ArticleLiterature Review

The "push" for evidence: Management of the second stage

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Abstract

Recognition that the available evidence does not support arbitrary time limits for the second stage of labor has led to reconsideration of the influence of maternal bearing down efforts on fetal/newborn status as well as on maternal pelvic structural integrity. The evidence that the duration of 'active' pushing is associated with fetal acidosis and denervation injury to maternal perineal musculature has contributed to the delineation of at least two phases during second stage, an early phase of continued fetal descent, and a phase of "active" pushing. The basis for the recommendation that the early phase of passive descent be prolonged and the phase of active pushing shortened by strategies to achieve effective, but non-detrimental pushing efforts is reviewed. The rational includes an emphasis on the obstetric factors that are optimal for birth and conducive to efficient maternal bearing down. Explicit assessment of these obstetric factors and observation of maternal behavior, particularly evidence of an involuntary urge to push, should be coupled with the use of maternal positions that will promote fetal descent as well as reduce maternal pain. The use of epidural analgesia for pain relief can also be accompanied by these same principles, although further research is needed to verify the strategies of "delayed pushing" and maintenance of pain relief along with a reconceptualization of the second stage of labor.

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... 6 Mobility promotes optimal uterine perfusion, alignment of the foetal head in the pelvis and descent. 7 It has been reported that women who articulated preferences for birth position ahead of birth were more likely to be in a preferred position at birth. 8 The use of various positions is, however, facilitated or constrained by the policies and philosophy of the birth care environment. ...
... 8 The use of various positions is, however, facilitated or constrained by the policies and philosophy of the birth care environment. 7 Upright positioning has been associated with reduction of labour pain and an increase in maternal satisfaction. 9 Other obstetrical advantages of an upright position include shorter second stage, fewer episiotomies, 10,11 and less use of synthetic oxytocin in the second stage of labour. ...
... In most cultures, birthing in a bed is regarded as customary and expected by both parents-to-be and for birth attendees. 7 The preferences for birth positions and the philosophies of professionals have an impact upon positions that women adopt during birth. 9 The fathers in this study had a more overall positive birth experience when the spouse had an upright position in the second stage of labour compared to fathers who had an experience of a horizontal position. ...
Article
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Fathers often want to be involved in labour and birth. To investigate how maternal birth position during second stage of labour may influence fathers' experience of childbirth. Mixed method study with 221 Swedish fathers completing an on-line questionnaire. Descriptive statistics and qualitative content analysis were used. In total 174 (78.7%) had a positive overall birth experience. The theme An emotional life-changing event influenced by the birth process and the structure of obstetrical care was revealed and included the categories; Midwives ability to be professional, The birth process' impact, and Being prepared to participate. The most frequently utilised birth position during a spontaneous vaginal birth was birth seat (n=83; 45.1%), and the fathers in this group were more likely to assess the birth position as very positive (n=40; 54.8%) compared to other upright and horizontal birth positions. Fathers with a partner having an upright birth position were more likely to have had a positive birth experience (p=0.048), to have felt comfortable (p=0.003) and powerful (p=0.019) compared to women adopting a horizontal birth position during a spontaneous vaginal birth. When the women had an upright birth position the fathers deemed the second stage of labour to have been more rapid (mean VAS 7.01 vs. 4.53) compared to women in a horizontal birth position. An upright birth position enhances fathers' experience of having been positively and actively engaged in the birth process. Midwives can enhance fathers' feelings of involvement and participation by attentiveness through interaction and communicating skills. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
... The questionnaire for the women included questions on sociodemographic and childbirth factors known from literature to be related to choice of birthing positions, such as age, education, place of birth, duration of second stage, antenatal information, women's preferences in birthing positions during pregnancy, influence of care provider (Roberts, 2002;De Jonge et al., 2007;Nieuwenhuijze et al., 2012). Information was collected about women's sense of control, their experience of pain during birth, and women were asked for the feelings they had towards birth during their pregnancy. ...
... The model includes general factors that are related to sense of control, such as education, parity, information, feelings towards birth, place of birth, pain, influence on what is happening during birth (Green and Baston, 2003;Borquez and Wiegers, 2006;Ford et al., 2009;Janssen et al., 2009). Factors related to use and choice in birthing positions are age, education, place of birth, duration of second stage, antenatal information, preference in birthing position, influence of environment (Roberts, 2002;De Jonge et al., 2007;Seefat-van Teeffelen et al., 2011;Nieuwenhuijze et al., 2012). ...
... Moreover, circumstances may necessitate the use of other positions (De Jonge et al., 2008). The possibility to change positions during labour might be more important than using one single chosen position (Roberts, 2002). In addition, being able to rely on the support of the care providers also contributes to women's experience of birth and is linked to feeling in control (Walker et al., 1995;Halldorsdottir and Karlsdottir, 1996). ...
Article
Objective: to explore whether choices in birthing positions contributes to women's sense of control during birth. Design: survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control. Setting: midwifery practices in the Netherlands. Participants: 1030 women with a physiological pregnancy and birth from 54 midwifery practices. Findings: in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves. Key conclusions: women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value. Implications for practice: midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.
... Overexertion can also overstretch vaginal and pelvic structures, contributing to future bladder control problems, unnecessary perineal tearing and increase in episiotomies rate. [9] The fi ndings of our study were relatively in the match with the results of Roberts JE (2002), [10] and Williams E et al. (2000). [11] They found out that delayed pushing did not increase the risk of cesarean birth or operative vaginal deliveries and it is safe to allow a period of passive descent until the women feel the real urge to push, also the newborn status at birth as measured by APGAR scores, were not affected negatively by the longer overall length of the second stage. ...
... Regarding APGAR score our study is in line with a study conducted by Roberts 2002, [10] who cited that the most stressful time for the fetus during labor is in active pushing phase of the second stage of labor. Prolonged pushing and breath holding can cause changes in maternal cardiovascular system and consequently uteroplacental perfusion, leading to acid base imbalance of the fetus and the development of fetal acidosis and hypoxia. ...
Article
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Objectives: The objective of the following study is to find out the effects of two different pushing techniques in the second stage of labor on postpartum maternal fatigue and APGAR score of neonates in Saudi females, as very few such studies are available in these patients. Hence this study was carried out in this population to see the results and to do a comparison with other studies in literature as well as to find out how we can make labor awareness in our females. Design: Quasi experimental study. Settings: It was carried out in two hospitals in the eastern province of Saudi Arabia from 1 January, 2011 up to 31 December, 2011. One hundred Saudi women who fulfilled criterion were included in the study. They were randomized and the results seen. Results: There was a significant difference in postpartum fatigue within 60 min and 24 h in two groups as P = 0.001, P < 0.001 respectively. There was a significant difference of APGAR score of newborn in both groups, i.e., P < 0.001. Conclusion: It is concluded that physiological pushing technique has a better outcome with regard to postpartum maternal fatigue and neonatal APGAR score when compared to directed pushing during the second stage of labor.
... Overexertion can also overstretch vaginal and pelvic structures, contributing to future bladder control problems, unnecessary perineal tearing and increase in episiotomies rate. [9] The fi ndings of our study were relatively in the match with the results of Roberts JE (2002), [10] and Williams E et al. (2000). [11] They found out that delayed pushing did not increase the risk of cesarean birth or operative vaginal deliveries and it is safe to allow a period of passive descent until the women feel the real urge to push, also the newborn status at birth as measured by APGAR scores, were not affected negatively by the longer overall length of the second stage. ...
... Regarding APGAR score our study is in line with a study conducted by Roberts 2002, [10] who cited that the most stressful time for the fetus during labor is in active pushing phase of the second stage of labor. Prolonged pushing and breath holding can cause changes in maternal cardiovascular system and consequently uteroplacental perfusion, leading to acid base imbalance of the fetus and the development of fetal acidosis and hypoxia. ...
... When providers are attentive to the dynamic process of birth and open to changing positions during labor, this approach might be more beneficial than only using one position. 16 This seems especially significant in longer second stages of labor or for women who receive epidural analgesia when a change of positions may contribute to the comfort of the woman, the alignment of the fetus with the pelvis, and progress towards birth. 17 In observational studies of women giving birth in non-prescriptive environments where they were encouraged and supported to choose their own positions, women tended to use a variety of positions during second stage of labor as opposed to a single position. ...
... 21,22 Aspects of shared decision making regarding birthing position include how much maternity care providers support and enable women to explore preferences in birthing positions and identifying comfortable and effective positions to support progress. 16,20,[23][24][25] In prior studies, researchers suggested that women value the support that care providers can offer, but they also want to have an influence on the decisions regarding birthing positions in conjunction with care providers. 15 Insight into the interaction between women and maternity care providers regarding birthing positions during second stage labor can contribute to a better understanding of how to involve women in shared decision making regarding other aspects of care during birth. ...
Article
Introduction: Through the use of a variety of birthing positions during the second stage of labor, a woman can increase progress, improve outcomes, and have a positive birth experience. The role that a maternity care provider has in determining which position a woman uses during the second stage of labor has not been thoroughly explored. The purpose of this qualitative investigation was to explore how maternity care providers communicate with women during the second stage of labor regarding birthing position. Methods: A literature-informed framework was developed to conduct a process of deductive content analysis of communication patterns between nulliparous women and their maternity care providers during the second stage of labor. Literature discussing shared decision making, control, and predictors of positive birth experiences were reviewed to develop a coding framework. The framework included the following categories: listening to women, encouragement, information, offering choices, and style of support. Forty-one audiotapes of women and their maternity care providers during the second stage of labor were transcribed verbatim and analyzed. Results: Themes identified in the transcripts included all those in the analytic framework, plus 2 added categories of communication: empathy and interaction. Maternity care providers in this study enabled women to select various birthing positions using a dynamic process that moved between open, informative approaches and more closed, directive approaches, depending on the woman's needs and clinical condition. As clinical conditions unfolded, women became more actively involved in shared decision making regarding birthing positions, and maternity care providers found the right balance between being responsive to the woman's questions or directives. Discussion: Enabling shared decision making during birth is not a linear process using a single approach; it is dynamic process that requires a variety of approaches. Maternity care providers can support a woman to use different birthing positions during the second stage of labor by employing a flexible style that incorporates clinical assessment and the woman's responses.
... There is limited evidence pertaining to women's experiences of bearing down in the second-stage although the role of the midwife has an important influence on women's confidence to follow their physiological urges to push (Anderson, 2010). Physiological processes supporting spontaneous pushing include descent and position of the presenting fetal part to evoke the Fergusons reflex (Lemos et al, 2017), which enhances maternal spontaneous pushing (Roberts, 2002). This reflex may be hindered in women with epidural anaesthesia and contribute to the increase in instrumental births associated with epidural anaesthesia (Anim-Somuah et al, 2011). ...
... Descent and position of the presenting fetal part evokes the Fergusons reflex(Lemos et al, 2017), which enhances maternal spontaneous pushing(Roberts, 2002) however this reflex may be hindered in women with epidural anaesthesia. ...
Thesis
Aim: The aim of the study was to explore midwifery practice during the second-stage of labour to understand how midwives make decisions at this time. Background: Whilst there is much discussion within the literature about the various care issues that may present themselves as dilemmas for midwives throughout the second-stage, little information is available about how midwives make decisions during this time. Methods: A qualitative single instrumental case study methodology has been applied to facilitate an in-depth understanding of midwives decision-making in the second-stage and the use of observation and interview to gather a rich data set to examine the case. Key Findings: Midwives employed fast thinking using pattern-matching to make rapid decisions during the second-stage which was supported by a slower more focused assessment of cues using the principles of the Hypothetico-deductive model. Within the Alongside Midwifery Unit (AMU) midwives used observation, interpretational and interpersonal skills to assess labour and inform their decision-making. This skill-set did not appear to transfer to the Obstetric Unit (OU) where the focus of care shifted to the completion of tasks and was influenced by midwives perceptions of surveillance and the introduction of technology. Conclusion: Decision-making during the second-stage was influenced by context and midwives used their skills to assess labour progress holistically paying attention to physiological and behavioural cues exhibited by women on the AMU. Implications for Practice: The skill-set used by midwives on the AMU did not transfer to the OU where midwives perceived that their ability to make autonomous decisions was reduced and the focus of care shifted from being woman-centred to task-centred.
