"I worked with a woman whose doc said at week 10 of pregnancy that he thought she would need a c-section because of her anatomy. He induced her at week 39 to avoid big baby. Told her the baby felt BIG like 8.5. Labor moved a long. she got epidural at 4 cm, 80% -2. Was complete 7 hours later with lots of pitocin. Pushed for three hours, mostly in lithotomy position (My suggestions of side pushign shot down and laboring down too.) and doc called it. Baby didn't move past 2. Mom had been up all previous night and not eaten in 24 hours. She was toasted. Mom started pushing before she had pressure. Doc wanted coached pushing instead of laboring down. I see it all as an orchestrated c-section set up. But I don't know. So I am wondering if you have some gems up your sleeve for helping a mom with an epidural push through a "tight fitting pelvis."I feel like hands and knees or a supported drape could have been helpful, but those are not going to happen with an epidural. I don't know. Or something with one leg higher. By the way, the baby weighed 6.5. Not so big. This hospital is super management oriented, very high c-section rate. Most moms get induced. No one goes past 40 weeks."
This is a sad sad story. Now, it is possible that her pelvis was too small but in hindsight, knowing the baby was only 6-5...Hmmm, I'm inclined to think that mismanagement of labor was more likely.
Do I think she was set up for a section? Looks that way! First of all, no research supports induction for suspected macrosomia or LGA babes - in fact, these women are more likely to end up with a section!
Suggestions for pushing with an epidural? Here they are.... Everyone feel free to add any other tidbits that I may not have listed.
1. Laboring down is important - specifically with the woman on her side and a peanut wedged between her legs. This opens up the pelvis and allows baby to get in an optimal position for being born.
2. Once actually pushing - I usually have the woman push for a bit in a semi fowlers. We experiment with towel tug-of-war, using the hand grips, pulling legs back. Whatever seems to get the most out of her pushes and feels more productive to the woman.
3. I then like to flip to one side and push for about 15-20 minutes, then to the other side 15-20 minutes. I've not had this fail me once :) We can usually see a fair amount of the head after this. I then put them back into either semi-fowlers or squatting (this can be done with a birth bar - lower the foot of the bed and raise the back of the bed for support - works great for epiduralized women). Important note with squatting - the baby needs to be low in the pelvis for this position to be effective.
4. We have a baby!
There are various positions for OP babies as well. Also, hands and knees c an work for some women with epidurals - just depends on how heavy the epidural is. I had a woman who we ended up cutting the epidural off and was able to walk to the toilet with assistance after awhile, where she pushed for a bit.
I really suspect though, in the previous scenario that pushing was only a small contributing factor. I think the induction was inappropriate, coached pushing instead of waiting until mom had pressure, not allowing laboring down. Lotta things wrong in this scenario.
As an aside, Rixa has a post with references regarding this subject so go check that out on Stand and Deliver.