Thursday, August 8, 2013

How to Push with an Epidural

Sounds simple enough doesn't it, pushing? What could possibly be hard about that? Well thats what I thought anyway!

The thing is we haven't EVER pushed out a baby before and if you have an epidural then theres a good chance that you won't feel a contraction telling you to push, never mind know and feel what to do!

My First Birth!
The first time I was in labour, my baby turned posterior after 5 hours so it took a little longer than expected, after 2 gas canisters and Pitocin about to be administered I was asking actually begging for an epidural!

Once the epidural took effect I could rest on the bed which is what I really needed as I had been on my feet for 24 hours up to this point. I could now relax and watch my baby's heart-rate on the monitor.

After the epidural I was surprised that I could feel and move my legs, I didn't  request a top up but my midwife gave it to me anyway. Soon after the second top up she checked to see if I had progressed and to determine baby's position. Hooray I was 10 cm and baby had turned anterior. Since then I have always questioned if the top up was necessary? 

On this assessment I would now have to wait for the effects of the epidural to wear off to enable me to push, I just wanted to get it over with!

I'm not sure how long I waited but I don't think it was long and I was encouraged to start pushing, this was when the real marathon phase started! 

First time Pusher!
I couldn't feel a thing, I had no idea when my uterus was contracting to be able to push and then when I did push nothing was happening! So after 2 3/4 hours an Obstetrician came in to check everything was ok?

She (the Ob) wasn't happy, adding to the epidural, was a full bladder which she emptied, you can't push a baby out with a full bladder. I couldn't feel the need to go but my midwife should have possibly checked me more frequently than she did?

I also know now that my Pelvic Floor Muscles (PFM) were too tight from too many pelvic squeezes/kegels and it was almost impossible for me to relax these muscles. I had a lot going against me, it was looking like an episiotomy, my worse fear!

Midwife to Obstetrician
Now the Obstetrician in charge changed a few things, first of all she said if I didn't get this baby out soon she would have to cut me, she got me to sit up, so I was now inclined with my knees bent and then she showed me. Yes thats right she put a mirror right where I could see everything, I nearly had a heart attack there and then! BUT it was amazing I had a visual. 

As this phase had taken some time, I could now feel the contractions slightly as the epidural had started to wear off with this, the threat of stitches and the mirror view it gave me the strength to continue, I had a chance! 

The main benefit of these changes was that I could now see for myself that I was making progress each time I pushed, I don't think I could have done it without this?
By sitting up and holding on to the back of my legs to help me push whilst watching everything gave me valuable feedback I would definitely recommend the above.

I didn't tear and our first daughter, Kate was born within 15 minutes of these changes.

How to Push:
We are often not taught how to push, even at many antenatal classes, why is this often not discussed?!

I try now to help and educate my clients on how to push and pushing effectively with or without an epidural and the different techniques that women can use.

Pregnancy- Prepare yourself!:
First of all don't over exercise your pelvic floor muscles, I certainly didn't make that mistake again and my next 2 births were a damn site easier!

Practice relaxing your pelvic floor muscles and do exercises regularaly that help you prepare specifically for labour and birth:

Exercise during your pregnancy will assist you in labour and can even shorten your labour time.
Specific exercise enables you to adopt better birthing positions during a labour with or without medical interventions.  

I have always found that it helps to have something to use to push against so you can exert force downwards towards your bottom a bedpost, ledge of a bath, your partner can work very well.
You can also pull a towel or sheet held by another support person to help you exert a similar pressure, you just have to make sure that you are not stronger than the other person! 


Lets have a look at what happens when your uterus contracts:

During a contraction your uterus muscles form opposing spirals from the top of the uterus first progressing to the lower section.

During the dilation phase your cervix becomes incorporated into the lower segment of the uterus. When your uterus contracts the muscles also contract causing the upper segment to shorten which draws the lower segment upwards this happens in a gradual but expulsive motion!

Work with What's Happening Naturally!

During a contraction I have always suggested to clients to think about themselves as a tube of toothpaste try to do what your uterus muscles are naturally doing.

At the start of the contraction squeeze your abs together from the top of your rib cage first gradually squeezing down whilst counting slowly to 10 or more seconds, pushing downwards.
Breath out slowly, as you do this relax your face and mouth this is when you can scream/curse which I found really helpful in a natural birth situation with numbers 2 and 3!
You may be able to push twice like this if its a big contraction. Some professionals may teach holding your breath but I believe this increases tension in the face which therefore tenses your bottom-relaxed face equals relaxed bottom! 

Lastly what you really need to do at the end of your push is make sure that your PFM are relaxed, like my friend Beth from Fit2b added in a blog and I hadn't thought of it this way until she mentioned it- don't push down and leave the top on the toothpaste!

All women and labours are different and each women may react differently to an epidural, some may find that they lose complete feeling whilst others can find if their epidural has been administered correctly they can feel enough of the contraction to push effectively.
I would suggest if you need or have to have an epidural it will help you deal with the situation if you have discussed the effective pushing techniques with your LMC.

Two questions I asked NZ, Auckland Hospital Anaesthetist:

Why do some women experience varying levels of pain relief?

" An ideal epidural gives good pain relief but there is a sensation of when the contraction occurs with no motor block i.e. local anaesthetic blocking nerve-muscle transmission causing leg, pelvic and abdominal muscle weakness.
Too much motor block hinders the woman's ability to push during second stage."

Is the measure of anaesthetic based on a woman's weight?

"To achieve this we use relatively dilute local anaesthetic which is given in incremental small doses which are standardised and not weight based. The effect of this is tested and then further given if necessary. 

Women differ in how much local anaesthetic they require to achieve an optimal block.
Many things will affect whether an epidural is effective mums expectations, fetal position, previous pain experiences, the rate of progress in labour.

There is usually a mild degree of motor weakness though on average this will only prolong labour by 15 minutes!

However if the epidural is in for a long time (<12hrs) the motor block becomes more prominent. Also there may be cases when a stronger local anaesthetic is required to achieve pain relief the side effect of this is more motor blockade.

If a caesarean is required we use a very strong local anaesthetic which totally stops all sensation from skin, internal organs and there is no sensation of contractions. A womans legs will be immobile for 4-5 hours then return to normal" 

 This is a video I found on Youtube teaching different pushing techniques, the squat however may be challenging as I am unsure how many hospitals have the bar facility. There is also increased pressure on the knee and the pelvis is in a posterior position (tucked under). It is a very different squat compared to a squat that you can hold in a natural birth situation.

I hope you have found the article helpful, please feel free to add any other advice and positions you used whilst using an epidural and what helped you to push, it may help others. 

I also wish to add that I have nothing against midwives I don't want to offend any with my comments above, I went on to birth my next 2 daughters with 2 different totally amazing Midwives and had 2 natural births.

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If you feel any pain or discomfort whilst exercising, stop. If pain continues consult you L.M.C or G.P. The information included in this article has been written by Lorraine Scapens: She is not able to provide you with medical advice, information is used as guide. You cannot hold Lorraine liable in any way for any injuries that may occur whilst training.

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