... The upright positions result in less discomfort and difficulty in bearing down; less labour pain; less perineal or vaginal trauma; and fewer wound infections ( Gupta et al., 2009 ). Studies also have reported less frequent abnormal heart rate patterns, and less frequent low Apgar scores in neonates of women who used upright positions compared to women adopting dorsal positions ( de Jong et al., 1997;Gupta and Nikodem, 2000;Roberts, 2002 ). In a few trials, it was found that blood losses were greater in women who used birthing chairs to give birth ( Crowley et al., 1991;Gupta and Nikodem, 2000 ). ...
... Studies have reported that spontaneous pushing of the fetus protects maternal tissues and improves perineal outcomes by lowering the number of episiotomies performed and lacerations to cervix and perineum in comparison to the directed pushing technique ( Righard, 2001;Roberts and Woolley, 1996;Roberts et al., 1987 ). Directed pushing is associated with fetal heart rate changes that suggest fetal hypoxia and acidosis at birth ( Roberts et al., 1987 ) and increased incidence of birthing by use of forceps and perineal trauma ( Lemos et al., 2015;Roberts, 2002 ). ...
... The nature of the physiology of the second stage labour has been subject of debate for many years (Cohen, 1977;Yeates and Roberts, 1984;Simkin, 1986;Maresh, 1987;Roberts et al., 1987Roberts et al., , 2004Buxton and Redman, 1990;Roberts and Woolley, 1996;Petersen and Besuner, 1997;McCandlish et al., 1998;Roberts, 2002;Downe, 2003;Sampselle et al., 2005;Roberts and Hanson, 2007). ...
Article
Objective: to investigate the early pushing urge (EPU) incidence in one maternity unit and explore how it is managed by midwives. The relation to some obstetric outcomes was also observed but not analysed in depth. Design: prospective observational study. Setting: Italian maternity hospital. Sample: 60 women (44 nullips and 16 multips) experiencing EPU during labour. Findings: the total EPU incidence percentage was 7.6%. The single midwives' incidences range had a very wide margin, noting an inverse proportion between the number of diagnoses of EPU and midwife's waiting time between urge to push and vaginal examination. Two care policies were adopted in relation to the phenomenon: the stop pushing technique (n=52/60) and the 'let the woman do what she feels' technique (n=8/60). In case of stop pushing techniques, midwives proposed several combined techniques (change of maternal position, blowing breath, vocalisation, use of the bath). The EPU diagnosis at less than 8cm of cervical dilatation was associated with more medical interventions. Maternal and neonatal outcomes were within the range of normal physiology. An association between the dilatation at EPU diagnosis and obstetric outcomes was observed, in particular the modality of childbirth and perineal outcomes. Conclusions and implication for practice: this paper contributes new knowledge to the body of literature around the EPU phenomenon during labour and midwifery practices adopted in response to it. Overall, it could be argued that EPU is a physiologic variation in labour if maternal and fetal conditions are good. Midwives might suggest techniques to woman to help her to stay with the pain, such as change of position, blowing breath, vocalisation and use of the bath. However, the impact of policies, guidelines and culture on midwifery practices of the specific setting are a limitation of the study because it is not representative of other similar maternity units. Thus, a larger scale work should be considered, including different units and settings. The optimal response to the phenomenon should be studied, considering EPU at different dilatation ranges. Future investigations could also focus on qualitative analysis of women and midwives' personal experience in relation to the phenomenon.
... Directed / spontaneous pushing data were also not recorded for vacuum and forceps births, the database assumes that for these births a directed pushing approach is routine., However as we were unable to reliably make this assumption we decided to exclude this group from the analysis. All women with epidurals and spinal analgesia were also excluded from this study, as regional analgesia is known to effect the spontaneous pushing urge and duration of second stage.. 9 Although it is recognised that in early second stage a period of passive descent with little or no spontaneous maternal effort may precede a more 'active' phase 10 , it can be difficult to accurately determine at which point effective and continuous expulsive effort commences. Previous studies have used differing definitions of commencement of active second stage depending on the technique used. 1 We considered that even though directed pushing may be commenced earlier than spontaneous, without a period of passive descent, that a consistent and clinically relevant approach would be to define second stage as commencing from diagnosis of full dilatation. ...
Article
Aim: To compare the effect of directed or spontaneous maternal pushing effort on duration of second stage labour, perineal injury and neonatal condition at birth. Methods: A retrospective cross-sectional design provided data for term women with singleton, cephalic presentation experiencing a non-operative vaginal birth without regional analgesia from January 2011 to December 2017 (n=69,066) Participants matching the inclusion criteria (n=19,212) were grouped based upon spontaneous or directed pushing. Propensity score matching was used to select equally sized cohorts of similar characteristics (n=10,000). The associations with outcomes of interest were estimated using odds ratios obtained by multivariate analysis. Findings: Directed pushing was associated with a longer duration of second stage labour for nulliparous (mean 14.4min [12.0-16.8]) and multiparous (mean 8.0min [6.8-9.2]) women, and an increased risk of prolonged 2nd stage of labour in multiparous women. The use of episiotomy in the directed pushing group was significantly higher both prior to and following PS matching and adjustment. Directed pushing was also associated with an significantly increased risk of neonatal resuscitation and nursery admission. There was no difference in rates of Apgar <7 recorded at 5min of age. Conclusion: Directed pushing is associated with an increased duration of second stage labour and risk of adverse neonatal outcomes. Our study suggests that in the absence of regional analgesia women should be supported to follow their own expulsive urges.
... The second stage of delivery, which starts from complete cervical dilation and is called the out driving stage, is one of the crucial stages for both mother and fetus. This stage is known as the emergency, acceleration, and instruction-to-push stage, with the assumption that shortening its length is beneficial (1). ...
Article
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Background There are concerns about the harmful effects of the Valsalva maneuver during the second stage of labor. Objectives Comparing the effects of spontaneous pushing in the lateral position with the Valsalva maneuver during the second stage of labor on maternal and fetal outcomes. Methods Inclusion criteria in this randomized clinical trial conducted in Iran were as follows: nulliparous mothers, live fetus with vertex presentation, gestational age of 37 - 40 weeks, spontaneous labor, and no complications. The intervention group pushed spontaneously while they were in the lateral position, whereas the control group pushed using Valsalva method while in the supine position at the onset of the second stage of labor. Maternal outcomes such as pain and fatigue severity and fetal outcomes such as pH and pO2 of the umbilical cord blood were measured. Results Data pertaining to 69 patients, divided into the intervention group (35 subjects) and control group (34 subjects), were analyzed statistically. The mean pain (7.80 ± 1.21 versus 9.05 ± 1.11) and fatigue scores (46.59 ± 21 versus 123.36 ± 43.20) of the two groups showed a statistically significant difference (P < 0.001). Moreover, the mean duration of the second stage in the intervention group was significantly higher than that in the control group (76.32 ± 8.26 minutes versus 64.56 ± 15.24 minutes, P = 0.001). The umbilical cord blood pO2 levels of both groups showed a statistically significant difference (28.29 ± 11.76 versus 18.83 ± 9.86, P < 0.001), whereas their pH levels were not significantly different (P = 0.10). Conclusions Spontaneous pushing in the lateral position reduced fatigue and pain severity of the mothers. Also, it did not worsen fetal outcomes. Thus, it can be used as an alternative method for the Valsalva maneuver.
... However, if manual rotation was performed later in the second stage of labor, then it would be necessary to allow sufficient time for maternal expulsive efforts to affect adequate descent. In these circumstances, a longer second stage of labor may be considered, given that neonatal outcomes appear to be more related to the period of active pushing rather than the overall length of the second stage (20). ...
Article
The management of the occiput posterior (OP) position has been controversial for many years. Manual rotation can be performed by midwives and could reduce cesarean sections and instrumental births. We aimed to determine current midwifery views, knowledge, and practice of manual rotation. A de-identified, self-reported questionnaire was e-mailed to all Australian College of Midwives full members (n = 3,997). Of 3,182 surveyed, 57 percent (1,817) responded, of whom 51 percent (920) were currently practicing midwifery. Seventy-seven percent of midwives thought that manual rotation at full dilatation was a valid intervention. Sixty-four percent stated the procedure was acceptable before instrumental delivery, but 30 percent were unsure. Most practicing midwives (93%) had heard of manual rotation, but only 18 percent had performed one in the last year. Midwives would support the routine performance of manual rotation for OP position if it reduced operative births from 68 to 50 percent and would support manual rotation for occiput transverse (OT) position if it reduced operative births from 39 to 25 percent. This study indicates that manual rotation is considered acceptable by most midwives in Australia, yet is only performed by a minority. Midwives would be willing to perform prophylactic manual rotation if it was known to facilitate normal vaginal births suggesting a scope to introduce this procedure into widespread clinical practice.
... This condition evokes the Ferguson's reflex, through increased oxytocin release, which augments maternal bearing down efforts by making them more effective and less fatiguing. The same uncertainty occurs in relation to the second-stage labour care of women [4,5]. ...
... where statements were substantiated with literature only, whereas sources classified with a low credibility rating (14%) were purely anecdotal ( Table 2). We synthesized data into six conceptual groups, using key terminology for each group label: Cervical reversal or recoil, 17,25,26,[33][34][35][36] plateaus, 17,24,28,[37][38][39][40][41][42][43][44][45] lulls during transition, 46-54 "rest and be thankful" stage, 50,52,55-57 deceleration phase, [58][59][60] and latent phases during 2nd stage 1,27,41,[61][62][63][64][65][66] and 3rd stage 67,68 of labor (Table 3). ...
Article
Full-text available
Background: Physiological plateaus (slowing, stalling, pausing) during normal labor and birth have been reported for decades, but have received limited attention in research and clinical practice. To date, heterogeneous conceptualizations and terminology have impeded effective communication and research in this area, raising concern as to whether some physiological plateaus might be misinterpreted as dystocia. To address this issue, we provide a point of orientation, mapping contemporary concepts, and terminologies of physiological plateaus during normal labor and birth. Methods: We conducted a scoping review, considering published and unpublished reports of physiological plateaus, reported in any language, between 1990 and 2021. Database searches of CINAHL, EMBASE, Emcare, MIDIRS, MEDLINE, Scopus, and Open Grey yielded 1,953 records, with an additional 35 reports identified by hand searching. In total, 43 reports from eleven countries were included in this scoping review. Results: Conceptualizations of physiological plateaus are heterogeneous and can be allocated to six conceptual groups: cervical reversal or recoil, plateaus, lulls during transition, “rest and be thankful” stage, deceleration phase, and latent phases. Across included material, we identified over 60 different terms referring to physiological plateaus. Overall, physiological plateaus are reported across the entire continuum of normal labor and birth. Conclusions: Physiological plateaus may be an essential mechanism of self-regulation of the mother-infant dyad, facilitating feto-maternal adaptation and preventing maternal and fetal distress during labor and birth.
... The second stage of labor begins when the cervix is completely dilated (open) and ends with the birth of the baby. In research, the second stage is often divided into a passive phase, an active phase, and the actual birth of the baby when the baby actually emerges [1]. Giving birth in an upright position can benefit the mother and baby for several physiologic reasons [2]. ...
Article
Full-text available
Background: It is believed that giving birth in an upright position is beneficial for both mother and the infant for several physiologic reasons. An upright positioning helps the uterus to contract more strongly and efficiently, the baby gets in a better position and thus can pass through the pelvis faster. Upright and lateral positions enables flexibility in the pelvis and facilitates the extension of the outlet. Before implementing a change in birthing positions in our clinics we need to review evidences available and context valid related to duration of second stage of labor and birthing positions. Therefore this review aimed to examine the effect of maternal flexible sacrum birth position on duration of second stage of labor. Method: The research searched articles using bibliographical Databases: Medline/PUBMED, SCOPUS, Google scholar and Google. All study designs were considered while investigating the impact of maternal flexible sacrum birthing positioning in relation duration of second stage of labor. Studies including laboring mothers with normal labor and delivery. A total of 1985 women were included in the reviewed studies. We included both qualitative and quantitative analysis. Results: We identified 1680 potential citations, of which 8 articles assessed the effect of maternal upright birth positioning on the reduction during the duration of second stage of labor. Two studies were excluded because of incomplete reports for meta analysis. The result suggested a reduction in duration of second stage of labor among women in a flexible sacrum birthing position, with a mean duration from 3.2-34.8. The pooled weighted mean difference with random effect model was 21.118(CI: 11.839-30.396) minutes, with the same significant heterogeneity between the studies (I2 = 96.8%, p < 000). Conclusion: The second stage duration was reduced in cases of a flexible sacrum birthing position. Even though the reduction in duration varies across studies with considerable heterogeneity, laboring women should be encouraged to choose her comfortable birth position. Researchers who aim to compare different birthing positions should consider study designs which enable women to choose birthing position. PROSPERO REGISTRATION NUMBER: [CRD42019120618].
