Wednesday, September 2, 2009

Pushing with an Epidural

"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.


Anonymous said...

An FP commented on one of Rixa's posts, about how moms with epidurals can still get into vertical/upright positions, with help. Scroll down to the last few comments on this post.


Ciarin said...

Thanks for the heads up - I have read doctorjen's comments many times and she sounds like she rocks!

Beetus said...

As you do Ciarin, with someone who has an epidural, I try to simulate movement. I believe it is so critical to success. As an RN, I've inherited too many patients who were given an epidural and then just left in semi-fowlers for the duration. Then they push them in nearly the same position and wonder why its taking forever and/or unsuccessful.

When someone is without an epidural, I find they go a lot faster if they move during descent: to and from the toilet in most cases. A lot of people are hesitant about walking a woman who is complete, but I find that if they are well hydrated and haven't been starved they do great. They have the energy reserves and they go a heck of a lot quicker. I digress...

Anywho, so applying this knowledge to a woman with an epidural, I do A LOT of repositioning as you recommend. Anything to simulate what a woman would do if she could walk/reposition. In my experience, repositioning frequently makes all the difference in the world in shortening the second stage and avoiding vacuum, forceps and sections.

I believe also that what we have done (or not done) in the hours leading up to second stage can effect that stage greatly. I believe I can save the woman a longer labor and long second stage if I educate her about positioning and sleep. After the epidural, I will put them on their side, pillow behind back, pillow between legs, pillow to hug and enc them to sleep/rest. I will quiet the room and enc partner to rest. I will flip her every 45-60 minutes to let her sleep if she can do so. I will flip her more often if she can't sleep. Once complete, if she is well rested and alert and not nauseated, and if baby is well positioned, occasionally, I may suggest she be in the throne position to labor down for awhile. Sitting up high, foot of bed down, legs spread open as in a squat. For Mom, this helps her wake from (hopefully) a long nap. She starts to socialize a bit and get mentally prepared for pushing. I would guess I only use this position about 10% of the time and only if they have been sleeping well and sidelying for the majority of the rest of the time. Otherwise, IMO, they should be sleeping/resting on side with peanut during laboring down.

As for OP babies, I've had some luck using rebozos with unmedicated Moms during the first stage. But if the epiduralized Mom has enuf sensation to get on hands and knees while laboring down, this could work for them too if everything has failed (i.e. sidelying, peanut)or they just would prefer to move. A hospital sheet can work as a rebozo. Place around mother's body so the ends can be held be the coach who standing behind her. I find this works esp well with multips with pendulous bellies. It provides support to mother and it also helps babe line up better. Gentle support of rebozo by labor coach while Mother assumes desired position.

I'm getting all excited....guess I'm ready to go back to work!!!

Paula said...

Ciarin, you are a rock star. Thank you from my heart for posting this. Very helpful. Also validating. But even more so, helpful.

Joy said...

OMG!!! You are an ANGEL! I was so worried that if I ended up with an epidural (I have a low pain threshold and while I will try this time to hold off, I know myself and know it's a possibility) that I COULD STILL BIRTH IN SQUAT POSITION!

Hallelujah! You just made my night.