Is this normal practice?

[DanceLikeTheWind]

A friend just delivered her baby in America. She was telling me that for the first one hour she pushed the baby did not move at all. She pushed for a further hour before the baby was born.
Now, I'm curious if anyone knows whether letting her push for an hour with nothing happening is normal?
I read some medical papers and they state that the duration if the second stage of labour should not exceed 1 hour without analgesia and 2 hours with.
(she didn't have epidural)

It's a Known fact that a prolonged second stage of labour is a cause of incontinence and prolapse as well as brachial plexus nerve palsy.
So I'm wondering if anyone knows what is the maximum time they'll let you push for?

I pushed DD for two hours (epidural, UK) and she was not budging for about an hour of that.

She was eventually a forceps delivery. There was a delay in getting the consultant in for the birth as he was attending an emergency in the theatre so I was pushing for longer than they would have liked.

NICE guidelines say:

Nulliparous women:
? Birth would be expected to take place within 3 hours of the start of the active second stage in most women.

? A diagnosis of delay in the active second stage should be made
when it has lasted 2 hours and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent.

Parous women:
? Birth would be expected to take place within 2 hours of the start of the active second stage in most women.
? A diagnosis of delay in the active second stage should be made when it has lasted 1 hour and women should be referred to a healthcare professional trained to undertake an operative vaginal birth if birth is not imminent

So if it's your first baby, then they'll "let" you push for two hours before advising forceps or ventouse, if you've already had one then they'll "let" you push for one hour before advising forceps or ventouse.

I was pushing for well over two hours with my first, but I did end up with a third degree tear for my pains. I didn't have an epidural or pethidine.

Is an operative vaginal birth the only option given? Can you opt for a c section instead? (On the NHS?)

If we talk about private care, is it possible to speak to your consultant in advance and let him/her know that you don't want to push for more than an hour and that if nothing happens in that time you'd want a c section?
I know someone who made a similar pact with her doctor about the duration of labour. She didn't want to prolong labour beyond 24 hours.

If you are pushing I am guessing baby would be in the birth canal and so c section not an option. I pushed for an hour with my first but he was back to back so probably a bit wedged! BTW I am not incontinent!:-o

Wolfiefan

C sections are performed with baby in the birth canal. Several hospitals give an option between assisted birth and c section, so I'm sure it's possible.

BTW, I never said it will certainly make you incontinent just that the longer you push, the greater your chances.

NatashaBee,

I thought they didn't use forceps in the USA?

Also, could you clarify, was it a c section you ended up with after 3 hours of pushing?

I'm also curious, what about women who want to refuse forceps? And what about hospitals which have a no forceps policy? How do they manage?

I think it can be very difficult to perform a CS once the baby descends a certain amount into the vagina - it has to be pulled up and out rather than just out, so although it is possible I think it's generally preferable to have a VB with assistance rather than a CS. I think this is also due to the increased risks that come along with a CS as well as the generally increased recovery time.

FWIW, I was adamant that I did not consent to forceps before having DD, when it came to it I was happy to do whatever necessary to get her out. My notes state that I had lengthy discussion with DH before agreeing to forceps (he was excellent, making sure that I was absolutely certain) and I ended up with a 3a tear because I wasn't told to stop pushing and the episiotomy extended.

If a CS had been necessary, I would have agreed to that. If she was only coming out by taking drawing and quartering me, then I would have agreed to that too.

I don't know anything about what you can ask for re. private care.

Flisspaps,

My point is that there are hospitals all over the world which don't even have forceps. The only interventions used are ventouse and c sections.
Surely if they can manage without them, it must be possible?

You've made another valid point. Women in labour are too much in pain, discomfort and too exhausted and vulnerable to refuse interventions.
Unfortunately, some of them regret it later.

What would have happened had you and your husband refused forceps?

Secondly, there is no point even mentioning the risks of a c section when the alternative is forceps. I posted links in another thread which clearly state that the risks to mother and child are higher with forceps.
The baby can get cerebral palsy, spinal cord injuries, brachial plexus nerve damage and mother can end up with a stoma bag like soapy.
C section may have a herder recovery but the risks are lesser than forceps.

I pushed for 4 hours with my first - 2 hrs with midwife no.2 and then her shift changed and the clock was reset and I pushed for 2 hrs with midwife no.3. (Midwife no.1 watched over me for 8 hrs of clues that things were really not going well and wrote patronising comments in my notes.) All of this could explain why I then spent 5 days in HDU and baby spent 3 days in SCBU. A prize example of the NHS at it's worst - it's great they have the expertise to 'rescue' you but it would be even greater if they managed to avert such situations to start with.

In spite of the above, there should be no time limit on the length a woman pushes for. An intelligent and educated midwife should be able to make a judgement call as to whether a woman can be safely allowed to push for a longer time or if she needs urgent help instead. Prior to my second labour, which was a VBAC labour, the hospital had told me they would call in the cavalry if I was in second stage for more than an hour. As it was I called my midwife at home and she came out to me - I spent 2 hrs of my 3 hr labour pushing, but I was able to continue as the baby was descending well, he was just taking his time to improve his position every now and then.

