Pushing Methods Used by the UK Midwives during the Second Stage of Labor: Current Practice and Rationale - Research Proposal Example

 Pushing methods used by UK midwives during the second stage of labor: current practice and rationale. Research proposal Contents Pushing methods used by UK midwives during the second stage of labor: current practice and rationale. 1 Research proposal 1 Pushing methods used by UK midwives during the second stage of labor: current practice and rationale. 2 1.0 Background 2 2.0 Introduction 4 2.1 Problem statement 4 2.2 Purpose of the study 5 2.3 Research Questions 5 3.0 Review of the Literature 5 4.0 Methodology 7 References 10 Appendix I: Abstracts of 5 Articles used. 12 Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Trauma at Birth: A Randomized Trial 13 Abstract 13 Effects of pushing techniques in birth on mother and fetus: a randomized study. 13 Abstract 13 Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. 15 Source 15 Abstract 15 A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. 17 Abstract 17 Source 17 Abstract 17 Pushing methods used by UK midwives during the second stage of labor: current practice and rationale. 1.0 Background The second stage of labor is the period between the moment when the cervix attains complete dilatation and when the baby is born (Caldeyro-Barcia et al. 1981). This stage is portrayed by frequent and regular contractions and it is the period when the mother experiences rectal pressure, vaginal pressure, and an irresistible need to push down. For a long time in the history, the management of the second stage of labor has consisted of a set of behaviors that start when the midwives become aware that the woman has attained full dilatation and hence prepared to push. The midwives proceed by instructing the mother to continue pushing while holding their breath, with successful contractions (Hanson 2006; Hansen, Clark and Foster, 2002). This kind of practice has been done by many midwives for the purpose of shortening the occurrence of the second stage of labor and speeding up fetal descent, though the rationale and safety of the practice has not been substantiated (Yildirim, Beji, 2008). Nevertheless, there is mounting evidence showing that unplanned pushing is a better way of managing the second stage of labor than directed planning, which is typically done by Valsalva maneuver. When all is said and done, many midwives in the United Kingdom (U.K.) and other parts of the world have continuously adopted the directed mode of attending to mothers when giving birth, during the second period of labor. In their study, Beynon (1957) observed that if allowed to undergo unplanned pushing in the second stage of labor. A recent study by Osborne (2010) found that midwives felt the need of supporting women without epidural anesthesia to start the efforts of bearing-down on when the women felt the need to do so. The majority of the participants, however, revealed that they did not provide direction when helping the mothers, which means many of them often, supported spontaneous bearing-down. Their study further revealed that most of the midwives started providing directive support when the fetal head appeared and when the final drawing out of the perineum was occurring. The other factor that influenced directive support was the tendency by the mothers to ask for more direction or when they appeared to be exhausted (Osborne 2010) An unplanned push is accompanied by a release of numerous breaths and air within the intervals of bearing-down attempts (Roberts et al. 1987; Bloom 2006). Albers et al. (2005) scrutinized pushing techniques used by Certified Nurse-Midwives (CNMs) and found that the largest proportion of midwives preferred non-Valsalva methods. For quite a long time, the practice of subjecting women to long pushes in the course of the second-stage of labor has been disapproved by critics. 2.0 Introduction The practice of midwifery is premised on the view that labor and birth are ordinary physiological phenomenon that takes place in the life of a woman. The practice of midwifery involves use of various interventions such as non-intervention, watchful waiting, and suitable application of interventions and technology. Midwives actions are based on the view that women have the ability of giving natural birth, but take part in persistent risk evaluation, chipping in the process of labor only when they deem it necessary to do so, with the practice tied on evidence (Osborne 2010). This study is aimed at identifying the current practices and rationale of Pushing methods used in the UK midwives during the second stage of labor. 