Effects of Delayed Pushing During the Second Stage of Labor on Postpartum Fatigue and Birth Outcomes in Nulliparous Women

Journal of Nursing Research Vol. 17, No. 1, 2009

Man-Lung Lai & Kuan-Chia Lin* & Hsin Yang Li** & Kuang-Shing Shey*** & Meei-Ling Gau****

ABSTRACT: This article studied differences in postpartum fatigue and birth outcomes between women who pushed immediately and those who delayed pushing during the second stage of labor. Data were collected from primiparous women in their 38th to 42nd gestational week who did not receive epidural analgesia during labor and were free of complications during pregnancy. Using a quasi-experimental design, 72 participants selected by convenient sampling were assigned based on individual participant’s preference to either an experimental or control group. For the experimental group, pushing was delayed until the point after full cervical dilation at which (a) the mother felt a strong physical pushing reflex, (b) the fetal head had both descended to at least the +1 level in the pelvis and turned to the occiput anterior position, and (c) uterine contractions were at least 30 mmHg. For the control group, the physician instructed mothers to begin pushing after full cervical dilation at the point when the fetal head was in the occiput anterior position and uterine contractions were at least 30 mmHg. The authors administered the Modified Fatigue Symptom Checklist at 1 and 24 hr after delivery to measure participant’s fatigue levels. Birth outcomes were assessed based on medical chart data. Findings showed a significant difference between the two groups in terms of 1- and 24-hr postpartum fatigue scores. The duration of the second labor stage (experimental group, 70.31 T 37.17 min; control group, 129.06 T 75.69 min) also differed significantly. The group that pushed immediately recorded higher cesarean and instrument-assisted birth rates. No significant differences were observed in terms of perineal tears, maternal/neonatal complications, or neonatal Apgar scores. Results of this study provide important insights for caregivers working in the delivery room and suggest that current care procedures change to include the delayed pushing during the second stage of labor. By delaying pushing exertions until the mother feels a reflexive urge to do so, mothers’ feelings of fatigue are significantly reduced. Key Words: pushing immediately, delayed pushing, second stage of labor, postpartum fatigue.

Introduction ified to secure an optimal birth outcome (Tseng, 2000). An exploratory study by Evans and Jeffrey (1995) identified A large majority of mothers retain particularly strong proper pushing techniques, proper breathing techniques, and impressions and deep feelings about their first childbirth an explanation of the birthing course as the health education experience (Simkin, 1992). For the family, labor and topics of most interest to women in labor. After the slow and childbirth represent important life events fraught with painful first stage of labor, women are typically anxious to strain and anxiety. Family members naturally seek the commence the second stage because it represents the assistance of professionals who are experienced and qual- conclusion of the birth process and birth-related pains.

RN, MS, Department of Nursing, Taipei Veterans General Hospital; *PhD, Associate Professor, Department of Nursing, National Taipei College of Nursing; **MD, PhD, Physician, Division of Obstetrics and Gynecology, Taipei Veterans General Hospital & Assistant Professor, School of Medicine, National Yang-Ming University; ***MD, Director, Obstetrics and Gynecology Department, Cheng Hsin Rehabilitation Medical Center; ****RN, PhD, Professor, Graduate Institute of Nurse-Midwifery, National Taipei College of Nursing. Received: July 9, 2008 Revised: September 23, 2008 Accepted: October 24, 2008 Address correspondence to: Meei-Ling Gau, No. 365, Ming-Te Rd., Peitou, Taipei 11219, Taiwan, ROC. Tel: +886 (2) 2822-7101 ext. 3260; E-mail: [email protected]

