Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study.

PROBLEMS: Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings. AIM: We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage. METHODS: Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care. FINDINGS: We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers. DISCUSSION & CONCLUSION: These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

How do midwives facilitate women to give birth during physiological second stage of labour? A systematic review.

Both nationally and internationally, midwives' practices during the second stage of labour vary. A midwife's practice can be influenced by education and cultural practices but ultimately it should be informed by up-to-date scientific evidence. We conducted a systematic review of the literature to retrieve evidence that supports high quality intrapartum care during the second stage of labour. A systematic literature search was performed to September 2019 in collaboration with a medical information specialist. Bibliographic databases searched included: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Maternity and Infant Care Database and The Cochrane Library, resulting in 6,382 references to be screened after duplicates were removed. Articles were then assessed for quality by two independent researchers and data extracted. 17 studies focusing on midwives' practices during physiological second stage of labour were included. Two studies surveyed midwives regarding their practice and one study utilising focus groups explored how midwives facilitate women's birthing positions, while another focus group study explored expert midwives' views of their practice of preserving an intact perineum during physiological birth. The remainder of the included studies were primarily intervention studies, highlighting aspects of midwifery practice during the second stage of labour. The empirical findings were synthesised into four main themes namely: birthing positions, non-pharmacological pain relief, pushing techniques and optimising perineal outcomes; the results were outlined and discussed. By implementing this evidence midwives may enable women during the second stage of labour to optimise physiological processes to give birth. There is, however, a dearth of evidence relating to midwives' practice, which provides a positive experience for women during the second stage of labour. Perhaps this is because not all midwives' practices during the second stage of labour are researched and documented. This systematic review provides a valuable insight of the empirical evidence relating to midwifery practice during the physiological second stage of labour, which can also inform education and future research. The majority of the authors were members of the EU COST Action IS1405: Building Intrapartum Research Through Health (BIRTH). The study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration CRD42018088300) and is published (Verhoeven, Spence, Nyman, Otten, Healy, 2019).

Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives' experiences in Northern Italy.

OBJECTIVE: To explore midwives' experiences of the management of the second stage of labour in women with epidural analgesia. DESIGN: Descriptive qualitative study using semi-structured face-to-face interviews. PARTICIPANTS: Purposive sample of twelve midwives working in three Obstetric Units. Among them six were senior midwives with more than five years' experience on labour ward and six were junior midwives with less than five years' experience on labour ward. FINDINGS: The findings included four themes: a) timing of second stage of labour and maternal pushing; b) maternal positions and mobility; c) perspectives on epidural boluses; d) midwifery presence and support. The time 'allowed' by midwives for the passive phase of the second stage of labour ranged from zero to two hours, with some of them avoiding vaginal examinations to delay the recorded starting time of active pushing. The semi-sitting and the lithotomy positions were the most used respectively in labour and at birth. Some midwives encouraged the kneeling position or the lateral position. Regarding the management of the epidural bolus during the second stage of labour, the interviewees' opinions were divided between favourable and unfavourable to the administration of analgesic boluses after the full cervical dilatation. Midwives reported their experiences of providing different care to women with epidural analgesia when compared to women without epidural, mainly due to a more medicalised approach and the midwives' sense of 'usefulness' when caring for women not experiencing labour pain. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To our knowledge, this was the first study on this topic conducted in an Italian setting. Despite the consistent body of evidence on the effects of epidural analgesia in the second stage on birth outcomes, the lack of clear guidelines, the presence of different hospital protocols and Obstetricians' opinion, introduce uncertainty in midwifery practice and lead midwives with feelings of 'uselessness'. Across the four themes, midwives frequently had to negotiate a space for their professional autonomy with other healthcare professionals, whilst adhering to the Obstetric Units' protocols. An influencing factor on the care provided to women with epidural was the years of midwife's experience on labour ward. Further research and the development of comprehensive midwifery care guidelines on the management of the second stage of labour in women with an epidural analgesia appears essential.

Using Hourly Time-Outs and a Standardized Tool to Promote Team Communication, Medical Record Documentation, and Patient Satisfaction During Second-Stage Labor.

BACKGROUND: During labor, effective communication and collaboration among the healthcare team is critical for patient safety; however, there is currently no standard for communication and documentation of the plan of care as agreed upon by healthcare team members and the woman in labor. OBJECTIVES: The goal of this project was to increase consistency in communication and collaboration between clinicians and laboring women during second-stage labor. METHODS: An hourly "time-out" meeting of all healthcare team members was initiated for all women during second-stage labor. A documentation tool was implemented to ensure regular and clear communication between the clinical team and laboring women. Data were collected via medical review of cases of second-stage labor lasting more than 2 hours (n = 21 in the pre-implementation group; n = 39 for 3 months postimplementation; and n = 468 patients for 2 years post-implementation). Surveys were conducted of the clinical team (n = 40) and patients (n = 28). RESULTS: Following implementation, documented agreement of the plan of care increased from 14.3% before the project to 82.1% 3 months after implementation and remained at 81.6% 2 years after implementation. All nurses who participated in the survey reported a clear understanding of how and when to complete necessary medical record documentation during second-stage labor. The providers viewed the project favorably. Most women (92.9%) reported satisfaction with their experience. This project enhanced collaborative communication between members of the clinical team and laboring women and improved patient satisfaction. The improvements were sustainable over a 2-year period.

