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Laboring Down versus Pushing at Complete Dilatation

Authors: Kristie Bruesch RN Holly Ehrke RN Rebecca Feil RN Melissa Nestle RN. Laboring Down versus Pushing at Complete Dilatation. Ferris State University Nursing 350- Fall 2011. PICO Statement.

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Laboring Down versus Pushing at Complete Dilatation

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  1. Authors: Kristie Bruesch RN Holly Ehrke RN Rebecca Feil RN Melissa Nestle RN Laboring Down versus Pushing at Complete Dilatation Ferris State University Nursing 350- Fall 2011

  2. PICO Statement • The format for the PICO statement highlights the need to include population or participants of interest, interventions needed for practice, comparisons of interventions to determine the best for practice and the outcome needed for practice (Burns & Grove, 2011). • P- Laboring moms • I- Cervical Dilatation • C- Laboring down versus direct pushing • O- Effect of the comparison “In the second stage of laboring, what is the effect of laboring down after complete cervical dilatation on mother and baby compared with pushing before cervical dilatation is complete?” Burns, N., & Grove, S. (2011). Understanding Nursing Research. Maryland Heights: Elsevier Saunders.

  3. Method of the Research • Articles selected were found using; • Ferris State University Library • Internet Searches • Databases • PubMed • CINAHL • Medline “The most relevant nursing online database is CINAHL, which contains citations of nursing literature, published commonly starting in the 1980s, but some versions may have information back to the 1930s” (p.211) • Burns, N., & Grove, S. (2011). Understanding Nursing Research. Maryland Heights: Elsevier Saunders.

  4. Hierarchy of evidence • Brancato, R. M., Church, S., & Stone, P. W. (2008). A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 4-12. doi: 10.1111/J.1552-6909.2007.00205.x • Roberts, C. L., Torvaldsen, S., Cameron, C. A., & Olive, E. (2004, December). Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. An International Journal of Obstetrics and Gynaecology, 111, 1333-1340. doi:10.1111/j.1471-0528.2004.00282.x • Simpson, K. R., & James, D. C. (2005, May-June). Effects of immediate versus delayed pushing during second-stage labor on fetal well-being. Nursing Research, 54(3), 149-157. • Hanson, L. (2009, January-March). Second-stage labor care Challenges in spontaneous bearing down. Journal of Perinatal & Neonatal Nursing, 23(1), 31-39. • Kelly, M., Johnson, E., Lee, V., Massey, L., Purser, D., Ring, K.., Sanderson, S., Styles, W. & Wood, D. (2010, March). Delayed versus immediate Pushing in second stage of labor. The American Journal of Maternal/Child Nursing, 35(2), 81-88. The hierarchy of evidence indicates the rank of authority in types of research. The lower the level of the hierarchy of evidence, the higher the level of authority an article or type of research has. Level I Level II

  5. Recommendations & Findings • Brancato et al., (2008) states, “Passive decent increases a woman’s chance of having a spontaneous vaginal delivery, decreases risk of having an instrument-assisted delivery, and decreases pushing time.” • Hanson (2009) states, “Women that respond to physiologic responses to bearing down had a shortened second-stage of labor and improved perineal outcomes.” • Kelly et al., (2010) states women who labored down and delayed pushing for up to 90 minutes, had “almost 50% reduction in the length of time mothers spent in pushing” as compared to women who started immediate pushing at complete cervical dilatation. • Hanson (2009), states when patients used Valsalva’s maneuver fetal compromise was detected. • Simpson and James (2005) state fetal compromise is evident in patients that perform immediate pushing upon complete cervical dilatation . • Fraser et al., (2000) stating immediate pushing group has decreased fetal oxygen de-saturation, more variable fetal heat tone decelerations, and increase of the length of active pushing. • In Hanson’s (2009) findings, patients performing immediate pushing experienced increased bladder and perineum problems. Laboring Down at Complete Dilatation Pushing at Complete Dilatation

  6. Analysis of shortcomings Kelly, M., Johnson, E., Lee, V., Massey, L., Purser, D., Ring, K.., Sanderson, S., Styles, W. & Wood, D. (2010) Study: *The scale used to detect maternal fatigue was not “sensitive enough to detect different levels of maternal fatigue .” Only nulliparous mothers were examined and due to financial constraints limited fetal outcomes were measured. Brancato, R. M., Church, S., & Stone, P. W. (2008): Sample sizes were small and the method of pushing was not consistent. Also, “Epidural protocols were not discussed in the study and could have affected the results”. Simpson, K. R., & James, D. C. (2005): The study was limited to healthy nulliparous women and women only receiving an epidural.

