Common Nursing Practices in Labor

Practices During Labor

Kathleen Rice Simpson, PhD, RNC, FAAN

356 VOLUME 30 | NUMBER 6 November/December 2005

The Context & Clinical Evidence for

Common Nursing

The current state of intrapartum nursing practice isthe result of an evolution of knowledge and tech-nologies since childbirth moved from home to thehospital. However, much of what we do is still based onnonscientific routines (Enkin et al., 2000). We know thatchildbirth is a natural physiologic process, but its oftenhard to keep this concept in clear focus when practicing inthe high-tech clinical environments that characterize mostbusy labor and delivery units in the United States today.What is clear is that the evidence for some of these high-tech practices is lacking.

Excellent intrapartum care requires a team effort. Mem-bers of the interdisciplinary perinatal team have comple-mentary, and sometimes overlapping, roles and responsi-bilities. Although many nursing interventions during laborand birth are based on physician orders, there are manycare processes that remain mainly within the realm ofnursing practice. For example, women are admitted to thelabor and delivery unit by physicians with the assumptionthat nurses will carefully monitor the mother and babyduring the labor process. Nurses identify maternal-fetalrisk factors on admission and plan the type and amount ofassessment based on both those initial data and ongoingdata gathered as labor progresses. The decision for laborinduction or augmentation rests with the physician, whiletitration of the oxytocin infusion is often based on the

November/December 2005 MCN 357

nurses assessment of labor progress and the maternal-fe-tal response. In many institutions, nurses identify whensecond-stage labor has begun and choose the method ofsecond-stage care. They remain at the bedside during sec-ond-stage pushing, encouraging the mother in her effortsto effect fetal descent, and notify the physician when birthis imminent.

The focus of review of evidence in this article is on thethree most common clinical practices for which nurses haveprimary responsibility in most settings. These practicescomprise the majority of nursing time spent caring forwomen during labor: (1) maternal-fetal assessment, (2)management of oxytocin infusions, and (3) second-stagecare. Evidence exists about these nursing interventions thatcan be used to promote maternal-fetal well-being, minimizerisk, and enhance patient safety. In many cases, particularlyin community hospitals, routine physician orders for intra-partum care provide wide latitude for nurses in how theyultimately carry out those orders (James, Simpson, &Knox, 2003). Before evaluating evidence for common nurs-ing practices during labor, its worthwhile to consider thecontext or practice model in which those practices occur.

Intrapartum Nursing Care ModelsThe model of intrapartum nursing care in each institutionsignificantly determines how much nursing autonomy is

ABSTRACT

The purpose of this article is to review the context and current evidence for common nurs-

ing care practices during labor and birth. Although many nursing interventions during

labor and birth are based on physician orders, there are a number of care processes that

are mainly within the realm of nursing practice. In many cases, particularly in community

hospitals, routine physician orders for intrapartum care provide wide latitude for nurses in

how they ultimately carry out those orders. An important consideration of common nurs-

ing practices during labor is the context or practice model in which those practices occur.

Nursing practice is not the same in all clinical environments. Intrapartum nursing practice

consists of an assortment of different roles depending on the circumstances, hospital set-

ting, and context in which it takes place. A variety of intrapartum nursing practice models

have evolved as a result and in response to the range of sizes, locations, and provider prac-

tice styles found in hospitals providing obstetric services. A summary of intrapartum nurs-

ing models is presented. The evidence is reviewed for the three most common clinical

practices for which nurses have primary responsibility in most settings and that comprise

the majority of their time in caring for women during labor: (1) maternal-fetal assessment,

(2) management of oxytocin infusions, and (3) second-stage care. Evidence exists for these

nursing interventions that can be used to promote maternal-fetal well-being, minimize risk,

and enhance patient safety.

Key Words: Models of intrapartum nursing practice; Labor and birth; Evidence-based intra-

partum nursing care.

involved in caring for women during labor and birth, yetno evidence exists as to which model is best for patientsand members of the perinatal healthcare team (James et al.,2003). Intrapartum nursing is generally thought of and de-scribed as a discrete area of nursing practice with a specificset of clinical skills, requisite knowledge, and responsibili-ties, that is, a recognized and universally defined specialty.In reality, however, intrapartum nursing practice consists ofan assortment of different roles depending on the circum-stances, hospital setting, and context in which it takesplace. A variety of practice models have evolved as a resultand in response to the range of sizes, locations, andprovider practice styles found in hospitals providing obstet-ric services. A summary of intrapartum nursing models ispresented in Figure 1.

Most inpatient institutions in the United States are com-munity hospitals. Of the 3,024 U.S. hospitals that provideobstetric care, only 241 are academic medical centers (Amer-ican Hospital Association, 2005). Fifty percent of hospitalsin the United States that provide obstetric care have less than500 births per year (American College of Obstetricians andGynecologists [ACOG] & American Society of Anesthesiol-ogists [ASA], 2000). Based on these data, it can be assumedthat nurse-managed labor is the predominant model of intra-partum nursing care in the United States; however, researchabout interventions during labor and birth is more likely tobe conducted in academic centers.

