When and How to push – Lamaze paper on “Best Practices”

Abstract

THE “OLD WAY”

The “old way” of assisting women during second-stage labor typically involves pushing immediately at 10 cm regardless of whether the woman has an urge to push; telling the woman to take a deep breath and hold it (closed-glottis pushing) while someone (partner, nurse, nurse midwife, or physician) counts to 10 during at least four to five pushing efforts per contraction as the woman lies in the supine lithotomy position (often using stirrups); and a care provider forcing the woman’s legs back against her abdomen (Simpson & James, 2005). These techniques have the potential to cause harm to the mother and baby (Simpson, 2004).

A full discussion of the potential harm in the traditional approach and recommendations for practice changes are presented in the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Evidence-Based Clinical Practice Guideline: Nursing Management of the Second Stage of Labor (2000).

A recent review of the literature (Roberts, 2002) provides additional information. Staying current with rigorous evidence related to labor and birth is crucial for childbirth educators so they are able to provide women and their families with the best information available to promote safe care.

A BETTER WAY BASED ON CURRENT EVIDENCE

The “J” shape of a woman’s pelvis means the baby must change directions as it spins around the bottom curve of the letter  “J” while going under the pubic bone and simultaneously moving up and out as it’s being born. If the mother is lying on her back, the curve of the “J” requires her to push the baby uphill, towards the ceiling, which means working against the forces of gravity (i.e. anti-gravitational position)

A better approach based on current evidence is to delay pushing until the woman feels the urge to push. With epidural anesthesia, pushing can be delayed up to 2 hours for nulliparous women and up to 1 hour for multiparous women (Hansen, Clark, & Foster, 2002; Simpson & James, 2005).

Shows the baby tracking with the letter “J” (the technical term for bend at the bottom is the “Curve of Carus”; its head turns sideways to slip under the mother’s pubic bone (head #1); then turns face down as the crown of its head begins to distend the mother’s perineum (head #2); the head moves uphill as it literally crowns and the baby is born (head #3) and then the head turns to face sideways in order to lines up with the rest of the baby’s body (head #4).

There are two phases to the second stage of labor: the initial latent phase and the active pushing phase (Roberts, 2002). The most stressful period of labor for the fetus is the active pushing phase; thus, shortening this phase minimizes fetal stress and promotes fetal well-being (Caldeyro-Barcia, 1979; Caldeyro-Barcia et al., 1981; Roberts, 2002; Simpson & James, 2005).

When pushing is delayed until the woman’s urge to push, there are fewer fetal heart rate (FHR) decelerations and less of a negative effect on fetal acid-base status and oxygenation (Caldeyro-Barcia et al., 1981; Hansen et al., 2002; Nordstrom, Achanna, Nuka, & Arulkumaran, 2001; Piquard, Schaefer, Hsiung, Dellenbach, & Haberey, 1989; Roemer, Harms, Buess, & Horvath, 1976; Simpson & James, 2005; Thomson, 1993).

The latent phase is an ideal time to allow the woman to rest in preparation for pushing efforts at the appropriate time (Roberts, 2002). When the time is right for pushing, the best approach based on current evidence is to encourage the woman to do whatever comes naturally; for example, bearing down and holding it as long as she can, rather than insisting that she hold her breath for 10 to 15 seconds to the count of 10 (AWHONN & InJoy Videos, 2006).

{Editor’s note: As an L&D nurse during the “knock’em out, drag’em out” Twilight Sleep era (Dark Ages deep South 1960s), heavily medicated women can’t and don’t pay any attention to what you tell them. They pushed when their body gave them the physiologic stimulus and that pushing rarely ever lasted longer than 6 seconds, but they usually had 3 “urges” for each UC with a nice deep breath between each push}.

Prolonged maternal breath-holding results in maternal apnea and negative maternal hemodynamic changes that lead to decreased blood flow to the placenta and, ultimately, negative consequences for the fetus (Barnett & Humenick, 1982; Caldeyro-Barcia et al., 1981; Simpson & James, 2005). Three to four pushing efforts of 6 to 8 seconds in length per contraction are physiologically appropriate (AWHONN, 2000; Roberts, 2002; Simpson & James, 2005).