The Routine Use of Intrapartum Ultrasound in Clinical Decision-Making during the Second Stage of Labor - Does It Have Any Impact on Delivery Outcomes?

BACKGROUND/AIMS: The study aimed to assess whether the use of intrapartum transperineal ultrasound (US) can reduce the rate of failed vacuum extraction (VE). METHODS: This is a retrospective cohort study including all women delivering at term with the diagnosis of protracted second stage of labor. The mode of delivery and rate of failed VE were compared between women who underwent a US examination prior to the decision on obstetrical interventions ("+US" group) and those in whom clinical decisions were based upon digital assessment only ("no-US" group). RESULTS: The study included 635 women. Among the "no-US" group (536), there were 13 failed VE attempts (3.6%) vs. none in the "+US" group (99, p = 0.1). There was a significant difference between the groups regarding mode of delivery (p = 0.001), with a lower cesarean section (CS) rate (20.2 vs. 27.8%) among the "+US" group. Maternal age, body mass index, nulliparity, gestational age at delivery, and birth weight, as well as neonatal short-term outcome did not differ significantly between the 2 groups. CONCLUSIONS: We demonstrate that among women who had the addition of intrapartum US during the second stage of labor there was a trend toward a lower rate of failed VE (although not reaching statistical significance), with a lower rate of CS but not affecting neonatal outcome.

Psychometric properties of the Swedish childbirth self-efficacy inventory (Swe-CBSEI).

BACKGROUND: Previous research has reported that women who are admitted to delivery wards in early labour process before an active stage of labour has started run an increased risk of instrumental deliveries. Therefore, it is essential to focus on factors such as self-efficacy that can enhance a woman's own ability to cope with the first stage of labour. However, there was no Swedish instrument measuring childbirth self-efficacy available. Thus, the aim of the study was to translate the Childbirth Self-efficacy Inventory and to psychometrically test the Swedish version on first- time mothers within the Swedish culture. METHODS: The method included a forward-backward translation with face and content validity. The psychometric properties were evaluated using a Principal Component Analysis and by using Cronbach's alpha coefficient and inter-item correlations. Descriptive statistics and non-parametric tests were used to describe and compare the scales. All data were collected from January 2011 to June 2012, from 406 pregnant women during the gestational week 35-42. RESULTS: The Swedish version of the Childbirth Self-Efficacy Inventory indicated good reliability and the Principal Component Analysis showed a three-component structure. The Wilcoxon Signed-Ranks Test indicated that the women could differentiate between the concepts outcome expectancy and self-efficacy expectancy and between the two labour stages, active stage and the second stage of labour. CONCLUSIONS: The Swedish version of Childbirth Self-efficacy Inventory is a reliable and valid instrument. The inventory can act as a tool to identify those women who need extra support and to evaluate the efforts of improving women's self-efficacy during pregnancy.

Birth setting, transfer and maternal sense of control: results from the DELIVER study.

BACKGROUND: In the Netherlands, low risk women receive midwife-led care and can choose to give birth at home or in hospital. There is concern that transfer of care during labour from midwife-led care to an obstetrician-led unit leads to negative birth experiences, in particular among those with planned home birth. In this study we compared sense of control, which is a major attribute of the childbirth experience, for women planning home compared to women planning hospital birth under midwife-led care. In particular, we studied sense of control among women who were transferred to obstetric-led care during labour according to planned place of birth: home versus hospital. METHODS: We used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Sense of control during labour was assessed 6 weeks after birth, using the short version of the Labour Agentry Scale (LAS-11). A higher LAS-11 score indicates a higher feeling of control. We considered a difference of a minimum of 5.5 points as clinically relevant. RESULTS: Nulliparous- and parous women who planned a home birth had a 2.6 (95% CI 1.0, 4.3) and a 3.0 (1.6, 4.4) higher LAS score during first stage of labour respectively and during second stage a higher score of 2.8 (0.9, 4.7) and 2.3 (0.6, 4.0), compared with women who planned a hospital birth. Overall, women who were transferred experienced a lower sense of control than women who were not transferred. Parous women who planned a home birth and who were transferred had a 4.3 (0.2, 8.4) higher LAS score in 2nd stage, compared to those who planned a hospital birth and who were transferred. CONCLUSION: We found no clinically relevant differences in feelings of control among women who planned a home or hospital birth. Transfer of care during labour lowered feelings of control, but feelings of control were similar for transferred women who planned a home or hospital birth.As far as their expected sense of control is concerned, low risk women should be encouraged to give birth at the location of their preference.

