Monday, December 28, 2009
“Okay, you’re complete! It’s time to push!”
These are the words that seem to bring changes into the birthing room. The laboring patient is usually relieved to hear these words, sometimes surprised, sometimes anxious, but most often you can catch a glimpse of a smile pass her lips when she hears these wonderful words. For some women, nobody has to tell her it’s time to push, she is already pushing! She may have been trying not to push for the last several minutes, or in some cases (hours). Sometimes there is no stopping that freight train urge and mom pushes like there’s no tomorrow! Some mom’s aren’t so sure of what is happening. She doesn’t ‘have an urge to push’, (this is due to the baby just not being low enough in the birth canal where those nerves are that say ‘push!’). There is the occasional laboring mom who never feels the urge to push (but I assure you that her baby would still be born as the uterus still presses down on it’s own).
The pushing phase is the 2nd stage of labor (the first stage is all the dilation that takes place, the second is the pushing phase, and the third stage is the delivery of the placenta). Although it’s not considered a stage of labor, there is another phase between the dilation and pushing that sometimes occurs: The resting phase.
Some women get to 10cm (or complete whatever that centimeter of dilation is), and feel no urge to push, and in fact may stop having contractions all together. These women rest or fall asleep (providing that there is no nurse or doctor yelling that it’s time to push). Sheila Kitzinger aptly calls this “the rest and be thankful phase’. This phase can be non-existent or last 30 minutes (and I’ve heard some women go up to an hour). I tell you this so you won’t feel ‘broken’ if this happens to you. It can be a normal part of labor and delivery, and you absolutely have the right to enjoy this break. As long as you and the baby are doing fine, there is no need to hurry this process, even if the doctor’s pizza is getting cold :-) There is nothing harder than trying to push when there is no urge, and worse - when there’s barely a contraction facilitating it. It’s like trying to poop when you don’t have to go! Never fear though, the hospitals have a backup plan for this resting phase: Pitocin!! Sorry mom, you can’t enjoy your resting phase today, you are broken, and we need to give you Pitocin so that we can make you contract, so that this baby can be born in a timely fashion. Argh. Just so you pregnant women out there know, you have the right to refuse any medical treatment - and this is an example of a good time to exercise this right. If the baby is doing well, and so are you, why fix what is NOT broken. If you are resting, your body probably needs that rest. What is TERRIBLY frustrating is when women refuse such treatment and then they’re told from their nurse or worse yet, their doctor, that if they refuse, their baby will DIE. Really? Without any warning? Why do studies not show this? Why is it that women with an epidural are allowed to labor down, and are sometimes told not to push for an extra long time, because the doctor is not available?
There is so much to write about the pushing stage of labor, but what I’d like to write on today is the methods of pushing. There are three basic types of pushing:
*Directed (often called “purple pushing”)
*Mother directed pushing (also called spontaneous pushing)
My primary concern is with directed pushing. After a vaginal exam confirming that mom is complete, a coaching session ensues on how to push. The mother is directed to push for 10 seconds, allowed to take one breath in, and “Go back at it again, 1,2,3,4,5,6,7,8,9,10, now take another deep breath and push again..1,2,3,4,5,6,7,8,9,10". Sometimes the mother say’s things like “I don’t feel the urge to push”, or she can’t push that 3rd set of 10 seconds, and get’s scolded. Heaven forbid the woman let out noise during the pushing stage! I’ve heard it too many times “don’t make noise, hold your breath and PUSH!”. Do they tell men who are bench-pressing, or karate-chopping to stop making noise? Isn’t it normal when there is so much power going on within a woman’s body, to just make noise? Studies show that making noise can help with pain! Nurses and doctors have a trick for giving a laboring patient that gives them an urge to push. A couple of fingers in the vagina, pressing down on the rectum will make you feel like you have to push!
Directed pushing comes with a list of cons, which is why I want to write about it. Again, if mom and baby are doing fine, there is no reason to hurry this stage of labor. Directed pushing increases the risks for tearing, fetal distress (due to the lack of oxygen), blood shot eyes in the mother, a drop in her blood pressure, a drop in maternal oxygen levels, and exhaustion ensues much sooner (causing the need for episiotomies, forceps, vacuum extraction, and in some cases - cesareans). We call it “purple pushing”, or sometimes “Valsalva pushing” because it can lead to the Valsalva's Maneuver (producing the effects listed above).
Now if a woman has an epidural, she may need directed pushing, because she may not feel that urge to push, or push hard enough because of her lack of feeling. She will not have the feedback to her brain providing telling her to push harder, or slower, and this will increase her risks for tears. For the rest of this blog, unless otherwise stated , I will be talking about these pushing methods for women who are not having an epidural.
