When and How NOT to push — negative hospital and obstetrician-based practices

by faithgibson on April 21, 2020

in Contemporary Childbirth Politics, OB Interventions: Dubious or Detrimental

Easy-2-share Link: https://tinyurl.com/y9ltxguk

Women in Labor Can’t Hold In Their Babies. Nurses Tell Them To Do It Anyway

By Kimberly Lawson

Jul 16 2019, 7:47am

Mothers in labor are often asked to delay birth to accommodate doctors’ schedules. In many cases, it can have harmful consequences.

One day, three weeks before my baby’s due date, I started feeling bouts of teeth-clenching pain at about eight in the morning. By 11, I was settled into a hospital room, marveling at how effective my epidural was, but terrified about giving birth.
Within a few hours, the medication wore off, and I felt the uncontrollable urge to push. (For those who have never delivered a baby, imagine the feeling of an urgent bowel movement, times 10,000.) My doctor, however, had left to see other patients.
The only people in the room with me were my partner, a labor and delivery nurse, and a medical student. The nurse asked me matter-of-factly if I could try not to push until the doctor returned. I panicked. Of course I couldn’t not push—my baby was coming.
Perhaps noting the look of terror on my face, the med student quickly grabbed a pair of gloves and a mask and positioned himself below me. The nurse muttered something about having to do additional paperwork, but readied herself as I started screaming about it being “go time.” Seconds later, the med student handed me my daughter.
As California-based licensed midwife Lindsey Meehleis explained, if an unmedicated person in labor feels a natural urge to push—meaning, the baby is low enough to be push on rectal nerves—any dilation that’s left usually happens on its own with the pushes. “It’s something that happens instinctually and automatically, and you can’t really fight it. It just happens.”
The standard of care in many hospitals is to utilize directed pushing, which is when the birth attendant offers the laboring person guidance including how to push and when to breathe. But there is momentum building in the medical community to have women listen to their bodies and push when they feel like pushing.
This doesn’t work as well for people who opt to have an epidural—approximately 71 percent of American women. For those who aren’t numb to the pains of labor, however, the need to push is impossible to ignore—with potentially serious consequences for the baby and mother if it is.
According to Dana Gossett, chief of gynecology at the University of California, San Francisco Medical Center, “If a woman’s cervix is fully dilated and she has the urge, she should be allowed to push, barring some unusual complication with mother or baby. Her progress through labor should be dependent on what’s happening with her body and her baby, and not on the location of her doctor or midwife. Because, really, the location of the doctor or midwife should be responsive to how she’s progressing through labor.”
Any baby-centric online discussion board has people sharing similar anecdotes to mine, about being told to stop pushing during labor—and, in some cases, actually fighting to hold babies in their wombs when their instincts tell them otherwise, describing it as one of the most painful things a person can endure.
Elaina Loveland, 41, chose to have a natural birth in 2011 because of her blood platelet disorder. By the time she arrived at the hospital, she was 10 centimeters dilated. “When I got there, I was begging to go to the bathroom,” said Loveland, who lives in Virginia. “This was my first child, so I didn’t know exactly what the sensation was, but now I know I needed to push the kid out. They would not let me move. They had run out of beds, so they put me on a metal table and strapped me down to check the baby’s heart rate.”
Loveland said the nurses made her hold off on pushing until the doctor arrived. “I’ve never felt a more painful experience in my life [than] being strapped down and forced to hold a baby in. It was almost worse than the pushing. It was horrible.”
When the doctor finally showed up, she told Loveland she had 20 minutes to push her baby out before she’d have to undergo a Cesarean section. The threat was particularly frightening for Loveland because of her platelet disorder, and because she hadn’t been medicated. She did it, though—she pushed so hard, she burst all the capillaries in her face. “I felt like my rights were completely violated,” Loveland said. The experience spurred her to launch Take Back Birth, a website that aims to help educate women about the birth experience.
The problem, Gossett said, has to do with the availability of providers. “In many places in the country, OB-GYN practices are small, and the providers are trying to both be present in the office and see patients while also covering patients who are laboring. They themselves are torn trying to take care of everybody. That can be really difficult.”
Accordingto the American Congress of Obstetricians and Gynecologists (ACOG), the United States is facing an OB-GYN workforce shortage: By 2020, there will be 8,800 fewer obstetricians and gynecologists to manage the country’s growing need for reproductive care. That deficit is expected to rise to 22,000 by 2050.
“If you go to a solo practitioner or a very small [medical] group, the availability of those providers to be present through the course of your labor and delivery is going to be lower,” Gossett said.
“Naturally, they’re going to have additional demands on their attention and time.”
But the impact of holding in a baby during birth for something as simple as waiting on a doctor to show up can be harmful.
“The best outcomes happen when birth is left undisturbed and it proceeds naturally,” said Emiliano Chavira, a California-based maternal fetal medicine specialist and the medical director of ImprovingBirth, a maternal health consumer advocacy organization.
“When you start doing extreme things like trying to hold the baby in or clamping the mom’s legs closed, there can be risk of creating injury either to the baby or to the mother.”