A fundamental determinant of each nursing care modelis the predominant type (face-to-face on-site versus off-site

via telephone) and amount of communi-cation that occurs between the labornurse and the primary healthcare provider.Other key distinctions between models in-clude the amount and type of hands-onassessment and care by the labor nurseand the primary care provider. Limitednurse-physician communication and lim-ited hands-on care by primary careproviders suggests additional nursing dis-cretion in making clinical decisions; thus,increasing amounts of nursing autonomyare required (Kramer & Schmalenberg,2003). The distinctions between intra-partum nursing models are not mutuallyexclusive. Within a given clinical setting,multiple degrees of intrapartum nursingautonomy simultaneously coexist depend-ing on the primary care provider for eachpatient.

Terms to describe perinatal servicessuch as labor-delivery-recovery (LDR), la-bor-delivery-recovery-postpartum (LDRP),single-room maternity care (SRMC), laborand delivery, well-baby nursery, specialcare nursery, neonatal intensive care, an-tepartum, postpartum, etc., are usually as-sumed to be indicative of the practice

model but in reality often just reflect the physical layout ofthe unit. With the wide variety of descriptive terms and set-tings discussed in the literature, it is difficult to determinewhether one type of care model promotes better outcomesas compared with another. Published research reports aboutintrapartum nursing practice have not routinely provideddescriptions of the model of nursing care on the units inwhich nursing interventions were studied (Corbett & Callis-ter, 2000; Gale, Fothergill-Bourbonnais & Chamberlain,2001; Hodnett et al., 2002; Miltner, 2002; Sleutel, 2000).

For the most part, intrapartum nursing practice has beenconsidered monolithic and homogenous by nurse re-searchers; however, this assumption is not valid. Perhapsprevious published research results would have been differ-ent if data had been analyzed based on the practice modelof the units studied. Although one recent study suggestsnurses working in the nurse-managed labor model enjoyautonomy in practice (James et al., 2003), it is not knownif labor nurses would select one care model over another ifthey were given a choice and had sufficient knowledge ofalternative models available. Likewise, there are no dataavailable concerning patient preferences for a distinct mod-el of nursing care. These are important questions thatshould be evaluated by nurse researchers. Future researchabout intrapartum nursing practice should include clear de-scriptions of the model of the units in which study inter-ventions were implemented. This factor could have impor-tant implications for generalizability of findings and appli-cation to specific clinical practice.


Nurse-managed labor modelCommunication is limited to as needed between the labor nurse and thephysician who may be in the office or at home. The labor nurse is in a relativelyautonomous role, making many key clinical decisions during the labor processand providing the majority of hands-on clinical care.

Academic/teaching modelResident physicians in training and faculty attending physicians are present on thelabor unit. Nurses do not routinely perform vaginal examinations to assess theprogress of labor; rather, these examinations are part of the resident learningprocess. Nurses are encouraged to communicate primarily with the resident physi-cians about labor management decisions rather than with attending physicians.Resident physicians in consultation with their faculty attending physicians makemany of the decisions about labor management. The nurse and resident physicianshare responsibility for hands-on clinical care.

Nurse-attending physician communication on-site modelThere is an attending physician in-house covering all women in labor or attendingphysicians for each practice group designate a physician from the group to be in-house to cover their patients in labor. The labor nurse and the attending physiciancollaborate on labor management decisions and have the ability to communicatein person. The nurse provides the majority of hands-on clinical care.

Nurse-nurse midwife communication on-site modelThere is a nurse midwife in-house covering their patients in labor. The labornurse and the nurse midwife collaborate on labor management decisions andhave the ability to communicate in person. The nurse and nurse midwife shareresponsibility for hands-on clinical care.

Based on James, Simpson, & Knox, 2003.

Figure 1. Models of intrapartum nursing care.

Intrapartum Nursing Care PracticesMaternal-Fetal Assessment During Labor

Maternal

There have been no randomized trials comparing type andamount of nursing assessment for women during labor. In-dividual unit protocols are based on established routinesand what seems to make sense based on perceived patientneeds and staffing availability. Usually, protocols for fetalassessment are linked to maternal assessment and includevital signs, uterine activity, how the woman is tolerating la-bor, and her level of pain. In an attempt to gather all of thedata required, nurses often use automatic blood pressure(BP) devices and pulse oximeters to mechanically recordmaternal vital signs and leave them in place continuouslyduring labor. With the widespread use of fetal monitorsthat assess maternal vitals signs simultaneously, this prac-tice has become more common. However, there are data tosuggest that these devices do not provide accurate clinicalinformation in this population.

