Spontaneous pushing during birth. Relationship to perineal outcomes

Efficacy of spontaneous pushing with pursed lips breathing compared with directed pushing in maternal and neonatal outcomes

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-556d22IMPACT STATEMENTWhat 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.

Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study

INTRODUCTION

Most women who give birth for the first time experience some form of perineal trauma. Second-degree tears contribute to long-term consequences for women and are a risk factor for occult anal sphincter injuries. The objective of this study was to evaluate a multifaceted midwifery intervention designed to reduce second-degree tears among primiparous women.

METHODS

An experimental cohort study where a multifaceted intervention consisting of 1) spontaneous pushing, 2) all birth positions with flexibility in the sacro-iliac joints, and 3) a two-step head-to-body delivery was compared with standard care. Crude and Adjusted OR (95% CI) were calculated between the intervention and the standard care group, for the various explanatory variables.

RESULTS

A total of 597 primiparous women participated in the study, 296 in the intervention group and 301 in the standard care group. The prevalence of second-degree tears was lower in the intervention group: [Adj. OR 0.53 (95% CI 0.33-0.84)]. A low prevalence of episiotomy was found in both groups (1.7 and 3.0%). The prevalence of epidural analgesia was 61.1 percent. Despite the high use of epidural analgesia, the midwives in the intervention group managed to use the intervention.

CONCLUSION

It is possible to reduce second-degree tears among primiparous women with the use of a multifaceted midwifery intervention without increasing the prevalence of episiotomy. Furthermore, the intervention is possible to employ in larger maternity wards with midwives caring for women with both low- and high-risk pregnancies.

Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial

Introduction:

One of the important tasks in managing labor is the protection of perineum. An important variable affecting this outcome is maternal pushing during the second stage of labor. This study was done to investigate the effect of breathing technique on perineal damage extention in laboring Iranian women.

Materials and Methods:

This randomized clinical trial was performed on 166 nulliparous pregnant women who had reached full-term pregnancy, had low risk pregnancy, and were candidates for vaginal delivery in two following groups: using breathing techniques (case group) and valsalva maneuver (control group). In the control group, pushing was done with holding the breath. In the case group, the women were asked to take 2 deep abdominal breaths at the onset of pain, then take another deep breath, and push 4–5 seconds with the open mouth while controlling exhalation. From the crowning stage onward, the women were directed to control their pushing, and do the blowing technique.

Results:

According to the results, intact perineum was more observed in the case group (P = 0.002). Posterior tears (Grade 1, 2, and 3) was considerably higher in the control group (P = 0.003). Anterior tears (labias) and episiotomy were not significantly different in the two groups.

Conclusions:

It was concluded that breathing technique of blowing can be a good alternative to Valsalva maneuver in order to reduce perineal damage in laboring women.

[Methods of pushing at vaginal delivery and pelvi-perineal consequences. Review]

INTRODUCTION

The main objective of that review was to evaluate the pelvi-perineal consequences of the different methods of pushing at vaginal delivery.

METHODS

A review on PubMed, the Cochrane Library and EM-Premium was performed from 1984 to 2014. Among 29 manuscripts analysed, only nine randomised controlled trials (including one meta-analysis of three trials) comparing Valsalva and spontaneous pushing were selected. A 10 th study, secondary analysis of a randomized controlled trial comparing different methods of perineal protection (warm compresses, massage and manual protection), was also selected.

RESULTS

Two trials have shown that spontaneous pushing reduces the risk of perineal tears, but studies were heterogeneous and discordant results do not allowed definitive conclusions. Results on the duration of the second stage of labour are conflicting. The method of pushing does not seem to affect the rate of episiotomy, instrumental delivery and cesarean section. Maternal satisfaction seems to be better after spontaneous pushing. It seems that there is no negative effect of spontaneous pushing on neonate well-being, and one study has shown a significant improvement of prenatal fetal parameters during the expulsive phase.

CONCLUSION

According to current knowledge, both techniques of pushing during the expulsive phase at delivery seem comparable in terms of duration, risk of perineal tears and neonatal outcome.

Midwives' verbal support of nulliparous women in second-stage labor

OBJECTIVE

To describe how nurse-midwives verbally support nulliparous women during second-stage labor and document specific details of each second stage.

DESIGN

Descriptive qualitative study.