Spontaneous pushing is mother directed pushing - simply put, pushing when she feels the urge and for as long as she needs to with each contraction. Most women do not push for more than 6 seconds when pushing on their own. They may push once, twice or several times during the contraction. Baby will get more oxygen when pushing this way, and the pelvic floor has less chance of being compromised. “Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations” (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8N-3VSP400-5&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1143346928&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ea8cfc9677c166938518a39214667fbc)
Spontaneous pushing provides more oxygen to mom and baby, decreasing fetal distress, drops in maternal blood pressure, and doesn’t necessarily make a difference in the time that it takes for the baby to be born. Some studies say that directed pushing is about 15 minutes faster, but the following study shows that there was no difference in time, but that babies had better APGAR’s when mother was spontaneously pushing:
“This pilot study focuses on the bearing-down phenomenon of the second stage of labor, within the theoretical framework of Levine's conservation principles for nursing practice. The purpose of this study is to contrast the effects of two learned approaches to parturient participation during the second stage of labor. A control group (n = 5) was taught the traditional approach to second stage bearing-down efforts: sustained breath-holding. An experimental group (n = 5) was taught to bear-down only with the involuntary urge. No differences were found in the mean duration of the second stage, phases within second stage, Apgar scores, or maternal report of effort. Perineal integrity was preserved in the experimental group. These findings suggest that involuntary bearing-down efforts are accompanied by adequate labor progress and result in less perineal trauma. Further examination of the common practice of encouraging women to bear down strenuously during the second stage, instead of responding to their involuntary urge, is recommended.”
There are several studies out there showing that there is a direct correlation between directed pushing and an increase in perineal tearing. Even the World Health Organization says that the mother should push when she feels the urge, and should not be directed unless medically necessary! So why is this still being practiced? Feel free to answer!
The final type of pushing is exhaled pushing. This is the type of pushing, that is still mother controlled (or mother directed) but without her holding her breath. Instead as she pushes, she exhales her breath. Many women instinctively do this anyway. They make noise, grunt, and do a “Schhhh” as they finish pushing. This is where they are usually told to stop making noise and hold their breaths to push. Some women simply ‘breathe’ their baby’s into the world, and it is absolutely serene to watch! This may take a bit longer for baby to come, but is really great for reducing tears. It’s can also be very difficult to do when mom’s have a really strong pushing urge. The general rule is that when baby is crowning, you should stop pushing and pant, blow or breathe so that you have plenty of time to stretch s-l-o-w-l-y. Unfortunately, when baby starts to crown, caregivers get very impatient and tell you to “push NOW, push hard, GO GO GO GO!”. Baby pops out like a cork in a champagne bottle and poor mom’s perineum tears in the process.
Again, as long as baby is doing fine, why hurry this process? I’ll be the first to admit that one reason is because IT HURTS! However, I also know how bad it hurts to heal from huge tears due to forcing baby out like a rocket. I would much rather endure a minute or two of that ring of fire, than 6 (or more) weeks of healing and pain. I’ve done it both ways, and if get pregnant again, my husband has orders to hit me over the head before baby crowns so that I don’t listen to that little devil on my shoulder saying “push! Get the pain over-with NOW!”
Positioning can also cause or reduce tears (depending on the position). Stir-ups are the worst for causing tears, in fact, any time mom is on her back, it not only makes it harder for mom to push (because she is pushing uphill against gravity), but the pressure is increased on the perineum - from the vagina to the rectum. Using a squat bar, a birth stool, laying on the side, or even a hands and knees position can help reduce tearing - especially when mom is breathing her baby out after baby begins to crown. Last but not least consider asking your birth attendant to keep their hands out of your vagina while baby is crowning. Some like to reach in and ‘help’ gently stretch mom while baby’s head is coming down, but this may actually lead to tearing. Baby’s have been born since the dawn of man, without this practice, and there really is no reason for it.
Please remember that tearing is scientifically proven to be better than having an episiotomy, and is not as painful as you might expect - especially during the birth itself. There are plenty of things you can do to heal, and manage pain afterwards, but I won’t go into that right now. Many women fear tearing so much that they would rather have a cesarean with increased risks of all kinds of things. But do remember that tearing can most often be prevented by just doing the above (spontaneous pushing, exhaled pushing and pushing upright). Some women do everything right, and they still tear, and some women do everything wrong, and they don’t tear! We are all different. I’m just giving you the odds, and I hope that someone out there benefits from this information.