Article

When will we change practice and stop directing pushing in labour?

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Abstract

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.

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... 10,11 Common interventions include administration of oxytocin, artificial rupture of membranes, and directed forceful pushing. [18][19][20] These interventions can have devastating effects including, but not limited to, fetal acidosis, premature separation of the placenta, hemorrhage, extensive damage to maternal perineal tissues, impaired long-term mental health, and fetal or maternal adverse outcomes. [21][22][23] Paradoxically, and despite the associated risks, many of these interventions are reported as unnecessary in retrospect; for example, Swedish studies have found labor augmentation with oxytocic agents to be unjustified in 43% to 66% of cases. ...
Article
Objective: In this scoping review, contemporary concepts and definitions of phenomena during normal labor and birth, wherein the process appears to plateau (slow, stall, or pause) but remains within physiological limits, will be mapped. Introduction: During labor and birth, it is frequently perceived as pathological if contractions, cervical dilation, or fetal descent plateau. However, there is evidence to suggest that some plateaus during labor may be physiological, and a variety of concepts and terms refer to this phenomenon. Where a physiological plateau is perceived as pathological arrest, this may contribute to undue interventions, such as augmentation of labor. Therefore, it is important to advance understanding of physiological labor patterns, including potentially physiological labor plateaus. Inclusion criteria: Publications mentioning any plateaus of the processes of normal human labor and birth will be considered. This may also include phenomena where labor is perceived to "reverse," for example, a closing cervix or a rise of the presenting fetal part. Publications where plateaus are defined as pathological will be excluded. Methods: All types of evidence, published and unpublished, will be considered. The search strategy will be applied to the databases MEDLINE, Embase, MIDIRS, Emcare, CINAHL, and Scopus, and will be limited to the past 30 years. Gray literature will be searched via Open Grey, reference list screening, and contacting authors. Data extraction will comprise information on concept boundaries, terminology, precedents, consequences, concept origin, and types of evidence that report this phenomenon. Results will be presented in tabular, diagrammatical, and narrative manner.
... It describes the process of pushing whilst breath holding (Downe, 2009) and is usually performed under direction from a midwife and/or obstetrician and because of this is often referred to as directive pushing. The origins of this manoeuvre has been traced to the obstetrician Mauriceau's textbook of 1678 and its use, when combined with a semi recumbent bed posture, has been challenged and debated for decades (Caldeyro-Barcia et al, 1981;Petersen and Besuner, 1997;Perez-Botella and Downe, 2006;Cooke, 2010). ...
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.
... However, the greater experience was a mixture of both (n = 158; 48%). With hindsight the option of only two categories (directed and spontaneous) would have been preferable, as it would have precluded a third interpretation of pushing which has limited the value of this finding (Hollins Martin, 2009;Cooke, 2010). Students are exposed to more 'hands on' the perineum than 'hands poised' in normal vaginal births, a pattern of normative practice which has been recognized by researchers (Stapleton et al, 2002). ...
Article
All midwifery students must provide evidence of attending 40 women in labour and birth. The shortened midwifery programme at the University of Stirling's Highland Campus in Inverness, which completed in 2010, required this care to be logged by the student on a specifically designed intrapartum template which was signed by the student's mentor. This article presents an audit of the completed intrapartum templates of the care recorded for low- and high-risk women. A review of both individual and collective student experience identified that students may have no experience in specific areas such as non-directed pushing and physiological third stage. In this audit student midwives cared for many more high-risk women than low-risk women in labour. Therefore, midwife educators, students and mentors should examine in detail the experience of all students to highlight any apparent deficits in their skills in order to ensure they are prepared for contemporary midwifery practice.
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
This is the second of two articles looking at cultural change in maternity services using Johnson's cultural web model (1992). Part one explored and explained the model in terms of the dominant cultural paradigm, and its analysis and potential for change (Freemantle, 2013). This article demonstrates the application of the cultural web model to maternity services and its potential impact on women-centred care—specifically labour ward culture. A cultural web is developed and summarised before using the model to consider change and identify a desired culture that aligns with the Chief Nursing Officer's (CNO) ‘6 Cs’ vision for nursing and midwifery care (Department of Health (DH), 2012), the Safer Childbirth report (Royal College of Obstetricians and Gynaecologists (RCOG) et al, 2007) and Maternity Matters (DH, 2007). For demonstration purposes, the change focus or problems are continued use of outdated, entrenched labour ward practices around the second stage of labour, which conflict with National Institute for Health and Care Excellence (NICE) (2007) best practice guidance and may well diminish or deny the opportunity for normal birth (Williams, 2007). It recognises the fundamental part midwives and midwifery leadership plays in shaping and changing the culture of care, with particular reference to Supervisors of Midwives (SoM). Consequently, this model has the potential for widespread application throughout maternity services by improving efficiency, effectiveness and the environment of care.