SETTING

A university hospital labor and delivery unit in the southwestern United States.

PARTICIPANTS

Nulliparous women (n = 14) older than age 18 and their attendant midwives (n = 9).

METHODS

A single research midwife observed the entire second stage of each woman and used a standardized data collection form to record spontaneous or directed pushing, position changes, open and closed glottis pushing. A digital audio recorder was employed to capture verbal communication between the midwife and laboring woman. The research midwife and two qualitative experts employed content analysis to analyze the audio transcripts and identify categories of verbal support.

RESULTS

Analysis revealed four categories of verbal support: affirmation, information sharing, direction, and baby talk. The vast majority of verbal communication by nurse-midwives consisted of affirmation and information sharing. Nurse-midwives gave direction for specific reasons. Women pushed spontaneously the majority of the time, regardless of epidural use.

CONCLUSION

Nurse-midwives use a range of verbal support strategies to guide the second stage. Directive support was relatively uncommon. Most verbal support instead affirmed a woman's ability to follow her own body's lead in second-stage labor, with or without epidural.

When and how to push: providing the most current information about second-stage labor to women during childbirth education

Childbirth educators can have a significant impact on safe care for mothers and babies during the second stage of labor. In this guest editorial, educators are encouraged to make sure they are knowledgeable about the latest evidence for best second-stage-care practices so they can adequately prepare women to advocate for themselves during this time.

Directive versus supportive approaches used by midwives when providing care during the second stage of labor

INTRODUCTION

Although the risks associated with using sustained and forceful maternal bearing-down efforts during the second stage of labor have been well documented, most women who give birth in the United States bear down in response to direction from care providers about when and how to push rather than in response to their own physiologic urges. The purpose of this study was to describe the practices used by certified nurse-midwives/certified midwives (CNMs/CMs) in response to maternal bearing-down efforts when caring for women in second-stage labor and to identify factors associated with the use of supportive approaches to second-stage labor care.

METHODS

A national survey of 705 CNMs/CMs was conducted using mailed questionnaires. The instrument was an 84-item, fixed-choice questionnaire using Likert type scales that had been validated. A 72.6% response rate was achieved, and 375 of the respondents cared for women during the second stage of labor.

RESULTS

Most CNMs/CMs (82.4%) often or almost always supported women without epidural anesthesia to initiate bearing-down efforts only when the woman felt an urge to do so. When caring for women without an epidural, most of the respondents (67%) reported that they often or almost always supported a woman's spontaneous bearing-down efforts without providing direction. Most participants reported using more directive practices when caring for women with epidural anesthesia. Whether caring for women with or without an epidural, most respondents (77.1% and 79.6%, respectively) often or almost always provided more direction as the fetal head emerged and the final stretching of the perineum was taking place. A change in fetal heart tones that led the midwife to believe the birth needed to occur quickly was the circumstance that had the greatest degree of influence on the participant's (90.6%) decision to provide more direction during bearing-down efforts. Many participants indicated that they also were influenced to provide more direction when women in labor asked for more direction (73.3%) or appeared to be fatigued (74.6%).

DISCUSSION

The majority of CNMs/CMs use supportive approaches to bearing-down efforts during second-stage labor care and most used directive approaches as an intervention aimed at avoiding potential problems.

Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials

OBJECTIVES

To critically evaluate any benefit or harm for the mother and her baby of Valsalva pushing versus spontaneous pushing in the second stage of labour.

SEARCH STRATEGY

Electronic databases from MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were systematically searched (last search May 2010). The reference lists of retrieved studies were searched by hand and an internet hand search of master theses and dissertations was performed. No date or language restriction was used.

SELECTION CRITERIA

Randomised controlled trials that compared instructed pushing with spontaneous pushing in the second stage of labour were considered. Studies were evaluated independently for methodological quality and appropriateness for inclusion by two authors (MP and JB).

DATA COLLECTION AND ANALYSIS

The primary outcome was instrumental/operative delivery. Other outcomes were length of labour, any perineal repair, bladder function, maternal satisfaction. Infant outcomes included low Apgar score < 7 after 5 minutes, umbilical arterial pH <7.2, admission to neonatal intensive care unit and serious neonatal morbidity or perinatal death.