A dream birth? Try hypnobirthing!

Hypnobirthing is often regarded as a method of pain relief without drugs. This is to miss the point, as it presupposes that pain is there in the first place. When a woman learns to release the preconceptions, fears and worries about birth that are endemic in our society, her experience of giving birth to her baby can be the most wonderful and empowering experience of her life. Mind and body working together can be a powerful and efficient combination. This is how birth is designed to be, as midwives and hospitals are beginning to discover. Thus hypnobirthing can provide a service that women want as well as save scarce NHS funds.

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.

Influence on birthing positions affects women's sense of control in second stage of labour.

OBJECTIVE: to explore whether choices in birthing positions contributes to women's sense of control during birth. DESIGN: survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control. SETTING: midwifery practices in the Netherlands. PARTICIPANTS: 1030 women with a physiological pregnancy and birth from 54 midwifery practices. FINDINGS: in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves. KEY CONCLUSIONS: women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value. IMPLICATIONS FOR PRACTICE: midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.

Hypnotherapy for childbirth.

The birthing process, although often a joyful and proud moment, can also create an overwhelming sense of anxiety. As a result some women are now turning to hypnobirthing to help them to cope. This practice is used to relax women before and during their labour. It also helps encourage a stress free birth and reduce the need for drugs and interventions, such as caesarean section. In this article, Sheila Granger helps to dispel some of the myths surrounding the use of hypnotherapy and looks specifically at its application to childbirth. The role of midwives and the benefits to them are also discussed.

Preferred place of birth: characteristics and motives of low-risk nulliparous women in the Netherlands.

OBJECTIVE: to explores preferences, characteristics and motives regarding place of birth of low-risk nulliparous women in the Netherlands. DESIGN: a prospective cohort study of low-risk nulliparous women and their partners starting their pregnancy in midwifery-led care or in obstetric-led care. Data were collected using a self-administered questionnaire, including questions on demographic, psychosocial and pregnancy factors and statements about motives with regard to place of birth. Depression, worry and self-esteem were explored using the Edinburgh Depression Scale (EDS), the Cambridge Worry Scale (CWS) and the Rosenberg Self Esteem Scale (RSE). SETTING: participants were recruited in 100 independent midwifery practices and 14 hospitals from 2007 to 2011. PARTICIPANTS: 550 low-risk nulliparous women; 231 women preferred a home birth, 170 women a hospital birth in midwifery-led care and 149 women a birth in obstetric-led care. FINDINGS: Significant differences in characteristics were found in the group who preferred a birth in obstetric-led care compared to the two groups who preferred midwifery-led care. Those women were older (F (2,551)=16.14, p<0.001), had a higher family income (χ(2) (6)=18.87, p=0.004), were more frequently pregnant after assisted reproduction (χ(2)(2)=35.90, p<0.001) and had a higher rate of previous miscarriage (χ(2)(2)=25.96, p<0.001). They also differed significantly on a few emotional aspects: more women in obstetric-led care had symptoms of a major depressive disorder (χ(2)(2)=6.54, p=0.038) and were worried about health issues (F (2,410)=8.90, p<0.001). Women's choice for a home birth is driven by a desire for greater personal autonomy, whereas women's choice for a hospital birth is driven by a desire to feel safe and control risks. KEY CONCLUSIONS: the characteristics of women who prefer a hospital birth are different than the characteristics of women who prefer a home birth. It appears that for women preferring a hospital birth, the assumed safety of the hospital is more important than type of care provider. This brings up the question whether women are fully aware of the possibilities of maternity care services. Women might need concrete information about the availability and the characteristics of the services within the maternity care system and the risks and benefits associated with either setting, in order to make an informed choice where to give birth.

Concentration and the second stage of labor: outcomes associated with the interactive metronome.

OBJECTIVE: To analyze the association between concentration, as measured by the Interactive Metronome, and a prolonged second stage of labor in nulliparous patients. STUDY DESIGN: From September 2008 to November 2009, nulliparous women at ≥34 weeks' gestation who were planning to use an epidural were asked to perform a 1-minute Interactive Metronome clapping test. Scores and demographic information were recorded. Data were then abstracted regarding each patient's labor course. The main outcome measure was the frequency of the second stage of labor exceeding 2 hours. Only patients with epidural anesthesia who completed the second stage of labor and did not require operative delivery performed for fetal indications prior to 2 full hours of pushing were included. RESULTS: Of the patients whose Interactive Metronome test scores were in the last quartile, which we associated with poor concentration, 52.9% (18/34) had a second stage of labor exceeding 2 hours compared with only 31.7% (33/104) of patients whose scores placed them in the first three quartiles (p = 0.026). CONCLUSION: Nulliparous patients with poor concentration scores, as measured by the Interactive Metronome, were more likely to push greater than 2 hours in the second stage of labor.

