Strategies for designing a research utilization project with labor and delivery nurses

Labor down or bear down: a strategy to translate second-stage labor evidence to perinatal practice

Scientific evidence supports spontaneous physiologic approaches to second-stage labor care; however, most women in US hospitals continue to receive direction from nurses and birth attendants to use prolonged Valsalva bearing-down efforts as soon as the cervix is completely dilated. Delaying maternal bearing-down efforts during second-stage labor until a woman feels an urge to push (laboring down) results in optimal use of maternal energy, has no detrimental maternal effects, and results in improved fetal oxygenation. Although most commonly used with women who are undergoing epidural anesthesia, laboring down is just one component of physiologic second-stage labor care that can be used to achieve optimal maternal and neonatal outcomes for women with or without an epidural. Prior efforts to translate evidence regarding second-stage labor care to practice have not been successful. In this article, the scientific evidence for second-stage labor care and previous efforts at clinical translation are reviewed. The Ottawa Hospital Second Stage Protocol is presented as a model with potential to allow translation of evidence to practice. Recommendations to enhance widespread adoption of evidence-based practice are provided, including improved collaboration between nurses and birth attendants.

Second-stage labor care: challenges in spontaneous bearing down

Substantial scientific evidence supports spontaneous maternal bearing down for its associated maternal and fetal physiologic benefits. Imposing specific directions for Valsalva pushing does not result in optimal outcomes but continues to be widely used, particularly when labor progress is less than optimal. However, there are numerous evidence-based approaches that can be used to avoid reverting to directed, prolonged Valsalva bearing down. Nursing care challenges may be encountered when using physiologic approaches; therefore, strategies are detailed to alleviate a variety of problems including ways to promote physiological descent and effectively support women's spontaneous efforts. For example, maternal postural interventions are suggested for asynclitic and occiput posterior fetal positions. When fetal heart rate abnormalities present and the fetus may be compromised, modifications to spontaneous bearing down are suggested as alternatives to longer and stronger Valsalva pushing, such as encouraging the women to use short pushes or breath through contractions until the fetus recovers. Open knee-chest maternal positioning can help to diminish a premature urge to push, while the closed knee-chest position may be more useful if cervical edema occurs. Even with clinical challenges, evidence-based care can help achieve the improved outcomes documented from women's spontaneous bearing-down efforts during the second stage.

The integration of research and practice: the importance of examining the evidence

IN PREVIOUS COLUMNS, I HAVE covered the following topics: types of research design (September/October 2003), study reliability and validity (January/ February 2004), instrument reliability and validity (May/June 2004), selection and use of research instruments (September/ October 2004), and issues and methods related to data collection and study implementation (January/February 2005). This column addresses some issues related to the integration of research and clinical practice across many clinical professions.

Implementing evidence-based practice: reducing risk for low birth weight through pregnancy smoking cessation

In 1989, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) developed a research utilization program to integrate evidence into practice areas where there were large discrepancies between research evidence and clinical practice. The current program, renamed Research-Based Practice (RBP), uses translational research methods to build from evidence such as that in the Cochrane database and to create protocols for integration of research directly into clinical practice. This article describes the development of the sixth project (RBP6), in which an evidence-based protocol to address smoking in pregnancy was integrated into clinical practice. The protocol includes screening women using descriptive statements and integrates the 5 As (ask, advise, assess, assist, arrange) into prenatal and postpartum care at every visit. By integrating smoking cessation counseling into care, nurses may reduce the risk of low birth weight among pregnant women in both the United States and Canada.

Use of upright positioning with epidural analgesia: findings from an observational study

PURPOSE

To present research findings and related nursing implications from an observational study designed to evaluate the use of upright positioning during second stage labor with patients who had received low-dose epidural analgesia.

STUDY DESIGN AND METHODS

This descriptive study evaluated outcomes from a sample of 74 healthy women having their first childbirth. They had all received epidural analgesia during the first and second stages of labor. Data were also collected by nurses on the use of birthing beds, and the extent of physical and emotional support the women needed while following the upright positioning study protocol.

RESULTS

All women were able to maintain upright positions throughout the second stage of labor following epidural analgesia administration. No adverse neonatal outcomes or maternal problems (such as excessive vaginal bleeding) were documented.

CLINICAL IMPLICATIONS

Although women were capable of assuming upright positions during second stage, the study results indicated that constant physical and emotional support was necessary for most women. Future research on methods to prepare women for multiple position options after administration of low-dose epidural analgesia should be undertaken. In addition, nurses should evaluate the benefits of upright positioning in terms of facilitating progress of labor.

The "push" for evidence: management of the second stage

Recognition that the available evidence does not support arbitrary time limits for the second stage of labor has led to reconsideration of the influence of maternal bearing down efforts on fetal/newborn status as well as on maternal pelvic structural integrity. The evidence that the duration of 'active' pushing is associated with fetal acidosis and denervation injury to maternal perineal musculature has contributed to the delineation of at least two phases during second stage, an early phase of continued fetal descent, and a phase of "active" pushing. The basis for the recommendation that the early phase of passive descent be prolonged and the phase of active pushing shortened by strategies to achieve effective, but non-detrimental pushing efforts is reviewed. The rational includes an emphasis on the obstetric factors that are optimal for birth and conducive to efficient maternal bearing down. Explicit assessment of these obstetric factors and observation of maternal behavior, particularly evidence of an involuntary urge to push, should be coupled with the use of maternal positions that will promote fetal descent as well as reduce maternal pain. The use of epidural analgesia for pain relief can also be accompanied by these same principles, although further research is needed to verify the strategies of "delayed pushing" and maintenance of pain relief along with a reconceptualization of the second stage of labor.