MAIN RESULTS

Three randomised controlled studies covering 425 primiparous women met the inclusion criteria. Women who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 women; relative risk 0.70; 95% CI 0.34-1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in women who used the Valsalva pushing technique (three studies; 425 women; mean difference 18.59 minutes; 95% CI 0.46-36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 women; mean difference respectively 41.50 ml, 95% CI 8.40-74.60, and 54.60 ml, 95% CI 13.31-95.89).

AUTHORS' CONCLUSION

The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed. Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

Fear causes tears - perineal injuries in home birth settings. A Swedish interview study

Background

Perineal injury is a serious complication of vaginal delivery that has a severe impact on the quality of life of healthy women. The prevalence of perineal injuries among women who give birth in hospital has increased over the last decade, while it is lower among women who give birth at home. The aim of this study was to describe the practice of midwives in home birth settings with the focus on the occurrence of perineal injuries.

Methods

Twenty midwives who had assisted home births for between one and 29 years were interviewed using an interview guide. The midwives also had experience of working in a hospital delivery ward. All the interviews were tape-recorded and transcribed. Content analysis was used.

Results

The overall theme was "No rushing and tearing about", describing the midwives' focus on the natural process taking its time. The subcategories 1) preparing for the birth; 2) going along with the physiological process; 3) creating a sense of security; 4) the critical moment and 5) midwifery skills illuminate the management of labor as experienced by the midwives when assisting births at home.

Conclusions

Midwives who assist women who give birth at home take many things into account in order to minimize the risk of complications during birth. Protection of the woman's perineum is an act of awareness that is not limited to the actual moment of the pushing phase but starts earlier, along with the communication between the midwife and the woman.

Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning

Despite evidence of adverse fetal and maternal outcomes from the use of sustained Valsalva bearing down efforts, current second-stage care practices are still characterized by uniform directions to "push" forcefully upon complete dilatation of the cervix while the woman is in a supine position. Directed pushing might slightly shorten the duration of second stage labor, but can also contribute to deoxygenation of the fetus; cause damage to urinary, pelvic, and perineal structures; and challenge a woman's confidence in her body. Research on the second stage of labor care is reviewed, with a focus on recent literature on maternal bearing down efforts, the "laboring down" approach to care, second-stage duration, and maternal position. Clinicians can apply the scientific evidence regarding the detrimental effects of sustained Valsalva bearing down efforts and supine positioning by individualizing second stage labor care and supporting women's involuntary bearing down sensations that can serve to guide her behaviors.

Common Problems of Urination in Nonpregnant Women: Causes, Current Management, and Prevention Strategies

This article uses a case-based approach to review common problems of urination in nonpregnant women, including overactive bladder; stress, urge, and mixed incontinence; and retention and prolapse. Up-to-date clinical issues related to assessment, diagnosis, treatment, and follow-up are reviewed, with a discussion of underlying pathophysiology and prevention strategies. Suggestions are made for relevant curriculum content at both the basic and advanced levels of advanced practice education.

Why Do Supportive Birth Attendants Become Directive of Maternal Bearing-Down Efforts in Second-Stage Labor?

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.

Biomechanical analyses of the efficacy of patterns of maternal effort on second-stage progress

OBJECTIVE

To develop and use a biomechanical computer model to simulate the effect of varying the timing of voluntary maternal pushes during uterine contraction on second-stage labor duration.

METHODS

Published initial pelvic floor geometry was imported into technical computing software to build a simplified three-dimensional biomechanical model with six representative viscoelastic levator muscle bands interconnected by a hyperelastic iliococcygeal raphe. An incompressible sphere simulated the molded fetal head. Forces from uterine contraction and voluntary expulsive efforts were summed to push the model fetal head along the curve of Carus opposed by the resistance of the pelvic floor structures to stretch. Holding uterine maximal contraction force and push strength constant, pushes were timed before ("pre"), at ("peak"), and after ("post") maximal uterine contraction force. The effect of different combinations of pushes on second stage duration and the number of pushes required for delivery were evaluated.

RESULTS

Calculated second stage durations ranged from 57.5 minutes (triple or pre-peak-post pattern) to 75.8 minutes (prepush and postpush patterns). Delivery with the triple-push pattern required 59 voluntary pushes, while the peak-push pattern required 23 voluntary pushes, a 61% reduction. The corresponding reduction for the pre-and-peak-push pattern was 29%, the peak-and-post push pattern was 30%, the prepush pattern was 54%, and the postpush pattern was 56%.