Article
The following article considers the possibility of redefining the second stage of labour to place the emphasis on descent rather than dilatation. The idea for this was triggered when the author attending the Jean Sutton's Optimal Fetal Positioning study day. The article suggests that the new definition for 2nd stage would be ‘From when the presenting part has passed through the cervix and is therefore below the ischial spines, to the baby being born’. It discusses the current problems seen in labour – that of a mother pushing too early and the delaying tactics used by midwives – and how the new definition would help to overcome these issues> It also incorporates the two other stages often seen in labour; ‘transition’ stage and the ‘rest and be thankful stage’, offering an order in which these stages could work with the new definition.
Article
To test the hypothesis that long, hard Valsalva pushing during second stage labor may increase fetal acidosis and decrease neonatal Apgar scores, ten women with normal pregnancies and first stage labors were randomly assigned to a long Valsalva pushing group or a short, open glottis pushing group. Neonatal outcomes were measured by umbilical vessel blood gasses. Open glottis pushers showed a non-significant trend toward longer second stage labors and higher umbilical artery pH. Umbilical vein pH was significantly higher among open glottis pushers. Long Valsalva pushers had less frequent expulsive contractions. Whether women use long Valsalva or open glottis pushes may be only one of several factors which affect neonatal outcome, including not only the length and force of the push but also the condition of the fetus at the onset of pushing, the frequency and length of contractions during second stage, and the speed of delivery after crowning of the fetal head.
Article
Objective. While obstetrical management has changed significantly over years, the optimal duration of the second stage of labor still remains to be defined. The purpose of this study was to evaluate the effect of the duration of labor on fetal distress and maternal perinatal morbidity. Methods. There were 1457 consecutive patients delivered of a singleton fetus in cephalic presentation beyond the 34th week of gestation at the I. Frauenklinik, Ludwig-Maximilians University, Munich between May 1999 and June 2000. The 257 patients (17.6%), who underwent cesarean section prior to or during labor, were excluded from the study. Of the 1200 vaginal deliveries, 1017 (84.8%) were normal spontaneous deliveries, while 183 (15.2%) were instrumentally assisted. Data were contemporaneously collected and analyzed for the presence of severe pelvic floor damage, maternal hemorrhage, maternal fever, delayed involution of the uterus, fetal acidosis and APGAR score, and the necessity for admitting the newborn to the intensive care unit (NICU). A second stage duration of > 2 hr was considered to be prolonged. Results. The mean duration of the second stage of labor was 70 min (range 2–387, SD 73 min). For 952 patients (79.3%), the second stage was less than 2 h. For 47 patients (3.9%), it exceeded 4 h. A prolonged duration of the second stage was not associated with low Apgar scores 5 and 10 min postpartum (P = 0.76 and P = 0.38, respectively), a higher incidence of umbilical artery pH levels of < 7.20 (P = 0.60), nor with an increased rate of admission to the NICU (P = 0.24). A significant increase in the rate of maternal blood loss was noted after long second stages (1.84 g/dl median difference between the intrapartum and postpartum hemoglobin level) in comparison to patients with normal duration of second stage (0.79 g/dl), both by univariate (P < 0.0001) and multivariate (P < 0.001) analysis. The incidence of third degree anal sphincter tears was significantly correlated with a prolonged duration of second stage in univariate analysis (7.7%, P = 0.001), but not in multivariate analysis after allowing for duration of the second stage, maternal age, birth weight, episiotomy, and mode of delivery (P = 0.26). Conclusion. There is no evidence that prolonged second stage of labor is a serious disadvantage to the fetus, if adequate monitoring is provided. Because the increase of maternal morbidity in patients with prolonged labor may be partially attributed to a higher rate of operative procedures in these patients, interventions should not be solely based on the elapsed time after full cervical dilatation.