2.1 Problem statement Midwives apply a number of techniques when helping their clients during the second stage of labor. If not careful, the midwives can use methods that would expose the mothers to different risks when undergoing their second stage of labor, including obstetric genital tract. During this stage, the mothers experience a lot of challenges including sharp pain and muscle clamps. This calls for the midwives to exercise due care to ensure the safety of the mother as well as the unborn baby is safeguarded (Osborne 2010). In attempted to examine the methods used by midwives during the second stage of delivery, different researchers have come up with divergent views on the rationale of certain techniques. For example, there has been a heated debate on whether women should start pushing immediately the cervix is fully dilated; which is usually be done in a manner that allows the woman to continuously take a deep breath (BeFitzhugh & Newton, 1956). These techniques, among many others that are used during the second stage of labor, have prompted conducting of this study. 2.2 Purpose of the study The purpose of this study will be to learn from Certified Nurses-Midwives (CNM) and Certified Midwives (CM) about current methods of pushing used during the second stage of labour in the UK. This information can be used, by different health professionals, to help them improve their health care deliver. Most importantly, this information will help midwives to refresh on the risks that mothers are involved in when in the second stage of labor. More so, the hospital management and other health foresight bodies can rely on the information derived from this study to make policies that will improve health care delivery. 2.3 Research Questions 1. What prompts the UK midwives to support the mother’s spontaneous bearing-down? 2. What are the factors that prompt the UK midwives to use directive methods when helping mothers? 3. What is the underlying principle of the methods used by UK midwives to support mothers during the second stage of labour? 4. What are the available perineal care measures as part of current practice in UK? 3.0 Review of the Literature During the second stage of labor, midwives apply a number of hand-based methods, with the aim of helping the mothers lower genital tract rates that happens after vaginal birth (Albers et al. 2005. This stage has a vast body of evidence, which will be discussed in this section. Some of the methods that help with therapeutic effects include massage with lubricants and warm compresses. These include pain perception, muscle relaxation, tissue stretching or extensibility and increased blood supply. Although the choice of hand intervention is a common clinical practice during the second stage of labor, there is no credible evidence that supports its application(Osborne 2010). A study carried out by Albers et al. (2005) compared keeping hands off the perineum late and lubricants or warm compresses in the second stage of labor, and found no tangible advantages of disadvantages in any of the interventions in lessening obstetric genital tract trauma. Their study was also interesting in that 77+% in each group did non-Valsalva and the type of pushing was not identified as a significant variable with respect to perineal trauma or Apgars. The potential deleterious impacts of Valsalva pushing had earlier led to emergence of evidence proposing that the directive techniques of managing the second phase of labor should be revisited. In his study, Sinquefield (1985) gave a summary of the recommendations of veteran nurse-midwives who explained the way they managed the second stage of labor. All the nurse-midwives emphasized the significance of upholding the sensitivity of the exclusive needs that individual women undergo during their labor, as well as upholding flexibility in order to satisfy those exclusive needs as management resolutions were being discharged. Although all the midwives disclosed that they sometimes applied directive practices, they also maintained that they provided their clients with constant human presence and support in their second stage labor (Sinquefield, 1985). When criticism of directed methods during the second stage of labor surfaced, the physicians were commonly involved in encouraging the women to start pushing immediately the cervix was fully dilated which was supposed to be done in a manner that allowed the woman to continuously take a deep breath (Sinquefield, 1985). This method of pushing was particularly criticized because it was though that its expulsive and strong pushing early in the course of the second stage would cause maternal fatigue. It was also argued that pushing in the lothotomy position caused inefficient use of abdominal muscles and unnecessary uneasiness (Fitzhugh and Newton 1956). 