CONCLUSION

Although the triple-push pattern resulted in a 16% shorter second stage, this came at the energetic expense of a 61% increase in the number of pushes required.

LEVEL OF EVIDENCE

III.

Second-stage labor care: challenges in spontaneous bearing down

Substantial scientific evidence supports spontaneous maternal bearing down for its associated maternal and fetal physiologic benefits. Imposing specific directions for Valsalva pushing does not result in optimal outcomes but continues to be widely used, particularly when labor progress is less than optimal. However, there are numerous evidence-based approaches that can be used to avoid reverting to directed, prolonged Valsalva bearing down. Nursing care challenges may be encountered when using physiologic approaches; therefore, strategies are detailed to alleviate a variety of problems including ways to promote physiological descent and effectively support women's spontaneous efforts. For example, maternal postural interventions are suggested for asynclitic and occiput posterior fetal positions. When fetal heart rate abnormalities present and the fetus may be compromised, modifications to spontaneous bearing down are suggested as alternatives to longer and stronger Valsalva pushing, such as encouraging the women to use short pushes or breath through contractions until the fetus recovers. Open knee-chest maternal positioning can help to diminish a premature urge to push, while the closed knee-chest position may be more useful if cervical edema occurs. Even with clinical challenges, evidence-based care can help achieve the improved outcomes documented from women's spontaneous bearing-down efforts during the second stage.

The use of liquid petroleum jelly in the prevention of perineal lacerations during birth

Most of vaginal births are accompanied by lacerations in the genital tract. This was a randomized study carried out in a Birth Center located in São Paulo city to evaluate the efficacy of liquid petroleum jelly in reducing perineal laceration. The sample was composed of 38 nulliparous women per group (experimental and control). In the experimental group was used 30 ml of the petroleum jelly in the perineal region during the expulsive period. The parturient were allowed to push spontaneously during the delivery and remained in the left side position. The frequency of perineal laceration was similar in both groups (experimental 63.2% versus control 60.5%). The posterior perineum region presented the highest frequency of trauma (53.2%). Of the total cases of perineal trauma, 72.3% were first-degree lacerations. The use of liquid petroleum jelly of perineal protection does not reduce the frequency neither the degree of lacerations in childbirth.

Effects of pushing techniques in birth on mother and fetus: a randomized study

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.

Does cesarean section reduce postpartum urinary incontinence? A systematic review

BACKGROUND

The impact of delivery mode on the development of urinary incontinence has been much debated. The primary objective of this systematic review was to compare the prevalence of postpartum urinary incontinence after cesarean section compared with vaginal birth.

METHODS

The MEDLINE (1966-2005) and CINAHL (1982-2005) databases were searched for reports specifying postpartum prevalence or incidence of unspecified, stress, urge, and mixed urinary incontinence by mode of birth. Primary authors were contacted to request unpublished data about severity, parity, and timing of cesarean section. All data were entered into Review Manager software, and odds ratio (OR), absolute risk reduction, and number needed to prevent were calculated.

RESULTS

Cesarean section reduced the risk of postpartum stress urinary incontinence from 16 to 9.8 percent (OR = 0.56 [0.45, 0.68], number needed to prevent = 15 [12,22]) in 6 cross-sectional studies, and from 22 to 10 percent in 12 cohort studies (OR=0.48 [0.39, 0.58], number needed to prevent = 10 [8,13]). Differences persisted by parity and after exclusion of instrumental delivery, but risk of severe stress urinary incontinence and urge urinary incontinence did not differ by mode of birth.

CONCLUSIONS

Although short-term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent by mode of birth. Risk of postpartum stress urinary incontinence must be considered in the context of associated maternal and newborn morbidity and mortality.

Minimizing genital tract trauma and related pain following spontaneous vaginal birth

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.

Getting Through Birth in One Piece

PURPOSE

To identify factors related to perineal trauma in childbirth, replicating the work of .

STUDY DESIGN AND METHOD

A retrospective descriptive analysis of pregnancy and birth data recorded into the Nurse Midwifery Clinical Data Set for women (N = 510) with a singleton pregnancy and largely uncomplicated prenatal course. Prenatal care occurred at four prenatal clinics with births at a tertiary care facility during 1996-1997, with care provided by nurse midwifery faculty. Multivariate statistics detailed clinical characteristics associated with perineal trauma.