Article
Fetal heart rate patterns, and intrauterine and maternal blood pressures were recorded during various types of maternal bearing-down efforts. Bearing-down efforts which lasted more than 5 seconds resulted in late decelerations of the fetal heart rate, marked falls in the maternal systolic and diastolic blood pressures and resultant delayed recovery of the fetal heart rate, with fetal hypoxia and acidosis in some cases. When women are not urged to bear down long and hard, their spontaneous efforts are usually within physiologic limits-5–6 seconds long-and fetal acidosis is thereby avoided.
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
This study was conducted to compare two types of maternal bearing-down techniques as they relate to the fetal and maternal outcomes of arterial umbilical cord blood pH and length of the second stage of labor. A convenience sample was drawn from the laboring women at a 305-bed medical center who met specific inclusion criteria. Women self-selected to one of two bearing-down groups: spontaneous or Valsalva. Subjects were given specific instructions for the chosen method. The Valsalva group was comprised of 14 subjects, and the spontaneous group was comprised of 16 subjects. The groups were found to be comparable after analysis of several variables. Results of statistical analysis using t-test indicated that, in this small sample, there is no relationship between the second stage bearing-down method and arterial umbilical cord blood pH or length of the second stage of labor. These findings support the conclusions of several studies: using the spontaneous bearing-down method does not have a deleterious effect upon the mother or the fetus. Several recommendations are made for future research based on methodological issues raised during this study.
Article
To define the contemporary characteristics of the second stage of labour in one Health Region. Retrospective analysis of a regional obstetric database. Seventeen 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. Second stage duration, obstetric intervention and maternal and fetal morbidity. The duration of the second stage and the use of operative intervention were strongly negatively associated with parity and positively associated with the use of epidural analgesia. Maternal age, fetal birthweight and maternal height were also independently associated with the duration of the second stage. There were small but significant differences in the characteristics of women using epidural analgesia and those using alternative methods of pain relief. Parous women using epidural analgesia behaved in a similar manner to nulliparae without epidurals. Despite the longer second stages observed in women using epidural analgesia there appeared to be no significant increase in fetal morbidity. Within the region the epidural rate in individual units positively correlated with the overall forceps rate, the rate of caesarean section in the second stage of labour and the duration of the second stage. In our study the duration of the second stage in women not using epidural analgesia was similar to previous findings, but in those using epidural analgesia, the duration of the second stage was longer than has been reported previously, possibly reflecting a more conservative approach to operative intervention. Survival analysis indicates that in multiparae not using epidural analgesia the likelihood of spontaneous vaginal delivery after 1 h in the second stage was low, but in those multiparae using epidural analgesia and in all nulliparae there was no clear cut-off point for expectation of spontaneous delivery in the near future; they continue to give birth at a steady rate over several hours. While maternal and fetal conditions are satisfactory, intervention should be based on the rate of progress rather than the elapsed time since full cervical dilatation.
Article
In 69 patients with uneventful pregnancies, term labor was studied prospectively with respect to length of second stage, number of bearing down efforts, maternal and fetal levels of lactate, epinephrine and norepinephrine. Maternal venous blood concentrations were measured in early labor and at the time of delivery while samples from umbilical artery and vein provided fetal blood. There was a significant rise of lactate and catecholamines in maternal blood during labor and at delivery fetal lactate concentration was lower than the maternal level while for epinephrine and norepinephrine fetal levels were higher. For all three compounds umbilical artery concentrations were higher than umbilical venous levels. While there was no correlation between the biochemical parameters in maternal blood and length of second stage maternal lactate and norepinephrine concentration at the time of delivery significantly correlated with the number of bearing down efforts. Umbilical artery lactate correlated with both, length of second stage and number of bearing down efforts.
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
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
We compared different procedures for seeking consent to participate in a sham randomised clinical trial and assessed whether refusal is affected by awareness of the severity of outlook. 2035 healthy subjects aged between 20 and 80 years, who visited a scientific exhibition, were enrolled in a hypothetical trial of experimental versus standard therapy, and randomly assigned to groups asked for conventional informed consent or prerandomisation consent. There were four study groups: one-sided informed consent for randomisation (subjects who refused would receive standard treatment); two-sided informed consent for randomisation (subjects who refused could choose between standard and experimental treatment); randomised consent to experimental treatment (subjects who refused would receive standard treatment); and randomised consent to standard treatment (subjects who refused would receive experimental treatment). The refusal rates were 16.2%, 19.9%, 12.1%, and 49.2%, respectively. The perceived severity of the simulated disease affected the refusal rate: the worse the outlook, the lower the refusal rate for informed consent or for consent after randomisation to new treatment, and the higher the refusal rate for consent after randomisation to standard treatment. The prerandomisation design seems to be efficient in a one-sided clinical scenario (eg, a trial of a new drug that would not be given outside the trial) because the refusal rate was substantially lower for prerandomisation to the new treatment than for conventional one-sided informed consent. However, in a two-sided clinical scenario (eg, a trial comparing similar treatments) the prerandomisation design is potentially highly inefficient; the refusal rate was much higher for prerandomisation to standard treatment than for conventional two-sided informed consent.