During pregnancy, labor, and the postpartum period, useof a manual BP cuff and stethoscope is the more accuratemethod of assessing BP. Automatic BP devices tend to over-estimate systolic BP by 4 to 6 mmHg and underestimate di-astolic BP by 10 mmHg when used for childbearing women(Brown et al., 1994; Franx et al., 1994; Natarajan et al.,1999; Pomini, 2001). Inaccuracies in BP data can lead to in-appropriate treatment. For example, a diastolic BP of 95mmHg obtained by a nurse using a manualBP cuff and stethoscope would be recordedas 85 mmHg by an automatic BP device;thus, with this practice an elevated BPwould potentially be missed and not treatedappropriately or in a timely manner. In con-trast, an underestimated diastolic BP couldresult in treatment for hypotension follow-ing epidural dosage, potentially leading tofetal compromise if a vasopressor is givenfor hypotension that does not actually exist.

There is the perception that use of con-tinuous pulse oximetry will assist with dis-tinguishing between the maternal and fetal heart rate anddecrease liability by producing an uninterrupted recordingof both rates permanently on the fetal monitoring strip.Pulse oximeters are designed to measure oxygen saturation(SpO2) rather than heart rate. They are subject to variationsin accuracy due to placement, maternal position, bloodflow, and the patients condition. Often they produce inac-curate data for some time before noted by the nurse becausethe data are automatically generated and printed on thestrip while the nurse is away from the bedside. When peri-ods of inaccurately recorded low SpO2 readings are accom-panied by nonreassuring fetal heart rate (FHR) patterns,there is increased liability risk. Claims that the mother wasinadequately oxygenated when low SpO2 readings occurredduring nonreassuring FHR patterns have been made suc-

cessfully in obstetric malpractice cases. Although during re-al-time recording on the fetal monitoring strip the data fromthe pulse oximetry are lighter than the FHR, when printedfrom the electronic archival system later as part of the retro-spective review process that occurs during litigation thesematernal and fetal data are virtually indistinguishable. In-ability to distinguish between the rates during retrospectivereview is an additional source of liability.

Direct bedside evaluation of maternal status should co-incide with times of assessment data recorded in the med-ical record. When these data are automatically generated inthe nurses absence, there is no ability to retrospectivelyknow whether maternal conditions at that time could havecontributed to the findings. For example, the mother mayhave repositioned herself or may be having a uterine con-traction when the BP device is activated, or the BP cuffand/or pulse oximeter may be malpositioned. These factorsaffect device accuracy.

There is no evidence or standards for routine continuoususe of automatic devices for maternal assessment during la-bor; preliminary data even suggest that they can be a liabil-ity risk. Studies about maternal discomfort and activity re-striction with their use do not exist; however, anyone whohas had their BP assessed by an automatic BP device canappreciate the discomfort, multiplied by the number oftimes these devices activate during labor, particularly if theyare set for every 5- to 15-minute assessments. Whenwomen in labor are attached to multiple devices, their abil-ity to reposition for comfort is likely limited and they may

fear that their movement will affect the monitors. Routineuse of automatic maternal vital sign assessment devicesduring labor should be questioned.

FetalThe basis for the traditionally recommended fetal assess-ment frequencies during labor is a series of randomizedcontrolled trials comparing intermittent auscultation (IA)and continuous electronic fetal monitoring (EFM) thatwere conducted after the introduction of EFM into clinicalpractice (American Academy of Pediatrics [AAP] &ACOG, 2002). When using protocols that included one-to-one nursing assessment of FHR patterns every 15 minutesduring the active phase of the first stage of labor and every5 minutes during the second stage of labor for patients


Routine use of automaticmaternal vital sign assessmentdevices during labor shouldbe questioned.

with and without identified risk factors, no differenceswere found in the rate of intrapartum fetal deaths (AAP &ACOG, 2002). However, rates of cesarean births were in-creased in women who were monitored via EFM. Despitethese findings, continuous EFM (rather than IA) is themost common obstetric procedure in the United States(Kozak, Hall, & Owings, 2002). Recently, ACOG (2005)changed its long-standing guidelines for fetal assessmentduring labor. IA is no longer recommended for womenwith high-risk conditions, and the frequency for fetal as-sessment using IA for women without identified risk fac-tors has been increased to every 15 minutes during the ac-tive phase of first-stage labor and every 5 minutes duringsecond-stage labor. There are many reasons for the di-chotomy between evidence and clinical practice for fetal as-sessment during labor, including lack of financial resourcesto support one-to-one nursing care required for IA, lack ofan adequate number of perinatal nurses in some areas, lackof knowledge for how to perform IA, lack of patient choicein many institutions, and liability concerns (Priddy, 2004;Wood, 2003).

Despite the problems with the sensitivity and specificityof EFM in detecting fetuses who are in distress, there aresome FHR patterns that most experts would agree warrantclose observation, and in some cases, emergent birth(ACOG & AAP, 2003; Freeman, Garite, & Nageotte,2003). FHR patterns that may suggest that the fetus is de-pressed, hypoxic, or acidotic include recurrent variable de-celerations that become progressively deeper or longer last-ing (generally 60 sec-onds) and show persistent slow return to baseline, recur-rent late decelerations, prolonged decelerations, sinusoidalpatterns, bradycardia, and absent baseline variability(ACOG & AAP, 2003; National Institute of Child Healthand Human Development Research Planning Workshop,1997). Variability of the FHR, evolution of the pattern,and association with clinical events are important addition-al considerations (Fox, Kilpatrick, King, & Parer, 2000).Labor nurses should be aware of the potential significanceof these types of FHR patterns and initiate appropriate in-terventions based on the pattern displayed.