RESULTS

Episiotomy was related to parity, marital status, infant weight, fetal bradycardia, prolonged second stage labor, and lack of perineal care measures. Factors related to laceration were age, insurance status, and marital status. For all women, laceration was more likely when in lithotomy position for birth (p = .002) or when prolonged second stage labor occurred (p = .001). Factors that were protective against perineal trauma included massage, warm compress use, manual support, and birthing in the lateral position. found that ethnicity and education were related to episiotomy and that warm compresses were protective. In this study, use of oils/lubricants increased lacerations, as did lithotomy positioning. Laceration rates were similar in both studies. Episiotomy use was lower in this study.

CLINICAL IMPLICATIONS

Side-lying position for birth and perineal support and compress use are important interventions for decreasing perineal trauma. Strategies to promote perineal integrity need to be implemented by nurses who provide prenatal education and care for the laboring woman.

The context & clinical evidence for common nursing practices during labor

The purpose of this article is to review the context and current evidence for common nursing care practices during labor and birth. Although many nursing interventions during labor and birth are based on physician orders, there are a number of care processes that are mainly within the realm of nursing practice. In many cases, particularly in community hospitals, routine physician orders for intrapartum care provide wide latitude for nurses in how they ultimately carry out those orders. An important consideration of common nursing practices during labor is the context or practice model in which those practices occur. Nursing practice is not the same in all clinical environments. Intrapartum nursing practice consists of an assortment of different roles depending on the circumstances, hospital setting, and context in which it takes place. A variety of intrapartum nursing practice models have evolved as a result and in response to the range of sizes, locations, and provider practice styles found in hospitals providing obstetric services. A summary of intrapartum nursing models is presented. The evidence is reviewed for the three most common clinical practices for which nurses have primary responsibility in most settings and that comprise the majority of their time in caring for women during labor: (1) maternal-fetal assessment, (2) management of oxytocin infusions, and (3) second-stage care. Evidence exists for these nursing interventions that can be used to promote maternal-fetal well-being, minimize risk, and enhance patient safety.

Provider Support of Spontaneous Pushing During the Second Stage of Labor

OBJECTIVE

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.

DESIGN

Descriptive.

SETTING

Midwest hospital birth unit.

PARTICIPANTS

Twenty primigravidas who gave birth vaginally.

INTERVENTION

Type of provider communication (supportive of spontaneous or directed pushing).

MAIN OUTCOME MEASURE

Maternal pushing behavior (spontaneous or directed) documented by videotape review.

RESULTS

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.

CONCLUSION

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.

A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function

OBJECTIVE

The purpose of this study was to determine if refraining from coached pushing during the second stage of labor affects postpartum urogynecologic measures of pelvic floor structure and function.

STUDY DESIGN

Nulliparous women at term were randomized to coached (n = 67) vs uncoached (n = 61) pushing. At 3 months' postpartum women underwent urodynamic testing, pelvic organ prolapse examination (POPQ), and pelvic floor neuromuscular assessment.

RESULTS

Urodynamic testing revealed decreased bladder capacity (427 mL vs 482 mL, P = .051) and decreased first urge to void (160 mL vs 202 mL, P = .025) in the coached group. Detrusor overactivity increased 2-fold in the coached group (16% vs 8%), although this difference was not statistically significant (P = .17). Urodynamic stress incontinence was diagnosed in the coached group in 11/67 (16%) vs 7/61 (12%) in the uncoached group (P = .42).

CONCLUSION

Coached pushing in the second stage of labor significantly affected urodynamic indices, and was associated with a trend towards increased detrusor overactivity.

Obstetric "conveniences": elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions

Common obstetric interventions are often for "convenience" rather than for clinical indications. Before proceeding, it should be clear who is the beneficiary of the convenience. The primary healthcare provider must make sure that women and their partners have a full understanding of what is known about the associated risks, benefits, and alternative approaches of the proposed intervention. Thorough and accurate information allows women to choose what is best for them and their infant on the basis of the individual clinical situation. Ideally, this discussion takes place during the prenatal period when there is ample opportunity to ask questions, reflect on the potential implications, and confer with partners and family members. A review of common obstetric interventions is provided. While these interventions often are medically indicated for the well-being of mothers and infants, the evidence supporting their benefits when used electively is controversial.