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
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
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
Vaginal birth is a recognized factor in perineal tissue damage and postpartum perineal pain. This study examined outcomes of 39 primiparous women who had spontaneous vaginal births. In a retrospective survey, women were asked to describe the type of pushing used to give birth and what the level of pain had been in the perineal (or vaginal) area during the first week postpartum. Labor and delivery chart data documented extent of episiotomy and/or laceration sustained. Eleven (28%) women reported using spontaneous bearing down efforts, and the remaining 28 (72%) were directed. Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations (chi 2 [3, N = 39] = 8.1, P = .043). Other variables, such as maternal age, infant birth weight, length of second stage, provider type, and use of epidural, did not demonstrate a significant difference in perineal outcome. Further analysis showed a significant relationship between the extent of perineal disruption and pain (F [3,30] = 5.08, P = .005).
Article
The parameters of fatigue have been studied in recent years in relation to women's health and the childbearing period. Less research emphasis has been placed on second stage labor, a period of time that can encompass considerable physiologic and psychologic fatigue. Consideration to minimizing second stage labor fatigue by altering conventional support practices is needed. This includes minimizing long periods of strong pushing or bearing down efforts in conjunction with sustained breath holding, particularly for women receiving epidural anesthesia. The potential sequelae of second stage labor fatigue, recommendations for practice changes, and new research directions are discussed.
Article
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.
Article
To reevaluate the average length of each phase/stage of labor for multiparous and primiparous women in North America who received no regional anesthesia or oxytocin augmentation or induction, to describe a range of labor lengths associated with good childbirth outcomes, and to determine if there is a consensus among labor and delivery nurse managers responding to the survey regarding the need to revise Friedman's Labor Curve. This pilot study used a descriptive and anonymous cross-sectional survey design. Surveys were mailed to 500 maternity care agencies in the United States, Canada, and Mexico with a return rate of 17.8% (n = 89). Each participating agency was asked to submit five patient cases to be included in the analysis. The sample of patient cases (n = 419) was drawn from randomly selected maternity care agencies throughout North America representing all sizes of agencies and geographic locations. The cases submitted for analysis represented women 14 to 44 years of age with varying ethnicities who received no regional anesthesia or oxytocin augmentation or induction. Twenty-three percent of the women in the sample (n = 97) were primigravidas. The average length of labor for primiparous and multiparous women today is similar to the average length of labor described by Friedman in 1954. However, a wider range of "normal" was found in cases included in the current study. Primiparous women remained in the first stage of labor for up to 26 hours and the second stage of labor up to 8 hours with no adverse effects to mother or infant. Multiparous women remained in the first stage of labor for up to 23 hours and the second stage of labor for up to 4.5 hours with good birth outcomes. In addition, 87.6% of nurse managers responding to the survey believed that Friedman's Labor Curve should be revised to meet the needs of current patient populations, technological advances, and nursing responsibilities. This study suggests that the parameters to determine if a labor is progressing satisfactorily may need to be expanded. With the availability of technology to assess maternal and fetal well-being, labor should be allowed to progress past the rigid 2-hour time limit for the second stage of labor artificially imposed on women in some childbirth settings. More emphasis should be placed on the nursing assessment techniques used to reassure the family and health care practitioners that labor is progressing safely and the nursing interventions that may have an impact on the length of each stage of labor.
Article
To describe the association between provider communication and actual maternal pushing behavior in second-stage labor and to test differences in length of second stage and total maternal pushing time by maternal pushing behavior. Descriptive. Midwest hospital birth unit. Twenty primigravidas who gave birth vaginally. Type of provider communication (supportive of spontaneous or directed pushing). Maternal pushing behavior (spontaneous or directed) documented by videotape review. The percentage of provider communication supporting spontaneous pushing versus directed pushing and the percentage of actual spontaneous versus directed maternal pushing behavior were associated (Pearson r = .80, p = .001, for spontaneous and r = .89, p = .001, for directed). Neither duration of second stage (t = .06, p = .95) nor time spent pushing (t = .15, p = .89) differed by spontaneous versus directed pushing style. The proportion of spontaneous pushing by the birthing woman was positively and significantly associated with the proportion of caregiver communication supporting and encouraging spontaneous pushing. Importantly, spontaneous pushing did not significantly lengthen the duration of second-stage labor or total time spent pushing.
