Exploring the effects of second stage management from the maternal and midwifery perspectives: are there any benefits to directing women?

Cooper, Kerry (2016) Exploring the effects of second stage management from the maternal and midwifery perspectives: are there any benefits to directing women? MIDIRS Midwifery Digest, 26 (2). pp. 209-216.

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Background: The management of second stage varies considerably, with directed pushing, by recourse to Valsalva Technique or a variation of this, being frequently utilised as a replacement for progression through spontaneous maternal effort. The evidence for directed management versus spontaneous is unclear.

Objectives: This review aims to consider the effects of directed pushing on maternal perspectives of second stage management and to assess midwives’ attitudes in relation to this in direct comparison to how spontaneous pushing affects the above measures. The effects on maternal and fetal outcomes of such practice are also evaluated.

Search Methods: The electronic databases MIDIRS Research Database, CINAHL, Wiley Online, Cochrane Library, PubMed, NHS Evidence and Google Scholar were searched. Additionally reference list, author and hand searches were completed. No restrictions were placed on parity, age or gestation of the women although all selected studies comprised women of 37-42 weeks gestation. English language studies only were accessed. Epidural usage was excluded.

Selection Criteria and Data Collection: RCTs and non-randomised qualitative literature was accessed to gain statistically comparative data and understanding of maternal perspectives and midwifery practice and attitudes. Outcome measures relating to maternal perspectives, midwives’ behaviours, length of second stage, mode of delivery, APGARs, cord blood pH and base excess and perineal trauma were assessed.

Main Results: Eleven studies were included. One study observed a statistically significant increase in length of second stage with spontaneous pushing (t = 3.455, p < 0.002), another study contradicted this finding it to be shorter with spontaneous effort (t = 2.028, p < 0.05). Two studies demonstrated a reduction in instrumental deliveries with spontaneous pushing. No other statistically significant differences were discovered in maternal outcomes. One study found a statistically significant increased risk of fetal acidosis related to Valsalva pushing (r = 0.040, p = 0.020). Maternal satisfaction was demonstrated to be increased by midwifery support of spontaneous effort; disempowerment was observed when unsolicited direction was given. Midwives felt they provided such support (82.4%); observation of practice supported this in one study but contradicted this in two studies.

Conclusion: The evidence of this review does not support the practice of directed pushing, as it does not appear to confer any tangible benefits to mother or infant and has a negative effect on the autonomy of women. The evidence is limited and recommendations are made for further research. At present, the practice should be discouraged and women should be supported to choose their own method. N.B. The care givers involved include midwives and nurse-midwives dependent on geographical location of the study; for the purposes of clarity in this review they are categorised as midwives.

Item Type: Article
Journal / Publication Title: MIDIRS Midwifery Digest
Publisher: The National Childbirth Trust
ISSN: 0961-5555
Departments: Academic Departments > Nursing, Health & Professional Practice (NHPP)
Depositing User: Anna Lupton
Date Deposited: 05 Jul 2016 10:11
Last Modified: 12 Jan 2024 15:46
URI: https://insight.cumbria.ac.uk/id/eprint/2363


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