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Therefore, as soon as the cervix is fully dilated, women in effected, and it ends when the fetus is expelled. This is the second stage of labor tendtopushwithexceptional also known as the pushing stage (Roberts, 2003). Com- force. Roberts (2002) pointed out that pushing forcefully plete dilation of the cervix has typically served as the before the optimal time for such exertion can lengthen the determining factor in advising the mother when to com- total time spent pushing and quicken the onset of fatigue, mence bear-down efforts (Cunningham et al., 2005). which can foster doubts in the mother about her strength and However, Roberts (2003) and Roberts and Woolley ability to complete the labor process successfully. (1996) suggest that the second stage of labor should be Williams Obstetrics, the basic educational obstetrics further subdivided into two substages, namely, the early and gynecology reference used by most teaching hospitals phase and later phase. The former, also called the pelvic in Taiwan, defines the second stage of labor as beginning stage, is the period after full dilation of the cervix during when the cervix becomes fully dilated, at which point the which the fetal head passes over the pelvis, begins to turn, expectant mother may begin pushing. The reference and proceeds down the birth canal. The later phase is further advises the expectant mother to breathe deeply, called the perineal phase because the fetal head is lower hold her breath, and push hard as soon as uterine con- in the pelvis and distends the perineum. The mother soon tractions commence (Cunningham et al., 2005). Many feels an involuntary urge to push. researchers have conducted studies in recent years into the Drake, Hammond, Jacobson, and White (1997) di- specific point in time at which force should be applied vided the second stage of labor into three substages, during the second stage of labor and have raised diverse namely the latent, active, and transition phases. In the opinions on the subject (Fraser, Cayer, Soeder, Turcot, & latent phase, women experiencing uterine dilation will Marcoux, 2002; Fraser et al., 2000; Petersen & Besuner, begin to feel a growing, but not yet intense, desire to 1997; Roberts, 2002, 2003; Roberts & Woolley, 1996). push. Mothers should be allowed to rest up to the point These researchers argued that cervical dilation represents where the desire to push becomes irresistible. The cervix just one of several indicators to be considered during the may be completely or nearly completely dilated during second labor stage. The progress of the fetus down the this phase. The active phase is marked by a reflexive de- birth canal and the feelings of the mother also represent sire to push hard 3Y4 times more during uterine con- important considerations. Thus, time should not be tractions after the passage of the fetal head downward limited to a precise 2-hour period. The second stage of through the birth canal. The transition phase begins with labor may be extended in the absence of concomitant the crowning of the head, when contractions cause the medical conditions because it is considered safe for both greatest pain levels, accompanied by the strongest desire mother and child (Petersen & Besuner, 1997). As a result, to push and an inability to control pushing exertions. the point in time when pushing begins has a very signifi- Therefore, some researchers recommended that cant effect on both mother and child. Research focusing decision making with regard to the time at which in- on optimal time for pushing to begin has yet to be con- structions or directions should be given to the expectant ducted in advanced countries. mother to push cannot be based solely on full cervical Many studies have pointed to early pushing having an dilation and that fetal position and station represent adverse effect on maternal and fetal outcomes, citing higher important additional considerations (Petersen & Besuner, rates of fetal heart rate deceleration, cesarean and instrument- 1997; Roberts, Gruener, & Mendez-Bauer, 1987; Yildirim assisted deliveries, and postpartum fatigue. Most research & Beji, 2008). Once approximately 1 cm past the is- studies suggest that the benefits to the mother of waiting to chial spine, the fetal head begins turning toward the oc- push exceed those of pushing immediately. Therefore, this ciput anterior (OA) position, after which the head should article studied the comparative effects on postpartum fatigue begin descending more rapidly. The mother does not ex- and birth outcomes of pushing immediately and delaying perience a strong reflexive desire to push while her child pushing during the second stage of labor. is in the OA position. Rather, the strongest desire occurs once the head has reached the base of the pelvis and trig- Literature Review gered the Ferguson’s reflex in pelvic muscles (Roberts, Second stage of labor is typically defined as the 2003). This is the point at which forceful pushing is most point at which the cervix becomes completely dilated and productive.

Copyright @ 2009 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited. Journal of Nursing Research Vol. 17, No. 1, 2009 Man-Lung Lai et al.