4.0 Methodology Essentially, qualitative phenomenological is a non-standardized study as opposed to quantitative study. Since the aim of the study is not to establish the relationships of the research variables, a strictly quantitative study is not necessary. Furthermore, quantitative study is not suitable in this study since the primary goal is to obtain themes and central phenomena as regards the management of the second stage of labor. The questions that will be asked will be aimed at giving the CNMs and NMs an opportunity to discuss their current practices and rationale during the second stage of labor, including their differences, similarities, barriers, and facilitating factors they experience when applying those care practices that support women during the second stage of labor. Furthermore, qualitative phenomena are better designed to capture the personal experiences, observations, opinions, perceptions as well as storytelling, which will be used to assess the rationale of the techniques they apply in helping women during their second stage of labor (Moustakas, 1994). The phenomenological study will involve interviewing of between five and ten CNMs and NMs (both males and females) within maternity hospitals within the London area. The interview will be semi-structured and carried on a one-on-one approach. For the gender balance purpose, the study will ensure a 1:1 ratio of men to women. Each interview will last for about 45 to 60 minutes (Weber, 1949). The inclusion criteria of the participants will include a requirement that the selected CNMs and NMs must be active and registered members of the association of nurse-midwives and they must have at least 5 years of midwifery experience. The primary instrument in a qualitative study is usually the researcher, who is essentially charged with the responsibility of collecting the required data for the study. Before data collection, the researcher will conceptualize and consider the ideas, but in accordance with the suggestions of Neuman (2003), creation of new processes and new ideas during data collection will be important. In addition, the forms that will be used for data collection will be designed in accordance with the research questions as well as the information that will be collected during the interview. The process of data collection will entail one-on-one interviews, storytelling, answering of open-ended questions and explaining of the personal perception as regards the rationale of the kind of care practices they use during the second stage of labor. In the one-on-one interview, the researcher will directly ask the participants questions that are deemed important for the study and then the participant will be left to respond to those questions freely and without undue influence or pressure. To allow for clarification and transcription during triangulation, the research will also include an audiotape the interview. Once each transcribed text is accomplished, triangulation will be conducted (Machlup 1978). To ensure informed participation, Cone and Foster (2003) pointed out that it is critical to seek informed consent from the participants and also ensure their confidentiality. In this view, the researcher will ensure that a clear informed and voluntary agreement is made with the participants (Ellis and Earley, 2006). The kind of informed consent, which will be used in this study, will have to meet specific requirements including a statement that the study is about research, a description of the procedures that will be involved, an explanation of the purpose of the research, and details of the expected period of participants’ involvement. Most importantly, no participant will be coerced to take part in the study. All participants will be informed that they are free to withdraw from the participation anytime they want without any consequences. Before signing the consent form, the participant will also be given a chance to analyze its content so their choice to participate or not to participate can be fully informed. The participants will be guaranteed that all the information that they will reveal in the course of the study will remain strictly confidential and a statement of confidentiality will, therefore, be attached in the consent form. The data analysis method that will be used will need to reflect the purpose and the results of this study. In this study, appropriate coding techniques will be used to ensure that qualitative information is analyzed accurately. The data will be coded in a manner that will derive appropriate themes. Then, this data will be entered into NVivo 7.0 software, which will enhance segmentation, coding and analysis of the data. Also, a central phenomenon will be derived by use of the software, which will help in the final analysis. The software will assist in coding of qualitative rate categories and analyzing between and within categories. In addition, the software will be very useful for merging and formation and clustering of various responses in the course of the interview, which also helps in the development of central phenomena and themes. The findings of this study cannot be generalised because the participants were highly experienced. References Albers, L., Sedler, K., Bedrick, E., Teaf, D. and Peralta, P., 2005. Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized Trial. Journal of Midwifery & Women’s Health, 50(5), pp. 365-372. Yildirim, G, Beji, N., 2008. Effects of pushing techniques in birth on mother and fetus: a randomized study. Birth, 30, pp. 25-30. Beynon, C., 1957. The normal second stage of labour: A plea for reform in its conduct. Journal of Obstetrics and Gynaecology, 64(6), pp. 815-820. Cone, J.and Foster, S., 2003. Dissertations and theses from start to finish: Psychology and related fields. Washington, DC: American Psychology Association. Ellis, J. and Earley, M., 2006. Reciprocity and constructions of informed consent: Researching with indigenous populations. International Journal of Qualitative Methodology,5(4), pp. 1-9. Fitzhugh, M. and Newton, M., 1956. Muscle action during childbirth. The Physical Therapy Review, 36(12), pp. 805-809. Caldeyro-Barcia, R., Giussi, G., Storch, E., et al., 1981. The bearing-down efforts and their effects on fetal heart rate, oxygenation and acid base balance. J PerinatMed, 9, pp. 63-67. Hanson L., 2009. Second-stage labor care: challenges in spontaneous bearing down. J Perinat Neonatal Nurs.23, pp. 31-39. Machlup, F., 1978. Methodology of economics and other social sciences. New York: Academic Press. Moustakas, C., 1994. Phenomenological Research Methods. New Delhi: International educational and professional publisher. Neuman, W. L., 2003. Social research methods: Quantitative and qualitative approaches (5th ed.). Upper Saddle River, NJ: Prentice Hall Osborne, K., 2010. Pushing Techniques Used By Midwives When Providing Second. A dissertation in degree of philosophy. Hansen, S., Clark, S., Foster, J., 2002. Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Obstet Gynecol, 99, pp. 29-34. Roberts, J., Goldstein, S., Gruener, J., Maggio, M. and Mendez-Bauer, C., 1987. A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor. JOGNN, 16(1), pp. 48-55. Sinquefield, G., 1985. Midwifery management of second stage of labor. Journal of Nurse- Midwifery, 30(2), pp. 112-116. Bloom, S., Casey, B., Schaffer, J., McIntire, D., Leveno, K. A., 2006. Randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol, 194, pp.10-13. Weber, M., 1949. The methodology of the social sciences. (E. Shils, & H. Finch, Trans.). New York, NY: The Free Press. Appendix I: Abstracts of 5 Articles used. Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Trauma at Birth: A Randomized Trial Leah L. Albers, CNM, DrPH, Kay D. Sedler, CNM, MN, Edward J. Bedrick, PhD, Dusty Teaf, MA, and Patricia Peralta Abstract Genital tract trauma following spontaneous vaginal childbirth is common, and evidence-based prevention measures have not been identified, beyond minimizing the use of episiotomy. This study randomized 1211 healthy women in midwifery care at the University of New Mexico teaching hospital to one of three care measures late in the second stage of labor:1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant’s head. The purpose was to assess whether any of these measures was associated with lower levels of obstetric trauma. After each birth, the clinical midwife recorded demographic, clinical care, and outcome data, including the location and extent of any genital tract trauma. The frequency distribution of genital tract trauma was equal in all three groups. Individual women and their clinicians should decide whether to use these techniques based on maternal comfort and other considerations. Keywords: childbirth, midwifery, perineal management, genital tract trauma, perineal trauma Effects of pushing techniques in birth on mother and fetus: a randomized study. Yildirim G, Beji NK. Florence Nightingale School of Nursing, Department of Obstetric and Gynecologic Nursing, Istanbul University, Istanbul, Turkey. Abstract 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. Obstet Gynecol. 2002 Jan;99(1):29-34. Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Hansen SL, Clark SL, Foster JC. Source Intermountain Health Care, Salt Lake City, Utah, USA. Abstract OBJECTIVE: To compare perinatal outcomes among women with epidural anesthesia who were encouraged to push at complete dilatation with those who had a period of rest before pushing began. METHODS: After a power analysis to determine appropriate sample size (based upon an alpha error rate of.05% and 80% power), a prospective randomized trial of 252 women with epidural anesthesia was conducted. Patients were randomized to a rest period or immediate pushing at complete dilatation. Variables measured included rate of fetal descent, length of time of pushing, the number and type of fetal heart rate decelerations, Apgar scores, arterial cord pH values, perineal injuries, type of delivery, length of second stage, maternal fatigue, and endometritis. RESULTS: When a period of rest was used before pushing, we found a longer second stage, decreased pushing time, fewer decelerations, and, in primiparous women, less fatigue compared with control patients. Apgar scores, arterial cord pH values, rates of perineal injury, instrument delivery, and endometritis were similar in both groups. CONCLUSION: Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Bloom SL, Casey BM, Schaffer JI, McIntire DD, Leveno KJ. Abstract Source Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA. Abstract OBJECTIVE: The objective of this study was to compare obstetrical outcomes associated with coached versus uncoached pushing during the second stage of labor. STUDY DESIGN: 