Backinthebox,

There should definitely be a time limit on how long a woman pushes. Letting someone push for 5 hours is insanity!

Secondly, the longer you push, the greater your chances for developing incontinence, prolapse and pelvic floor disorders. It's can also distress the baby and cause undetected brain heammorrheage In light of these facts, there should certainly be a limit on how long a woman pushes.

There should also be a limit on how long she labours, if for no other reason but humanitarian. Letting a woman labour on for some 60 hours is just heartless.

I asked if ventouse could be used and was told they were really sorry but it wouldn't shift DD. Hospitals without forceps may well have very high CS rates - so they might manage without them but again, the risks of a CS are hardly negligible so in many cases forceps are probably the lesser of two evils.

I thought that it was Keillands forceps which were no longer used in the US as opposed to Neville Barnes forceps - I know there are lots of issues with damage from Kiellands forceps to mother and baby.

You could argue that if a woman in labour is in no fit state to agree to forceps then she can't make an informed decision about CS - or any intervention. You can't plan for every eventuality so you can't discuss every decision in advance with a consultant or midwife so there will always be a need to make a decision there and then when the woman is in agony and desperate to make it stop.

And if I had refused forceps (not my husband's choice, it had to be mine - he was just checking I was sure) then perhaps DD would have suffered in some way - the cord was round her neck, I was exhausted after 20 odd hours of induction and labour, and I think it was the right decision and the only one I could have responsibly made at the time.

I believe the risk of maternal death is up to 16 times higher for women undergoing a CS (something I read when deciding about a VB over CS this time) so to say the risk of damage from forceps is greater than CS is, frankly, rubbish. There is also a 3x greater risk of PPH with CS compared to 2x increased risk of PPH with VB intervention.

I pushed for over two hours with DD, for the first hour nothing was moving (so I was told later on). Then the midwife started directing me and it was another 1.5 hours till she was out. I had put in my birth plan for non-directed pushing but now I wonder if that was a mistake, I think it might have been better if the midwife had intervened after the first half hour of no progress and offered to tell me what to do. Perhaps then I might not have ended up with the mild prolapse I now have, but I'll never know. On the other hand, DD coming out with hand up by her head might well have caused the problem anyway.

I wonder what the medical papers you read meant about the difference between with and without epidural - why that would make a difference.

I had a homebirth. Pushed for 1 hour undirected in water without making much progress, then 1 hour direct pushing while mobile out of the pool. It was hard work but I didn't need analgesia - I thought pushing was far less painful than transition and the pain was really useful to control how and when I pushed. Without that incentive, I'm not sure I'd have been able to push so hard.

Agree women shouldn't be left indefinitely but surely judgement has to be on a case by case basis, with the final decision being made by the woman on medical advice?

Dance, with dd1 i pushed for about 4 hours, dd1 was stuck and she was born with ventouse, they said cs would not have been possible.

I had a 3rd degree tear, which healed brilliantly and which would have been fine had I not had dd2 a year later. She was born with one push! Which resulted in a second degree tear - which would have been fine, had it not been a particularly awkward repair.

I did suffer continence issues as a result, which were made much worse when i was pregnant with ds, with whom I had an elc, which as you know from the other thread did not end well.

Since having ds i was very strict with physio and pelvic floor exercises and have had no further continence issues.

NatashaBee - There are lot of reasons. Because many people believe that their body knows best how and when to push. That directed pushing may result in people pushing when they shouldn't be (or not when they should) for a reason the midwife or doctor may not be aware of. Because 'purple pushing' is very ineffective (if this is the direction). Because direction can be distracting if you feel instinctive about what you are doing...

OP please could you direct me to the links about risks of forceps v c section? I need to have a discussion with my consultant about thisnon tuesday and this would be really useful. Thanks.

LOL.

The risk of death with a c section is NOT sixteen times higher. Where on earth did that come from?! It's about 2 times more, but that data included emergency c sections.

Secondly, forceps can cause the baby to get cerebral palsy, brachial plexus nerve damage, spinal cord injuries and brain heammorrage. C sections in comparison might cause breathing difficulties but normally if they're planned prematurely. You decide which risks are worse. To me the answer is pretty clear.

Forceps are very often used during c sections though. I wonder if there is anywhere that splits up risks of c sections using forceps and those without?

DLTW I got the 16x increased risk from here:

A quick summary by Olubusola Amu, Sasha Rajendran and Ibrahim I Bolaji,
BMJ 1998;317:462-465 ( 15 August )
www.bmj.com/cgi/content/full/317/7156/462

"Caesarean sections are not without complications and consequences. Maternal risks in the short term include haemorrhage, infection, ileus, pulmonary embolism, and Mendelson's syndrome. The prevalence of hysterectomy due to haemorrhage after caesarean section is 10 times that after vaginal delivery, and the risk of maternal death is increased up to 16-fold.

Long term morbidity including formation of adhesions, intestinal obstruction, bladder injury, and uterine rupture is often underestimated during subsequent pregnancy"