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

Labor epidural analgesia versus without labor epidural analgesia for multiparous women: a retrospective case control study

BACKGROUND

Labor epidural analgesia (LEA) effectively relieves the labor pain, but it is still not available consistently for multiparous women in many institutions because of their obviously shortened labor length.

METHODS

A total of 811 multiprous women were retrospective enrolled and firstly divided into two groups: LEA group or non-LEA group. And then they were divided into seven subgroups and analyzed according to the use of LEA and cervical dilation. The primary outcomes (time intervals, blood loss and Apgar scores) and secondary outcomes (maternal demographic characteristics and birth weight) were collected by checking electronic medical records.

RESULTS

The prevalence of using LEA in multiprous women was 54.5 %. Using LEA significantly lengthened the duration of labor stage by 56 min (P < 0.001), increased the blood loss (P < 0.001) and lowered Apgar scores (P = 0.001). In the comparison of sub-group analysis, using LEA can obviously prolong the duration of first-second stage in women with 2 cm cervical dilation (P < 0.001) and 3 cm cervical dilation (P = 0.014), while there was no significant difference with 4 cm or more cervical dilation (P = 0.69). Using LEA can significantly increased the blood loss when the initiation of LEA in the women with 2 cm cervical dilation (P < 0.001) and 3 cm cervical dilation (P = 0.035), meanwhile there were no significantly differences in the women with 4 cm or more cervical dilation (P = 0.524). Using LEA can significantly lower the Apgar scores when the initiation of LEA in the women with 2 cm cervical dilation (P = 0.001) and 4 cm or more cervical dilation (P = 0.025), while there were no significantly differences in the women with 3 cm cervical dilation (P = 0.839).

CONCLUSIONS

Labor epidural analgesia for the multiparous woman may alter progress of labor, increase postpartum blood loss and lower Apgar scores. Early or late initiation of LEA should be defined as with cervical dilatation of less or more than 3 cm and the different effect should be understand.

TRIAL REGISTRATION

ChiCTR2100042746. Registered 27 January 2021-Prospectively registered, http://www.chictr.org.cn .

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study

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.

Practices during the active second stage of labor: A survey of French midwives

OBJECTIVE

the principal objective of our study was to describe the practices reported by French midwives during the active second stage of labor (expulsion phase).

DESIGN

this cross-sectional Internet survey questioned French midwives who attended at least one childbirth in 2013.

SETTING

this open survey was posted on a website from June 15 through December 1, 2014.

PARTICIPANTS

1496 midwives from 377 maternity units participated in the study.

MEASUREMENTS AND FINDINGS

the midwives most often reported suggesting horizontal positions during the active second stage (supine with footholds, lithotomy, lithotomy with knees turned in, or lateral positions). Non-horizontal positions were more often proposed by midwives in level I units (p<0.0001). Almost half the midwives responding (46.4%), especially those working in level III units (51.1%, p = 0.006), advised Valsalva pushing. The mean maximum pushing time was 35.3 minutes±12.8 minutes. Nearly all the midwives favored the 'hands on' technique at childbirth (91.4%), and 24% reported using warm compresses on the perineum at childbirth.

KEY CONCLUSION

most midwives advised horizontal positions for childbirth. The practices of French midwives differed as a function of where they worked. The midwives, especially those in level III facilities, reported that they cannot always ensure 'physiological childbirth'.

IMPLICATIONS FOR PRACTICE

the practices of French midwives must become more evidence-based. The development of professional guidelines for midwives in France appears essential. This study also helps to prioritise national training for midwives.

Maternal and Neonatal Outcomes With Early Compared With Delayed Pushing Among Nulliparous Women

OBJECTIVE

To describe factors associated with delayed pushing and evaluate the relationship between delayed pushing and perinatal outcomes in nulliparous women with singleton term gestations.

METHODS

This was a secondary analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Assessment of Perinatal Excellence cohort of 115,502 women and their neonates born in 25 U.S. hospitals from 2008 to 2011. Nulliparous women with singleton, cephalic, nonanomalous term births who achieved 10-cm cervical dilation were included. Women in whom pushing was delayed by 60 minutes or greater (delayed group) were compared with those who initiated pushing within 30 minutes (early group). Multivariable regression analyses were used to assess the independent association of delayed pushing with mode of delivery, length of the second stage, and other maternal and perinatal outcomes (significance defined as P<.05).

RESULTS

Of 21,034 women in the primary analysis sample, pushing was delayed in 18.4% (n=3,870). Women who were older, privately insured, or non-Hispanic white as well as those who had induction or augmentation of labor, diabetes, or epidural analgesia were more likely to have delayed pushing. Delayed pushing was more common when the second stage began during daytime hours or in hospitals with dedicated 24-hour obstetric anesthesia, although differences were small. After adjusting for differences in baseline and labor characteristics including center, women in the delayed group had longer mean durations of the second stage (191 compared with 84 minutes, P<.001) and of active pushing (86 compared with 76 minutes, P<.001). Delayed pushing was associated with greater rates of cesarean delivery (11.2% compared with 5.1%; adjusted odds ratio [OR] 1.86, 95% confidence interval [CI] 1.63-2.12), operative vaginal delivery (adjusted OR 1.26, 95% CI 1.14-1.40), postpartum hemorrhage (adjusted OR 1.43, 95% CI 1.05-1.95), and blood transfusion (adjusted OR 1.51, 95% CI 1.04-2.17). Delayed pushing was not associated with increased odds of adverse neonatal outcomes compared with early pushing.

CONCLUSION

In this large birth cohort, delayed pushing was associated with longer second stage duration, increased odds of cesarean delivery, and increased odds of postpartum hemorrhage, but was not associated with neonatal morbidity.

Labor down or bear down: a strategy to translate second-stage labor evidence to perinatal practice

Scientific evidence supports spontaneous physiologic approaches to second-stage labor care; however, most women in US hospitals continue to receive direction from nurses and birth attendants to use prolonged Valsalva bearing-down efforts as soon as the cervix is completely dilated. Delaying maternal bearing-down efforts during second-stage labor until a woman feels an urge to push (laboring down) results in optimal use of maternal energy, has no detrimental maternal effects, and results in improved fetal oxygenation. Although most commonly used with women who are undergoing epidural anesthesia, laboring down is just one component of physiologic second-stage labor care that can be used to achieve optimal maternal and neonatal outcomes for women with or without an epidural. Prior efforts to translate evidence regarding second-stage labor care to practice have not been successful. In this article, the scientific evidence for second-stage labor care and previous efforts at clinical translation are reviewed. The Ottawa Hospital Second Stage Protocol is presented as a model with potential to allow translation of evidence to practice. Recommendations to enhance widespread adoption of evidence-based practice are provided, including improved collaboration between nurses and birth attendants.

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.