The evidence for appropriate intrauterine resuscitationtechniques when the FHR pattern is nonreassuring couldbe more robust; however, there is enough evidence to sug-gest that the following interventions do improve fetal well-being to some extent (based on the individual clinical situa-

tion): (1) lateral maternal repositioning, (2) an intravenousfluid bolus of lactated Ringers solution, (3) oxygen admin-istration at 10 L per nonrebreather face mask, (4) amnioin-fusion, (5) correction of maternal hypotension, and (6) re-duction of uterine activity (discontinuation of oxytocin, re-moval of dinoprostone insert, terbutaline .25 mg subcuta-neously) (ACOG, 2005; Freeman et al., 2003; Simpson &James, 2005b). In selected cases, especially if there is a cat-astrophic event such as placental abruption, uterine rup-ture, umbilical cord prolapse, or ruptured vasa previa, anemergent birth is the best option to rescue the fetus (AAP& ACOG, 2002; ACOG & AAP, 2003; Freeman et al.,2003). Labor nurses are often the first members of the peri-natal team to identify and initiate intrauterine resuscitationtechniques, and their ability to notify other providers to setin motion what needs to be accomplished to promote fetalwell-being and protect the fetus from harm is critical.

Although fetal assessment is a shared responsibility, peri-natal nurses and our professional association (Associationof Womens Health, Obstetric and Neonatal Nurses[AWHONN]) have traditionally devoted far more attentionto education on this topic than our physician colleagues. Inmost institutions, nurses are required to regularly attend fe-tal monitoring classes on an annual or at least biannual ba-sis, while many physicians have not attended an educationalprogram about EFM since their residency. Since nurses andphysicians are jointly responsible for fetal assessment andcommunicate daily about fetal status via EFM, developmentof programs that include expectations for attendance ofboth physicians and nurses together has merit and couldpromote patient safety (Joint Commission on Accreditationof Healthcare Organizations [JCAHO], 2004).

Oxytocin for Induction and Augmentation of LaborBecause of the lack of knowledge about the exact physiolo-gy of labor, it is difficult to determine the optimal dosagesnecessary to induce labor or correct abnormal labor withartificial pharmacologic agents (Simpson, 2002). Eachwoman has individual myometrial sensitivity to oxytocin(Ulmsten, 1997). The primary goals are to achieve ade-quate progress of labor using the lowest possible dose withthe fewest side effects and to have continued evidence ofmaternal-fetal well-being. During the initial incrementalphase of oxytocin administration (first 1.5 to 2 hours),uterine contractions will progressively increase in frequencyand duration (Phaneuf, Rodriguez-Linares, TambyRaja,


The approach to intravenous oxytocin administration associated

with the fewest side effects is to begin at 0.5 to 1 mU per minute

and increase by 1 to 2 mU per minute at intervals no less than every

30 to 40 minutes until active labor is achieved.

MacKenzie, & Lopez-Bernal, 2000). Once the stable phasehas been reached (after 3.5 to 4.5 hours of administration),any further increase in dosage will not result in more fre-quent normal uterine activity, but rather a risk of medica-tion side effects such as hyperstimulation and nonreassur-ing FHR changes (Phaneuf et al., 2000). Uterine oxytocinreceptor sites decrease significantly during prolonged oxy-tocin-induced or augmented labor compared to sponta-neous labor. This desensitization is directly related to oxy-tocin dosage rate and length of administration (Phaneuf etal., 2000). Thus, although it seems counterintuitive tomany practitioners, more exogenous oxytocin does not re-sult in more effective contractions.

The approach to intravenous oxytocin administrationassociated with the fewest side effects is to begin at 0.5 to 1mU per minute and increase by 1 to 2 mU per minute atintervals no less than every 30 to 40 minutes until active la-bor is achieved (ACOG, 1999; Crane & Young, 1998;Simpson, 2002). There is a cumulative body of evidence tosuggest that using oxytocin at high rates, increasing thedosage at intervals inconsistent with basic pharmacologicprinciples (less than every 30 to 40 minutes), and causinguterine hyperstimulation will not result in a clinically signif-icant decrease in the length of labor (Crane & Young,1998; Daniel-Spiegel, Weiner, Ben-Shlomo & Shalev,2004). Multiple clinical studies and current data based onphysiologic and pharmacologic principles have shown that90% of pregnant women at term will have labor success-fully induced with less than 6 mU per minute of oxytocin(Daniel-Spiegel et al., 2004; Simpson, 2002).

