Cesarean birth, Epidural analgesia, Laboring down, Maternal positioning, Peanut ball, Physiologic birth, Pushing, Second-stage labor, Urinary catheterization



  1. Garpiel, Susan J. MSN, RN, CNS, C-EFM


Background: There is renewed interest in second-stage labor practices as recent evidence has challenged historical perspectives on safe duration of second-stage labor. Traditional practices and routine interventions during second-stage have uncertain benefit for low-risk women and may result in cesarean birth.


Purpose: The purpose of this quality improvement project was to implement an interdisciplinary second-stage practice bundle to promote safe outcomes including method of birth and women's birth experience.


Methods: Standardized second-stage labor evidence-based practice recommendations structured into a 5 Ps practice bundle (patience, positioning, physiologic resuscitation, progress, preventing urinary harm) were implemented across 34 birthing hospitals in the Trinity Health system.


Results: Significant improvements were observed in second-stage practices. Association of Women's Health, Obstetric and Neonatal Nurses' perinatal nursing care quality measure Second-Stage of Labor: Mother-Initiated Spontaneous Pushing significantly improved [pre-implementation 43% (510/1,195), post-implementation 76% (1,541/2,028), p < .0001]. Joint Commission Perinatal Care-02: nulliparous, term, singleton, vertex cesarean rate significantly decreased (p = 0.02) with no differences in maternal morbidity, or negative newborn birth outcomes. Unexpected complications in term births significantly decreased in all newborns (p < 0.001), and for newborns from vaginal births (p = 0.03). Birth experience satisfaction rose from the 69th to the 81st percentile.


Clinical Implications: Implementing 13 evidence-based second-stage labor practices derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines achieved our goals of safely reducing primary cesarean birth among low-risk nulliparous women, and optimizing maternal and fetal outcomes associated with labor and birth. By minimizing routine interventions, nurses support physiologic birth and improve women's birth satisfaction.