A recent study that investigated the effectiveness of timing of pushing found that anesthetized women who delayed pushing in order to allow the baby to labor down on their own were at higher risk for maternal hemorrhage and tearing. “A growing body of observational data has suggested that every additional hour spent during the second stage of labor compared with the first hour, regardless of an immediate pushing versus delayed pushing management strategy, is associated with an increase in maternal and neonatal morbidity,” the study’s authors wrote. In other words: The longer the labor, the higher the risk of either or both mother and baby getting sick.
“Holding in a baby can do damage to the pelvic floor muscles,” Meehleis said. “If we have something that’s trying to be ejected out of our bodies and yet we’re counteracting that and holding the baby in, we know there can be significant trauma to the pelvic floor.” Research shows that people with very long second stages of labor are at a higher risk for pelvic floor disorders, including urinary incontinence.
As for the baby, the likelihood of a newborn’s being admitted to the neonatal intensive care unit also increases with the duration of labor. For example, neonatal sepsis, a blood infection, has been linked with prolonged second-stage labor. “The longer the pushing phase lasts, whether you’re actively pushing or sitting there, the higher the chances are for things like lower Apgar scores (which are a measure of how well the baby transitions), lower blood gases and lower oxygen level. We know those things are not good,” Gossett said.
It makes sense that health care facilities prefer a licensed practitioner be in the room when a person gives birth in case of complications. “A nurse is not trained to deliver a baby,” Gossett said. “You don’t have a competent provider to do the maneuvers to help the baby deliver safely with as little damage to mom as possible. The nurse is not capable of, for example, doing a perineal repair or dealing with a postpartum hemorrhage.”
In some rare cases, not being allowed to push out a baby when a person’s body wants to has led to permanent damage. Caroline Malatesta, a mother of four in Alabama, garnered media attention in 2016 after she won a $16 million lawsuit against a Birmingham hospital. The birth of her fourth child there four years earlier led to diagnoses of PTSD and a little-known, yet debilitating nerve condition called pudendal neuralgia. While the condition is seen in both men and women, childbirth can damage the pudendal nerve, which tells the pelvic floor muscles what to do.
“The nurse told me to get on my back,” Malatesta recounted in a Cosmopolitan article. “I stayed on my hands and knees and breathed, trying to relax, as that is what came naturally to me. But the nurse pulled my wrist out from under me and flipped me over onto my back! Then another nurse held my baby’s head into my vagina to prevent him from being delivered. The nurses were holding me down, and I was struggling—really struggling.”
Instructing a person not to push during the second stage of labor should only happen in certain circumstances, such as if the baby is in distress and delivery is not imminent, Gossett explained. “If the baby’s not crowning and about to come out and another two pushes isn’t going to get the baby out, we need to talk about what to do to expedite delivery or consider a C-section,” she said.
Another reason why pushing would be halted by a provider is the occurrence of shoulder dystocia, where the baby’s head delivers and the shoulders get stuck behind the pubic bone. “Having mom push or having the doctor or midwife pull actually makes it worse because it further drives that shoulder bone into the pubic bone, and what actually needs to happen is that the baby needs to be rotated to dislodge that impacted shoulder,” said Gossett.
According to Meehleis, some providers might tell a laboring person to slow down or stop pushing to help prevent perineal tearing. Or, sometimes, the cervix isn’t dilated all the way.
The latter was Jessica Badger’s experience with her first child in 2012. Badger, who lives in North Carolina, chose to deliver her baby naturally in a hospital setting. It felt monumental, the 34-year-old recalled, to give birth. “I wanted to do it without drugs, so it was even more intense, and I thought I needed to trust the people around me even more.”
Not long after settling into her hospital room, Badger’s water broke. She was seven centimeters dilated. “Five minutes later, I felt the urge to push,” Badger said. “That’s not how it’s supposed to work. You’re supposed to need more time. [The nurses] just kept saying, ‘Honey, we just checked you, you don’t need to push.’ I’m like, ‘No, it’s time to push.’”
Because her doctor wasn’t available—she thought he might have gone to lunch—Badger said the nurses asked her not to push until he arrived. “‘You’re just going to have to wait,’” she recalled them saying. “I would have launched myself out of a window in order to be able to push.”
When the doctor did show up, it only took three pushes to deliver her baby. “I was the one who knew what was going on with my body, and I was the only one they were ignoring,” Badger said. “That feels unforgivable.” Especially, she added, after the birth of her second child, which took place in a birth center with a midwife. There, she said, she felt supported and in control of her experience. “It felt like I was being inconvenient somehow with my first one—like I was cramping their style by telling them what I wanted to do.”
Emotionally, being directed not to push can be traumatic. “[T]elling a woman not to push when her body is instinctively pushing suggests that her body is wrong, and that she needs to resist her urges,” wrote Rachel Reed, a senior lecturer in midwifery at the University of the Sunshine Coast in Australia. “After resisting her body’s urges, she may find it difficult to switch into trusting and following her body once given the ‘go-ahead.’ Encouraging a woman not to push when she is instinctively pushing can be distressing for her.”
Badger relates to that sentiment. “It makes you question everything,” she said. “When I think back on [my experience] now, it makes me angry.”
Whether a person should be instructed not to push is highly contingent on the situation, said Chavira. But, as he also pointed out, the reality is that sometimes unexpected things happen during birth, and they happen very quickly. “It’s very important that providers maintain their composure and maintain dignity and respect for the patient,” he said. “No matter what the scenario is.”
Follow Kimberly Lawson on Twitter.
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