I recently cared for a patient who was at 38 weeks gestation, was 8 cm dilated, and had a strong urge to push. Should I have encouraged her to push or delayed pushing until she was completely dilated?-G.K., MO.

Roxanne Ferguson, EdD, MSN, RN, replies: The urge to push despite being fully dilated is a phenomenon known as early pushing urge (EPU). It's been thought to be caused by the fetal head pressing on the mother's pelvic floor. Although some women don't experience this urge, the women that do seem to have an involuntary, uncontrollable urge to push. The incidence of EPU reportedly ranges from 7.6% to 54%.1 Although EPU seems to be common, how to manage it is controversial.

A literature review by Tsao identified two recommendations for management of EPU.2

* The first is to support the patient and let her do what she feels is best for her, meaning that she can push when she feels the urge. This recommendation is usually based on the presence of physiologic signs of labor progression, such as a soft cervix, dilation of 8 to 9 cm, and normal fetal parameters such as a normal baseline heart rate, with moderate variability and no repetitive decelerations. Encouraging the laboring mother to breathe until the strongest part of the contraction occurs and then to have her gently push is recommended.2

* The second recommendation is based on the stop pushing technique, achieved through interventions such as changing position, breathing, vocalizing, having a bath, and possibly having lumbar massage. Positions such as hands and knees, knee-chest, and lateral positioning are some options the nurse can use to help the patient when EPU occurs. A multimodal approach to prevent pushing is commonly used.2 As a last resort, 8 of the 60 midwives studied by Borelli et al. suggested epidural anesthesia to prevent pushing, and 87% of the midwives suggested that the stop pushing method was the method of choice due to the lack of evidence about the ramifications of cervical damage from pushing.1 However, Borelli et al. found no evidence that early pushing is harmful or causes cervical damage.1

The National Institute for Health and Care Excellence in the United Kingdom recommends that women in labor should be in charge of their own pushing urges.3 The American Congress of Obstetricians and Gynecologists published a position statement in 2017 on the management of low-risk women in labor, noting that obstetric care providers should be familiar with and consider using low-interventional approaches for the intrapartum management of labor to decrease operative interventions. Examples of these approaches include interventions such as side-lying pushing and alternating pushing.4

Labor nurses caring for a patient experiencing EPU need to provide supportive care and notify the healthcare team to determine a plan of care. Each patient's labor process is unique and should be individualized. Labor nurses should feel comfortable when instructed to let patients push when they experience EPU, but only when they've consulted with the healthcare provider and specific maternal conditions have been met, such as the cervix being 8 to 9 cm dilated with continued progression of dilation, including a soft, pliable cervix.

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