... Facilitation of maternal/fetal circulation (Roberts, 2002) Less maternal fatigue (Mayberry et al., 1999) Unaltered bladder function (Schaffer et al., 2005) Decreased incidence of perineal tears due to gradual fetal descent (Simpson & James, 2005) ...
... De plus, les femmes incluses dans notre étude avaient quasiment toutes une analgésie péridurale (96,8% du GI et 95,2% du GC). L'adhésion à l'expiration peut donc également être modulée par la présence de cette analgésie puisque de nombreux auteurs ont décrit une diminution de l'envie de pousser des femmes sous APD (Lemos et al., 2017 ;Roberts, 2002 ;Roberts et al., 2007) justifiant, pour certains, l'utilisation de la poussée bloquée. Notre étude visait justement à étudier une poussée en expiration dirigée mimant un réflexe de poussée spontanée. ...
Thesis
Les pratiques obstétricales utilisées lors des accouchements sont nombreuses et certaines peuvent avoir un impact sur son déroulement ainsi que sur les issues maternelles et foetales. Durant le travail, ces pratiques reposent sur l’utilisation de différentes positions ou de techniques antalgiques pharmacologiques (analgésie péridurale, protoxyde d’azote) ou non (déambulation, utilisation de la baignoire, de la douche, du ballon etc.). Au moment de l’accouchement, il existe également différentes techniques de poussée, de maintien de la tête foetale, de soutien périnéal ou encore différentes positions d’accouchement. Cependant, à ce jour, ces pratiques ne sont pas ou très peu étudiées en France et ne répondent à aucune recommandation pour la pratique clinique. Dans le premier volet de cette thèse (n=1496), nous avons réalisé un état des lieux des pratiques déclarées par les sages-femmes et étudié si les pratiques différaient en fonction du lieu d’exercice et de l’ancienneté. Les sages-femmes françaises proposaient largement le recours à l’analgésie péridurale, surtout celles exerçant en maternité de type II ou III. Le décubitus latéral était la position préférée des sages-femmes durant le 1er stade avec analgésie péridurale et durant la phase de descente du 2ème stade. Pour l’accouchement, la plupart des sages-femmes conseillaient des positions en décubitus. La poussée en bloquant était celle la plus conseillée par les sages-femmes et majoritairement par celles ayant ≤ 5 ans d’ancienneté. Ces données ont montré que les pratiques des sages-femmes françaises étaient hétérogènes et variaient selon le niveau des maternités et l’ancienneté des sages-femmes. Notre deuxième volet repose sur un essai randomisé multicentrique (n=250) dont l’objectif principal était d’évaluer l’efficacité de la poussée dirigée à glotte ouverte vs celle à glotte fermée. Le critère de jugement principal était un critère de jugement composite : accouchement spontané, sans lésion du périnée (épisiotomie ou lésion spontanée des 2ème, 3ème ou 4ème degrés). Les femmes éligibles étaient celles ayant suivi intégralement la séance de formation aux types de poussées, avec une grossesse monofoetale en présentation céphalique, un accouchement par voie basse acceptée, admises en maternité entre 37 et 42 semaines d’aménorrhée pour un travail spontané ou induit, à partir d’une dilatation cervicale utérine ≥ 7 cm. Les critères d’exclusion étaient une pathologie contre-indiquant des efforts expulsifs ou un antécédent d’utérus cicatriciel, ou une anomalie du rythme cardiaque foetal avant la randomisation. Nous n’avons pas retrouvé de risques absolus ou bruts statistiquement différents en terme d’efficacité de la poussée, ni sur la morbidité maternelle (déchirures périnéales sévères ou hémorragies du post-partum) et néonatale immédiate (pH défavorable). Après prise en compte des facteurs de confusion et des facteurs pronostiques cliniquement pertinents, l’efficacité de la poussée n’était pas, non plus, statistiquement différente entre les deux types de poussées (RR ajusté : 0,92 [IC95% : 0,74-1,14]). En conclusion, les pratiques maïeutiques différent durant l’accouchement en France et il n’y a pas lieu de conseiller un type de poussée plutôt qu’un autre. Les femmes doivent, toutefois, être informées des différentes positions et des types de poussées lors des préparations à l’accouchement et doivent pouvoir choisir la position et la poussée qui leur conviennent, voir en changer, au cours du travail (Fédération Internationale de Gynécologie Obstétrique, 2012).
Article
The second stage of labour has provided debates concerning when maternal pushing efforts should begin and how long they should last for in order to safeguard maternal and fetal wellbeing. Spontaneous maternal pushing may begin before or following full cervical dilatation. Either way, midwives need to fully comprehend the boundary between the first and second stages of labour and respond to maternal cues for spontaneous pushing. Fixed time limits for the duration of the second stage of labour are frequently being discussed and have even been described as unnecessary. Providing maternal and fetal wellbeing is maintained, and until more conclusive evidence is available, midwives are encouraged to pay attention to the rate of progress of the second stage of labour and act on signs of maternal pushing rather than being preoccupied with time limits for the second stage of labour. This second article of a three-part series explores the issues of limits on pushing and time in the second stage of labour and critically analyses the evidence available.
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The second stage of labour has traditionally been managed by the midwife, directing women how and when to push. This usually involves women being instructed to use the Valsalva manoeuvre within prescribed time limits in supine or lithotomy positions. The rationale is that the duration of second stage of labour is reduced and therefore the risks of adverse effects to mother and fetus minimised. However, there is accumulating evidence that directed pushing within arbitrary time limits in supine positions is disadvantageous to the woman and fetus and is actually unjustified. Spontaneous pushing, which allows the woman to follow her own instincts and push in the second stage of labour, does not put the women or the fetus at risk of adverse effects. On the contrary, it offers clear benefits to both. Furthermore, the woman should be allowed to adopt positions that are most comfortable for her, yet encourage fetal rotation and descent through the maternal pelvis. The positions adopted can be variable, as long as labour is progressing, although upright positions are advocated during the second stage of labour compared to supine positions, which are not recommended.
Article
In den aktuellen geburtshilflichen Lehrbüchern wird das Gebären in der Regel in nicht mehr als drei Phasen eingeteilt: Eröffnungsphase, Austreibungsphase, Nachgeburtsphase. Ältere Lehrbücher verwenden hingegen eine fünfgliedrige Einteilung. Die erste Geburtszeit bezieht sich auf den Geburtsbeginn, die zweite auf die aktive Eröffnung, die dritte auf die so genannte Übergangsphase, die vierte auf den Kindsdurchtritt und die fünfte auf die Nachgeburtsphase. Ziel dieser Übersichtsarbeit ist ein besseres Verständnis der intrapartalen Dynamik in Relation zu den verschiedenen Geburtsphasen. Dabei wird die ältere fünfgliedrige Einteilung verwendet. Je nach Zeitgeist der Forschung werden die einzelnen Phasen unterschiedlich operationalisiert. Definitionsschwierigkeiten zeigen sich in der Praxis in entsprechend gröberen Kategorien der geburtshilflichen Qualitätssicherung zu Fallpauschalen und Sonderentgelten, die bis Ende 2000 als Perinatalerhebung bezeichnet wurde. Diese Diskrepanz konnte für die dritte Geburtszeit aufgezeigt werden, die bei einigen Autoren den Abschluss der Eröffnungsphase bildet, bei anderen jedoch bereits zur Austreibungsphase gezählt wird. Für die weitere Erforschung des Gebärens erscheint es nicht dienlich, sich hinsichtlich der Angaben zur Geburtsdauer an einem Zeitgeist zu orientieren, der nicht mehr an der Dynamik des Gebärens orientiert ist.
Article
This article endeavours to evaluate and critique the evidence and the associated limitations with many studies that look at time limits during the second stage of labour. It also seeks to examine the consequences of using delayed spontaneous pushing versus the Valsalva manoeuvre, in conjunction with time restraints in relation to maternal morbidities and neonatal complications. It discusses how midwives can best support and empower women in the second stage of labour and how information giving can lead to empowerment, informed decision making and woman's autonomy.
Article
There have been many papers written about the issue of pushing in the second stage of labour, and yet anecdotally some midwives are still restricted by labour ward policies of timed second stages, active pushing once fully dilated and subsequent interventions when time runs out. Research is fraught with frustration on occasion; some studies stop early because of preliminary findings indicating obvious benefits, while others, although offering beneficial findings, are often ignored and traditional practices continue. This article considers the research supporting spontaneous pushing in labour; it asks why change is so difficult and then considers what could be done to encourage a change in practice. The article finds that women should be allowed to push spontaneously. A change in clinical practice is recommended. It considers whether further research is necessary, or whether a change in the definitions used for the stages of labour would allow midwives to let women dictate when to push.
Article
Much debate exists between spontaneous and directed pushing in the second stages of labour. Whilst directed pushing seems common practice in delivery rooms, there is evidence to suggest that this prescriptive technique should be avoided. Conversely, sufficient evidence exists supporting spontaneous pushing – where the woman is allowed to follow her own instincts. Furthermore, spontaneous pushing is advocated as it avoids the adverse effects to the woman and fetus that directed pushing may cause. This final article compares spontaneous and directed pushing, provided maternal and fetal wellbeing is maintained and labour is progressing normally.
Article
Many articles in this section of Comprehensive Physiology are concerned with the development and function of a central pattern generator (CPG) for the control of breathing in vertebrate animals. The action of the respiratory CPG is extensively modified by cortical and other descending influences as well as by feedback from peripheral sensory systems. The central nervous system also incorporates other CPGs, which orchestrate a wide variety of discrete and repetitive, voluntary and involuntary movements. The coordination of breathing with these other activities requires interaction and coordination between the respiratory CPG and those governing the nonrespiratory activities. Most of these interactions are complex and poorly understood. They seem to involve both conventional synaptic crosstalk between groups of neurons and fluid identity of neurons as belonging to one CPG or another: neurons that normally participate in breathing may be temporarily borrowed or hijacked by a competing or interrupting activity. This review explores the control of breathing as it is influenced by many activities that are generally considered to be nonrespiratory. The mechanistic detail varies greatly among topics, reflecting the wide variety of pertinent experiments. © 2012 American Physiological Society. Compr Physiol 2:1387-1415, 2012.
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BACKGROUND: Although there is evidence to support the benefits for women of using a variety of birth positions, particularly upright birth positions, there is limited research into practices that facilitate or inhibit physiological birth positioning. AIM: To explore how physiological birth positioning is facilitated by midwives and experienced by women in two main settings in New South Wales (NSW), Australia (birth center and delivery ward). METHOD: An ethnographic approach guided data collection and analysis in this study. Data was collected using observation of women in the second stage of labor, focus groups with midwives, and interviews with women. RESULTS: Women were more likely to assume upright birth positions in the birth center setting (81.84%) than in the delivery ward setting (24.47%). They also instinctively wanted to lean forward during labor and birth. Midwives and women constantly "juggle instinct and fear" as they work to adapt to the birth environment, and this impacts physiological birth positioning. CONCLUSION: Women are more likely to adopt physiological birth positions during the first and second stage of labor in a birth center setting compared to a delivery ward setting. The birth center setting acts as a facilitator for physiological birth positions by providing a buffer from medicalized care. CLINICAL IMPLICATIONS: An in-depth exploration into facilitators and inhibitors of physiological birth positioning in two different birth settings provided new insights. Findings from this study have the potential to inform clinical practice through the design of birth environments and models of care that are available to women.
Article
Senior Staff Nurse Midwife at HFS Birth Center (2001-2005) Diana.jolles@dhha.org Synopsis Holy Family Services Birth Center in Weslaco Texas is a freestanding non-profit birth center located in a region rich with cultural heritage while plagued by poverty and acculturation. The birth center is in its 21 st year of service to the Rio Grande Valley under the direction of Sister Angela Murdaugh and is unique for its autonomy, model of "high touch, low tech" midwifery care, and dedication to collection and analysis of service data. The presentation explores the task of being a birth center in its second decade-documenting the importance of continual community needs assessments. It is a tale of the changing face of malnourishment, and an account of service to the underserved, who's children have now grown to be the childbearing mothers of today; qualifying for Medicaid and the "best" healthcare options-affording them one of the highest cesarean section rates in the country. It is a report of how the center serves a community of women that believe pregnancy is not a pathology, yet drop into local hospitals to give birth-embracing the idea that childbirth is inherently an emergency. Finally, the presentation is a tribute to an institution that has offered close to 200 health care professionals the opportunity to work as a public health servants and an exploration of the importance of such models in the future of our profession. The presentation examines the birth center and its relationship to the health statistics of the region. Using the past eight years of clinical data we will explore the effect the birth center has had on decreasing childhood obesity rates, the attempt to market prenatal care and midwifery model care to the community, and the validation of clinical practice by exploring rates of morbidities and their correlates, including rates of technological intervention, delivery position and perineal integrity and nonmedical induction of labor.