Positioning is an important component of safe and effective pushing. An upright position or lateral position works better than supine positioning and has fewer negative maternal hemodynamic changes (Roberts, Algert, Cameron, & Torvaldsen, 2005). Encourage the woman to choose a position of comfort and to change positions as often as needed.

Forcing women’s legs back against their abdomen during pushing should be avoided because this results in stretching the perineum and increases the risk of perineal lacerations (Sampselle & Hines, 1999; Simpson & James, 2005).

No evidence suggests that manual massaging or stretching the perineum is beneficial, and many women find this technique uncomfortable (Albers, Sedler, Bedrick, Teaf, & Peralta, 2005).

PROMOTING FETAL WELL-BEING

It is particularly important to recognize non-reassuring FHR patterns during the second stage of labor and to intervene appropriately (AWHONN & InJoy Videos, 2006). A commonly held myth suggests that it is better to “get the baby out” rather than to allow the mother to rest and the fetus to recover.

Many care providers fail to realize that their aggressive coaching techniques are the cause of non-reassuring FHR patterns (Simpson, 2004). If the fetus does not respond well to pushing, the best approach is to stop pushing temporarily and let the fetus recover (Freeman, Garite, & Nageotte, 2003).

If the fetus continues to respond poorly—as evidenced by abnormal changes in the FHR and recurrent variable or late decelerations—and there is a compelling reason to continue pushing, pushing with alternate contractions works best. It may be necessary to have the woman push with every other contraction or every third contraction to maintain a reassuring FHR pattern (AWHONN & Injoy Videos, 2006; Freeman et al., 2003).

The woman should be assisted to a lateral position. A baseline FHR should be able to be identified between contractions.

If the fetus does not tolerate pushing and the woman has received an epidural, the passive fetal descent approach is quite useful (AWHONN, 2000; AWHONN & InJoy Videos, 2006). Evidence suggests that, for women with epidurals, coached pushing beginning immediately at 10 cm does not result in a clinically significant decrease in the length of the second stage (Fraser et al., 2000; Hansen et al., 2002; Mayberry, Hammer, Kelly, True-Driver, & De, 1999; Roberts, 2002).

Passive fetal descent will result in about the same length of the second stage for women with epidural anesthesia as does the coached-pushing approach. Patience and encouragement are most helpful, rather than insisting that the woman push before it is appropriate and/or when the FHR is nonreassuring.

The FHR pattern should be used as an indicator as to how well the fetus responds to second-stage labor (Simpson, 2004). Recurrent variable or late decelerations during the second stage are associated with respiratory acidosis at birth (Parer, King, Flanders, Fox, & Kilpatrick, 2006). I

n addition, the fetus may develop metabolic acidosis if this type of pattern continues over a long period (Parer et al., 2006). These babies are difficult to resuscitate and may not transition well to extrauterine life.

THE ROLE OF CHILDBIRTH EDUCATORS AS MEMBERS OF THE PERINATAL TEAM

Ideally, clinical practice is consistent with the latest evidence; however, in some labor units, care providers may not be completely up-to-date on best second-stage labor care. Pregnant women and their families can overcome this limitation if they are fully informed and prepared to ask for selected care processes.

Childbirth educators help to facilitate this knowledge. For women who choose to use a birth plan, consider sharing the information in Table 1 to add to their birth plan as requests for second-stage labor care.

Often, childbirth educators are not well connected to other members of the perinatal team; however, they can take the initiative to be more active team members by sharing information and participating in discussions about the latest evidence applicable to clinical practice during labor and birth.

Make an effort to coordinate childbirth education content with those who provide the care during labor and birth. Arrange to observe clinical practice during second-stage labor.

If practices are not consistent with current evidence and AWHONN clinical guidelines, work with care providers to promote change. Discuss best practice during second-stage labor with physicians and nurse leaders. Offer to share the information in Table 2. Use the AWHONN (2000)Evidence-Based Clinical Practice Guideline and AWHONN and InJoy Videos (2006) Second Stage Labor Support production as a basis for this discussion. Include additional pertinent literature as well, some of which is listed in the reference list below.

Childbirth educators can influence unit practice to make second-stage labor care as safe as possible. Do whatever it takes to become a visible, highly knowledgeable member of the perinatal team. We are all invested in the most optimal birth outcomes for mothers and babies. Working together is our best hope for success.

References