A meta-analysis of low-dose versus high-dose oxytocinfor labor induction by Crane and Young (1998) found thatlow-dose protocols resulted in fewer episodes of excessiveuterine activity, fewer operative vaginal births, a higher rateof spontaneous vaginal birth, and a lower rate of cesareanbirth. Pharmacologic agents increase the risk of uterine hy-perstimulation, nonreassuring FHR due to hyperstimula-tion, and cesarean birth for nonreassuring FHR patterns(ACOG, 1999; Crane, Young, Butt, Bennett, & Hutchens,2001; Rayburn, 2002). Since 50% of hyperstimulation re-sults in a nonreassuring FHR pattern (Rayburn, 2002), thisis a significant concern for the nurse who is responsible fortitrating the oxytocin infusion to labor progress and thematernal-fetal response (Clayworth, 2000).

Often during oxytocin infusion, nurses are focused onthe rate increase section of the protocol while ignoring theclinical criteria for dosage increases (Simpson & Atterbury,2003). For example, if cervical effacement is occurring or ifthe woman is progressing in labor at approximately 1 cmper hour, there is no need to increase the oxytocin rate,even if contractions appear to be mild and infrequent. La-bor progress and maternal-fetal response to the drugshould be the primary considerations (Simpson, 2002).When there is evidence of a nonreassuring FHR pattern orcontractions are excessive in strength and/or frequency, thedosage should be decreased or discontinued based on theindividual clinical situation. Although recommended nurse-

to-patient staffing is 1:2 while caring for women receivingoxytocin (AAP & ACOG, 2002), providing the type of in-tensive nursing care required to carefully monitor morethan one mother and baby is often difficult. Failure to rec-ognize and timely treat hyperstimulation and resultant non-reassuring FHR patterns is a significant source of successfulclaims against physicians, nurses, and healthcare institu-tions (Simpson & Knox, 2003).

Second-Stage LaborThere are two methods of nursing care when the secondstage of labor begins. One method is to coach the womanto push immediately and the other method is to allow pas-sive fetal descent until the woman feels the urge to push.The immediate pushing method involves instructing thewoman to hold her breath while pushing three to fourtimes with each contraction while the nurse counts to 10 tohelp the woman focus on pushing for at least 10 secondswith each pushing effort. Women are told to bring theirknees up to their chest with their elbows outstretched andnot to make a sound. The Valsalva maneuver is instituted,resulting in an increase in intrathoracic pressure, impairedblood return from the lower extremities, and initially in-creased and then decreased blood pressure, resulting in adecrease in blood flow to the placenta (Caldeyro-Barcia etal., 1981). Periods of 9 to 15 seconds of closed-glottispushing results in a decrease in maternal pO2 and increasein pCO2, thus affecting the pO2 and pCO2 of blood flowto the placenta and ultimately to the fetus (Caldeyro-Barcia


i Avoid the use of automatic blood pressure devices during labor.

i Promote intermittent auscultation for fetal assessment during labor.

i Evaluate the fetal heart rate (FHR) based on patterns thatare known to suggest fetal compromise, pattern evolution,and clinical context.

i Initiate appropriate intrauterine resuscitation techniques in a timely manner based on the FHR pattern.

i Use the lowest dose of oxytocin possible to promote ade-quate labor progress.

i Avoid hyperstimulation of uterine activity, and if it occurs,treat in a timely manner.

i Allow passive fetal descent during second-stage labor untilthe woman feels the urge to push.

i Avoid coached closed-glottis pushing techniques; allow thewoman to bear down as long as she feels is appropriate.

Figure 2. Recommended clinical practicesbased on available evidence.

et al., 1981). Over the course of the average 2-hour secondstage, these maternal hemodynamic changes have the po-tential to have a progressive negative effect on fetal status(Bassell, Shaesta, Humayun, & Marx, 1980; Nordstrom,Achanna, Nuka, & Arulkumaran, 2001).

Coached closed-glottis pushing beginning at 10-cm cer-vical dilation and continuing until birth has been usedmore frequently in the last 15 years since the increased inci-dence of epidural anesthesia, yet it has no scientific basis(Roberts, 2002). Proponents of this method intuitively be-lieve that it results in a clinically significant shortening ofthe second stage and decreases risk of cesarean birth; how-ever, results of recent randomized clinical trials do not sup-port these beliefs (Fraser et al., 2000; Hansen, Clark, &Foster, 2002; Mayberry, Hammer, Kelly, True-Driver, &De, 1999; Parnell, Langhoff-Roos, Iversen, & Damgaard,1993; Vause, Congdon, & Thornton, 1998).