Article
Aims: To know the attitude of the woman and her partner the use of the mirror in the second stage of labor. Methods: This descriptive cross - sectional study was carried at Hospital Universitario Fundación Alcorcón (Madrid, Spain). The data were collected using an 14 Items scale based on the semantic differential technique developed from a pilot study with 92 subjects. A sample de 159 subjects they completed the scale, as well as the State Trait Anxiety Inventory (STAI). Results: The percentage of acceptance was of 90%. The mean score in the scale overcame the neutral value in all items. The 88,5% (CI 95%:78,8 a 98,1) of women who experienced the experience thought that the use of the mirror stimulates to push versus 73,6% (CI 95%:62,7 a 84,4) before the delivery. Conclusions: The use of the mirror during the second stage of labor is valued favorably by the majority of the women and her pairs.
Article
Background and purpose: Most women suffer some degree of perineal trauma during vaginal delivery. Second stage management strategies, including vocalization, to protect the perineum have been investigated. Objective: To compare the frequency and degree of perineal trauma at vaginal delivery, with and without use of the vocalization maneuver during the second stage of labor. Materials and methods: This is an open-label, randomized controlled trial. We conducted the study at the Center for Normal Deliveries of IMIP. We included low-risk women without prior cesarean deliveries. Women who met the inclusion criteria and signed the informed consent form were randomized to one of two groups: Group A (experimental) and Group B (control). A physical therapist encouraged women in Group A to maintain an open glottis during pushing and to emit sounds when exhaling (vocalization). Women in Group B underwent routine humanized vaginal deliveries. The outcomes of the study were perineal integrity and degree of perineal laceration. These were measured by the study team immediately after completion of the third stage of labor. Results: Women in Group A tended to have less severe perineal tear (less second and third degree lacerations) and smaller lacerations than women in group B. The vocalization maneuver reduced the risk of a perineal tear greater than 2 cm by 68% (NNT 2.2). There was no difference in other outcomes. Conclusion: Encouraging women to follow a vocalization protocol coached by a physical therapist during the second stage of labor can be a helpful labor assistance technique, since this study showed that vocalization is associated with less extensive perineal tears. Clinical trial registration: This study was registered on ClinicalTrials.gov (www. Clinicaltrial: gov) registration number: NCT03605615.
Article
Background: The physical positions that are adopted by women during childbirth significantly impact their childbirth outcomes and experiences. Literature studies have associated using a squatting position with reduced childbirth pain and increased comfort and pushing efficiency. However, the major disadvantage of the squatting position is that women may lack the muscular fitness and stamina necessary to sustain this position for a long period. Purpose: The aim of this study was to compare the pushing experiences and birth outcomes of three different pushing positions during the second stage of labor. Methods: A randomized controlled trial was conducted at a regional teaching hospital in northern Taiwan. Data were collected from 168 primiparous women during the 38th to 42nd gestational weeks. None of the participants received epidural analgesia during labor, and all were free of pregnancy and labor-related complications. During labor, after full cervical dilation and when the fetal head had descended to at least the +1 station and had turned to the occiput anterior position, the experimental group was asked to push in the squatting position while using the ergonomically designed ankle support. For purposes of comparison, Comparison Group A was asked to push in the squatting position without the use of the support, and Comparison Group B was asked to push in a standard semirecumbent position. All of the participants completed a demographic and obstetrics data sheet, the short-form McGill Pain Questionnaire, and the Labor Pushing Experience scale within 4 hours postpartum. Results: In terms of delivery time, the duration between the start of pushing to crowning for the experimental group (squatting with ankle supports) averaged 25.79 minutes less (F = 6.02, p < .05) than the time for Comparison Group B (semirecumbent). The duration between the start of pushing to infant birth averaged 25.21 minutes less for the experimental group than for Comparison Group B (F = 6.14, p < .05). Moreover, the experimental group had a lower average visual analog scale pain score (5.05 ± 3.22) than Comparison Group B (F = 42.67, p < .001), and the average McGill pain score for the experimental group was lower than both comparison groups (F = 18.12, p < .001). The participants in the group that delivered from a squatting position with ankle support had better labor pushing experiences than the comparison groups (F = 14.69, p < .001). Conclusions/implications for practice: In comparison with both unsupported squatting and semirecumbent pushing, squatting with the aid of ergonomically designed ankle supports reduced pushing times, ameliorated labor pain, and improved the pushing experience. Thus, this intervention may reduce the caring needs of women during the second stage of labor. This intervention may be introduced in midwifery education programs and in clinical practice as a method to improve the care of women during the second stage of labor.
Article
This is a quasi-randomised clinical trial, with 62 low-risk pregnant women in the second stage of labour. They were randomly allocated in control (CG) (n = 31) and intervention (IG) (n = 31) groups. The IG performed spontaneous pushing with pursed lips breathing while the CG was oriented to perform directed pushing associated with Valsalva Manoeuvre (VM). There was no difference between the groups regarding the occurrence of episiotomy (RR 1,1; 95%IC 1,0 to 1,2). However, there was a decrease in the duration of the maternal pushing by 3.2 min (MD 3,2; 95%CI 1,4 to 5,1) and a difference in maternal anxiety (Md (IQR) IG 46 (35–52), CG 51 (44–56) p:0,049), both favouring the IG. Spontaneous pushing was effective in reducing the duration of the pushing and showed a difference in maternal anxiety but did not decrease the maternal and neonatal outcomes. Brazilian Clinical Trials Registry (ReBEC) under the identifier: RBR-556d22 • IMPACT STATEMENT • What is already known on the subject? Spontaneous pushing reduces the duration of pushing time when compared to directed pushing with VM but has no effect on other maternal and neonatal outcomes, based on a low quality of evidence. • What do the results of this study add? No subject has been published on the subject. Our results suggest that the use spontaneous pushing with pursed lips breathing reduces the duration of the pushing by 3.2 min, also showing a difference in maternal anxiety. This result may indicate its use for emotional control when compared to the directed pushing. • What are the implications of these findings for clinical practice and/or further research? These findings may signal an attitude in decision-making about guiding the breathing pattern in the expulsive stage.
Article
Pain relief during childbirth continues to stimulate controversy as new treatments emerge and continuing interventions in the birth process invoke concerns about safety, technologic imperatives, and informed consent. In this historical commentary, I identify a complex dissonance between scientific advances and women’s needs and expectations regarding childbirth. Evidence-based practice became the standard during the last 50 years and has reinforced a more conservative and parsimonious use of technology to respond to women’s needs for pain relief. In reviewing this history, it is apparent that pain relief during labor is inextricably linked to interventions. Nurses can advance evidence-based practice and facilitate robust informed consent as they support women during childbirth.
Article
The midwifery profession is increasingly applying the results of evidence‐based research findings. Several researchers were asked if they would answer questions regarding the essential research skills necessary for midwives, the relevance of applying valid evidence to practice, and concerns regarding evidence‐based practice overall. The objectives were to share expert researchers' responses that could be used by educators to help introductory midwifery students understand the importance of developing skills in assessing “the best evidence” and to stimulate interactive discussion in the classroom. Consideration of the expert opinions stimulated student thinking on the relation of evidence‐based findings to practice in an exciting approach characterized by inquiry and debate, which got favorable responses and evaluations from the students.
Article
Objective To compare the effectiveness of directed open-glottis and directed closed-glottis pushing. Design Pragmatic, randomised, controlled, non-blinded superiority study. Settings Four French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals). Participants 250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm. Interventions In the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing. Measurements The principal outcome was “effectiveness of pushing” defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR). Findings In our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74–1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85–1.10). Key conclusions In maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups. Implications for practice If directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.
Article
Aim: A plethora of physiologic and biochemical changes occur during normal pregnancy. The changes in the respiratory system have not been as well elucidated, since radio-imaging studies are usually not feasible. We aimed to use several non-invasive methods to characterize the adaptation of the respiratory system during the full course of pregnancy in preparation for childbirth. Methods: Eighteen otherwise healthy women (32.3±2.8 years) were recruited during early pregnancy. Spirometry, opto-electronic plethysmography and ultrasonography were used to study changes in chest wall geometry, breathing pattern, lung and thoraco-abdominal volume variations and diaphragmatic thickness in the first, second and third trimester. A group of non-pregnant women were used as controls. Results: During the course of pregnancy, we observed a reorganization of ribcage geometry, in shape but not in volume. In spite of the growing uterus, there was no lung restriction (forced vital capacity: 101±15 %predicted), but reduced ribcage expansion. Breathing frequency and diaphragmatic contribution to tidal volume and inspiratory capacity increased. In spite of the abdominal expansion, the thickness of the diaphragm was maintained (first trimester: 2.7±0.8 mm; third trimester: 2.5±0.9 mm, p=0.187), possibly indicating a length adaptive mechanism and/or a conditioning effect to compensate for the thinning effects of the growing uterus. Conclusions: Pregnancy preserved lung volumes, abdominal muscles and the diaphragm at the expense of rib cage muscles.
Chapter
Women have a high mortality rate and pain in childbirth before modern medicine. Current natural childbirth might take 12–16 h on labor, the body weight on the spine and pelvic make pregnant women fatigue, it might cause to use medical drugs to relieve pain, or cesarean delivery way. If women use birth squatting allows the pelvis to expand exports about 25% reduction in the second stage of labor, there is less pain, reduce the use of analgesics, increase comfort, increased fetal blood oxygen and carbon dioxide to reduce the value of fetal blood, significantly reduce perineal laceration, and there is less use of episiotomy surgery and auxiliary equipment. Squatting is not easy to maintain even in minutes, therefore, this study used “squatting support device” to provide women with a ramp birth squatting 20–30°, so that the body forward, the body’s center of gravity and support points remained at the same paw on the vertical axis, so that women can effectively contraction of the abdominal muscles to help viviparous through the birth canal. As comparing the time from starting pushing to crowning, ergonomics ankle support squatting is 25.52 min (F = 6.02, p < .05) shorter than semi-recumbent group in average. The time from starting pushing to fetal childbirth is 25.21 min shortened (F = 6.14, p < .05). Score of ergonomics ankle support squatting group is 5.05 to 3.22 (rating from 0 to 10) lower than semi-recumbent group in average as showing in visual analogue scale (VAS). The overall score of ergonomics ankle support squatting group is lower than semi-recumbent group and squatting group (F = 18.12, p < .001) as measured with short form McGill pain questionnaire (MPQ-SF). Ergonomics ankle support squatting group expressed better labor pushing experiences than other groups.
Article
Background: Vaginal application of lubricant during labor has been studied to shorten the length of the second stage of labor. Objective: To evaluate whether vaginal application of lubricant shortens the second stage of labor. Data sources: Electronic databases were searched from their inception until February 2018. No restrictions for language or geographic location were applied. Study eligibility criteria: Randomized controlled trials (RCTs) comparing the use of lubricant of the vaginal canal (ie intervention group) with a control group (ie no lubricant) in pregnant women with singleton gestation and cephalic presentation undergoing spontaneous vaginal delivery at term. Trials on other interventions that might impact second stage of labor (pushing methods, perineal massage, Ritgen’s maneuver, etc.) were not included. Study appraisal and synthesis methods. All analyses were done using an intention-to-treat approach. The primary outcome was the length of the second stage of labor. Pooled analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of mean difference (MD) with 95% confidence interval (CI). Tabulation, integration, and results. Three RCTs including 512 women evaluating the effect of lubricant application during labor were included in the meta-analysis. All trials included pregnant women with singleton gestations in cephalic presentation at term undergoing spontaneous vaginal delivery. One trial included only nulliparous women, while the other two included both nulliparous and multiparous women. Lubricant application started in the first stage before the active phase of labor, and was done intermittently by the midwife or the physician. A sterile gel was applied into the vaginal canal manually or with an applicator. All trials used water-soluble gel. The quantity of gel used was about 2–5 ml for each vaginal examination. There were no statistically significant differences, comparing women who received lubricant gel during labor with those who did not, in the lengths of second stage of labor (MD −7.11 minutes, 95% CI −15.60–1.38), of the first stage of labor, or of the active phase of the first stage of labor. No between-group differences were noticed in the risk of perineal lacerations, mode of delivery, and in the neonatal outcomes. Conclusion: Vaginal application of lubricant during labor does not reduce the length of the second stage of labor in pregnant women with singleton gestations undergoing an attempt at spontaneous vaginal delivery at term.
