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Running head: PUSHING IN SECOND STAGE LABOR 1

Coached Versus Spontaneous Pushing In Second Stage Labor

Margaret Gerulski

Ferris State University

PUSHING IN SECOND STAGE LABOR 2

Abstract

Second stage labor management is highly modifiable and greatly influenced by nursing care.

Research of the care of laboring women is a highly controversial topic. Explanation of the

second stage labor process is broken down into phases. The fetal and maternal effects of

coached versus uncoached pushing efforts will be reviewed and evaluated through journal

evidence. Implementation of evidence-based practice by healthcare providers is essential to

ensure a positive outcome.


Coached Versus Spontaneous Pushing In Second Stage Labor

The birth of a baby is an exciting and emotional event in a woman’s life. “Patients give

nurses permission to enter their lives and share their most intimate life experiences” (American

Nurse Association (ANA), 2004, p. 17). Supportive care of a woman in labor allows her to be an

active participant in deliver, rather than have it managed. Guidance of nursing interventions

through use of evidence-based practice will contribute to successful management of second stage

labor. “Nursing is a dynamic profession, blending evidence-based practice with intuition, caring,

and compassion to provide quality care” (ANA, 2004, p. 17).

The obstetrical outcomes, associated with coached versus uncoached pushing during the

second stage of labor are a practice that is under study (Bloom, et al., 2006). Management of the

patient in second stage labor has been a controversial topic among the various medical

disciplines. “The second stage of labor is a profound experience for expectant mothers and a

period of intense, continuous care by a nurse or other qualified person” (Roberts, 2003, p. 794).

Care providers goals are to provide the mother and infant with the best outcomes, as well as a

pleasant birth experience. Differing opinions between medical and midwifery models of care

will guide this practice paper.

The avoidance of invasive surgical interventions, such as cesearean sections or use of

forceps, is a major goal of birth attendants who favor spontaneous births. An inter-relational

aspect of childbirth, including support and communication, is necessary to promote a

spontaneous birth. Women have given birth at home for centuries, being allowed to let their

bodies guide the process of birth. The evolution of medical technology has forced the

interruption of what is natural by providing interventions that medical personnel have deemed

necessary.


In the first 9 editions of Williams Obstetrics textbooks, which encompasses the first half

of the 20th century, there was no mention of coaching maternal expulsive efforts during the

second stage of labor. Coaching is not routinely indicated, and the normal reflexive urge to bear

down results from the fetal presenting part to distend the pelvic floor. By the 10th edition (1950),

Eastman stated, “In most cases, bearing-down efforts are reflex and spontaneous in the second

stage of labor, but occasionally the patient does not employ her expulsive forces to good

advantage and coaching is desirable” (Bloom, et al., 2006, p. 10). The William’s Obstetrics

textbook (Cunningham et al., 1997) advises providers to instruct women to “take a deep breath

as soon as the next uterine contraction begins, and with her breath held, to exert downward

pressure” (Sampselle, C., Miller, J., Luecha, Y., Fischer, K., & Rosten, L., 2005, p. 696).

In the role of Clinical Coordinator of the Birth Center at Covenant Healthcare in

Saginaw, Michigan, the unique opportunity to observe many deliveries by a wide variety of

nurses, midwives, residents, and attending physicians. It is totally amazing despite the research

done for evidence-based practice how many healthcare providers are resistant to change. The

Clinical Nurse Specialist in the department is very thorough in her investigation into the most

current research and practices. There are extensive educational offerings to familiarize all

aspects of the healthcare team as to the current recommended practice. Eventually the practices

are adopted, but with great resistance by members of the healthcare team.

Phases of Second Stage Labor

The traditional definition of second stage is the time from the diagnosis or detection of

complete cervical dilatation to the birth and is seen as the explosive phase, that is, the

portion of labor when the woman experiences an urge to bear down and to push.

However, an involuntary urge to push may precede the complete dilatation of the cervix


or may occur sometime after the recognition of complete cervical dilatation. This

variation in the time of the initial urge to push is due to other obstetric factors that must

be favorable for further fetal descent and birth. (Roberts, 2003, p.795)

The physical and behavioral characteristics of second stage need to be understood to

appropriately provide the interventions necessary. “Second stage care practices can have an

adverse impact on fetal oxygenation, pelvic floor dysfunction, urinary or fecal incontinence, and

sexual dysfunction, as well as cesearean birth rates” (Roberts & Hanson, 2007, p. 238). The

possible adverse effect of coached versus spontaneous pushing efforts will be examined.