In an alternative but less common approach (also knownas laboring down, passive descent, and physiologicsecond stage), pushing is delayed until the woman feels theurge to push, passive fetal descent is allowed, and open-glottis pushing is encouraged when the woman reports theurge to push. If the fetus has not descended sufficiently aftera 2-hour period of passive fetal descent, the woman is en-couraged to grunt without holding her breath (open-glottis)and bear down during contractions. There is no count to 10or instruction to hold her breath. No more than three push-es are encouraged with each contraction and the womanbears down as long as she feels the urge (AWHONN, 2000;Roberts, 2002). This method has been found to be as effec-tive in aiding fetal descent as traditional closed-glottis push-ing, but without the negative maternal hemodynamic impli-cations of the Valsalva maneuver and its effects on fetal sta-tus such as FHR decelerations, hypoxemia, and abnormalacid-base changes (AWHONN, 2000; Mayberry, Wood, et

al., 2000; Roberts, 2002; Simpson & James,2005a). Additional benefits include less operativevaginal births, less maternal fatigue, less perinealtrauma, protection of the pelvic floor, and avoid-ance of incontinence and pelvic organ prolapsein the future (Fraser et al., 2000; Handa, Harris,& Ostergard, 1996; Hansen et al., 2002; May-berry, Gennaro, Strange, Williams, & De, 1999;Sampselle & Hines, 1999; Schaffer et al., 2005).

An evidence-based practice resource with a re-view of the literature and recommendations forsecond-stage nursing care has been published byAWHONN (2000). Although more data areneeded about all aspects of second-stage care,there is enough evidence to support delayed push-ing until the woman feels the urge to push andavoiding coached closed-glottis pushing and thesupine lithotomy position (Roberts, 2002). Thesepractices will not increase risk of cesarean birth orresult in a clinically significant lengthening of thesecond stage (Fraser et al., 2000; Hansen et al.,2002; Mayberry, Hammer, et al., 1999).

SummaryRecommendations for these three common nursing prac-tices during labor based on the evidence to date are listedin Figure 2. Clearly there is a need for more evidence aboutour intrapartum care practices, and since nurses providethe majority of this care, nurses are in an ideal situation toconduct meaningful studies. The foundation for safe andeffective nursing care during labor and birth should be theresults of rigorous research. Science rather routine shouldguide what we do every day. We have a collective obliga-tion to keep mothers and babies safe during the childbirthprocess. Nursing practices based on solid evidence will con-tribute to our ability to fulfill this responsibility. Sugges-tions for future nursing research on these important topicsare listed in Figure 3. Nurses in the clinical setting shouldexplore partnership with their colleagues in the academicsetting to design and conduct research studies that will addto what is known about how to provide the most optimalcare for mothers and babies during labor and birth.

Kathleen Rice Simpson, PhD, RNC, FAAN, is a Peri-natal Clinical Nurse Specialist, St. Johns Mercy MedicalCenter, St. Louis, MO, and an Editorial Board Memberof MCN. Dr. Simpson can be reached via e-mail at [email protected].

ReferencesAmerican Academy of Pediatrics & American College of Obstetricians

and Gynecologists. (2002). Guidelines for perinatal care (5th ed.). Elk-grove Village, IL: Author.

American College of Obstetricians and Gynecologists. (2005). Intrapartumfetal heart rate monitoring. (Practice Bulletin No. 62). Washington, DC:Author.

American College of Obstetricians and Gynecologists. (1999). Induction oflabor. (Practice Bulletin No. 10). Washington, DC: Author.


Intrapartum practice models

i Do nurses prefer one model over another?

i Would women choose one model over another if fully informed?

i Does one model promote better outcomes for mothers and babies?

Maternal-fetal assessment

i How often should maternal vital signs be assessed during low-risk labor?

i Is intermittent auscultation during labor feasible in the current conditionsin labor and delivery units in the United States?

Oxytocin during labor induction and augmentation

i How would a nursing protocol of increasing the rate of oxytocin only ifthere has been no cervical change within the last hour and contractionsare not of adequate frequency and intensity affect the length of labor?

i Would this type of protocol result in less uterine hyperstimulation and/ornonreassuring fetal heart rate patterns?

Second-stage labor care

i What strategies would be effective to convince all members of the peri-natal team to adopt second-stage practices based on available evidence?

Figure 3. Suggestions for future nursing research.

American College of Obstetricians and Gynecologists & American Academyof Pediatrics. (2003). Neonatal encephalopathy and cerebral palsy: Defin-ing the pathogenesis and pathophysiology. Washington, DC: Authors.

American College of Obstetricians and Gynecologists & American Soci-ety of Anesthesiologists. (2001). Optimal goals for anesthesia care inobstetrics. (Committee Opinion No. 256). Washington, DC: Author.

American Hospital Association. (2005). Directory of Americas hospitals.Chicago, IL: Author.

Association of Womens Health, Obstetric and Neonatal Nurses. (2000).Nursing management of the second stage of labor. (Evidence-basedclinical practice guideline). Washington, DC: Author.

Bassell, G. M., Shaesta, G., Humayun, M. B., & Marx, G. F. (1980). Mater-nal bearing down: Another fetal risk. Obstetrics and Gynecology,56(1), 39-41.

Brown, M. A., Reiter, L., Smith, B., Buddle, M. L., Morries, R., & White-worth, J. A. (1994). Measuring blood pressure in pregnant women: Acomparison of direct and indirect methods. American Journal of Ob-stetrics and Gynecology, 171(3), 661-667.