Article
The American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 49 on Dystocia and Augmentation of Labor defines a prolonged second stage as more than 2 hours without or 3 hours with epidural analgesia in nulliparous women, and 1 hour without, or 2 hours with epidural in multiparous women. This definition diagnoses 10% to 14% of nulliparous and 3% to 3.5% of multiparous women as having a prolonged second stage. Although current labor norms remained largely based on data established by Friedman in the 1950s, modern obstetric population and practice have evolved with time.
Article
Background: Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterus contraction. Currently, there is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on mother and fetus. Objectives: To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. Selection criteria: Randomised and quasi-randomised assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion.We considered the following comparisons.Timing of pushing: to compare pushing, which begins as soon as full dilatation has been determined versus pushing which begins after the urge to push is felt.Type of pushing: to compare pushing techniques that involve the 'Valsalva Manoeuvre' versus all other pushing techniques. Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias. Two review authors independently extracted data. Data were checked for accuracy. Main results: We included 20 studies in total, seven studies (815 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 studies (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. The results come from studies with a high or unclear risk of bias, especially selection bias and selective reporting bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingOverall, for this comparison there was no difference in the duration of the second stage (mean difference (MD) 11.60 minutes; 95% confidence interval (CI) -4.37 to 27.57, five studies, 598 women, random-effects, I(2): 82%; T(2): 220.06). There was no clear difference in perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) and episiotomy (average RR 1.05 ; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I(2) = 81%; T(2) = 0.14). The primary neonatal outcomes such as five-minute Apgar score less than seven was no different between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, n = 393) also showed no difference between spontaneous and directed pushing and no data were available on hypoxic ischaemic encephalopathy.The duration of pushing (secondary maternal outcome) was five minutes less for the spontaneous group (MD -5.20 minutes; 95% CI -7.78 to -2.62, one study, 100 women). Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 54 minutes in the duration of the second stage of labour (MD 54.29 minutes; 95% CI 38.14 to 70.43; 10 studies, 2797 women, random-effects; I(2) = 91%; T(2) = 543.38), and there was no difference in perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) and episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 20-minute decrease in the duration of pushing (MD - 20.10; 95% CI -36.19 to -4.02, 10 studies, 2680 women, random-effects, I(2) = 96%; T(2) = 604.37) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.03 to 1.11, 12 studies, 3114 women).For the primary neonatal outcomes, there was no difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00, three studies, n = 413). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). Authors' conclusions: This review is based on a total of 20 included studies that were of a mixed methodological quality.Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and double the risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no difference in the caesarean and instrumental deliveries, perineal laceration and episiotomy, and in the other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing. Futhermore, the adverse effects on maternal pelvic floor is still unclear.Therefore, there is insufficient evidence to justify routine use of any specific timing of pushing since the maternal and neonatal benefits and adverse effects of delayed and immediate pushing are not well established.For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort.In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.Further properly well-designed randomised controlled trials are required to add evidence-based information to the current knowledge. These trials should address clinically important maternal and neonatal outcomes and will provide more complete data to be incorporated into a future update of this review.
Article
Background Little is known about recommendations for safe and appropriate instruction of Pilates exercises to women during pregnancy. The aim of this study was to examine Pilates practitioners’ perspectives regarding Pilates program design for pregnant women. We also sought to elucidate their views on the potential benefits, restrictions and contraindications on Pilates in pregnancy. Methods A cross-sectional survey was performed. Pilates practitioners were invited to participate via email. Participants were surveyed about their experience and views on: screening processes in alignment with The American College of Obstetricians and Gynecologists (ACOG) (2002) guidelines; (ii) optimal exercise program features and (iii) physical and mental health benefits of Pilates for pregnant women. Results The survey was completed by 192 Pilates practitioners from a range of settings. Practitioners reported conducting formal screening (84%) for safety in pregnant women prior to commencing Pilates classes. Most did not routinely seek medical approval from the woman’s general practitioner. Divergent views emerged regarding the safety and benefits of Pilates exercises in the supine position. Mixed opinions were also generated regarding the effects of spinal flexion exercises, single-leg stance exercises and breathing manoeuvres. There was little agreement on the optimal frequency or dosage of exercises. Views regarding absolute contraindications to exercise differed from The American College of Obstetricians and Gynecologists (ACOG) (2002) guidelines which cautioned about the dangers of persistent bleeding, premature labour, pre-eclampsia, placental praevia and incompetent cervix. The most frequent reported physical and psychological benefit of Pilates was improving pelvic floor strength (12%) and improved social wellbeing (23%). Conclusions The study highlighted wide variations in practice for Pilates exercises with pregnant woman as well as low adherence to clinical practice guidelines. Further evidence is required to advise on appropriate screening and individualised Pilates programming, particularly for women with medical conditions during pregnancy.
Article
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Background: Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterine contraction. There is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on the mother and fetus. Objectives: To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies. Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion, but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion in this review. Data collection and analysis: Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. Main results: In this updated review, we included 21 studies in total, eight (884 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. Our GRADE assessments of evidence ranged from moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Overall, the included studies varied in their risk of bias; most were judged to be at unclear risk of bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingThere was no clear difference in the duration of the second stage of labour (mean difference (MD) 10.26 minutes; 95% confidence interval (CI) -1.12 to 21.64 minutes, six studies, 667 women, random-effects, I? = 81%) (very low-quality evidence). There was no clear difference in 3rd or 4th degree perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) (low-quality evidence), episiotomy (average RR 1.05; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I? = 81%), duration of pushing (MD -9.76 minutes, 95% CI -19.54 to 0.02; two studies; 169 women; I? = 88%) (very low-quality evidence), or rate of spontaneous vaginal delivery (RR 1.01, 95% CI 0.97 to 1.05; five studies; 688 women; I? = 2%) (moderate-quality evidence). For primary neonatal outcomes such as five-minute Apgar score less than seven, there was no clear difference between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants) (very low-quality evidence), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, 393 infants) (very low-quality evidence) also showed no clear difference between spontaneous and directed pushing. No data were available on hypoxic ischaemic encephalopathy. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 56 minutes in the duration of the second stage of labour (MD 56.40, 95% CI 42.05 to 70.76; 11 studies; 3049 women; I? = 91%) (very low-quality evidence), but no clear difference in third or 4th degree perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) (moderate-quality evidence) or episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 19-minute decrease in the duration of pushing (MD -19.05, 95% CI -32.27 to -5.83; 11 studies; 2932 women; I? = 95%) (very low-quality evidence) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.02 to 1.11, 12 studies, 3114 women) (moderate-quality evidence).For the primary neonatal outcomes, there was no clear difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) (low-quality evidence) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00; three studies; 413 infants) (very low-quality evidence). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68, 4 studies, 2145 infants) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). Authors' conclusions: This updated review is based on 21 included studies of moderate to very low quality of evidence (with evidence mainly downgraded due to study design limitations and imprecision of effect estimates).Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and an increased risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no clear difference in serious perineal laceration and episiotomy, and in other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing.Therefore, for the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style as part of routine clinical practice, and in the absence of strong evidence supporting a specific method or timing of pushing, the woman's preference and comfort and clinical context should guide decisions.Further properly well-designed RCTs, addressing clinically important maternal and neonatal outcomes are required to add evidence-based information to the current knowledge. Such trials will provide more complete data to be incorporated into a future update of this review.
Article
Key to any perinatal safety initiative is buy-in and strong leadership from obstetric and pediatric providers, advanced practice nurses, and labor and delivery nurses in collaboration with ancillary staff. In the fall of 2007, executives of a large Midwestern hospital system created the Zero Birth Injury Initiative. This multidisciplinary group sought to eliminate birth injury using the Institute of Healthcare Improvement Perinatal Bundles. Concurrently, the team implemented a standardized second-stage labor guideline for women who choose epidural analgesia for pain management to continue the work of eliminating birth injuries in second-stage labor. The purpose of this article was to describe the process of the modification and adaptation of a standardized second-stage labor guideline, as well as adherence rates of these guidelines into clinical practice. Prior to implementation, a Web-based needs assessment survey of providers was conducted. Most (77% of 180 respondents) believed there was a need for an evidence-based guideline to manage the second stage of labor. The guideline was implemented at 5 community hospitals and 1 academic health center. Data were prospectively collected during a 3-month period for adherence assessment at 1 community hospital and 1 academic health center. Providers adhered to the guideline in about 57% of births. Of patients whose provider followed the guideline, 75% of women were encouraged to delay pushing compared with only 28% of patients delayed pushing when the provider did not follow the guideline.
Chapter
This chapter presents a discussion of evidence-based strategies that the maternity care providers can employ to support women during normal childbirth, avoiding the routine use of non-evidence-based medical interventions. It describes the supportive roles of maternity care providers, working within the social context of childbirth keeping the woman and her needs central. The chapter presents an overview of techniques that the maternity care providers can use to promote a physiologic approach to labor and birth, including how to be present, supportive, and responsive to the woman's needs as her labor and birth unfold. Finally, a review of specific routine maternity care practices that can disrupt normal labor and birth is identified, along with alternative approaches to care.
Article
Background: Although there are two methods of caring for women with epidural anesthesia during second-stage labor (coached closed-glottis pushing immediately at 10-cm cervical dilation or delayed pushing until the woman feels the urge to push, passive fetal descent, and encouragement of open-glottis pushing when the woman has the urge to push), there are limited data concerning which method is most optimal for fetal well-being. Objective: To evaluate effects on fetal well-being, as measured by fetal oxygen saturation, of two different methods of second-stage labor nursing care for women with epidural anesthesia. Methods: Forty-five nulliparous women who had progressed to the second stage were randomized to 1 of 2 groups (immediate or delayed pushing). Fetal oxygen saturation was continuously monitored and values at 10 cm, initiation of pushing and immediately prior to birth, as well as the amount of time that fetal oxygen saturation values were abnormal (< 30 %) were compared between groups. Also evaluated were additional measures of fetal well-being such as fetal heart rate patterns, Apgar scores, and umbilical cord blood gases and maternal outcomes including length of labor, method of birth, and perineal status. Results: There was a significant difference between groups in fetal oxygen desaturation during the second stage (immediate: M = 12.5; delayed: M = 4.6) F(1, 43) = 12.24, p =.001, and in the number of >= 2-min epochs of fetal oxygen saturation < 30 % (immediate: M = 7.9; delayed: M = 2.7), F(1, 43) = 6.23, p = .02. There were more variable decelerations of the fetal heart rate in the immediate pushing group (immediate: M = 22.4; delayed: M = 15.6) F(1, 43) = 5.92, p =.02. There were no differences in length of labor, method of birth, Apgar scores, or umbilical cord blood gases. Women who pushed immediately had more perineal lacerations (immediate: n 13; delayed: n = 5) chi(2)(1, N = 45) = 6.54, p = .01. Discussion: Delayed pushing results in less fetal oxygen desaturation and less >= 2-min epochs of fetal oxygen saturation < 30 % during second-stage labor than the immediate pushing method; thus, delayed pushing is more favorable for fetal well-being as measured by fetal oxygen saturation.
Article
The Valsalva technique for directed pushing during the second stage of labour is an intervention still used by some health care practitioners in the UK, despite evidence suggesting that this is not the best approach to intrapartum care. Current research in this area is limited, with ambiguous findings. The latest National Institute for Health and Care Excellence (NICE, 2014) guidelines recommend that until further research is forthcoming, women should be guided by their own instinctive urge to push during the second stage and directed pushing should not be used as part of routine intrapartum care. Midwives are encouraged to ensure that women are fully informed of the latest evidence, and use their professional judgement in conjunction with the woman's individual needs and preferences while undertaking care during the second stage of labour.
