1. Management strategies for early pushing urge
Sara Borrelli
RM, BMid, MSc, PhD Student
Teaching Associate
The University of Nottingham (UK)

2. EARLY PUSHING URGE
EPU: labouring woman’s urge to push before full cervical dilatation.
Diagnosis: perception of irresistible urge to push by the labouring woman before full cervical dilatation, confirmed by vaginal examination (Downe, 2008).
Pathological versus physiological phenomenon.
Controversies about the incidence of EPU, the nature of the phenomenon and the optimum approach to management.

3. SERIES OF PROJECTS ON EPU FROM 2009
QUANTITATIVE OBSERVATIONAL STUDY
60 EPU cases
Dattolo C., Borrelli S., Nespoli A. (2014)
Midwives’ views and experiences of EPU
Celesia M., Nespoli A., Borrelli S. (2014)
Women’s experiences of EPU
Ceppi C., Nespoli A., Borrelli S. (2015)
Women's perspectives on EPU on childbirth-related online forums
QUALITATIVE PHENOMENOLOGICAL STUDY 25 midwives working in labour ward with a mix of clinical expertise
QUALITATIVE PHENOMENOLOGICAL STUDY 8 women that experienced EPU during labour
QUALITATIVE THEMATIC ANALYSIS
121 users, 148 comments

4. Single midwives’ incidences range:
EPU INCIDENCE
9/10 (Yeates & Roberts, 1984)
54% (Roberts, 1987)
20% (Downe, 2008)
7.6%
Single midwives’ incidences range:
2.3% (n=1/44) –
20% (n=4/20)
(Borrelli et al., 2013)

5. EPU and WAITING TIMe
The number of diagnoses of EPU proportionally decreased the longer midwives waited to investigate it
Diagnosed EPU
‘Hidden’ EPU

6. EPU AND MEDICAL INTERVENTIONS
Medical interventions (epidural analgesia, amniorexi and labour augmentation) when EPU diagnosed at less than 8 cm
Anterior cervix reduction (8-9 cm)
Intervention rates lower when compared to OU statistics (2008)
AMX 35% - OX 25% - EA 22%

7. EPU AND PARITY
44 nulliparous women (73%)
16 multiparous women (27%)

8. Midwives’ approaches to epu
Hands and knees
Lateral
Most frequently in women with dilatation of 4-5 cm at EPU diagnosis
COMBINATION OF TECHNIQUES
Change of position + blowing breath: 30% (n=18/60)
Change of position + vocalisation: 15% (n=9/60)

9. MATERNAL AND NEONATAL OUTCOMES
Very good maternal and neonatal outcomes
CS: 2% VS 20% (OU statistics, 2008)
No third/fourth degree tears, cervical tears or postpartum haemorrhages.
Perineal tears: 34% VS 20% (OU statistics, 2008)
Association between dilatation at EPU diagnosis and some outcomes (?)
All operative deliveries: EPU diagnosis at 5-6 cm
All first degree tears: EPU diagnosis at 8-9 cm
Higher episiotomy rate: EPU diagnosis at 5-7 cm

10. MIDWIVES’ experiences of EPU
Drivers guiding midwives’ approaches to EPU Dilatation; parity; fear of cervical damages; maternal exhaustion; presence of physiological signs; respect of physiological times.
‘[when EPU appears at a lower cervical dilatation] I would be more worried with a nullip because she might not be able to manage to cope with this situation for a period of time of 5 hours or so’ (M17)
‘We know from the literature that if a woman pushes when the cervix is not fully dilated, we might have consequences on the cervical os’ (M2)
‘When I assist a woman with an EPU in a completely physiological situation, it means that there is a reason for that EPU so I usually don’t try to stop the pushes. If there are physiological elements, that pushing urge is physiological as well’ (M13)
‘The woman should avoid pushing ineffectively. Ineffective pushes are detrimental because she wastes her energies’ (M7)