Article
The objective of this study was to compare obstetrical outcomes associated with coached versus uncoached pushing during the second stage of labor. Upon reaching the second stage, previously consented nulliparous women with uncomplicated labors and without epidural analgesia were randomly assigned to coached (n = 163) versus uncoached (n = 157) pushing. Women allocated to coaching received standardized closed glottis pushing instructions by certified nurse-midwives with proper ventilation encouraged between contractions. These midwives also attended those women assigned to no coaching to ensure that any expulsive efforts were involuntary. The second stage of labor was abbreviated by approximately 13 minutes in coached women (P = .01). There were no other clinically significant immediate maternal or neonatal outcomes between the 2 groups. Although associated with a slightly shorter second stage, coached maternal pushing confers no other advantages and withholding such coaching is not harmful.
Article
A supportive approach to care for women during the second stage of labor that primarily relies on the laboring woman's involuntary expulsive urges has been advocated. We aimed to learn about the clinical circumstances surrounding the caregiver shift from being primarily supportive to directing women regarding their bearing-down efforts. This research analyzed the communications of 10 birth attendants and women during the expulsive phase of labor using videotapes recorded from two studies carried out between 1986 and the present. The occasions when a birth attendant shifted verbalizations were identified, and categories of the rationales that may have influenced the modification in caregiver behavior were developed. Birth attendants most frequently provided directions to help the woman push effectively, that is, to focus the woman's bearing-down efforts during maternal distress, fatigue, fear, and pain to expedite the labor process (38% of the occasions of caregiver change in verbalizations). The next most frequent clinical situations when caregivers offered directions about "pushing" were diminished urge to bear-down with epidural analgesia (10%), routine arbitrary practices (9% caregiver and 6% by supportive companion), and fetal distress (<1%). A category of "supportive direction" (20%) was identified. This care strategy has not been previously reported. It combined direction with support in a way that was supportive rather than overriding the woman's involuntary efforts.
Article
Background: The Valsalva pushing technique is used routinely in the second stage of labor in many countries, and it is accepted as standard obstetric management in Turkey. The purpose of this study was to determine the effects of pushing techniques on mother and fetus in birth in this setting. Methods: This randomized study was conducted between July 2003 and June 2004 in Bakirkoy Maternity and Children's Teaching Hospital in Istanbul, Turkey. One hundred low-risk primiparas between 38 and 42 weeks' gestation, who expected a spontaneous vaginal delivery, were randomized to either a spontaneous pushing group or a Valsalva-type pushing group. Spontaneous pushing women were informed during the first stage of labor about spontaneous pushing technique (open glottis pushing while breathing out) and were supported in pushing spontaneously in the second stage of labor. Similarly, Valsalva pushing women were informed during the first stage of labor about the Valsalva pushing technique (closed glottis pushing while holding their breath) and were supported in using Valsalva pushing in the second stage of labor. Perineal tears, postpartum hemorrhage, and hemoglobin levels were evaluated in mothers; and umbilical artery pH, Po(2) (mmHg), and Pco(2) (mmHg) levels and Apgar scores at 1 and 5 minutes were evaluated in newborns in both groups. Results: No significant differences were found between the two groups in their demographics, incidence of nonreassuring fetal surveillance patterns, or use of oxytocin. The second stage of labor and duration of the expulsion phase were significantly longer with Valsalva-type pushing. Differences in the incidence of episiotomy, perineal tears, or postpartum hemorrhage were not significant between the groups. The baby fared better with spontaneous pushing, with higher 1- and 5-minute Apgar scores, and higher umbilical cord pH and Po(2) levels. After the birth, women expressed greater satisfaction with spontaneous pushing. Conclusions: Educating women about the spontaneous pushing technique in the first stage of labor and providing support for spontaneous pushing in the second stage result in a shorter second stage without interventions and in improved newborn outcomes. Women also stated that they pushed more effectively with the spontaneous pushing technique.