Directing a woman in second stage labor to push when it is determined that the cervix is fully

dilated has been traditionally performed. There are several “rules” that have been followed

which may cause adverse clinical complications. “One rule is “not to push prior to complete

cervical dilation;” another is “to push when the cervix is complete” (Roberts, 2002, p. 3).

“Despite evidence that raises concerns about directed pushing, more than 75% of 3,000 labor and

delivery nursing staff members encourage prolonged Valsalva-type pushing during the second

stage of labor” (Sampselle, et al., 2005, p. 696).

Providers insist that involuntary urges to push be suppressed and label pushing as not

appropriate until a designated authority certifies full dilation of the cervix, while

apologetic women valiantly strive to hold back their body’s urge to push. Similarly,

provider direction of the process of pushing during the expulsive phase of labor discounts

the birthing woman’s innate rhythmic imperative pushing. (Sampselle, et al., 2005, p.

696)


Pelvic Phase

The pelvic phase is the first phase of second stage of labor. The fetal head is negotiating

the pelvis, rotation and descent occurs. By lengthening this phase, the active pushing is

shortened by ensuring the obstetrical conditions are truly optimal, which will decrease the

amount of perineal muscle and nerve damage that may occur with a lengthy pushing phase. This

is accomplished by not encouraging the patient to push until she has a strong urge to do so. This

represents that the head rotation and descent is well advanced (Roberts, 2003, p. 796).

Perineal Phase

In the perineal phase, the fetal head is lower in the pelvis and is distending the perineum.

The perineal phase may be marked with a significant decrease in fetal pH, strong maternal

bearing down efforts (BDE) and breath holding (Roberts, 2003, p. 796).

Pressperiode Phase

The pressperiode phase is the final stage, or active pushing phase of second stage labor.

Reinforcement of effective BDEs, instruction on effective pushing focus, or assistance in finding

a more efficient pushing position may be necessary in some women. “Directions should be

reserved for those who need assistance. For many women, only positive reinforcement,

encouragement, and comfort measures are needed to achieve progress and a timely birth”

(Roberts, 2003, p. 796).

Coached Versus Uncoached Pushing

Coached Pushing

“Care provider directions to laboring women to bear down with each contraction

immediately upon complete dilatation of the cervix continue to be common during the

management of second stage labor” (Roberts & Hanson, 2007, p. 238). The closed glottis and


strenuous bearing down associated with the Valsalva maneuver, brings about physiologic

changes that impact both the mother and baby during second stage of labor. The ritual mantra of

“push, Push, PUSH,” that is mostly used by the provider intending to be supportive, is

interpreted as that of drill sergeant or a demanding parent (Sampselle, et al., 2005)

Maternal adverse effects. There is an increase in thoracic cavity pressure causing a

decrease in venous return and a resulting decrease in oxygenated blood to perfuse the uterus,

placenta, and fetus (Roberts, 2002, p. 4). Use of sustained Valsalva bearing down efforts results

in maternal fatigue, more perineal tears, decreased urogynecologic function, including decreased

bladder capacity and an increase in stress incontinence postpartum (Roberts & Hanson, 2007, p.

238). Roberts, (2002, p. 4), states that in a comparative study by Beynon,

The reported need for forceps assistance and the incidence of perineal trauma (episiotomy

or laceration) were greater for women who were directed to push upon complete

dilatation than for 100 women for whom directions were delayed until they had an

involuntary urge to bear down (p.4).

Fetal adverse effects. The use of Valsalva maneuver has been reported to result in fetal

acidemia and de-oxygenation. There is the possibility of the fetal head not being situated in the

pelvis that is conducive to descent and progression may not occur. In the active maternal bearing

down phase, a study showed that the fetal acid base status did not change in the first phase, but

the higher levels of lactic acid and pCO2 and lower pH did occur in the final part of second

stage. “The fetus is more adversely affected by a longer phase of forceful pushing than by the

period of time between complete dilatation and active pushing” (Roberts, 2002, p. 6).


Spontaneous Non-Coached Pushing

Spontaneous pushing allows the woman in labor to listen to her own body cues. A non-

coached, non-directed, self-paced pushing pattern, with multiple short pushes and no sustained

breath holding is encouraged and observed by these women (Albers, 2007).

When women push spontaneously, they begin to push from their resting respiratory

volume, and they push multiple times per contraction (3-5) for 3-5 seconds per effort,

followed by about 2 seconds of breaths and the release of air. There is synchrony

between the woman’s respiratory and uterine function that may allow spontaneous

bearing-down efforts to take advantage of the force generated by abdominal muscle

action (Hanson, 2009, p. 32).