Caldeyro-Barcia, R., Giussi, G., Storch, E., Poseiro, J. J., Kettenhuber, K., &Ballejo, G. (1981). The bearing down efforts and their effects on fetalheart rate, oxygenation, and acid-base balance. Journal of PerinatalMedicine, 9(Suppl. 1), 63-67.

Clayworth, S. (2000). The nurses role during oxytocin administration.MCN The American Journal of Maternal Child Nursing, 25, 80-85.

Corbett, C. A., & Callister, L. C. (2000). Nursing support during labor. Clini-cal Nursing Research, 9(1), 70-83.

Crane, J. M., & Young, D. C. (1998). Meta-analysis of low-dose versushigh-dose oxytocin for labour induction. Journal of the Society of Ob-stetricians and Gynaecologists of Canada, 20(13), 1215-1223.

Crane, J. M., Young, D. C., Butt, K. D., Bennett, K. A., & Hutchens, D.(2001). Excessive uterine activity accompanying induced labor. Ob-stetrics and Gynecology, 97(6), 926-931.

Daniel-Spiegel, E., Weiner, S., Ben-Shlomo, I., & Shalev, E. (2004). Forhow long should oxytocin be continued during induction of labour?British Journal of Obstetrics and Gynaecology, 111(4), 331-334.

Enkin, M., Keirse, M. J. N. C., Neilson, J., Crowther, C., Duley, L., Hodnett,E., et al. (2000). A guide to effective care in pregnancy and childbirth(3rd ed.). Oxford, UK: Oxford University Press.

Fox, M., Kilpatrick, S., King, T., & Parer, J. T. (2000). Fetal heart rate moni-toring: Interpretation and collaborative management. Journal of Mid-wifery and Womens Health, 45(6), 498-507.

Franx, A., van der Post, J. A. M., Elfering, I. M., Veerman, D. P., Merkus, H.M. W. M., Boer, K., et al. (1994). Validation of automatic blood pres-sure recording in pregnancy. British Journal of Obstetrics and Gynae-cology, 101(10), 66-69.

Fraser, W. D., Marcoux, S., Krauss, I., Douglas, J., Goulet, C., & Boulvain,M., for the PEOPLE (Pushing Early or Pushing Late with Epidurals)Study Group. (2000). Multicenter randomized controlled trial of de-layed pushing for nulliparous women in the second stage of laborwith continuous epidural analgesia. American Journal of Obstetricsand Gynecology, 182(5), 1165-1172.

Freeman, R. K., Garite, T. J., & Nageotte, M. P. (2003). Fetal heart rate mon-itoring (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Gale, J., Fothergill-Bourbonnais, F., & Chamberlain, M. (2001). Measuringnursing support during childbirth. MCN The American Journal of Ma-ternal Child Nursing, 26(5), 264-271.

Handa, V. L., Harris, T. A., & Ostergard, D. R. (1996). Protecting the pelvicfloor: Obstetric management to prevent incontinence and pelvic or-gan prolapse. Obstetrics and Gynecology, 88(3), 470-478.

Hansen, S. L., Clark, S. L., & Foster, J. C. (2002). Active pushing versuspassive fetal descent in the second stage of labor: A randomized con-trolled trial. Obstetrics and Gynecology, 99(1), 29-34.

Hodnett, E. D., Lowe, N. K., Hannah, M. E., Willan, A. R., Stevens, B., West-on, J. A., et al. (2002). Effectiveness of nurses as providers of laborsupport in North American hospitals: A randomized controlled trial.Journal of the American Medical Association, 288(11), 1373-1381.

James, D. C., Simpson, K. R., & Knox, G. E. (2003). How do expert labornurses view their role? Journal of Obstetric, Gynecologic and Neona-tal Nursing, 32(6), 814-823.

Joint Commission on Accreditation of Healthcare Organizations. (2004).Preventing infant death and injury during delivery. (Sentinel EventAlert No. 30), Oak Brook, IL: Author.

Kozak, L. J., Hall, M. J., & Owings, M. F. (2002). National hospital dis-charge survey 2002: Annual summary with detailed diagnosis andprocedure data. National Center for Health Statistics, 13(153), 1-203.

Kramer, M., & Schmalenberg, C. E. (2003). Magnet hospital staff nursesdescribe clinical autonomy. Nursing Outlook, 51(1), 13-19.

Mayberry, L. J., Gennaro, S., Strange, L., Williams, M., & De, A. (1999). Ma-ternal fatigue: Implications of second stage nursing care. Journal ofObstetric, Gynecologic and Neonatal Nursing, 28(2), 175-181.

Mayberry, L. J., Hammer, R., Kelly, C., True-Driver, B., & De, A. (1999). Useof delayed pushing with epidural anesthesia: Findings from a random-ized controlled trial. Journal of Perinatology, 19(1), 26-30.

Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Niel-son-Smith, K. (2000). Second stage labor management: Promotion ofevidence-based practice and a collaborative approach to patient care.(Practice Monograph). Washington, DC: Association of WomensHealth, Obstetric, and Neonatal Nurses.

Miltner, R. S. (2002). More than labor support: Nursing interventions pro-vided to women in labor. Journal of Obstetric, Gynecologic andNeonatal Nursing, 31(6), 753-761.

Natarajan, P., Shennan, A. H., Penny, J., Halligan, A. W., de Swiet, M., &Anthony, J. (1999). Comparison of auscultatory and oscillometricautomatic blood pressure monitors in the setting of preeclampsia.American Journal of Obstetrics and Gynecology, 181(5, Pt. 1), 1203-1210.

National Institute of Child Health and Human Development Research Plan-ning Workshop. (1997). Electronic fetal heart rate monitoring: Researchguidelines for interpretation. American Journal of Obstetrics and Gy-necology, 177(6), 1385-1390, and Journal of Obstetric, Gynecologicand Neonatal Nursing, 26(6), 635-640.

Nordstrom, L., Achanna, S., Nuka, K., & Arulkumaran, S. (2001). Fetal andmaternal lactate increase during active second stage labour. BritishJournal of Obstetrics and Gynaecology, 108(3), 263-268.

Parnell, C., Langhoff-Roos, J., Iverson, R., & Damgaard, P. (1993). Pushingmethod in the expulsive phase of labor: A randomized trial. Acta Ob-stetricia et Gynecologica Scandinavica, 72(1), 31-35.

Phaneuf, S., Rodriguez-Linares, B., TambyRaja, R. L., MacKenzie, I. Z., &Lopez-Bernal, A. (2000). Loss of myometrial oxytocin receptors duringoxytocin-induced and oxytocin-augmented labour. Journal of Repro-duction and Fertility, 120(1), 91-97.

Pomini, F., Scavo, M., Ferrazzani, S., DeCarolis, S., Caruso, A., & Mancuso,S. (2001). There is poor agreement between manual auscultatory andautomatic oscillometric methods for the measurement of blood pres-sure in normotensive pregnant women. Journal of Maternal-FetalMedicine, 10(6), 398-403.

Priddy, K. D. (2004). Is there logic behind fetal monitoring? Journal of Ob-stetric, Gynecologic and Neonatal Nursing, 33(5), 550-553.

Rayburn, W. F. (2002). Preinduction cervical ripening: Basis and methods ofcurrent practice. Obstetrical and Gynecological Survey, 57(10), 683-692.

Roberts, J. E. (2002). The push for evidence: Management of the secondstage. Journal of Midwifery and Womens Health, 47(1), 2-15.

Sampselle, C., & Hines, S. (1999). Spontaneous pushing during birthrela-tionship to perineal outcomes. Journal of Nurse Midwifery, 44 (1), 36-39.

Schaffer, J. I., Bloom, S. L., Casey, B. M., McIntire, D. D., Mihira, M. A., &Leveno, K. J. (2005). A randomized trial of the effects of coached vsuncoached maternal pushing during second stage of labor on post-partum pelvic floor structure and function. American Journal of Ob-stetrics and Gynecology, 192(5), 1692-1696.

Simpson, K. R. (2002). Cervical ripening and induction and augmentationof labor. (Practice Monograph). Washington, DC: Association ofWomens Health, Obstetric, and Neonatal Nurses.

Simpson, K. R., & Atterbury, J. (2003). Labor induction in the UnitedStates: Trends and issues for clinical practice. Journal of Obstetric, Gy-necologic and Neonatal Nursing, 32(6), 767-779.

Simpson, K. R., & James, D. C. (2005a). Effects of immediate versus de-layed pushing during second-stage labor on fetal well-being: A ran-domized clinical trial. Nursing Research, 54(3), 149-157.

Simpson, K. R., & James, D. C. (2005b). Efficacy of intrauterine resuscita-tion techniques in improving fetal oxygen status during labor. Obstet-rics and Gynecology, 105(6), 1362-1368.

Simpson, K. R., & Knox, G. E. (2003). Common areas of litigation relatedto care during labor and birth: Recommendations to promote patientsafety and decrease risk exposure. Journal of Perinatal and NeonatalNursing, 17(1), 110-125.

Sluetel, M. R. (2000). Intrapartum nursing care: A case study of supportiveinterventions and ethical conflicts. Birth, 27(1), 38-45.

Ulmsten, U. (1997). Onset and forces of term labor. Acta Obstetricia et Gy-necologica Scandinavica, 76, 499-514.

Vause, S., Congdon, H. M., & Thornton, J. G. (1998). Immediate and de-layed pushing in the second stage of labour for nulliparous womenwith epidural analgesia: A randomized controlled trial. British Journalof Obstetrics and Gynaecology, 105(2), 186-188.

Wood, S. H. (2003). Should women be given a choice about fetal assess-ment in labor? MCN The American Journal of Maternal Child Nursing,28(5), 292-298.


Common Nursing Practices in Labor

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