11. MIDWIVES’ experiences of EPU
Influencing factors in helping women to cope with EPU
Woman’s personality; woman-midwife relationship; environment; team working and peer-support; knowledge of the physiology of childbirth.
‘If you need to manage an early pushing urge at 5 centimetres, the success lies in the relationship you established with her… which influences how much she trusts you and how much you are allowed to guide her’ (M19)
‘Sometimes you find women that absolutely don’t listen to you and refuse to change position, whereas sometimes they completely listen to you. The single person plays an essential role in it’ (M20)
‘This year we have been learning together to respect physiological times, debating with colleagues on the basis on what we read and catch from others, for example considering studies conducted by English midwives’ (M6)
‘The environment in which you work is really important. If physiology [of childbirth] is your responsibility, you are given more freedom in your decision-making. And I feel that having the opportunity to ask for your colleagues’ advice is essential as well’ (M23)

12. MIDWIVES’ experiences of EPU
Variation of midwives’ approaches to EPU over time Ability to establish a stronger woman-midwife relationship; increased professional competence, self-confidence and awareness of physiology of childbirth; personal experience of birth.
‘I feel that I gained more ability in guiding women and in establishing a stronger relationship with them. Being able to know which are the right words and how and when to talk to the couple… this helps a lot’ (M25)
‘Yes, my approach has surely changed due to my experience. Now I feel more confident in my everyday practice and I am aware that EPU might occur sometimes’ (M7)
‘It all changed when I gave birth to my baby. I think that when the baby’s head is pushing, it’s absolutely impossible to stop it and I experienced this during my labour. Therefore, while before I was more like ‘Don’t push! Ah-ah-ah’, now if a woman wants to push, I let her push and that’s it’ (M20)

13. WOMEN’S EXPERIENCES OF EPU
Women’s perceptions of EPU
Overwhelming, uncontrollable and involuntary
It was the most overwhelming feeling of pressure […] impossible to resist (ENG34)
How can they tell you not to push? It's like telling someone not to be sick. You simply have no control over those muscles, it's involuntary (ENG25)
Sense of obstruction
I felt like a bottle cap, as the baby’s head was like a bottle cap. After the pushing there was the contraction and this feeling was still there (W1)
Bone pain
It was really painful, I felt like something was pushing on my bones trying to move them (W2)

14. WOMEN’S EXPERIENCES OF EPU
Bodily sensations versus midwives’ advice:
struggling between conflicting messages
Body-mind dichotomy + difficulty in holding back EPU
It was strange because my body was telling me to do something and I had to do the opposite (W5) - My head was saying keep him in there but my body was pushing him out (ENG44)
Not being believed by healthcare professionals and birth partner
It was such a strange thing because no one believed me […] My husband didn’t understand me because he kept saying ‘the midwife told you should hold back the pushes’. He didn’t understand because he said ‘listen to the midwife’ (W5)

15. WOMEN’S EXPERIENCES OF EPU
The ‘a posteriori’ feeling of women
about midwives’ guidance during EPU
Mothers were overall very satisfied with their childbearing experience, even if they experienced an early pushing urge and found this difficult to cope with (independently from midwives’ advice).
A posteriori, the women recognised the importance of the midwife’s presence, support and guidance while experiencing EPU.

16. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
EPU can be considered as a physiologic variation in labour if maternal and fetal conditions are good
Midwives might suggest techniques to help the woman to cope with EPU (change of position, blowing breath, vocalisation and use of bath)
NO EVIDENCE THAT PUSHING IS
HARMFUL IN PHYSIOLOGICAL
CONDITIONS
Not enough evidence to determine optimum response to EPU
The midwife needs to work with each individual woman in the context of each labour to determine the best approach in the specific case.
HOWEVER
LET THE WOMAN DO
WHAT SHE FEELS?

17. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
One-one care / continuity of carer to establish a trusting woman-midwife relationship;
Supportive environment, team working and peer support;
Knowledge and respect of physiology of childbirth (audits, debates, discussion of EPU cases to stimulate evidence based practice);
Alternative methods for EPU diagnosis? e.g. maternal behaviours; no signs of second stage of labour; mw intuition…

18. FUTURE RESEARCH Larger scale work including different birth settings
Association between dilatation at EPU diagnosis and outcomes (EPU < 7 cm)
Association between midwives’ approaches and outcomes
Comparison between approaches
Comparison between hand and knees and lateral positions