A woman’s involuntary urge to bear down is evoked when a contraction pushes the fetal

head stretching the muscles of the pelvic floor and evokes Ferguson’s reflex, which happens with

a release of oxytocin. The release of oxytocin augments to quality of uterine contractions and

the expulsive efforts of the mother are initiated (Roberts, 2003, p. 797). Providers that support

spontaneous pushing provide feedback about how the woman is doing and encouraging her in the

birth (Sampselle, et al., 2005).

There was a strong positive association between the percentage of provider

communication phrases categorized as supportive of spontaneous pushing and the

percentage of maternal pushing behavior that was, in fact, spontaneous (Pearson’s r

= .80, p ≤ .001, n = 20). Likewise, there was a strong positive association between the

percentage of provider communication phrases categorized as directed and the percentage

of maternal pushing behavior that was directed (Pearson’s r = .89, p ≤ .001, n = 20).

(Sampselle, et al., 2005)


Maternal advantages of spontaneous uncoached pushing when this “urge” occurs are a

feeling of autonomy, an increase in self-esteem, and a positive perception of their birth

experience. The positive communication provided by healthcare providers in the birth

experience also facilitates a woman’s sense of accomplishment and can increase the mother

infant bonding. In the birth center, patients with an epidural are allowed and encouraged to labor

down (delay pushing) until the urge to push is felt. This is the practice of the majority of our

providers, with the exception being if the provider is nearing the end of their call and want to be

present for the delivery. It is very difficult sometimes to get the providers to think about what is

best for the patients, even some of the nurses observed have avoided checking a patient’s station

to not have a change of shift delivery. The focus should be what is best for the patient, not what

is best for the healthcare provider.

Barriers to the facilitation of spontaneous uncoached pushing efforts usually are the result

of lack of knowledge of healthcare providers. Most providers urge the prolonged bearing down

efforts in the belief of “the way we have always done it” or an impatience with the time involved

at the bedside. The experiences of the patient, family members, and healthcare providers can

strongly influence the behaviors in second stage labor management. The media has always

portrayed the “bear down and push” visual of the delivery process. A lack of knowledge may

contribute to this image being the only way the patient may know how to push without proper

guidance from her healthcare team.

Due to the intensive fetal heart monitoring systems, the length of the second stage is not

the only criteria to decide of interventions or operative termination of labor is necessary.

The guidelines recommend operative delivery be “considered” when 3 hours have

elapsed for a nullipara with regional anesthetic or 2 hours for one without, and when 2


hours have elapsed for a parous parturient with a regional anesthetic or 1 hour without.

An analysis of 4,745 births from the hospital records of nine midwifery services by

Albers et al. has identified the limits of labor (mean plus 2 standard deviations that

represents 95% of a population) in a population of U.S. women of mixed ethnicity…

Investigators have emphasized the importance of continued progress in fetal descent and

reassuring fetal heart tones to justify second stages that exceed the statistical “norms” for

that population. (Roberts, 2002, p. 5)

Studies for improved perineal floor outcomes have shown that women who had used the

Valsalva pushing had less favorable urodynamic indices, indicating pelvic floor dysfunction

from the forceful pushing effort (Albers, 2004).

Observations of the laboring patients of the Birth Center have shown the decreased time

of active directed pushing before the head has descended to a favorable station causes much less

swelling of the perineal tissue and subsequent trauma to the tissue. The providers who use their

fingers to help the patient “find the right spot” for pushing when they are not feeling the urge has

also been observed to result in increased perineal trauma. One of the Birth Center physicians,

along with many of the midwives, use the practice of warm compresses to the perineum when

the fetal head starts to cause visible bulging pressure. This practice has shown in our department

to decrease the incidence of perineal trauma. Most of the Birth Center physicians are not

supportive of this decrease in directed pushing with manual manipulation of the perineum. The

nurse’s whom support this practice will spend much time at the bedside facilitating the optimal

outcome and involving the physician only as necessary to avoid unnecessary interventions.

The nurses, midwives and other female healthcare providers are more accepting of the

natural process of the birth. There are some of our male physicians, who will support this


process, as well as, some female physicians who do not. This is most evident in those who

support Jean Watson’s Theory of Human Caring philosophy. The Theory of Human Caring

encompasses the “special kind of relationship involving a high regard for the whole person and

his or her being-in-the-world” (Kearney-Nunnery, 2008). Development of an inter-relationship

between care provider and patient enables the communication necessary to accomplish a

common goal. The process of birth, even though not an illness, involves the clinical caritas

process is applicable in bringing the patient and healthcare provider together to reach a common

goal. Applying this theory to practice is very essential in the makeup of a good obstetrical nurse.

At a time in a woman’s life when she is very vulnerable, a nurse is able to assist the woman to

maintain dignity, autonomy, and self-esteem.