Lie back, listen and relax: hypnotherapy.

This article looks at how hypnotherapy is currently being used within the Uk maternity system. It includes an overview of hypnotherapy for labour, research to date, the benefits to women and midwives and how it works. It highlights some key differences between the UK and US based approaches and includes tips for midwives supporting women who have chosen to use hypnotherapy.

Factors influencing the fulfillment of women's preferences for birthing positions during second stage of labor.

Having choices and being involved in decision making contributes to women's positive childbirth experiences. During a physiological birth, women's preferences can play a leading role in the choice of birthing positions. In this study, we explored women's preferences with regard to birthing positions during second stage of labor, with a special focus on women who preferred positions other than common supine positions. A questionnaire survey was conducted among women in 54 Dutch midwifery practices. Of the 1154 women in the study, 58.9% preferred supine positions, 19.6% preferred other positions (e.g. sitting or standing), and 21.5% had no distinct preference. Women who preferred supine positions gave birth in these positions more often than women with preferences for other positions. Among the women having a preference for other positions, the actual fulfillment of their preference was related to longer duration of second stage of labor, higher levels of education, the strength of the preference, and giving birth at home. These results demonstrate differences in women's use of preferred positions during childbirth. Midwives can contribute to women-centered care by proactively exploring women's preferences for birthing positions throughout pregnancy and birth, supporting women in developing well-informed choices and facilitating these choices where possible.

Maintaining power: women's experiences from labour onset before admittance to maternity ward.

BACKGROUND: In Sweden pregnant women are encouraged to remain at home until the active phase of labour. Recommendation is based on evidence, that women who seek care and are admitted in the latent phase of labour are subjected to more obstetric interventions and suffer more complications than women who remain at home until the active phase of labour. The aim of this study was to obtain a deeper understanding of how women, who remain at home until the active phase of labour, experience the period from labour onset until admission to labour ward. METHOD: Interviews were conducted with 19 women after they had given birth to their first child. A Constructivist Grounded theory method was used. FINDINGS: 'Maintaining power' was identified as the core category, explaining the women's experience of having enough power, when the labour started. Four related categories: 'to share the experience with another', 'to listen to the rhythm of the body', 'to distract oneself' and 'to be encased in a glass vessel', explained how the women coped and thereby maintained power. CONCLUSIONS: The first time mothers in this study, who managed to stay at home during the latent phase of labour, had a sense of power that was expressed as a driving force towards the birth, a bodily and mental strength and the right to decide over their own bodies. This implies that women who maintain power have the ability to make choices during the birth process. The professionals need to be sensitive, supportive and respectful to women's own preferences in the health-care encounter, to promote the existing power throughout the birthing process.

How caregivers manage pain and distress in second-stage labor.

Innovative care interactions are needed when helping a woman who exhibits severe pain or distress during the second stage of labor. We describe how caregivers and laboring women interacted during second-stage labor, with particular attention to how caregivers managed pain and distress. We used observational methods to perform a microanalysis of behaviors from video-recorded data. Pain occurred during labor contractions, and distress (an emotional response to pain) manifested primarily between contractions. Four patterns of women's behavior were identified: 1) no pain or distress, 2) low-level pain and/or distress, 3) focused working, and 4) severe pain and/or distress. Successful care was identified as enabling the woman to maintain herself in any state other than severe pain and/or distress. Particular modes of speech used by the caregiver enabled the attainment of successful care when the woman was not in severe pain or distress. When severe pain or distress existed, innovative caregiving transitioned the woman to another state. Successful intervention strategies included 1) giving innovative directions and 2) "talking down." Ordinary modes of "birth talk" can be used when severe pain or distress is not manifested and when the primary care problem is to assist women with bearing down. Innovative care interactions are needed when faced with severe pain or distress. Managing labor pain is an ongoing focus of clinicians who provide care to women in labor. In addition to pain, women might also experience distress, an emotional response to the labor experience. Whether from choice or necessity, caregivers for laboring women need nonpharmacologic interventions and interpersonal skills that can help women endure labor and give birth. Labor is hard work, and even in precipitous labors most women require assistance. Care given to a laboring woman consists of employing comforting strategies that help her cope with the pain of uterine contractions. The purpose of these comfort strategies is to help the woman find needed resilience during labor. Most cultures have mechanisms for providing this kind of support. In this article, we identify patterns of behavior used by laboring women and describe successful and unsuccessful strategies used by caregivers to help these women deal with pain and distress during the second stage of labor.