet Gynecol Neonatal Nurs] 2009 Mar-Apr; Vol. 38 (2), pp. 157-73.).

I would interview them first to see if they would fit well with what you want to do and how you feel about things. If you plan on having a hospital birth, I would also try and find a doula that has worked well with the medical staff in the past. If money is an issue, try and request a nurse that has had natural birth experience. Sometimes, you can get a nurse to help with the labor support if needed.

References:

The Journal Of The American Osteopathic Association [J Am Osteopath Assoc] 2006 Apr; Vol. 106 (4), pp. 199-202.

The Journal Of Perinatal Education: An ASPO/Lamaze Publication [J Perinat Educ] 2006 Fall; Vol. 15 (4), pp. 6-9.

Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN / NAACOG [J Obstet Gynecol Neonatal Nurs] 1997 Nov-Dec; Vol. 26 (6), pp. 727-34.