Conclusion

The benefits to both the mother and newborn with spontaneous uncoached pushing

efforts are apparent through the evidence in this paper. Mothers have fewer incidences of

operative delivery, perineal trauma, and bladder trauma when allowed to push spontaneously.

Newborns suffer less acidemia and de-oxygenation when a mother can push uncoached. “Even

in the face of clinical challenges, evidence-based nursing care can help achieve the improved

outcomes that have been documented from a women’s spontaneous bearing-down efforts during

the second stage” (Hanson, 2009). Due to the limitations of many studies, further research needs

to be conducted involving variables such as; primiparous and multiparous women, and women

with or without epidurals, and larger sample populations (Simpson & James, 2005).

Recommendations for studies comparing cord blood gases collected at the time of delivery.

Nurses must strive to make goais to promote evidence-based practices with even the most

resistant of healthcare


References

Adams, E. & Bianchi, A. (2008). A practical approach to labor support. JOGNN, 37, p. 106-115. doi:

10.111/J.1552-6909.2007.00213.x

Albers, L. & Borders, N. (2007) Minimizing genital tract trauma and related pain following spontaneous

vaginal birth. Journal of Midwifery & Women’s Health. 52(3), p. 246-253.

American Nurses Association (2004). Nursing: Scope and Standards of Practice. Silver Spring,

Maryland: Nursingbooks.org.

Bloom, S., Casey, B., Schaffer, J., McIntire, D., & Leveno, K.(2006). A randomized trial of coached

versus uncoached maternal pushing during the second stage of labor. American Journal of

Obstetrics & Gynecology, 194, p. 10-13.

Kearney- Nunnery, R. (2008). Advancing your career: Concepts of professional nursing (4th ed.).

Philadelphia: F.A. Davis Company.

Hanson, L. (2009). Second-stage labor care: Challenges in spontaneous bearing down. Journal of

Perinatal Neonatal Nursing, 23(1), p. 31-39.

Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and

positioning. Journal of Midwifery & Women’s Health, 52(3), p. 238-245.

Roberts, J. (2002). The push for evidence: Management of the second stage. Journal of Midwifery &

Women’s Health, 47(1), p. 2-15.

Roberts, J. (2003). A new understanding of the second stage of labor: Implications for nursing care.

JOGNN Journal of Obstetric, Gynecologic and Neonatal Nursing, 32, p. 794-801, doi:

10.1177/0884217503258497

Sampselle, C. M., Miller, J. M., Luecha, Y., Fischer, K., & Rosten, L. (2005). Provider support of

spontaneous pushing during the second stage of labor. JOGNN: Journal of Obstetric,

Gynecologic and Neonatal Nursing, 34(6), p. 695-702.

Simpson, K. R., & James, D. C. (2005). Effects of immediate versus delayed pushing during second-stage

labor on fetal well-being. Nursing Research, 54(3), p. 149-157.


Appendix AEvidence Based Practice Paper Grading RubricName: __Margaret Gerulski 10/20/2009_______________________

DESCRIPTION AND ANALYSIS OF PRACTICE ISSUE POINTS POSSIBLE

POINTS AWARDED

Clear Introductory Description of Practice Concern/Interest: Describes reason for interest or concern and description of issue.

10 10

Practice Environment:Provides clear description of practice area.

5 5

Causal Factors: Personal Perspective and Description/Analysis of Possible Contributing or Causative Factors for the Concern

10 10

Defined Area of Research Search: Narrows down and defines a specific area for research review and provides a clear statement of same.

5 5

RESEARCH REVIEW

Research Findings: Shares the findings of a minimum of 3 original research studies from professional journals on the selected topic. Briefly describes the research approaches and findings of each.

2020

Critique of the Research: Attempts to point out any research limitations/credibility of the studies. You did an exellent job with the research studies but did not really speak to their limitations

5 2

Implications For Practice: Identifies potential practice implications of research. This goes beyond implications included in the study itself, to include perceptions of implications for personal practice.

5 5

Critical Reflection: Identifies a nursing theory that this practice concern/research findings is an appropriate fit. Includes reflections on the significance/implications of integrating research into practice.

10 10

STANDARDS & APA CRITERIAAPA: Attaches and adheres APA checklist and APA manual guidelines. Length appropriate (5-6 pages of typed content excluding the reference page, abstract, and title page).

15 15

Writing: Development of a clear, logical, well-supported paper. Overall presentation: Grammar, punctuation, clean and legible.

