When and How to Push: Providing the Most Current Information About Second-Stage Labor

[Julie Doula]

Wow. I don't think much of this in "Figure 2":

For women with epidural anesthesia who do not feel the urge to push when they are completely dilated, delay pushing until the urge to push is felt (up to 2 hours for nulliparous women and up to 1 hour for multiparous women).

or how about until however long it takes for her to feel the urge? I've seen women fully go our for a walk, come back, and have a baby. One mother went to bed, had a sleep, got up and had a baby! What's the rush?

• Use upright positioning with the woman's feet flat on the bed.

um, what about, 'let the birthing women assume whatever position she chooses'. It is HER that 'uses' any given position, not the staff!

Change to a lateral position or other positions of comfort as necessary.

Let the WOMAN change positions as she wishes, as her body compels her - again, it's not the careproviders who 'change the position' - it's the woman!

• Avoid forcing the woman's legs back against her abdomen.

how about, keep your hands off her, don't do ANYTHING to any part of her body - rather, let HER use YOUR body for support if she chooses.

• Discourage prolonged breath-holding. Instead, instruct the woman to bear down and allow her to choose whether or not to hold her breath while pushing.

how about, do NOT instruct her, other than to tell her to go with her body?

• Discourage more than three to four pushing efforts with each contraction and more than 6 to 8 seconds of each pushing effort (avoid counting to 10 with each pushing effort).

Amazingly, if you don't presume to instruct her, this will never happen!!

• Take steps to maintain a reassuring fetal heart rate (FHR) pattern while pushing. Push with every other or every third contraction if necessary to avoid recurrent FHR decelerations. Reposition as necessary to treat FHR decelerations. Use the fetal response to pushing as a guide for second-stage care.

Once again, the language implies the careproviders are in control and are active, and the mother is passive. No - careproviders should not "reposition", it's the MOTHER who 'changes position'. Even to say, "encourage the mother to change position" is more honouring of her autonomy.

• Avoid uterine hyperstimulation during the second stage of labor. Make sure that contractions are no closer than every 2 to 3 minutes while pushing. Titrate oxytocin accordingly, use an intravenous fluid bolus of lactated Ringer's solution, and reposition to decrease contraction frequency.

How about just don't use syntocinon but practice unhindered birth principles so her own birth hormones are at peak levels? Not to say that there is *never* a time to use syntocinon - but this reads as if it's normal practice for a woman to be on a bed, with an IV in, and synto running!

• Allow the woman's perineum to stretch naturally rather than using manual massage or stretching.

[I]I repeat: keep your hands off her! And yes, there is evidence to show that manual stretching and the use of oils, lubricants etc actually increases tearing and does not decrease it - amazing, letting the body do its job naturally turns out to be best!

I think this is a useful article, especially for people planning in-hospital births, but the wording of this appendix is rather disappointing.

sorry i tried to have my comments in italics to differentiate from the actual text in the quote, but it turned out all in italics ??