Article
The labor induction rate is at an all‐time high in the United States. Although induction of labor is recommended as a therapeutic option only when the benefits of expeditious birth outweigh the risks of continuing the pregnancy, a "psychosocial indication" has become a common rationale for elective induction in the United States. It is unlikely that all women are provided with a complete discussion of the cascade of interventions that frequently accompany labor induction and the risks of cesarean birth. Although at first glance elective labor induction may seem more convenient, an appreciation of the inconvenience of the greater rates of interventions, the longer labor and overall hospital stay, the higher costs, the additional attention required by the primary health care provider when complications occur, and the risk of an adverse outcome for a mother or baby after an elective procedure with subsequent litigation should cause everyone to exercise caution and reevaluate current practice. Professional organizations should take proactive steps to advocate for pregnant women so they are fully aware of the risks and benefits. A public campaign to discourage elective labor induction for nulliparous women is worth serious consideration.
Article
Introduction: Episiotomy means cutting the muscles of perineum during the second stage of labor to widen pelvic outlet and speed up the withdrawal of the fetal head; it is the most common surgical incision in midwifery. Today, a variety of non-pharmacological methods during pregnancy and labor are used to reduce need for episiotomy and after delivery for pain reduction and early recovery. This study was performed with aim to review some of these approaches. Methods: In this study, all clinical trials which have been conducted to reduce the need for episiotomy and quick recovery and pain reduction after that until 2014 were used. To obtain the necessary information, the databases of PubMed, Sciencedirect, googlescholar, SID and Iranmedex were used. A total of 20 studies were evaluated based on the Jadad criteria and among them, there were 17 Iranian paper and 3 English articles. Results: The results showed that the majority of methods used during pregnancy and childbirth for reducing the need to episiotomy (perineal massage, Kegel exercises, etc.), as well as medicinal plants (Aloe vera, turmeric, lavender, marigold, pineapple, chamomile, etc.) used after episiotomy for wound healing and reducing pain are effective, but generally, further studies are needed for better understanding of these plants and their possible complications. Conclusion: In general, most of the methods used to reduce the need for episiotomy and improve healing are effective, but more studies should be performed for better understanding of their possible complications. © 2015, Mashhad University of Medical Sciences. All rights reserved.
Article
Aims: To know the attitude of the woman and her partner the use of the mirror in the second stage of labor. Methods: This descriptive cross - sectional study was carried at Hospital Universitario Fundación Alcorcón (Madrid, Spain). The data were collected using an 14 Items scale based on the semantic differential technique developed from a pilot study with 92 subjects. A sample de 159 subjects they completed the scale, as well as the State Trait Anxiety Inventory (STAI). Results: The percentage of acceptance was of 90%. The mean score in the scale overcame the neutral value in all items. The 88,5% (CI 95%:78,8 a 98,1) of women who experienced the experience thought that the use of the mirror stimulates to push versus 73,6% (CI 95%:62,7 a 84,4) before the delivery. Conclusions: The use of the mirror during the second stage of labor is valued favorably by the majority of the women and her pairs.
Article
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A new obstetric aid, the 'Birth Cushion' allows the parturient to sink into a supported squatting posture for the second stage of labour and delivery; it fits onto conventional delivery beds. A prospective, controlled trial of 427 primiparae compared the outcome of labour in women randomly allocated to squatting (218) or conventional semirecumbent (209) management. The squatting group had significantly fewer forceps deliveries (9% vs 16%) and significantly shorter second stages (median length of pushing 31 vs 45 min) than the semirecumbent group. There were fewer perineal tears, but more labial tears, in the squatting group. Apgar scores, blood loss, and post-partum vulvar oedema were similar in both groups. 82% of the women in the squatting group maintained upright positions for most of the second stage, and reported great satisfaction with the supported squatting position. The traditional birth posture of squatting can be easily adapted for modern labour management and has advantages for women in their first labour.
Article
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A controlled clinical trial involving 151 primigravidae and 18 midwives assessed the acceptability and outcome of second-stage labour in upright positions. Women who had no specific antenatal preparation and preferences regarding labour positions were managed either conventionally (semi-recumbent and lateral), or encouraged to adopt upright positions (squatting, kneeling, sitting or standing) according to individual preference. Of the women allocated to the upright position 74% completed the second stage upright, with kneeling being the most favoured position, but squatting was, despite all assistance, too difficult to maintain. Adoption of upright positions resulted in a higher rate of intact perineums. There was a clinically apparent reduction of forceps deliveries in the upright group which influenced midwives' attitudes. Moving the parturient from recumbent to upright positions was often perceived to be beneficial when there was slow progress. Estimated blood loss was similar in the two groups, as was the condition of the newborn (Apgar score and umbilical artery pH). Alternative positions in the second stage of labour, in particular kneeling, are achievable even without specific birth aids and antenatal preparation. They appear safe, acceptable to most parturients and their midwives, and are easily integrated into modern labour ward practice; they may have clinical advantages which need further investigation.
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To evaluate whether physicians' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth. Post-hoc cohort analysis of physicians and patients involved in a randomized controlled trial of episiotomy. Two tertiary care hospitals and one community hospital in Montreal. Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by residents or nurses were excluded. Patients: intact perineum v. perineal trauma, length of labour, procedures used (instrumental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assigning women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy. Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably (p < 0.05 to < 0.01), and the former physicians were more likely to use oxytocin augmentation of labour. Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that "fetal distress" or cesarean section necessitated exclusion of the subject. They used the lithotomy position for birth more often (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience (p < 0.01) than the patients of physicians who viewed the procedure very unfavourably. Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.
Article
Objective: To examine factors associated with the performance of episiotomy. Methods: A retrospective review was performed on 8647 deliveries during 1991 and 1992 at five medical centers. Episiotomy rates were compared based on variables involving patient demographics, obstetric condition, and physician factors for the 6458 vaginal deliveries in the sample. Logistic regression modeling using variables associated in bivariate analysis was performed to examine independent effects of each variable. Results: Several characteristics of the patient, her clinical status, and physician factors were all associated with episiotomy use. The strongest independent predictors of episiotomy were nulliparity (odds ratio [OR] 4.10, 95% confidence interval [CI] 3.59-4.68) and the use of forceps (OR 5.03, 95% CI 3.39-7.46) or vacuum extraction (OR 3.78, 95% CI 2.36-6.04). Provider specialty and the site of care were also associated independently with episiotomy. Episiotomy use was also associated with major perineal lacerations and an increased length of hospital stay. Conclusion: Although differences in episiotomy rates mainly reflect clinical circumstances, important site-to-site variations and interspecialty differences point to potential areas where physician behaviors influence the performance of episiotomy.
Article
Objective To investigate the relation between the duration of the second stage of labour and subsequent early neonatal and maternal morbidity. Design Retrospective analysis of a regional obstetric database. Setting 17 maternity units in the North West Thames Health Region. Subjects Selected from 36 727 consecutive singleton deliveries in 1988. The analysis was confined to the 25 069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour. Main outcome measures The relative risk of early maternal morbidity, postpartum haemorrhage (PPH) and postpartum infection, and neonatal morbidity, as judged by low Apgar scores or admission to the special care baby unit (SCBU), in relation to anthropomorphic characteristics (parity and birthweight), interventions (epidural analgesia, episiotomy and operative delivery), signs of fetal compromise (meconium staining of the amniotic fluid or abnormal cardiotocography (CTG)), maternal morbidity in labour (pyrexia) and the duration of the second stage of labour. Results The duration of the second stage of labour had a significant independent association with the risk of both PPH and maternal infection after adjustment for other factors. However, there was a similar or greater risk of PPH in association with operative delivery or a birthweight greater than 4000 g. Both maternal pyrexia in labour and primiparity were associated with a greater risk of post partum maternal infection than was the duration of the second stage, although all these factors were statistically significant. In contrast, the duration of the second stage was not significantly associated with the risk of a low Apgar score or admission to SCBU after adjustment for other factors. Conclusions The duration of the second stage of labour has a positive independent association with early maternal morbidity. We could show no such relation between time spent in the second stage of labour and the frequency of low Apgar scores or the rate of admission to SCBU. With current management approaches, in the absence of factors suggesting fetal compromise, second stage labours of up to 3 h duration do not seem to carry undue risk to the fetus.
Article
Objective: This study was undertaken to determine whether a policy of delayed pushing for nulliparous women with continuous-infusion epidural analgesia reduces the risk of difficult delivery (cesarean delivery, operative delivery from a midpelvic position, low-pelvic procedures with rotation >45°). Study Design: In this multicenter, randomized, controlled trial women in the delayed pushing group (n = 936) were advised to wait ≥2 hours after full dilatation before commencement of pushing. Women in the early pushing group (n = 926) were advised to commence pushing as soon as they had been randomly assigned. Results: Difficult delivery was reduced with delayed pushing (relative risk, 0.79; 95% confidence interval, 0.66-0.95). The greatest effect was on midpelvic procedures (relative risk, 0.72; 95% confidence interval, 0.55-0.93). Although there was little evidence for an effect on low-pelvic procedures, spontaneous delivery was more frequent among women who practiced delayed pushing (relative risk, 1.09; 95% confidence interval, 1.00-1.18). Abnormal umbilical cord blood pH (
The advantages of an upright position during labor are presented, with historic, physiologic, and psychosocial aspects discussed. The influences of modern obstetric practices such as electronic fetal monitoring and anesthesia practices are discussed with findings related to the use of upright positions from the Association of Women's Health, Obstetric, and Neonatal Nursing National Research Utilization Project on Second Stage Labor Management integrated. Recommendations for facilitating upright positions on the labor and delivery unit are presented.
Article
It has become custom and practice within the midwifery and obstetric professions in the English-speaking western world for women to be required to follow very specific instructions on how to push in the second stage of labour There is very little literature on the behaviour of women using spontaneous pushing in the second stage of labour In a pilot study of a randomized controlled trial comparing spontaneous (n= 15) with directed (n= 17) pushing, the behaviour of the women was observed and recorded The findings from the observational part of the study are reported in this paper When pushing spontaneously women do not instinctively take a deep breath, they do not start expulsive effort with the commencement of the contraction, and they use both open and closed glottis pushing In order to assist women in the second stage of labour, those caring for them should be aware of what is normal behaviour when women are using spontaneous expulsive effort
A series of descriptive studies was carried out to 1) characterize maternal respiration, type of bearing-down efforts, vocalization, and behavior; 2) describe the obstetric conditions and intrauterine pressure associated with the bearing-down reflex; and 3) describe the duration of second stage, fetal heart rate, and neonatal outcomes when women bear down spontaneously. Thirty-one healthy nulliparous women who had received no formal childbirth education were neither directed nor instructed to bear down with contractions. The women were supported in their involuntary bearing-down efforts throughout the second stage of their labors while the above features of their labor were recorded. The findings suggest that labor progress is adequate and fetal outcome is good when the management of the expulsion phase of labor encourages maternal pushing that is complementary with the involuntary bearing-down reflex rather than sustained breath-holding. These findings support the necessity for further research regarding the bearing-down techniques used during labor.
The process of implementing a research-based protocol (the Second Stage Labor Nursing Management) at 40 sites in North America is described. Both positive and negative factors involved in implementing and adhering to the protocol are presented based on the reports of site coordinators. Key findings from the process data are: (a) the term “research utilization” causes confusion, (b) it is essential that nurses collaborate with other disciplines when attempting to change practice, (c) administrative endorsement of research utilization is important for practice change to occur, (d) nurses know their own practice sites and how to facilitate protocol acceptance, and (e) practice change may not need to occur all at once.
Article
Twenty women were selected from public and private maternity services and interviewed by nurses and nurse-midwives on a research team. The women were shown videotapes of their second-stage labors that for 15 of them had been recorded by 2 other members of the research team. Four videos were provided by mothers who had had home births and one from a mother whose birth was filmed at a birth center. The interviews were analyzed for major themes; the theme reported here is women's experiences of pushing. Women reported wide variations in sensations during the second stage. Whereas 9 of 16 women expressed feelings of relief or pressure and stretching, 7 described pushing as painful, miserable, or horrible. Thirteen of 19 women had well defined urges to push, 1 had an intermittent urge, and 5 had no urge. Women often felt unprepared for the sensations and work of second-stage labor, and caregivers' instructions commonly did not seem to be in synchrony with physiological responses. We conclude that childbirth educators and caregivers must prepare women more realistically for the second stage. They would be more effective if they responded to maternal behavior, rather than giving arbitrary instructions about pushing.
