Directed vs. Non-Directed Second Stage Labor Care
and the Woman’s Perception of Control
Susan Cloud, BSN, JD, RNC and Carol Burke, MSN, RNC, APN
Northwestern Memorial Hospital, Department of Women’s Health
Background / Problem Statement
The second stage of labor is a potential period of risk for the mother
and fetus. Historically, the medical model uses directed care to
“shorten” the second stage. Directed Second stage labor care includes
Valsalva breathing (count to 10), prolonged vaginal pressure, minimal
position changes and loud verbal commands to push. Valsalva and
minimal position changes have been shown to reduce uteroplacental
flow resulting in decreased fetal arterial pH and lower APGAR scores.
Multiple vaginal examinations and deep vaginal massage while
pushing are associated with resultant bowel and bladder problems.
Women have expressed being overwhelmed and discouraged by
directed methods during second stage of labor. Evidence Based
Practice (EBP) does not support Directed Care (DC). In the current
practice setting, nulliparous women using combined spinal epidural
anesthesia, were viewed as needing Directed Care during second stage.
Nulliparous > 37 weeks singleton in 2nd stage labor, vertex,
spontaneous or induced labor,
using combined spinal-epidural
Directed (N=38) (Current practice)
• Valsalva breath holding
• Loud directed commands
• Minimal position changes
• Multiple vaginal exams
• Labor down time allowed, active
pushing may begin at 10cm
Non-Directed (N=22) (EBP)
• Open glottis pushing
• Minimal breath holding of 6-8 seconds
• Encouragement and positive coaching
• Frequent position changes
• Vaginal exam only as needed
• Labor down time encouraged
• Active pushing with Ferguson’s reflex
Labor Agentry Scale (LAS)
• 10 question Likert scale survey
• The higher scores indicate a relatively higher level of personal control
• Personal control is an element of satisfaction
Objectives
1. To compare directed vs. non-directed care using the following
variables: frequency of vaginal examinations, position changes,
Valsalva instructions and number of directed commands.
2. To compare personal perception of control between directed vs.
non-directed care groups measured by the Labor Agentry Score
(LAS)
3. To present Evidenced Based Practice Guidelines for second stage
labor care to nursing and medical staff.
4. To integrate non-directed methods to nursing and medical providers
as a preferred management strategy during second stage labor.
Comparing Directed Care (DC) vs. Non-Directed Care (NDC)
1. Statistically significant average effects were detected for all four
“Count” variables
• The DC group averaged a greater number of vaginal exams and
massage (mean = 27 vs. 18) p= 0.046
• The DC group averaged a greater number of Valsalva breath
holding (mean = 101 vs. 38) p= <0.001
• The DC group averaged a greater number of loud directed
commands ( mean = 44 vs. 16 ) p= 0.002
• The DC group averaged a fewer number of position changes
(mean 2.1 vs. 8.6) p= <0.001
2. The DC group averaged lower scores on The Labour Agentry
Scale (mean = 56.8) vs. NDC group scores (mean = 61.7), t (58) =
2.67, p = 0.010.
3.
Purpose of the Project
To evaluate if nullipara women using combined spinal epidural
anesthesia perceive increased satisfaction with their experience
(as measured by an increased perception of control) when they
utilize Non-Directed Care (NDC) during second stage labor.
Results/Outcome
Protocol
Other outcome measures included:
•
•
•
•
•
APGAR score
Arterial cord pH
Duration of second stage
Type of delivery
Perineal repair
The average labor down time was significantly shorter in the DC
group (mean = 21 minutes) compared to the NDC group (mean =
46minutes) p= 0.002
Conclusions
Plan
1. IRB approval granted
2. Collect data on directed group
3. Identify staff interested in learning about Evidenced Based Practice
(Non-directed)
• Dissemination of 4 key articles to interested nursing staff regarding
non-directed second stage care
• Present four hour class session on EBP including simulation
training to nursing staff
• Provide contact hours through INA
4. Gain interest and acceptance from key members of medical staff and
residents to implement EBP with select women
5. Utilize staff midwives as resources to model EBP techniques to medical
staff
6. Collected data on non-directed (experimental) group
7. Meet with statistician for analysis
8. Disseminate findings to L&D medical and nursing staff
Women have a greater sense of control and therefore greater
satisfaction when given the option to control second stage through
non-directed care.
A statistically significant difference was found between the two groups
(directed vs. non-directed care) in relation to position changes, vaginal
exams, Valsalva breath holding, directed instructions and labor down
time.
Although literature notes a difference in maternal and neonatal
outcomes, no statistical differences were detected in this study for the
duration of second stage, type of delivery, maternal repairs, umbilical
cord pH or APGAR score.
References
Birrell D. Management of second stage labour with an epidural – a problem in
isolation? Aust J Midwifery, 2001; 14(2), 5-10.
Mahlmeister LR. Implementing safe and effective practices for second-stage labor.
JPNN, 2008; 3: 183-185.
Sampselle CM, Miller JM, Luecha Y, Fischer K, and Rosten L. Provider support of
spontaneous pushing during the second stage of labor. JOGNN, 2005; 34:6, 695-702.