Researchers who advocate delaying forceful pushing This group also had a lower rate of instrument-assisted until the second stage of labor (Petersen & Besuner, 1997; births than that of the early pushing group, which helped Roberts & Woolley, 1996) hold that the reflexive desire to reduce perineal tearing and postpartum pain. push at this stage represents a natural physical reaction Researchers further stated that extended exertions in triggered by full cervical dilation and the downward the second stage of labor place greater physical demands progress of the fetal head. Delaying forceful pushing until on the mother, which fatigue muscles and increase the the mother feels a reflexive desire to do so can reduce the caesarean section rate. Overexertion can also overstretch total amount of time spent pushing. Relying on an entirely vaginal and pelvic structures, contributing to future blad- natural pushing reflex can further help mothers adopt the der control problems, unnecessary perineal tearing, and most effective pushing rhythm. Because the pushing increased episiotomy rates (Allen, Hosker, Smith, & reflex is extremely difficult to resist, it can enhance the Warrell, 1990; Mayberry, Gennaro, Strange, Williams, & effectiveness of pushing and reduce the amount of time De, 1999; Minato, 2000). spent on pushing exertions during the second stage of Roberts and Woolley (1996) stated that although labor. The reduction in pushing-induced fatigue that persistent and forceful exertion during the second stage of should follow can help improve a mother’s overall birth labor helps move the fetal head downward and speeds the experience (Yildirim & Beji, 2008). birthing process, such added pressure on the fetal head Hansen, Clark, and Foster (2002) compared mother/ and umbilical cord increases chances of neonatal hypo- child labor outcomes between delayed pushing and early glycemia. Their research also found that birth outcomes pushing for nulliparous women with continuous-infusion highly correlated with length of time spent in exertion epidural analgesia. Using 252 participants, results showed from full cervical dilation until birth. Recommendations that although the second stage of labor was longer for included advising against overintervention during the women in the group that delayed pushing, their time spent second stage of labor to achieve better labor outcomes in pushing exertions was shorter. This group also ex- for both mother and child. perienced fewer incidences of fetal heart rate deceleration In summary, most studies argued that enhancing the and postlabor fatigue. Apgar scores, pH values in the um- effectiveness of pushing exertions by the mother during bilical artery, and rates of perineal tearing and endometritis the second stage of labor represents the most effective way were similar between the two groups. Results suggested to reduce postpartum fatigue, amount of time spent push- that the benefits to the mother of waiting to push exceed ing, and occurrence of concomitant medical conditions. those of pushing immediately. Such findings highlight the importance of the point at In addition to facilitating a reduction in overall time which pushing begins, pushing method used, and position spent pushing, which helps prevent overexertion, delaying in which pushing is done in care delivered during the the commencement of forceful pushing has also been shown second stage of labor. The authors hope that related ad- to help prevent damage to pudendal nerves, lessen labor- justments to care delivery measures will help reduce injury induced fatigue, decrease length of time spent pushing dur- to mothers and infants and effectively diminish the degree ing the second stage of labor (Hansen et al., 2002), and of postpartum fatigue experienced by new mothers. reduce the need of instrument-assisted delivery techniques. Waiting to push until the mother feels a reflexive need to do so can reduce the need for an episiotomy and the inci- Methods dence of second- to fourth-degree perineal tearing (Minato, 2000). Albers and Borders (2007) conducted a critical re- This quasi-experimental study was conducted in the view of the literature to explore differences in outcomes maternity units of one teaching and one regional hospital in between waiting to push and pushing immediately during northern Taiwan. Written ethical approval for the study was the second stage of labor in mothers receiving epidural obtained from the ethical review board of the hospitals. analgesia. The study, which reviewed nine articles address- ing 2,953 cases of women awaiting delivery, found that Study Sample those in the delayed pushing group had relatively longer The study sample consisted of low-risk primiparous second stages of labor but relatively shorter pushing times. women between 38 and 42 weeks’ gestation who volunteered

Copyright @ 2009 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited. Effects of Delayed Pushing Journal of Nursing Research Vol. 17, No. 1, 2009 to participate in this study. They were expected to give .46Y.71, p G .01; stress, r = .36Y.73, p G .01) (Corwin, birth vaginally with a healthy single vertax fetus. Women Brownstead, Barton, Heckard, & Morin, 2005; Milligan were excluded if epidural analgesia had been administered et al., 1997; Pugh et al., 1999). Translation and back- or if any condition was present that necessitated a shorte- translation of the MFSC into Chinese by bilingual ning of the second stage of labor. Power Analysis and individuals with bicultural experience established both Sample Size for Window 6.0 (PASS 6.0) software was content and semantic equivalence (Lee, 2005). Internal applied on results from an initial pilot study to estimate an consistency reliability (KuderYRichardson formula) optimal sampling number. Each group consisted of 36 ranged from .82 to .85 (Corwin et al., 2005; Milligan participants to ensure that test results achieved power .80, et al., 1997; Pugh et al., 1999). Internal consistency for as recommended by PASS. the Chinese MFSC achieved .76 (2 weeks postpartum) and .77 (4 weeks postpartum; Lee, 2005) and .82 in this Study Variables study.