Article
Epidural analgesia provides effective pain relief for women during labor. However, like all medical interventions, it also has potential side effects such as longer labor and a higher rate of intrapartum fever and operative vaginal delivery. A recent meta-analysis of randomized studies by Halpern et al concluded there was no association between epidural use and cesarean delivery.A critique of that meta-analysis, included in this paper, concludes that there are currently insufficient data to determine whether epidural analgesia leads to increased rates of cesarean delivery. This paper also presents results from several recent studies related to epidural analgesia conducted at Brigham and Women's Hospital in Boston. One study demonstrates a significant influence of prenatal planning on use of epidural during labor. Additional studies examine the strong association of epidural analgesia with intrapartum fever and the consequences of that fever for mother and infant.Epidural analgesia should remain an option available to women during labor. A more complete understanding of the risks and benefits that accompany its use is essential so that women and their care providers can make informed choices about pain relief during labor. J Nurse Midwifery 1999;44:394–8 © 1999 by the American College of Nurse-Midwives.
Article
Objective To test the hypothesis that a policy of delaying active pushing in nulliparous women with epidural analgesia in labour reduces operative vaginal deliveries. Design A randomised controlled trial. Setting The delivery suite at Leeds General Infirmary. Sample One hundred and thirty-five nulliparous women with an effective epidural in labour. Methods The women were randomised to early pushing (commencement of pushing within one hour of the diagnosis of full dilatation) or delayed pushing (delaying pushing for a maximum of three hours from the time of diagnosis of full dilatation, unless the vertex was visible at the introitus sooner). epidural analgesia in labour reduces operative vaginal deliveries. Main outcome measure Rate of instrumental vaginal delivery. Results There was a nonsignificantly increased rate of instrumental vaginal delivery with early pushing (odds ratio 1.31,95% CI 0.62–2.78). No adverse effects were noted. Conclusion Although delayed pushing was associated with fewer instrumental vaginal deliveries, the size of the effect may have occurred by chance and the evidence does not, at present, justify a general recommendation towards either early or delayed pushing.
Article
To investigate the relation between the duration of the second stage of labour and subsequent early neonatal and maternal morbidity. Retrospective analysis of a regional obstetric database. 17 maternity units in the North West Thames Health Region. Selected from 36,727 consecutive singleton deliveries in 1988. The analysis was confined to the 25,069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour. The relative risk of early maternal morbidity, postpartum haemorrhage (PPH) and postpartum infection, and neonatal morbidity, as judged by low Apgar scores or admission to the special care baby unit (SCBU), in relation to anthropomorphic characteristics (parity and birthweight), interventions (epidural analgesia, episiotomy and operative delivery), signs of fetal compromise (meconium staining of the amniotic fluid or abnormal cardiotocography (CTG)), maternal morbidity in labour (pyrexia) and the duration of the second stage of labour. The duration of the second stage of labour had a significant independent association with the risk of both PPH and maternal infection after adjustment for other factors. However, there was a similar or greater risk of PPH in association with operative delivery or a birthweight greater than 4000 g. Both maternal pyrexia in labour and primiparity were associated with a greater risk of post partum maternal infection than was the duration of the second stage, although all these factors were statistically significant. In contrast, the duration of the second stage was not significantly associated with the risk of a low Apgar score or admission to SCBU after adjustment for other factors. The duration of the second stage of labour has a positive independent association with early maternal morbidity. We could show no such relation between time spent in the second stage of labour and the frequency of low Apgar scores or the rate of admission to SCBU. With current management approaches, in the absence of factors suggesting fetal compromise, second stage labours of up to 3 h duration do not seem to carry undue risk to the fetus.
Article
In recent years, the second stage of labor has become an area of interest to a number of observers who have described divisions or phases with behavioral characteristics. Using a descriptive case study design, four normal nulliparous women in spontaneous second stage labor were videotaped from the occurrence of involuntary bearing-down efforts or the recognition of complete cervical dilation until birth. Analysis of these videotapes, the accompanying narrative transcripts, and uterine monitor tracings provided evidence that some behaviors changed over the progression of the second stage. These changes could be divided into three behavioral phases that the nurse/midwife can identify in order to recognize the typical pattern of progression and possible deviations from normal.
Article
To determine whether nulliparae whose second stage of labour is conducted in an obstetric birth chair have a lower incidence of instrumental delivery than those using a conventional delivery bed. Randomized controlled trial using sealed, opaque envelopes for allocation. Delivery ward in a busy teaching hospital. 1250 nulliparae with a singleton live fetus with cephalic presentation, without epidural anaesthesia, who had achieved full dilatation. Intention to conduct second and third stages of labour in either the Birth-EZ chair or the conventional delivery bed, as randomly allocated. Primary measure: vaginal operative delivery; principal secondary measures: duration of second stage, perineal trauma, blood loss, women's views, and neonatal status. Delivery in the birth chair did not result in a reduction in operative delivery, overall. However, there was a reduction in vaginal operative delivery for fetal heart rate abnormality. There was no beneficial effect on perineal trauma or puerperal perineal pain. Post-partum haemorrhage was more frequent in the birth chair group. Delivery in the birth chair does not offer any obvious advantage to women over delivery on a bed.
Article
A study to evaluate the relationship between maternal birthing position and perineal outcome was undertaken on 335 patients in a rural family physician's practice whose babies were delivered vaginally between December 1980 and December 1988. The most common birthing position used by the women was the semi-sitting position in the birthing bed (44%, n = 146). Ninety-four women (28%) gave birth from the conventional lithotomy position, 80 (24%) used the birthing chair, and less than 5% used a side-lying position. Almost 30% of the women gave birth with intact perineum; the incidence of episiotomy was 44%. The use of a particular position for delivery varied with parity, and multiparous women used the semi-sitting position in the birthing bed more frequently than did primiparous women. There was no statistically significant relationship between birthing position and perineal outcome for primiparous women. A statistically significant relationship between delivery position and perineal outcome was found for multiparous women. Multiparous women using the birthing bed were more likely to have less perineal trauma than women giving birth on the delivery table.
Article
A seasoned nurse-midwife shares her experience identifying and managing potentially serious fetal heart changes during the crucial second stage of labor.
Article
In 228 patients, fetal blood pH, pCO2 and lactic acid were measured in two distinguishable parts of the second stage of labor. The 'first' part begins at full cervical dilatation and ends when the mother starts her first voluntary bearing down efforts. In our study, the fetal acid-base status did not change in this part, regardless of a late developing hypoxia. In contrast, higher levels of lactic acid and pCO2 and lower pH values were observed in the 'final' part of the second stage, indicating increasing acidosis. In this 'final' part, the fetuses with clinical signs of distress, as defined by an ominous Apgar score at birth, showed quicker and larger acid-base shifts than did the normal fetuses. Thus the two parts of the second stage of labor actually differ in their potential to stimulate fetal acidosis. Since such fetal acidosis may develop especially during the 'final' part of labor, we have concluded that special particular attention should be devoted to this part.
Article
An observational study was done on the positions and breathing techniques women will choose for second-stage labor when they are given the freedom and support to choose. In the 50 second stages and births observed, nine different positions were used in conjunction with three variations of expulsive breathing techniques. No adverse outcomes resulted from the nonprescriptive approach to birthing women. All outcome parameters were found to be within the range of normal. These findings support the acceptability of allowing women to respond to their birthing impulses. Further study is recommended to verify the safety of a nondirective approach to birth.
Article
A series of descriptive studies was carried out to characterize maternal respiration, type of bearing-down efforts, vocalization, and behavior; describe the obstetric conditions and intrauterine pressure associated with the bearing-down reflex; and describe the duration of second stage, fetal heart rate, and neonatal outcomes when women bear down spontaneously. Thirty-one healthy nulliparous women who had received no formal childbirth education were neither directed nor instructed to bear down with contractions. The women were supported in their involuntary bearing-down efforts throughout the second stage of their labors while the above features of their labor were recorded. The findings suggest that labor progress is adequate and fetal outcome is good when the management of the expulsion phase of labor encourages maternal pushing that is complementary with the involuntary bearing-down reflex rather than sustained breath-holding. These findings support the necessity for further research regarding the bearing-down techniques used during labor.
Article
The duration of second stage labour was studied, retrospectively, among 410 primigravidas who received epidural analgesia in the first stage of spontaneous labour at term (greater than 37 weeks). Survival analysis was used to investigate how the likelihood of a spontaneous delivery was related to time spent in the second stage, and how some maternal and fetal factors influenced this relationship. The proportion of spontaneous deliveries that had occurred by any given time was greatly influenced by maternal age and infant birthweight. However, the women who were least likely to have been delivered by any given time after full dilatation, were also the ones who were least likely to be delivered within any given subsequent time interval. If delivery had not occurred by 3 h, the probability that it would take place in the next 3 h was well under 30% in most cases. We conclude that second stage labour in excess of 3 h is likely to be beneficial only if certain criteria, which are defined in the paper, are met.
Article
This pilot study focuses on the bearing-down phenomenon of the second stage of labor, within the theoretical framework of Levine's conservation principles for nursing practice. The purpose of this study is to contrast the effects of two learned approaches to parturient participation during the second stage of labor. A control group (n = 5) was taught the traditional approach to second stage bearing-down efforts: sustained breath-holding. An experimental group (n = 5) was taught to bear-down only with the involuntary urge. No differences were found in the mean duration of the second stage, phases within second stage, Apgar scores, or matemal report of effort. Perineal integrity was preserved in the experimental group. These findings suggest that involuntary bearing-down efforts are accompanied by adequate labor progress and result in less perineal trauma. Further examination of the common practice of encouraging women to bear down strenuously during the second stage, instead of responding to their involuntary urge, is recommended.
Article
The data from 847 births from a home birth practice where six different positions were used for delivery permitted the analysis of the effect of maternal position on perineal outcome. The obstetrical log also permitted the identification of other factors that influenced maternal position and perineal outcome. The most frequently used birth position was semisitting, in 83% of the births. The incidence of episiotomy was 7%, and of lacerations, 55%. Factors significantly associated with maternal position were fetal presentation (breech) and birth attendant. Fetal position or presentation, infant weight, parity, and the birth attendant were significantly associated with perineal outcome. The predominant use of the semisitting position may explain why there was no association between maternal position and perineal outcome. The influence of the birth attendant on both these factors suggests the impact of attitudes, skill, or ease in assisting the birth on these aspects of obstetrical practice.
Article
The objectives of this study were to (a) determine if a safe, simple, and economic nursing procedure--maternal posturing--would result in the rotation of a fetus in the posterior or transverse position to the optimal anterior position and (b) evaluate the relative effectiveness of a series of maternal postures for facilitating anterior fetal rotation. One hundred healthy women at term pregnancy were randomly assigned to four treatment and one control posture for a 10-minute period. At two nurse-midwifery clinics, one certified nurse-midwife postured the subjects and one midwife measured the dependent variable (fetal position) with Leopold's maneuvers. Hypotheses I-IV, which predicted that the four rotation postures would have a greater proportion of anterior fetal rotations than the control posture, were supported (p less than .000). Essentially all four postures were effective and there was little difference between the treatment postures. A second posturing was performed to determine if an additional 10 minutes in a treatment posture would result in an anterior fetal position. There was a greater proportion of anterior fetal rotations with the four rotation postures than the control posture. The Sims posture was used as a maintenance posture for anterior positions, and was successful when done on the opposite side of the fetal back. The theoretical explication of how maternal postures effect fetal rotation remains sound.
Article
Two groups of parturients who had received selective extradural analgesia were studied. In Group A patients the regional block was allowed to wear off for the second stage of labour whereas in Group B patients' analgesia was maintained throughout labour. The maintenance of selective analgesia was of positive benefit to the mothers. They experienced much less pain, labour was not prolonged, dosage of bupivacaine was not increased, the forceps delivery rate was lower and there were fewer persistent malrotations.
Article
The effect of epidural analgesia on oxytocin release during the second stage of normal labour was studied by comparing 10 primigravidae who had epidurals with 10 control subjects who did not have epidurals. A significant increment in oxytocin between paired peripheral blood samples taken at the onset of full cervical dilatation and crowning of the fetal head was found in the control subjects but not in those with epidurals. Forceps delivery was required more often in the group with epidural analgesia and was associated with lower oxytocin levels at crowning. Since distension of the lower birth canal and stimulation of pelvic autonomic nerves leads to oxytocin release, and the need for forceps associated with epidurals can be reduced by oxytocin, these differences are attributed to the lumbar epidural block.