15 15

You are one beautiful writer ! You have a gift. Without a doubt, this paper could be published !!!! Well done.TOTAL

POINTS

100 97


Appendix BCHECKLIST FOR SUBMITTING PAPERS

CHECKDATE, TIME, & INITIAL

PROOFREAD FOR: APA ISSUES

10/20 mag 1. Page Numbers: Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)]

10/20 mag 2. Running head: Does the Running head: have a small “h”? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1” from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40]

10/20 mag 3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with the margin without an indentation?\ Is your abstract a summary of your entire paper? Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41]

10/20 mag 4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use ‘Introduction’ as a heading following the title. The first paragraph clearly implies the introduction and no heading are needed. [p. 27 and example on p. 42]

10/20 mag 5. Margins: Did you leave 1” on all sides? [p. 229]10/20 mag 6. Double-spacing: Did you double-space throughout? No triple or extra spaces

between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59]

10/20 mag 7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229]

10/20 mag 8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P. 229 for exceptions.

10/20 mag 9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a reference and initials in a person’s name? Do not space after periods in abbreviations. Space twice after punctuation marks at the end of a sentence. [p. 87-88]

10/20 mag 10. Typeface: Did you use Times Roman 12-point font? [p. 228]10/20 mag 9. Abbreviation: Did you explain each abbreviation the first time you used it? [p. 106-111]10/20 mag 11. Plagiarism: Cite all sources! If you say something that is not your original idea,

it must be cited. You may be citing many times…this is what you are supposed to be doing! [p. 170]

10/20 mag 12. Direct Quote: A direct quote is exact words taken from another. An example with citation would look like this:“The variables that impact the etiology and the human response to various disease states will be explored” (Bell-Scriber, 2007, p. 1).Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this? [p. 170-172]

10/20 mag 13. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? [p. 170-172]


10/20 mag 14. Paraphrase: A paraphrase citation would look like this:Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and multiple examples in text on p. 40-59]

10/20 mag 15. Headings: Did you check your headings for proper levels? [p. 62-63].10/20 mag 16. General Guidelines for References:

A. Did you start the References on a new page? [p. 37]B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same.C. Is your reference list double spaced with hanging indents? [p. 37]

PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE13. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.)

10/20 mag 14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesn’t make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this?

10/20 mag 15. Wordiness: check for the words “that”, and “the”. If not necessary, did you omit?

10/20 mag 16. Conversational tone: Don’t write as if you are talking to someone in a casual way. For example, “Well so I couldn’t believe nurses did such things!” or “I was in total shock over that.” Did you stay in a formal/professional tone?

10/20 mag 17. Avoid contractions. i.e. don’t, can’t, won’t, etc. Did you spell these out?10/20 mag 18. Did you check to make sure there are no hyphens and broken words in the right

margin?10/20 mag 19. Do not use “etc.” or "i.e." in formal writing unless in parenthesis. Did you check

for improper use of etc. & i.e.?10/20 mag 20. Stay in subject agreement. When referring to 1 nurse, don’t refer to the nurse as

“they” or “them”. Also, in referring to a human, don’t refer to the person as “that”, but rather “who”. For example: The nurse that gave the injection….” Should be “The nurse who gave the injection…” Did you check for subject agreement? Likewise, don’t refer to “us”, “we”, “our”, within the paper…this is not about you and me. Be clear in identifying. For example don’t say “Our profession uses empirical data to support ….” . Instead say “The nursing profession uses empirical data…..

10/20 mag 21. Did you check your sentences to make sure you did not end them with a preposition? For example, “I witnessed activities that I was not happy with.” Instead, “I witnessed activities with which I was not happy.”

10/20 mag 22. Did you run a Spell-check? Did you proofread in addition to running the Spell-check?

10/20 mag 23. Did you have other people read your paper? Did they find any areas confusing?10/20 mag 24. Did you include a summary or conclusion heading and section to wrap up your

paper?


25. Do not use “we” “us” “our” “you” “I” etc. in a formal paper! Did you remove these words?26. Does your paper have sentence fragments? Do you have complete sentences? 27. Did you check apostrophes for correct possessive use? Don’t use apostrophes unless it is showing possession and then be sure it is in the correct location. The exception is with the word it. It’s = it is. It is possessive.

Signing below indicates you have proofread your paper for the errors in the checklist:

__Margaret Gerulski_____________________________________DATE:_10/20/2009_______A peer needs to proofread your paper checking for errors in the listed areas and sign below:

_Erin Burdi / Amy Siler___________________DATE: 10/20/2009 _______________Revised Fall 2009

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Coached Versus Spontaneous Pushing In Second Stage …margaretgerulski.weebly.com/.../9/8/4/8984538/gerulski.… · Web viewNewborns suffer less acidemia and de ... trauma and related