Demographic and obstetric characteristics data Birth outcomes Demographic variables collected included age, level Birth outcomes were assessed based on factors that of education, physical height, prepregnancy weight, mari- included length of the second stage of labor, method of tal status, employment status, province of origin, religious delivery (spontaneous vaginal, caesarean, or instrument- affiliation, smoking status, alcohol status, and sleeping assisted vaginal delivery), labor complications (fever, condition. Obstetric characteristics data included gesta- blood loss more than 500 mL, fetal deceleration, or need tional weeks, use of induced labor techniques, analge- for admission to the neonatal intensive care unit), degree sics, or other medication during labor, and infant birth of perineal tearing, and Apgar scores at 1 and 5 min. weight. Intervention Protocol Fatigue scale Apart from the time at which pushing exertions The Fatigue Symptom Checklist was originally de- began, key labor variables, including pushing technique veloped to measure fatigue in Japanese industrial workers and physical position during pushing, were the same for (Yoshitake, 1978). Milligan, Parks, Kitzman, and Lenz experimental and control group participants. The re- (1997) created the Modified Fatigue Symptom Checklist searcher personally instructed participants in proper (MFSC) by adapting the Fatigue Symptom Checklist for pushing techniques and accompanied participants through use with new mothers of full-term infants. Milligan et al. labor and delivery. (1997) indicated that childbirth is a physically and emo- Key labor variables are explained below: tionally demanding period during which a woman 1. Timing: For the experimental group, pushing was may face labor pains, strain, anxiety, and/or feelings of delayed after full cervical dilation until the point at hopelessness. The MFSC consists of 10 statements that which the mother felt a strong physical pushing re- measure physical and psychological fatigue. Four ques- flex, the fetal head had descended to at least the +1 tions address physical aspects of fatigue, and 6 questions level in the pelvis and already turned to the OA po- address psychological aspects of fatigue, with answers sition, and uterine contractions became intense (at given as either Byes[ or Bno.[ Possible scores range from least 30 mmHg). For the control group, pushing was 0 to 10. The classification of participant’s fatigue status is instructed to begin after full cervical dilation once based on mean and standard deviation scores of the sam- the fetal head was in the OA position and uterine ple. A participant’s score 1 SD above the sample mean contractions were at least 30 mmHg. score is categorized as severe fatigue, whereas a score of 2. Technique: Mothers were instructed to push force- 1 SD below the sample mean score is categorized as mild fully 3Y4 times more for 4Y6 s per time at each fatigue (Pugh, Milligan, Park, Lenz, & Kitzman, 1999). In uterine contraction. Breath should not be held while previous studies, psychometric testing of the MFSC pushing, and the glottis should be open. established content (Milligan et al., 1997) and concurrent 3. Position: When pushing, the mother should be in the validity (tiredness, r = .64, p G .01; depression, r = Fowler’s position, clasping her knees with both

