You Made It to Ten Centimeters!

You Made It to Ten CentimetersTips for Preventing a Cesarean Section

Written By: Written by: >Dr. Jonathan Weinstein

In Labor & Delivery’s all around the country, reaching ten centimeters or complete dilation, frequently results in the immediate reflex to break out the stirrups and have mom start pushing her baby out.

Ask yourself, who is going to have a better birthing experience? A woman who labored for 24 hours then pushed for 2-3 hours using muscles she may have not have used all pregnancy, or one who waited for the urge to push and delivered in 30 minutes?

‘Laboring down’ is delayed or passive pushing, which allows uterine contractions and gravity to bring the baby closer to crowning before the patient develops an overwhelming urge to push. When you are fully dilated your uterus will continue to contract and direct the baby down the birth canal. This technique is most applicable to women who have Epidural anesthesia. Rarely is immediate pushing indicated. The most common medical reason for immediate pushing is fetal distress, which is rare in the typical low-risk population.

It was pointed out to me by one of my doula colleagues, Maria Pokluda that with natural childbirth, there is a term used in the holistic stages of labor called quiescence, a period of stillness that some women experience after transition; Mom rests and contractions may slow. Unfortunately, in a hospital setting, it is often a nursing reflex to bring out the stirrups, followed soon after by multiple nurses entering the room, then turning on the lights, thus disturbing this period of calm. Since arriving at Baylor Frisco, I have found certain nurses gravitate to the care of my natural childbirth patients, often because they themselves have had a natural childbirth. This has made for a very pleasant in-hospital birth experience.

So why is ‘laboring down’ such a useful technique?

Maternal exhaustion usually occurs when a patient spends hours pushing with a dense epidural block, or after being in pain for several hours. Patients are frequently instructed to push when they are unable to perceive an urge to push. If the baby does not move when the patient starts to push, a red flag should go up immediately. For example, I have been called by the labor nurse who reports, “we have pushed for two hours and the baby has not moved, I do not think it will fit.” I arrive to examine the patient and note the baby’s head is perfectly round in the birth canal. There is neither molding (overlapping of the cranial bones) nor caput (swelling of the skin overlying the fetal scalp) to suggest that appropriate force was directed toward moving the baby through the birth canal. This tells me that the patient who has “pushed” for two hours has not actually directed any energy toward the muscles needed to deliver the baby. Unfortunately, some physicians take this report to mean the baby’s head is too
big, an indication for Cesarean section. The patient described above proceeded to ‘labor down’ for an additional two and one-half hours then pushed out the baby in twenty minutes.

Fetal distress or the appearance of such can occur as a result of vigorous maternal effort. When a baby’s head is squeezed out of the birth canal, heart rate decelerations, or drops, frequently trigger a physiologic fetal nervous system response. If you squeeze your baby’s head hard enough, the decelerations can be long and deep, mimicking fetal distress. In addition, many babies are born with the umbilical cord around the neck. Do not freak out. Remember, the baby delivers head down so gravity alone makes it likely that the cord is around the neck. If the cord is tight, then vigorous pushing can often exacerbate the problem. Gentle descent of the head by laboring down often minimizes any significant change in the fetal heart rate.

Changing positions during ‘laboring down’ or active pushing decreases the likelihood of tearing, increases the diameter of the birth canal, and will assist in the rotation of the baby’s head to the most favorable position so it can pass under the pubic bone. One favorable position is squatting. Most cultures have used this technique for centuries and for good reason, it allows gravity do the work for you while widening your pelvis to accommodate the baby. Sitting up, kneeling, or even simply standing on your feet are also effective. For those patients with an Epidural, rotating your position from side to side or hip to hip every 20 – 30 minutes is often called the “go-fast” position. The worst position is often lying flat on your back. One squat is worth ten pushes lying on your back!

My one request: try to return to your bed before the head delivers so I can assist in the perineal massage and allow for controlled delivery of the head. Both of these assist in minimizing tearing.

On a final note, a full bladder may slow down your labor by getting in the way of your baby’s head passing through the birth canal. Make sure you continue to void regularly to keep your bladder empty. Those with an Epidural usually have a bladder catheter in place. Rest between contractions and be patient. Pay attention to your body and most important, be an advocate for yourself.

‘Labor down’ till you see the ears and enjoy your new addition to the family!!!

– Jonathan Weinstein, MD, FACOG

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