Authors:
Kristie Bruesch RN
Holly Ehrke RN
Rebecca Feil RN
Melissa Nestle RN
Ferris State University
Nursing 350- Fall 2011

The format for the PICO statement
highlights the need to include

P- Laboring moms

I- Cervical Dilatation

C- Laboring down versus direct
population or participants of interest,
interventions needed for practice,
pushing
comparisons of interventions to
determine the best for practice and

O- Effect of the comparison
the outcome needed for practice
(Burns & Grove, 2011).
“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.
 Articles
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selected were found using;
Ferris State University Library
Internet Searches
Databases

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
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.
Level I
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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.
Level II


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), 8188.
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.
Laboring Down at Complete
Dilatation
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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.
Pushing at Complete 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.
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.

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)
Laboring down
has positive
outcomes for
both mother
and baby
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.
Mother
1. Decreases Fatigue
2. Utilizes energy when needing to push
3. Avoids adverse outcomes of sustained
strenuous pushing
4. Improves the birthing experience
Infant
1.Decreases fetal distress
2. Enhances oxygenation
“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.
“Current research indicates
that immediate pushing can
increase birth
complications, whereas
passive descent can prevent
birth complications”
(Brancato et al, 2008, p. 11)
“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).
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American Psychological Association. (2009). Publication Manual of the American
Psychological Association. (6th Ed., 2nd print). Washington, DC: Author. ISBN 10:14338-0561-8
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