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hands,with legs held apart, and head raised and fac- college as their highest level of education (n = 41, 56.9%); ing toward abdomen. nearly all were married (n = 70, 97.2%), and most were employed (n = 42, 58.3%). Oxytocin was the most fre- Data Collection Procedures and Ethical quent medication used during labor (n = 24, 33.3%). Considerations The average weight of newborn infants was 3,110.10 T T After receiving approval from their institutional re- 289.42 g, and average head circumference was 32.93 view boards, the researchers visited target institutions and 1.06 cm. After using a chi-square test and t test to compare associated labor and delivery units to explain research pur- the two groups, a significant difference was found only in pose and methods to obstetricians, nursing managers, and fundal height. All other variables revealed no statistically nurse clinicians before data collection. Before this interven- significant differences (Table 1). tion study, the two hospitals targeted in this study routinely instructed laboring women to commence pushing immedi- Comparisons on Duration of the Second ately after full dilation. Potential participants who met study Stage, Expulsion Phase in Labor, and criteria were clearly briefed on research purposes, interven- Birth Outcomes tion benefits and risks, and procedures. Before participa- Table 2 shows that the average duration of the second tion, they were asked to sign a consent form. After doing stage and the expulsion phase of labor in the immediately so, women were assigned into one of the two groups based pushing group was longer than those stages in the delayed on their personal choice once full dilation was confirmed. pushing group, and the difference between groups was The researcher accompanied each participant from 8-cm statistically significant (p G .05). The experimental group dilation until birth and conducted a vaginal examination had a higher natural vaginal birth rate than that of the every 30 min. Participants were instructed on pushing tech- control group, and the difference between groups was niques, with control group participants asked to commence statistically significant (p G .05). In terms of neonatal birth immediately after full dilation and experimental group par- outcomes, no significant differences in Apgar scores at 1 ticipants asked to delay pushing until either the urge be- and 5 min or neonatal complications were observed came overwhelming or full dilation had already occurred between the groups. Differences in incidences of episiot- for a 2-hr period, the fetal head was in the OA position, omy and perineal tears, blood loss, and maternal compli- uterine contractions were at least 30 mmHg, and the fetal cations were not significant between the groups (Table 2). head had already descended to station +1 or below. Fathers were able to accompany the women through the entire process. A curtain was drawn during pushing exertions to The Impact of Different Methods of Pushing maintain privacy. Any sign of danger during pushing exer- on Postpartum Fatigue T tions (e.g., significant loss of blood, fetal distress) ended Scores for postpartum fatigue after 1 hr were 2.08 T the data collection, with the attending physician brought 1.87 for the experimental group and 4.17 2.6 for the j G in immediately to deliver emergency care. After each birth, control group (t = 3.825, p .01). Scores for postpartum T the researcher collected birth outcome data from patient fatigue after 24 hr were 1.47 1.66 for the experimental T j G medical records and at 1 and 24 hr postpartum collected group and 3.36 2.13 for the control group (t = 4.21, p data on fatigue using a structured questionnaire. .01). Results showed comparatively lower fatigue scores for the experimental group at both 1 and 24 hr postpartum. Demographic and obstetrics variables for which differences between the two groups were found to be signifi- Results cant (fundal height, length of second labor stage, and total expulsion time) were controlled. Using generalized esti- Participant Sociodemographic and Obstetric mating equation analysis to control these variables, results Characteristics found that none of the three variables (fundal height, Table 1 shows the sociodemographic and obstetric length of second labor stage, and total pushing time) im- characteristics of participants. The average age of partic- pacted postpartum fatigue. Only method of exertion regis- ipants was 29.42 T 3.86 years. Most patients noted junior tered an impact on postpartum fatigue levels. Fatigue

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Table 1. Sociodemographic and Obstetric Characteristics of Women Experimental Control All (N = 72) (n = 36) (n = 36) Variable n % n % n % 22 p Education 3.793a .051 High school and lower 27 37.5 18 50.0 9 25.0 University/college and higher 45 62.5 18 50.0 27 75.0 Marital status .493b Married 70 97.2 34 94.4 36 100 Not married 2 2.8 2 5.6 0 0 Employment status 2.800a .094 Not employed 30 41.7 19 52.8 11 30.6 Employed 42 58.3 17 47.2 25 69.4 Labor medication Oxytocin 24 33.3 13 36.1 11 30.6 0.063a .803 Prostaglandin 9 12.5 5 13.9 4 11.1 1.000b Demerol 20 27.8 13 36.1 7 19.4 1.730a .188 Buscopan 5 6.9 2 5.6 3 8.3 1.000b Variable M T SD M T SD M T SD t p Age 29.42 T 3.86 28.94 T 4.22 29.89 T 3.46 j1.039c .302 Height 159.83 T 5.15 159.51 T 5.55 160.13 T 4.78 j0.512c .610 Prepregnancy weight (kg) 52.80 T 8.3 51.76 T 7.65 53.83 T 7.65 j1.063c .292 Weight at term 65.58 T 11.78 65.89 T 9.62 65.28 T 13.74 0.218c .828 Weight gain in pregnancy (kg) 15.27 T 6.84 16.41 T 8.87 14.14 T 3.70 1.414c .162 Fundal height (cm) 33.31 T 1.97 32.79 T 1.46 33.82 T 2.27 j2.281c .026* Length of pregnancy (wk) 275.17 T 7.17 274.81 T 7.59 275.53 T 6.82 j0.425c .672 Newborn birth weight (g) 3110.10 T 289.42 3071.14 T 271.60 3149.06 T 305.02 j1.145c .256 Head circumference (cm) 32.93 T 1.06 32.77 T 1.05 33.1 T 1.07 j1.325c .190 Note. aChi-square test with Yate’s correlation for continuity; bFisher’s exact test; cIndependent t test. *p G .05. scores for participants in the delayed pushing group began pushing immediately and found the two groups to averaged 1.54 points less than those for participants in be similar in terms of perineal laceration incidence and use the control group, a difference that registered as signiﬁcant of instrument-assisted birth techniques. The different out- ( p G .01; Table 3). come result obtained in this study may result from differences in routine standards related to episiotomies between the institutions used in this study and hospitals overseas. Discussion In this study, with the exception of one participant who gave birth through cesarean section, all mothers received This study found that participants in the experimental routine episiotomies. Thus, there is no basis for comparing group spent less time on pushing exertions and a shorter this study with that of Hansen et al. along participant sub- average duration of the second stage, a result similar to sets categorized by degree (0Y2) of perineal laceration those of other researchers (Drake et al., 1997; Fraser et al., severity. 2000; Hansen et al., 2002; Roberts, 2003). In terms of This study found a higher rate of instrument-assisted birth outcomes, Hansen et al. (2002) compared perinatal delivery among participants in the group that pushed outcomes in women receiving epidural analgesia who immediately than those in the group that delayed pushing. waited to push until full cervical dilation and those who The ﬁnding is similar to that of Roberts (2002), who also

