Pushing the Limits

How long is too long for second stage


Patti wrote with questions about her granddaughter's birth. She says her daughter pushed for a long time but once her nurse emptied her bladder, she delivered right away. Patti's daughter has some speech problems and she's worried this might've been caused by oxygen deprivation during delivery. It sounds like Patti thinks her daughter pushed too long and this may have had an adverse affect on her granddaughter. Though there's no way for me to know whether Patti's granddaughter's speech problems were caused by a birth injury, I can answer a few questions here.

First of all, how long is a reasonable amount of time to push before its time to worry? That depends. If Mom's been pushing for a couple of hours, making progress, still has enough energy and her baby's not showing any signs of distress, most doctors and midwives will support her to continue pushing. The American College of Obstetricians and Gynecologists considers 3 hours or more (especially with a first time mom and/or those with epidurals) to be perfectly normal.

What if Mom's exhausted? As long as baby's OK, taking a pushing-break is fine. Moms with epidurals are sometimes encouraged to "labor down" which means instead of actively pushing, they allow the uterus and contractions to do some of the work for them while they rest. That's tougher on women who don't have epidurals because they're in pain and "laboring down" may extend the amount of time they're painful. If she's truly too worn out to push any longer and baby's nowhere near crowning, this delivery may wind up in the operating room.

What if baby's showing signs of fatigue or distress? We do a lot of fetal heart monitoring in second stage labor (pushing stage) because some baby's have a tough time. If baby's heart is slowing down or speeding up in specific ways that indicate distress, and again, is nowhere near delivery, this may be a situation that calls for a c-section. What if Mom's been pushing and pushing, tried several positions and techniques and baby just won't budge? If baby really won't come out the main exit, it may be time to try the side door.

Patti says as soon as the nurse emptied her daughter's bladder, she delivered. What does that mean? Emptying the bladder means the nurse put a catheter (specially designed tube) through the urethra and into the bladder to get the urine out. It sounds like her daughter had an epidural, otherwise, she'd have peed on her own. When a patient is anesthetized with an epidural, she won't feel the urge to pee and won't be able to relax the sphincters that allow us to "hold it." That's why we use catheters every few hours to keep the bladder empty. Don't worry, getting a catheter doesn't hurt when you have an epidural. Sometimes, "every few hours" isn't often enough. If our patient has taken in extra fluid (by mouth or IV) her bladder may get fuller faster. Part of our job is assessing if it's full and emptying it. A full bladder might get in the way of baby's descending head. It may be in Patti's daughter's case that the only thing holding the baby back was a little bit of bladder-space. It's hard to know though. Sometimes events happen concurrently and baby makes a sudden turn or wiggle and shoots out.

Oxygen deprivation is a big worry with every delivery. That's why we do so much monitoring. If baby's heart is decelerating (slowing down) in a certain way (we're trained to know the difference between a dangerous deceleration and one that's not), it sometimes means baby's finished being a good sport about labor. It may indicate the placenta's giving out, the umbilical cord's being pinched or yanked or mom's circulation is compromised. There's a lot we can do to improve those situations without wheeling Mom to the operating room. Repositioning Mom to take pressure off the cord and bumping up her circulation by giving oral or IV fluid are two simple ways we can make huge improvements to baby's blood and oxygen supply. We frequently give Mom extra oxygen through a facemask to ensure t she's delivering 100% oxygen to the baby through her own blood. If those measures don't work well and quickly, we call it quits and go to the Big Room for a c-section. Doctor's don't mess around with this sort of thing. That's part of the reason why the c-section rate is so high.

I can't pass judgment on Patti's granddaughter's birth. I have no idea what her oxygen situation was and whether that contributed to her speech problems. If she delivered with a reputable practitioner, had a good nurse and there were no indications the baby was in trouble during pushing, there may be no connection between the full bladder and the speech. Birth is a complicated process and though doctors and nurses practice under strict safety guidelines, we are not ultimately in control of everything that goes on. No one is. That's the mystery and miracle part.

I always say, you raise the baby you deliver, not the baby you dreamed of. We all hope of having perfect children and of course, no one wants their child to face difficult challenges. Life happens though and we discover that all children, despite their challenges, differences and quirks, are pretty close to perfect. The beautiful part is when parents recognize their child's uniqueness and individuality and raises him/her to be the best they can be, no matter what challenges they face. I'm not sure my answers will alleviate Patti's concerns but I wish her well and hope her daughter and granddaughter thrive.