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. RESULTS: 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. CONCLUSION: Although associated with a slightly shorter second stage, coached maternal pushing confers no other advantages and withholding such coaching is not harmful. Pushing Techniques Used By Midwives When Providing Second Stage Labor Care By Kathryn Osborne, Bsn Msn Cnm A growing body of evidence suggests that spontaneous pushing during the second stage of labor results in better outcomes than directed pushing, which usually involves repeated use of the Valsalva maneuver. However, birth attendants in the United States (U.S.) continue to use directive methods when caring for women in the second stage of labor. This study used quantitative methods with the Theory of Diffusion of Innovations as a framework to identify and describe the practices used by certified nurse-midwives and certified midwives, practicing in the U.S., when caring for women in second stage labor. Data were gathered using a questionnaire mailed through the U.S. Postal Service. Implications for nursing practice, nursing education and nursing research are identified. The literature regarding what is known about pushing methods used during second stage labor is reviewed, as well as the philosophical underpinnings and theoretical framework of the present study. Findings revealed that midwives provide care during second stage labor that is primarily supportive of women’s physiologic urge to bear down. When midwives use directive methods, they do so as an intervention to prevent potential problems. Further, midwives offer “supportive direction” in response to cues they receive from women in labor. Appendix II: Literature search strategy The literature search was started by pointing out the key words and phrases – these are the words and phrases which had significant implication on the subject being studied. Examples of key words and phrases for the current study included “midwifes”, “second stage of labor”, “Rationale”, “Practices”, and “pushing methods.” These key words and phrases were particularly important because the study focused on at least one of them at any given time. Having identified the key words, the first search platform to be used was the internet, whereby for example the phrase “second stage of labor” was entered in the Google search engine and the search button clicked. The same procedure was repeated with Cinhal and summons search engines. The search engine generated 28,300,000 search results. The second key word to add in the blank box at the top of the page and the search clicked – this reduced the search results to 401, 000. From this point, I started reviewing the available results while at the same time narrowing the useful articles to only articles from scholarly publications and, including the peer reviewed. For the parts of Cinhal and summon search engines, narrowing of the search can be done selecting the ‘peer reviewed’ from the refined box option, which leads to search of only the peer reviewed articles from the database. As I progressed with my search, I added more key words to make sure I got different articles that, in whole, contained all the necessary content to cover the research questions. The first procedure after downloading an article that was suspected to be relevant is to skim through the abstracts, and making comparisons of their strength and relevance to my topic such that I was left with the best five. For additional publications, all the references on these articles were searched from recent articles. All the databases were searched using similar databases. Appendix III: How I applied PICO strategy PICO was used to formulate the research question as follows: Concept questions Population, Patient, Client the clients are mothers; they are in their second stage of labor; others affected are midwives Intervention Interventions includes pushing by hands; watchful waiting; directive methods; and suitable application of technology Comparison Comparison of directive methods; spontaneous pushing and non-Valsalva methods. Outcome, expectation Find and measures methods that can be effectively used to reduction of pain, ensure safe and effective giving of birth by mothers, and reduce the second stage of labor. Setting Hospitals; Maternity wards. Evaluation Has the second stage of labor reduced? Has pain reduced? Has the baby been born safely? Scenario A mid-age mother who is struggling to give birth in the hospital’s maternity ward has been undergoing a lot of pain and the midwives are wondering whether they should intervene by directing her what do, i.e. instruct her to push while holding her breath. However, their misgivings can be read in their faces as they are weighing whether intervention or non-intervention is the best way to go, but they can’t wait to help the mother whose second stage of labor is already prolonged. Population: mother Intervention: directive pushing Comparator: non-intervention Outcome: reduction of pain during the second stage of labor Read More