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Table 2. Comparisons of Duration of the Second Stage, Expulsion Phase in Labor, and Birth Outcomes Between the Two Groups (N = 72) Experimental (n = 36) Control (n = 36) Item M T SD M T SD t p Duration of the second labor stage (min) 70.31 T 37.17 129.06 T 75.69 j4.180 G.001** Total pushing time (min) 47.53 T 30.85 123.19 T 73.93 j5.668 G.001** Apgar score at 1 min 7.94 T 0.41 7.92 T 0.37 0.302 .763 Apgar score at 5 min 8.97 T 0.38 8.97 T 0.167 0.000 1.000 Blood loss in delivery 262.50 T 63.67 283.89 T 73.65 j1.318 .192 Total time in labor (min) 820.64 T 866.19 782.58 T 671.83 0.208 .836 Item n % n % 22 p Method of delivery 4.759a .029* Natural birth 32 88.9 25 69.4 Forceps delivery 2 5.6 3 8.3 Vacuum extraction 2 5.6 7 19.4 Caesarean section 0 0 1 2.8 Episiotomy 0.231a .631 None 0 0 1 2.8 First degree 1 2.8 0 0 Second degree 29 80.6 31 86.1 Third degree 6 16.6 3 8.3 Fourth degree 0 0 1 2.8 Ward caring for infant 1.000b Nursery 35 97.2 35 97.2 Neonatal intensive care unit 1 2.8 1 2.8 Meconium aspiration 0.493b No 36 100 34 94.4 Yes 0 0 2 5.6 Maternal complications .054b No 36 100 31 86.1 Yes 0 0 5 13.9 Neonatal complications 1.000b No 35 97.2 35 97.2 Yes 1 2.8 1 2.8 Note. aLinear-by-linear association chi-square test; bFisher’s exact test. *p G .05. **p G .001. found that beginning exertions earlier than necessary in- intensive care unit or intensive care unit admittance. Such creases the need for instrument-assisted delivery. Fitzpatrick, is similar to findings by Menticoglous, Manning, Harman, O’Brien, McQuillan, O’Connell, and O’Herlihy (2000) and Morrison (1995) of a significant relationship between did a comparative study of birth outcomes for primipara length of the second stage of labor and either low 5-min women who had received epidural analgesia and either Apgar scores or neonatal intensive care unit or intensive pushed immediately or delayed pushing. The natural care unit admittance. Study findings also agreed with delivery rate was higher for the group that imme- those of Hansen et al. (2002) that Apgar score results diately pushed than the group that delayed pushing were no different between the two groups. (62% vs. 50%). Dunemn (1999) stated that fatigue is typically related This study found no significant relationship between to ineffectual labor progress or slow fetal progress through the two groups in terms of Apgar score or neonatal the birth canal after full dilation. This finding is similar to