  7. EBNP Recommendations • It was found that with delayed pushing, the active pushing phase was shortened which decreased the oxygen de-saturation effect and fetal heart rate effects on the infant. When decreased saturation occurs, the brain is deprived from oxygen which could have an adverse effects on the infants brain function if sustained for a long period of time. These effects could be effects the child would have to deal with their entire life. • The study conducted by Kelly et al., 2010, concluded delayed pushing for up to 90 minutes or until the mother felt the urge to push decreased the length of time mothers spent pushing (p. 85). Pushing expends a large amount of energy which increases fatigue. Limiting this with laboring mothers will enhance the amount of energy they can spend on pushing when extra energy is needed. • The study written by Brancato, Church and Stone (2008) states delayed pushing promoted safe and effective spontaneous vaginal births with a decrease use of instruments and decreasing the pushing time (p. 11). When using instruments to assist with deliveries, adverse conditions can occur. Natural, safe deliveries are encouraged with minimal use of instruments to assist with the delivery is recommended. “High verbal praise and a reflection to the woman that the nurse or midwife is present and aware of each contraction and her response” (Hanson, 2008, p. 34)

  8. Impact of nursing practice Mother 1. Decreases Fatigue 2. Utilizes energy when needing to push 3. Avoids adverse outcomes of sustained strenuous pushing 4. Improves the birthing experience To promote wellness and safety for mom and baby, nurses must be aware of the effects of delayed pushing on mother and baby and enforce interventions to assist mothers with delayed pushing. Laboring down has positive outcomes for both mother and baby Infant 1.Decreases fetal distress 2. Enhances oxygenation

  9. Changing Nursing practice “Significant positive effects were found indicating that passive descent should be used during birth to safely and effectively increase spontaneous vaginal births, decrease instrument-assisted deliveries, and shorten pushing time.” (Brancato et al., 2008,p. 4.) Laboring down allows the fetus to descend naturally causing a slow stretching of the perineum tissues without increasing stress on the fetus. This is correlated with a decrease in perineum lacerations. If permitted to labor down, a patients’ pushing time was decreased, the patient was less likely to be exhausted and was more over all satisfied with her labor experience. “Significant maternal morbidity, such a perineal damage, fecal incontinence, anal sphincter injury, and pudendal nerve damage have been correlated with immediate pushing.” (Brancato et al., 2008, p. 9). “Current research indicates that immediate pushing can increase birth complications, whereas passive descent can prevent birth complications” (Brancato et al, 2008, p. 11)

  10. references • American Psychological Association. (2009). Publication Manual of the American Psychological Association. (6th Ed., 2nd print). Washington, DC: Author. ISBN 10:1-4338-0561-8 • Brancato, R. M., Church, S., & Stone, P. W. (2008). A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(1), 4-12. doi: 10.1111/J.1552-6909.2007.00205.x • Burns, N., & Grove, S. (2011). Understanding Nursing Research. Maryland Heights: Elsevier Saunders. • Hanson, L. (2009, January-March). Second-stage labor care Challenges in spontaneous bearing down. Journal of Perinatal & Neonatal Nursing, 23(1), 31-39. • Kelly, M., Johnson, E., Lee, V., Massey, L., Purser, D., Ring, K.., Sanderson, S., Styles, W. & Wood, D. (2010, March). Delayed versus immediate Pushing in second stage of labor. The American Journal of Maternal/Child Nursing, 35(2), 81-88. • Simpson, K. R., & James, D. C. (2005, May-June). Effects of immediate versus delayed pushing during second-stage labor on fetal well-being. Nursing Research, 54(3), 149-157. • Roberts, C. L., Torvaldsen, S., Cameron, C. A., & Olive, E. (2004, December). Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. An International Journal of Obstetrics and Gynaecology, 111, 1333-1340. doi:10.1111/j.1471-0528.2004.00282.x

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