PROJECT TITLE: “A pilot study to develop a behavioral intervention to support self-regulated
pushing during second stage labor: A focus group of Certified Nurse-Midwives as Informants”
FACULTY NAME: L
isa Hanson, PhD, CNM, FACNM, Associate Professor, Nursing
STUDENT NAME: Kathryn Osborne, MSN, CNM, Nursing Doctoral Student
INTRODUCTION
The second stage of labor (SSL) is a time of labor from complete dilatation of the woman’s cervix through the
b
irth of the baby. The care and instructions that women receive during the SSL can directly impact maternal
and neonatal outcomes. Most women who experience the SSL are cared for in a manner that is not based in
scientific evidence but rather on arbitrary instructions that are routinely applied
1,2
. For example, early after the
onset of the SSL, women are instructed to hold her breath for prolonged periods, even if they have no urge to
push. This “traditional approach” jeopardizes maternal-fetal hemodynamics, and is associated with both short
and long-term maternal perineal damage, as well as maternal fatigue, distress and pain
1
. Further this approach
does not account for individual readiness to begin and maintain the strength and duration of pushing efforts.
Observational research has shown that women push spontaneously and effectively if provided the opportunity
3
.
Research results have contributed to a “re-conceptualized” SSL in two stages; latent (a period of maternal rest)
followed by active (desire and readiness to use spontaneous pushing)
1
. In this model of care, the woman’s
readiness to push is based on anatomic, physiologic and emotional readiness. What she needs to use this
approach is support from her care providers.
SIGNIFICANCE
Research has show that the re-conceptualized approach t
o SSL care improves circulation to the placenta and
fetus and is associated with less disruption of the delicate tissues of the pelvis and perineum. While scientific
evidence supports the use of this approach, the use of the traditional approach persists. Barriers and facilitating
forces related to the use of published evidence about SSL care need to be identified before an effective
intervention can be developed to promote evidence-based practice. The intent of this pilot study is to use a focus
group of CNMS as informants to identify factors that prevent and facilitate the use of evidence in the care of
women during SSL. The aim of this study is to gather information from practicing Certified Nurse-Midwives
(CNMs) that will be used to develop a full protocol for the behaviors that compose supportive care that is based
on the principle of self-directed pushing and a re-conceptualization of SSL. The behavioral intervention will
enable evidence to be more readily applied to bedside SSL care and improve the process of SSL care. The
ultimate goal of this study is develop further studies that will serve to improve SSL care.
FORWARD THINKING/INNOVATION
This study is innovative because it recognizes the challeng
es that CNMs face in using evidence in practice
during SSL care. CNMs provide direct SSL care. CNMs have more autonomy in practice that nurses in terms of
making decisions about the care that is provided during SSL
4
. Learning from CNM’s clinical experiences will
be helpful in building an intervention that has fidelity and can be tested in a prospective study. Dr. Hanson
plans to extend this study to observations of SSL care of CNMs in a separate funded, IRB approved study that is
in development. Kathryn Osborne will use the information gained from this study to develop an instrument for
use in her dissertation study. Therefore this study will facilitate further research of the student and faculty.
STUDENT INVOLVEMENT
Kathryn Osborne, MSN, CNM will take the lead on this p
roject with the support of and collaboration with Dr.
Lisa Hanson. Ms. Osborne will recruit the focus group participants (n=8), develop the focus group questions,
and lead the 2-3 hour focus group that will be tape recorded, transcribed and analyzed. Dr. Hanson and Ms
Osborne will systematically code the data and analyze for themes, coming to mutual agreement in the process.
Kathryn Osborne is a practicing CNM with good access to focus group informants who plans to study SSL care
for her dissertation. This study will help her develop a questionnaire that will be used in her dissertation that
will be a national survey of CNMs SSL practices.
REFERENCES
1. Robe
rts, J., & Hanson, L. Best practices in second stage labor care: Maternal bearing down and
positioning, J Midwifery Women’s Health, 52, 238-245.
2. Han
son, L. Editorial: Expert Opinion. Pushing for change. Journal of Perinatal and Neonatal Nursing
2006;20: 282-284.
3. Ha
nson, L. A pilot assessment of promoting passive fetal descent for management of low risk
primigravidas during the second stage of labor. ACNM Annual Meeting Salt Lake City, UT, June, 2006.
4. Hill-Karbo
wski, B., Hanson, L. Pushing for Change: Nurses’ knowledge, beliefs and autonomy concerning
second stage labor care and it relationship to birth attendant practices. ACNM Annual Meeting, Chicago,
IL, May, 2007.