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Table 3. fatigue. Therefore, adjusting approaches to care during the Comparing Factors of Influence on Postpartum second stage of labor can help reduce emotional distress Fatigue Using a Generalized Linear Model and postpartum fatigue. 95% Confidence Conclusions Variable Estimator SD interval Zp This study, in which women in labor were instructed to Groupa j1.54 0.44 j2.41 to j0.66 j3.45 G.01 delay pushing during the second stage of labor, found that Fundal height j0.05 0.10 j0.25 to 0.16 j0.44 .66 delayed pushing reduced the time these women spent in the G Duration of 0.01 0.01 j0.03 to 0.02 j0.62 .53 second labor stage, reduced the need for instrument-assisted the second delivery, and lessened postpartum fatigue. Extended fatigue labor stage affects indirectly the health of both mother and infant, Total pushing 0.01 0.01 j0.01 to 0.04 1.00 .32 time whereas fatigue-induced despondency can trigger postpartum depression and undermine the mother’s normal patience Note. aEarly pushing group as the reference group. and ability to think rationally. Concurrently, proper care for the newborn infant is negatively affected. Thus, such that of this study. Study results found no significant dif- a result serves to undermine the mother’s overall satisfac- ference in times in labor between the two groups. How- tion in the delivery process. Individuals who provide health- ever, it was found that degree of fatigue after 1 and 24 hr care service to mothers in labor in the hospital or clinic was higher in the group experiencing a longer second play a critical role. With delivery treated as a natural pro- stage of labor and larger time in exertion. cess and pushing exertions allowed to follow a mother’s Results agreed with the findings of this study, which natural rhythms (rather than being forced to fit external found no difference in total time in labor between the two standards and expectations), unnecessary harm to the groups and a relatively greater degree of 1 and 24 hr post- mother may be avoided. By delaying pushing exertions partum fatigue in the group that spent relatively longer until the mother feels a reflexive urge to do so, the need to times in the second stage of labor and in pushing exertions. remind the mother of proper pushing technique is signifi- This result is similar to that obtained by research done by cantly reduced. Minato (2000) and Ladewig, London, and Davidson The results of this study provide important insight to (2006). caregivers working in the delivery room and suggest a Pugh et al. (1999) also stressed the critical impor- change in current care procedures, which recommend that tance to nursing care delivery of understanding postpartum pushing exertions commence immediately upon com- fatigue factors and levels of fatigue severity. This research mencement of the second stage of labor. Proper pushing also found that the application of different pushing tech- techniques should also be taught to nurses in continuing niques during the second stage of labor could reduce education courses and through clinical demonstrations. postpartum fatigue severity. Fatigue that arises during the Videos and health pamphlets may also be produced to second labor stage can encourage the mother and family improve awareness on the subject. The results of this study members to abandon the natural birth process in hopes that may also be referenced when making revisions to relevant surgery will resolve birthing difficulties. Fatigue can also textbooks and reference manuals. Such dissemination of cloud rational thinking and lead to misjudgments and im- information will make it easier for both nurses and patience. Symptoms increasingly affect one another as expectant mothers to obtain the most up-to-date knowledge level of fatigue severity rises. Mother and family mem- on proper delivery care. ber’s confidence that a successful birth will increase if Ethical and clinical environment considerations dis- time spent in pushing exertions during the second stage of allowed this study from randomly assigning participants labor is reduced, and pushing exertions are made more to experimental and control groups. Although the authors productive. Also, utilizing aids such as mirrors to show found no significant variation in either sociodemographic fetal head progress to the mother can enhance positive or obstetric variables (with the exception of fundal height) anticipation and joy in the mother and family members, between the two groups, study results should be inter- ease the anxiety and discomfort of labor, and reduce preted with caution due to potential confounding factors

