To Push or Not to Push: An Evidenced-Based Guideline Shown to Improve Maternal and Neonatal Outcomes


Paper Presentation

Purpose for the Program

The goal of the project was to reduce the number of preventable birth injuries within a health care system in Minneapolis, Minnesota, while improving the quality of care during the second stage of labor.

Proposed Change

The project team developed and implemented a standardized evidence-based guideline for the second stage of labor after a careful review of the literature. The guideline set the following parameters: the duration of time a patient may remain in the second stage of labor, strategies to mitigate labor progress issues, confirmation measures to ensure that mother and fetus are not in jeopardy, and a process of determining the intervention steps if jeopardy is identified.

Implementation, Outcomes, and Evaluation

The implementation of a Second Stage of Labor Guideline builds on the Zero Birth Injury Initiative. The goal of reducing birth injuries to zero include preventing neonatal intensive care unit admissions, third and fourth degree lacerations, operative vaginal births (forceps and vacuum use), potentially avoidable cesarean births, and maternal and infant mortality.

This guideline was piloted at a 13-bed labor and delivery unit within a community hospital in the upper Midwest from April to July 2011. During this period, the delivery outcomes for 428 women were evaluated and compared with a baseline retrospective chart review of 403 deliveries.

When the guideline was used, a woman was half as likely to have a vacuum-assisted birth (OR = 0.44, 95% CI [.24, .78], p = .006). Those for whom the guideline was used also had a significantly shorter active pushing duration than those for whom the guideline was not used (median = 25 minutes, range 0-185 vs. 35 minutes, range 2-18, p < .001). The total length of the second stage, 5-minute Apgar score, number of third and fourth degree lacerations, and cesarean births were similar. If a woman had a vacuum-assisted birth, she was almost twice as likely to have an episiotomy (OR = 1.7, 95% CI [1.1, 3.7], p = .01) and if she had an episiotomy she was 5.6 times more likely to experience a third-degree laceration (95% CI [2.8, 11.1], p < .001).

Implications for Nursing Practice

A guideline for the second stage of labor can be developed within any labor and delivery unit. We hope to show these benefits and discuss how this process can be implemented.