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  1. Sommerness, Samantha A. DNP, APRN, CNM
  2. Gams, Rebecca MS, APRN, CNP
  3. Rauk, Phillip N. MD
  4. Bangdiwala, Ananta MS
  5. Landers, Daniel V. MD
  6. Avery, Melissa D. PhD, APRN, CNM, FACNM, FAAN
  7. Hirt, Charles MD
  8. Miller, Kristi MS, RN
  9. Millar, Amy MD
  10. Cho, Suzin MD
  11. Shields, Andrea MD


Key to any perinatal safety initiative is buy-in and strong leadership from obstetric and pediatric providers, advanced practice nurses, and labor and delivery nurses in collaboration with ancillary staff. In the fall of 2007, executives of a large Midwestern hospital system created the Zero Birth Injury Initiative. This multidisciplinary group sought to eliminate birth injury using the Institute of Healthcare Improvement Perinatal Bundles. Concurrently, the team implemented a standardized second-stage labor guideline for women who choose epidural analgesia for pain management to continue the work of eliminating birth injuries in second-stage labor. The purpose of this article was to describe the process of the modification and adaptation of a standardized second-stage labor guideline, as well as adherence rates of these guidelines into clinical practice. Prior to implementation, a Web-based needs assessment survey of providers was conducted. Most (77% of 180 respondents) believed there was a need for an evidence-based guideline to manage the second stage of labor. The guideline was implemented at 5 community hospitals and 1 academic health center. Data were prospectively collected during a 3-month period for adherence assessment at 1 community hospital and 1 academic health center. Providers adhered to the guideline in about 57% of births. Of patients whose provider followed the guideline, 75% of women were encouraged to delay pushing compared with only 28% of patients delayed pushing when the provider did not follow the guideline.