Copyright @ 2009 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited. Journal of Nursing Research Vol. 17, No. 1, 2009 Man-Lung Lai et al. caused by the nonrandom nature of distribution between Drake, E. E., Hammond, B. B., Jacobson, P. M., & White, the two (Shadish, Cook, & Campbell, 2002). Further M. (1997). Nursing care during labor and delivery. In E. studies with randomized designs are needed. This study E. Drake (Ed.), Contemporary maternity nursing (1st was limited to expectant mothers who did not receive ed., pp. 187Y236). St. Louis, MO: Mosby. epidural analgesia. In light of the fact that most women in Dunemn, K. N. (1999). Fatigue during labor. Unpublished labor in Taiwan receive epidural analgesia and that the doctoral dissertation, University of Illinois, Chicago. exertion experience of women under such conditions dif- Evans, S., & Jeffrey, J. (1995). Maternal learning needs fers from that of women not receiving epidural analgesia, during labor and delivery. Journal of Obstetric, Gyne- Y the effects on delivery outcomes and postpartum fatigue cologic, and Neonatal Nursing, 24(3), 235 240. of times spent in pushing exertion and pushing technique Fitzpatrick, M., O’Brien, C., McQuillan, K., O’Connell, P., & O’Herlihy, P. R. (2000). Comparison of immediate and should be greatly magnified. Because no relevant research delayed push in second stage of labor on anal sphincter into this participant has been conducted in Taiwan, it is integrity and mode of delivery. American Journal of hoped that future research can examine the different out- Obstetrics and Gynecology, 182(1, Pt. 2), S37. comes realized by women in labor who received or did Fraser, W. D., Cayer, M., Soeder, B. M., Turcot, L., & not receive epidural analgesia injections in terms of de- Marcoux, S. (2002). Risk factor for difficult delivery layed pushing, postpartum fatigue, and delivery results. in nulliparas with epidural analgesia in second stage of labor. Obstetrics and Gynecology, 99(3), 409Y418. Fraser, W., Marcoux, S., Krauss, I., Douglas, J., Goulet, C., Acknowledgments & Boulvain, M. (2000). Multicenter randomized controlled trial of delayed pushing for nulliparous women in The authors express their greatest appreciation to the second stage of labor with continuous epidural the women who agreed to participate in this study. The analgesia. American Journal of Obstetrics and Gyne- Y assistance of the nursing staff and administrators of the cology, 182(5), 1165 1172. Taipei Veterans General Hospital and Cheng Hsin Hansen, S. L., Clark, S. L., & Foster, J. C. (2002). Active Rehabilitation Medical Center in recruiting women for pushing versus passive fetal descent in the second stage of labor: A randomized controlled trial. Obstetrics and this study is gratefully acknowledged. Gynecology, 99(1), 29Y34. Ladewig, P. W., London, M. L., & Davidson, M. R. (2006). Processes and stages of birth. In P. W. Ladewig, M. L. References London, & M. R. Davidson (Eds.), Contemporary maternalYnewborn nursing care (6th ed., pp. 412Y455). Albers, L. L., & Borders, N. (2007). Minimizing genital tract Upper Saddle River, NJ: Pearson Prentice Hall. trauma and related pain following spontaneous vaginal Lee, H. L. (2005). Women’s sleep quality, fatigue and birth. Journal of Midwifery & Women’s Health, 52(3), depression during the 2nd and 4th postpartum weeks. 246Y253. Unpublished master’s thesis, National Taipei College Allen, R. E., Hosker, G. L., Smith, A. T. B., & Warrell, D. of Nursing, Taiwan, ROC. (Original work published in W. (1990). Pelvic floor damage and childbirth: A neu- Chinese) rophysiological study. British Journal of Obstetrics and Mayberry, L. J., Gennaro, S., Strange, L., Williams, M., & Gynaecology, 97(3), 770Y779. De, A. (1999). Maternal fatigue: Implications of Corwin, E. J., Brownstead, J., Barton, N., Heckard, S., & second stage labor nursing care. Journal of Obstetric, Morin, K. (2005). The impact on the development of Gynecologic, and Neonatal Nursing, 28(2), 175Y181. postpartum depression. Journal of Obstetric, Gyneco- Menticoglous, S. M., Manning, F., Harman, C., & Morrison, logic, and Neonatal Nursing, 34(5), 577Y586. I. (1995). Obstetrics perinatal outcome in relation to Cunningham, F. G., Leveno, K. J., Hauth, J. C., Bloom, S. L., second-stage duration. American Journal of Obstetrics Gilstrap, L. C., & Wenstrom, K. D. (2005). Normal labor and Gynecology, 173(3), 906Y912. and delivery. In F. G. Cunningham (Ed.), Williams Milligan, R. A., Parks, P., Kitzman, H., & Lenz, E. (1997). obstetrics (22nd ed., pp. 409Y441). New York: McGraw Measuring woman’s fatigue during the postpartum Hill. period. Journal of Nursing Measurement, 5(1), 3Y16.

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