Urinary incontinence in pregnancy and the puerperium

OBJECTIVE

To describe the incidence of urinary incontinence (UI) during pregnancy and the puerperium and to identify potential contributing factors.

DESIGN

A descriptive correlational design, using participant interviews and reviews of the existing medical records to determine the incidence of UI in pregnancy and the puerperium and to examine relationships between and among several variables. The variables included parity, episiotomy, use of forceps/vacuum extractor, type of anesthesia, prolonged Stage II labor, and race. Data were collected via two personal interviews and review of medical records. The first interview was conducted during the recruitment of each participant; the second was a telephone interview conducted 4 to 6 weeks postpartum. Data collected from the medical records included obstetric history, weeks of gestation, and estimated date of delivery. Data were entered into data files for analysis with SPSS 8.0 and summarized with descriptive statistics.

SETTING

A secluded area of a university teaching hospital prenatal clinic.

PARTICIPANTS

A convenience sample of 50 pregnant women, at least 18 years old, who received their care at a large university hospital prenatal clinic in the southeastern part of the United States.

RESULTS

First Interview (N = 50). More than half (62%; n = 31) of the sample reported some degree of involuntary urine loss during their pregnancy. The racial distribution of those reporting UI was the following: white (70%; 21 out of 30); African American (44%; 8 out of 18); Hispanic/Asian (100%; n = 2). Among the participants who experienced UI (n = 31), 76% (n = 23) reported that their health care provider never asked if they were experiencing any UI symptoms. Second Interview (n = 24). Only 48% of the initial participants could be contacted for the second interview because of changes in residence or telephones being disconnected with no forwarding number. Of the women in this sample who reported UI during the first interview (59%; n = 14), 7 (50%) continued to experience UI 4 to 6 weeks postpartum. The 2 remaining participants who reported UI 4 to 6 weeks postpartum (22%) had not experienced UI during pregnancy. Of the participants experiencing postpartum UI, 77% (n = 7) were white. Almost half of the participants with postpartum UI were ages 35 or older (44%; n = 4). Among the participants reporting episiotomy (n = 4), 3 (75%) reported having UI 4 to 6 weeks postpartum.

CONCLUSIONS

Study results support the conclusion that childbirth, specifically vaginal birth, is a major factor in developing UI in the early postpartum period. Age, race, and use of episiotomy appear to be contributing risk factors.

Cochrane pregnancy and childbirth database: resource for evidence-based practice

The Cochrane Pregnancy and Childbirth database is an ongoing meta-analysis of evidence documenting effective health care practices for childbearing women and their neonates. It is proving invaluable to nurse educators, researchers, clinicians, and administrators working in a variety of health care delivery settings. Evidence-based nursing practice that is safe and effective can enhance rather than overpower pivotal and celebratory life events such as childbirth.

Using research to establish protocols for practice: a statewide study of acute care agencies

The purpose of the study was to examine research utilization practices relative to developing and revising practice protocols in acute care agencies in Delaware. Nurse leaders in 13 acute care agencies identified resource nurses most familiar with the development and revision of agency protocols. Thirty-two resource nurses from 11 agencies, representing critical care, emergency, general medical, general surgical, obstetric, and psychiatric nursing, were interviewed. Interviews were tape-recorded and transcribed. Examples of research-based protocols, defined as those supported by research citations, were obtained. The authors found that the majority of protocols submitted, although referenced, were not research-based. Most institutions used textbooks and standards to support nursing practice protocols. The authors concluded that nurses who are responsible for developing and revising agency protocols were not familiar with the use of research findings to guide the development or revision of protocols and were unsure what constituted the "use of research."

Maternal fatigue: implications of second stage labor nursing care

The parameters of fatigue have been studied in recent years in relation to women's health and the childbearing period. Less research emphasis has been placed on second stage labor, a period of time that can encompass considerable physiologic and psychologic fatigue. Consideration to minimizing second stage labor fatigue by altering conventional support practices is needed. This includes minimizing long periods of strong pushing or bearing down efforts in conjunction with sustained breath holding, particularly for women receiving epidural anesthesia. The potential sequelae of second stage labor fatigue, recommendations for practice changes, and new research directions are discussed.

The process for initiating nursing practice changes in the intrapartum: findings from a multisite research utilization project

The process of implementing a research-based protocol (the Second Stage Labor Nursing Management) at 40 sites in North America is described. Both positive and negative factors involved in implementing and adhering to the protocol are presented based on the reports of site coordinators. Key findings from the process data are: (a) the term "research utilization" causes confusion, (b) it is essential that nurses collaborate with other disciplines when attempting to change practice, (c) administrative endorsement of research utilization is important for practice change to occur, (d) nurses know their own practice sites and how to facilitate protocol acceptance, and (e) practice change may not need to occur all at once.