Reevaluation of Friedman's Labor Curve: A Pilot Study

OBJECTIVE

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.

DESIGN

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.

SAMPLE AND SETTING

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.

RESULTS

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.

CONCLUSIONS

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.

A New Understanding of the Second Stage of Labor: Implications for Nursing Care

A reconceptualization of the second stage of labor is proposed, with an early phase of descent and a later phase of active pushing, as the basis for nursing care related to direction or support of expectant mother's bearing-down efforts. This reconceptualization challenges the rules that have accompanied second stage by providing criteria for the obstetric conditions optimal for fetal descent that develop during the initial phase of second stage as the fetal head rotates to an anterior position and descends to at least a 1+ station. The phase of active pushing is accompanied by a decline in fetal pH and should be shortened, not only by assisting the woman with effective bearing-down but also by allowing a longer early phase of second stage and encouraging the woman to push only when the obstetric conditions are optimal.

Interleukin-1beta elevation during the postpartum period

During the postpartum period, women frequently report increased fatigue, which, if severe, may interfere with maternal-child bonding, delay a new mother's return to her activities of daily living, and contribute to depression. Several studies have sought to determine psychosocial contributions to fatigue during the postpartum period, but few evaluate any physiological changes that may contribute to fatigue during this time. The following study was designed to test whether the potent, pro-inflammatory cytokine interleukin-1beta (IL-1beta), known to be a physiological mediator of fatigue in several clinical and experimental conditions, is elevated in women during the postpartum period and whether it might be related to symptoms of fatigue. Levels of fatigue and the urinary excretion of IL-1beta were measured in 26 women over 4 weeks postpartum. Correlations between fatigue and activation of the inflammatory response were investigated. Results demonstrated a significant elevation in IL-1beta during the postpartum period compared to control participants (p < .05) and a significant, although delayed, correlation between IL-1beta elevation and fatigue (p < .05). These results suggest that activation of the inflammatory response, as reflected by elevation in urinary IL-1beta, occurs in association with postpartum fatigue. Studies to explore further this association and to identify specific mechanisms of action are needed.

Reducing genital tract trauma at birth: launching a clinical trial in midwifery

Genital tract trauma is a common outcome of vaginal birth, and can cause short-term and long-term problems for new mothers. Preventive measures have not been fully explicated. Midwives use a variety of hand maneuvers late in the second stage of labor, in the belief that genital trauma can be reduced. However, none of these care measures have been rigorously tested to determine if they are effective. A midwifery practice offers an ideal setting to study the relationship of hand techniques by the birth attendant to reduction of genital tract trauma.

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

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.

Accidental out-of-hospital deliveries: an obstetric and neonatal case control study

BACKGROUND

Accidental out-of-hospital (OHD) deliveries are associated with high rates of perinatal morbidity and mortality. The ability of health care workers to identify women at risk of out-of-hospital delivery is limited. The purpose of this study was to determine the prevalence of these deliveries in our population and to quantify the neonatal morbidity and mortality associated with such births. Further we aimed to determine whether women at risk of accidental out-of-hospital delivery in our population could be identified antenatally.

METHODS

A retrospective case-control study was performed. Women who delivered accidentally out-of-hospital in our catchment area between January 1995 and March 1999 were identified (cases) and compared with women who delivered in hospital following spontaneous labor (controls). Outcome measures included maternal demographic characteristics, obstetric features and neonatal outcome.

RESULTS

In the study period, 117 women delivering 121 babies were identified who delivered accidentally out-of-hospital, (0.6% of all deliveries registered at the hospital). Women who delivered before arrival at hospital were more likely to be of greater parity, unbooked, late bookers and/or poor attenders for antenatal care. Gestation at delivery, duration of labor and birthweight were less in the out-of-hospital delivery group compared with the control group. The rate of perineal suturing was lower for cases than controls. Babies who were delivered accidentally out-of-hospital were more likely to require admission to the neonatal unit and had a higher perinatal mortality rate than controls (51.7 versus 8.6/1000 deliveries, respectively).

CONCLUSIONS

Accidental out-of-hospital deliveries account for less than 1% of deliveries in our population, but are associated with significant perinatal morbidity and mortality. Women should be educated regarding the importance of both antenatal care and a planned delivery. Since the majority of women who deliver accidentally out-of hospital are parous, there is an opportunity to do this in a previous confinement.