Article
The second stage of labor has been thought of as a time of particular asphyxial risk for the fetus. This perceived risk has been invoked to justify arbitrary time limits and high rates of operative vaginal delivery. The purpose of this study was to determine whether perinatal outcome worsened as the second stage lengthened. Over a 5-year period at one university teaching hospital, 6041 nulliparous women reached the second stage of labor with a live singleton cephalic fetus with birth weight > or = 2500 gm. A retrospective review of perinatal morbidity and mortality was performed and the results related to the duration of the second stage. The second stage lasted > 3 hours in 11% of nulliparous women and > 5 hours in 2.7%. There were no perinatals death unrelated to anomaly. There was no significant relationship between second-stage duration and low 5-minute Apgar score, neonatal seizures, or admission to the neonatal intensive care unit. Operative intervention in the second stage is not warranted merely because some set number of hours has elapsed.
Article
Evidence about the effects of care practices is not a sufficient guide to the most appropriate care. Those who provide care, who receive care, who advocate care, or who pay for care must choose on the basis of many factors: personal experience, personal preference, personal values, availability of resources and facilities, and a myriad of other considerations, among which knowledge of the effects of care is certainly important. This knowledge is essential for choices to be properly informed. The most reliable evidence about the effects of care is provided by randomized controlled trials. Unfortunately, this evidence is not readily accessible. It is scattered through a large number of journals throughout the world, and is hidden among a mass of weak, inadequate, and sometimes frankly misleading studies. Those who wish to use all the valid evidence must rely on properly prepared, up-to-date, systematic reviews. The Cochrane Collaboration has taken on the task of preparing, maintaining, and disseminating reviews of randomized trials of health care, published electronically as the Cochrane Database of Systematic Reviews. The reviews are provided by a number of Collaborative Review Groups, and the Cochrane Pregnancy and Childbirth Database is the first specialty database to appear. It is regularly updated to incorporate data that have become available since the previous issue.
Article
A cohort study was designed to assess the effects of maternal squatting position for the second stage of labor on the evolution and progress of labor, and on maternal and fetal well-being. Outcomes from 200 squatting births, randomly selected from a sample of 1000, were compared with 100 semirecumbent births, randomly selected from a sample of 300. Data collection was by chart review. The two groups were similar with respect to most antepartal, intrapartal, and socioeconomic variables likely to affect labor outcomes. The mean length of the second stage of labor was 23 minutes shorter in squatting primiparas and 13 minutes shorter in squatting multiparas than in semirecumbent women. Squatting women required significantly less labor stimulation by oxytocin during second stage (P = 0.0016), and they showed a trend toward fewer mechanically assisted deliveries. Significantly fewer and less severe perineal lacerations occurred, and fewer episiotomies were performed in the squatting group (P = 0.0001). No statistically significant differences were found between groups for third-stage complications and infant complications.
Article
Pushing in the second stage of labor can be forced or follow the spontaneous urge to bear down. Recent studies have shown that spontaneous pushing results in a longer second stage, fewer CTG changes, higher arterial pH and less damage to the birth canal. Randomized trial of spontaneous vs. forced pushing in 350 primiparous women. There was no difference between the randomized groups in duration of second stage of labor, umbilical arterial pH or damage to the birth canal. Of the women allotted to spontaneous pushing, 65.6% used the closed glottis technique for more than half the expulsive phase. When dividing the women into two groups according to the actual pushing technique used most, open or closed glottis, it turned out that women who used the open glottis technique had a shorter second stage of labor and gave birth to infants with lower birth weight. Recommending of spontaneous bearing down during the expulsive phase of labor did not result in a significant difference in duration of the second stage of labor, fetal arterial pH or less damage to the birth canal. Women who chose the open glottis technique had a shorter expulsive phase and gave birth to smaller infants than those who used the closed glottis technique.
Article
It is routine to require women to 'take a deep breath in, hold it and push' in the second stage of labour, but there is no scientific evidence to support this practice. In a randomized controlled trial of spontaneous (n = 15) versus directed (n = 17) pushing in the second stage, no adverse effects of spontaneous pushing on the woman or baby were found. There was a negative correlation between the length of the second stage and the venous cord blood pH at delivery in the directed pushing group, suggesting that a long second stage was disadvantageous to the fetus when the woman was using a directed pushing technique. No such association was found in the spontaneous pushing group, despite the fact that the women in this group had a significantly longer mean second stage.
Article
Some practices and procedures that are common during the management of childbirth lack proof of efficacy, and some have adverse effects. The practice of withholding food and liquids and using intravenous fluids during labor may pose risks such as fluid overload, and maternal and fetal hyperglycemia. Enemas should be reserved for women with painful constipation. Evidence does not support the value of shaving the perineal area. Nonpharmacologic measures to control pain during labor are safe and moderately effective. Pharmacologic methods of analgesia and anesthesia provide good pain relief but pose significant risks. Continuous electronic fetal monitoring should be considered a diagnostic procedure, not a screening procedure. Amniotomy may shorten labor but can result in abnormally high uterine forces, infection, umbilical cord prolapse and fetal laceration. Position changes and alternative birth positions promote greater comfort and efficiency during labor. Finally, episiotomy has not been shown to reduce severe lacerations or prevent pelvic relaxation, and use of this procedure should be limited.
Article
To measure the length of active labor (first and second stages) in a low-risk population of non-Hispanic white, Hispanic, and American Indian women, and to identify any differences among these ethnic populations. Descriptive statistics are presented for 1473 low-risk women at term who delivered at the University of New Mexico Hospital. Data examined by ethnicity included demographics, intrapartum care and complications, and duration of the active-phase first stage (4 cm to complete cervical dilatation) and second stage (complete cervical dilatation to delivery) of labor. Compared with Friedman's criteria, 20% of these low-risk women had a prolonged active phase of the first stage, and 4% had a prolonged second stage, without excess maternal or infant morbidity. The mean length of active-phase, first-stage labor was 7.7 hours for nulliparas and 5.7 hours for multiparas (statistical limits 19.4 and 13.7 hours, respectively), with no differences according to ethnic group. The mean length of second stage was 53 minutes for nulliparas and 17 minutes for multiparas (statistical limits 147 and 57 minutes, respectively). American Indian nulliparas had significantly shorter second stages than non-Hispanic white women (P < .05). Active labor in healthy women lasted longer than is widely appreciated. Upward revision of clinical expectations for the length of active labor is warranted.
Article
It has become custom and practice within the midwifery and obstetric professions in the English-speaking western world for women to be required to follow very specific instructions on how to push in the second stage of labour. There is very little literature on the behaviour of women using spontaneous pushing in the second stage of labour. In a pilot study of a randomized controlled trial comparing spontaneous (n = 15) with directed (n = 17) pushing, the behaviour of the women was observed and recorded. The findings from the observational part of the study are reported in this paper. When pushing spontaneously women do not instinctively take a deep breath, they do not start expulsive effort with the commencement of the contraction, and they use both open and closed glottis pushing. In order to assist women in the second stage of labour, those caring for them should be aware of what is normal behaviour when women are using spontaneous expulsive effort.
Article
To review the literature regarding the effects of childbirth on the muscles, nerves, and connective tissue of the pelvic floor, review the evidence to support an association between childbirth and anal incontinence, urinary incontinence, and pelvic organ prolapse; and present recommendations for the prevention of these sequelae. Sources were identified from a MEDLINE search of English-language articles published from 1984 to 1995. Additional sources were identified from references cited in relevant research articles. We studied articles on the following topics: anatomy of the pelvic floor association of childbirth with neuromuscular injury, biomechanical and morphologic alterations in muscle function, and connective tissue structure and function; the long-term effects of childbirth on continence and pelvic organ support; and the effects of obstetric interventions on the pelvic floor. Articles were reviewed and summarized. An overview of the structure and function of the pelvic floor was developed to provide a context for subsequent data. Childbirth was found to be associated with a variety of muscular and neuromuscular injuries of the pelvic floor that are linked to the development of anal incontinence, urinary incontinence, and pelvic organ prolapse. Risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size. Cesarean delivery appears to be protective, especially if the patient does not labor before delivery. The pelvic floor plays an important role in continence and pelvic organ support. Obstetricians may be able to reduce pelvic floor injuries by minimizing forceps deliveries and episiotomies, by allowing passive descent in the second stage, and by selectively recommending elective cesarean delivery.
Article
This article focuses on the primary clinical issues during the second stage of labor: diagnosis, duration, maternal bearing-down efforts, and fetal descent, and ways to help women with their expulsive efforts during this time. A pattern of progression for the second stage/expulsive phase of labor is presented, with an emphasis on the importance of delaying direction to or encouragement of the woman to push until the obstetric conditions are optimal for descent and the women has entered the active phase of the second stage. Ongoing assessment of fetal status and descent, the quality of uterine contractions, and maternal condition are emphasized, rather than arbitrary time limits for the second stage. The use of various care practices, including maternal position and alternative bearing-down techniques, which optimize maternal and fetal outcomes, is described. Finally, women's concerns about this major life experience are considered in the context of the care that they receive during the second stage of labor.
Article
To assess the maternal and neonatal effects of upright compared with recumbent positions during delivery, in terms of defined outcome variables. A randomised controlled trial. St Monica's Nursing Home, a midwife based maternity unit in Cape Town, South Africa. Five hundred and seventeen women of low obstetrical risk assigned to deliver at the nursing home. The trial showed that women who adopted the upright posture for delivery experienced less pain. perineal trauma and fewer episiotomies than those who delivered in the supine position. The data suggest that in women of low obstetrical risk, choice of posture during delivery may be encouraged.
Article
Forms of social interaction may occur among the participants in medicalized births, in which a woman in labor is experiencing strong involuntary urges to push but has not yet been found to have a completely dilated cervix. This article examines the social events and communications that occur at the change between first and second stages of labor. Three cases are described from videotapes of women in the second stage of labor and their caregivers. Several social and interactive features occurred, in which (1) the caregiver, usually a nurse, by invoking the "no pushing rule," insisted that the woman suppress her involuntary urges to push; (2) both the caregiver and the parturient displayed an orientation toward the future and the eventual certification of full cervical dilation by a designated authority, usually a physician, regardless of the actual state of the woman's cervix or her involuntary urges to push; and (3) the certification process marked a ritual transition to "official" second stage labor, in which the woman's involuntary urges were considered appropriate and actively encouraged. A discrepancy between a laboring woman's sensations and caregivers' ideas about how labor should be conducted has implications for clinical care of women, wherein the goal should be to facilitate the woman's accomplishment rather than to direct the "delivery."
Article
Epidural anesthesia is used for relief of labor pain by 29% of women having hospital deliveries in the United States, a number that has doubled within the past 10 years. Although epidurals provide objective pain relief that is exponentially better than the other pain relief methods, there are many purported complications and side effects. This article reviews how epidurals work, summarizes the literature regarding complications, and presents some of the ethical dilemmas inherent in the use of this technology for labor.
Article
The advantages of an upright position during labor are presented, with historic, physiologic, and psychosocial aspects discussed. The influences of modern obstetric practices such as electronic fetal monitoring and anesthesia practices are discussed with findings related to the use of upright positions from the Association of Women's Health, Obstetric, and Neonatal Nursing National Research Utilization Project on Second Stage Labor Management integrated. Recommendations for facilitating upright positions on the labor and delivery unit are presented.
Article
The lack of support for spontaneous bearing down versus directed pushing efforts, varying opinions on the determination of readiness for pushing, and the prevailing use of prolonged breath holding associated with pushing during labor are aspects of second-stage labor management that continue to be areas of contention among physicians and nurses. A discussion of current practice outcomes surrounding these controversies from the AWHONN Second Stage Labor Research Utilization Project conducted in 1994-1995 is presented in view of the available research literature. In addition, recommendations for future nursing research are identified.
Article
The background and development of the second National AWHONN Research Utilization Project on Second Stage Labor Management that was conducted in multiple sites within the United States and Canada are presented. On the basis of the results of the project, recommendations for designing other research utilization projects are discussed.
Article
This, the second of a two-part article, describes the findings of a national survey of practicing certified nurse-midwives (CNMs) regarding factors that affect the use of eight second-stage maternal positions. Lower CNM self-reported autonomy scores were associated with the use of the lithotomy and dorsal supine positions; maternal preference and higher CNM self-reported autonomy scores were associated with the use of the nonlithotomy positions. The use of nonlithotomy positions is one nontechnologic way to enhance the normal process of birth.