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

Sommerness, Samantha A.

Monday, June 25, 2012 : 2:45 PM

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

Prince George's Exhibit Hall D (Gaylord National Harbor)

Samantha A. Sommerness, DNP, RN, CNM , The Birthplace, Fairview Southdale Hospital, Edina, MN

Charles Hirt, MD , Obstetrics, Paul Larson Clinic, Edina, MN

Phillip Rauk, MD , Department of Obstetrics Gynecology and Women's Health, University of Minnesota Medical School, University of Minnesota Medical Center, Fairview, Minneapolis, MN

Becky L. Gams, RN, MS, CNP , University of Minnesota Medical Center, Fairview, Minneapolis, MN

Audio File

Discipline: Childbearing (CB), Advanced Practice (AP)

Learning Objectives:

State the maternal and fetal potential evidence-based benefits of delaying pushing for nulliparous and parous women with epidural analgesia.
Identify management strategies for enhancing fetal descent while waiting for the urge to push in women with epidural analgesia.
Identify why an evidence-based guideline used to standardize the management of the 2nd stage of labor in both the immediate and delayed pushing group improves perinatal outcomes.

Submission Description:

Background:

The goal of the project was to reduce the number of preventable birth injuries, while improving the quality of care during the second stage of labor within a healthcare system in Minneapolis, Minnesota. The project team developed and implemented a standardized guideline for the second stage of labor after a careful review of the literature. The guideline set the following parameters: (a) the duration of time a patient may remain in the second stage of labor utilizing evidence-based guideline, (b) strategies to mitigate labor progress issues, (c) confirmation measures to assure that both mother and fetus are not in jeopardy and (d) determining intervention steps if jeopardy is identified. Implementation of a Second Stage of Labor Guideline builds on the Zero Birth Injury Initiative (ZBII). The goal of reducing birth injuries to zero include: NICU admissions, 3rd and 4th degree lacerations, operative vaginal births (forceps and vacuum use), potentially avoidable cesarean sections 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 – July, 2011. During this period, the delivery outcomes for 428 women were evaluated and compared to 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 as compared to those 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 3rd and 4^th degree lacerations and caesarean 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 3^rd degree laceration (95% CI (2.8, 11.1, p <.001).

Framework for the talk:

The presentation will review the above project: the literature, methods, results and its implications at our hospital.

Implications for 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.

Keywords: second stage, active pushing phase, delaying pushing, episiotomies, operative vaginal birth, 3rd/4th lacerations, cesarean sections.