1. Lewis, Judith A. PhD, RN, FAAN
  2. Jonsdottir, Sigridur Sia MS, CNM, RN

Article Content

Provider Support of Spontaneous Pushing During the Second Stage of Labor

Sampselle, C. M., Miller, J. M., Luecha, Y., Fischer, K., & Rosten, L. (2005). Journal of Obstetric, Gynecologic & Neonatal Nursing, 34(6), 695-702.

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Recent evidence suggests that there are no data supporting policies that direct women's pushing efforts during the second stage of labor, yet a recent study notes that more than 75% of labor and delivery nurses encourage prolonged Valsalva-type pushing efforts. Instructing women to use directive pushing is reinforced in leading medical obstetrics texts, and providers often use cheerleading-type efforts to exert greater and more sustained pushing efforts guided by external evidence such as the presence of contractions on electronic fetal monitor tracings. There is a growing body of evidence that suggests that spontaneous pushing, guided by women's internal body cues, is equally effective, and may be less harmful than the more directed pushing efforts. This study by Sampselle et al. sought to describe the association between communication from healthcare providers and maternal second-stage pushing efforts and to compare differences in total pushing time and the length of the second stage of labor. The authors found that the spontaneous pushing was associated with positive, supportive, and encouraging caregiver communication, and that it did not significantly lengthen the duration of the second stage or the total pushing time. Encouraging, positive communication is in accord with current evidence-based standards of practice, provides a less authoritarian role for nurses, and does so without any adverse outcomes.


Comment by Judith A. Lewis


Lived Experience of Pregnancy While Carrying a Child With a Known, Nonlethal Congenital Abnormality

Hedrick, J. (2005). Journal of Obstetric, Gynecologic & Neonatal Nursing, 34(6), 732-740.


In the past, women often were not aware of congenital abnormalities until after the birth of their child. Today, with the increasing use of prenatal diagnostic technology, women in countries with sophisticated healthcare systems often are aware of these problems during the pregnancy. The knowledge that she is carrying a fetus with an abnormality affects a woman's pregnancy experience. This phenomenological study sought to understand a woman's lived experience of pregnancy when she knew that her fetus had a nonlethal congenital abnormality. Fifteen women participated in the study; the anomalies included such conditions as neural tube defects, cardiac anomalies, cleft lip, and Down's syndrome. Women ranged in age from 18 to 44 years and learned of their fetus' diagnosis at 17-26 weeks of gestation. They were interviewed during 24-36 weeks gestation and knew of the diagnosis for 4-18 weeks at the time of interview. Women described paradoxical feelings on the three themes that emerged. They felt that "time" was good because it gave them time to prepare learning to deal with the situation and prepare for the birth of their child. Time was also viewed as the enemy because it made them worry and wonder regarding how the specific effects of the abnormality would be manifested in their particular child. The second theme was in the area of "grief". Women talked about negative emotional responses and also recognized that the experience was an opportunity for growth. In the area of the perfect baby, women were able to acknowledge the loss of the "perfect baby" and also exhibited claiming behaviors and became advocates for their particular child despite any problems the child might have. The author concludes that women exhibit positive attachment behaviors and find it beneficial to have the time before delivery to become knowledgeable about the condition of their child, seek appropriate care resources, and develop specific treatment plans. With one exception, all of the women were glad that before the birth of the child they were able to learn of the child's abnormality. Nurses can assist women by supporting them in their journey, encouraging information-seeking activities, providing support by active listening, and acknowledging their concerns while providing them with truthful information.


Comment by Judith A. Lewis


Use of a Dummy (Pacifier) During Sleep and Risk of Sudden Infant Death Syndrome (SIDS): Population-based Case-Control Study

Li, D.-K., Willinger, M., Petitti D. B., Odouli, R., Liu, L., & Hoffman, H. J. (2006). British Medial Journal, 332, 18-21.


This study brings very important information to all of us who care for mothers and babies, for it emphasizes the need to introduce a pacifier to a child after birth, soon after breastfeeding has been established. The aim of this study was to identify whether use of a pacifier during sleep is associated with a reduced risk of sudden infant death syndrome (SIDS) regardless of other risk factors. Although other studies have reported this reduced rate of SIDS with pacifiers (called a "dummy" in British literature), they did not compare the incidences with other risk factors.


Mothers of 185 infants who died of SIDS participated in this study. Two healthy infants were randomly selected into a case-control group (n = 312) to match each dead infant, matching on age at death or mother's interview, place of living, maternal race, and ethnicity. Use of a pacifier at each infant's last sleep before death or the night before the mothers' interviews was recorded. Information was compared regarding use and nonuse of pacifiers and (a) eight characteristics of maternal social demographic data; (b) five infant characteristics; and (c) three different sleeping characteristics. Data collected included known risk factors for SIDS, co-sleeping with a smoker, sleeping prone/on side, and sleeping in soft bedding.


Results indicated that the use of a pacifier decreased the likelihood of SIDS (0.08 odds ratio). The use of a pacifier was associated with reduced risk in every category of the maternal and infant factors included in the study. It also decreased the effects of the known risk factors of SIDS (such as cosleeping with a mother who smoked and sleeping in the prone position), though the difference was not significant. The authors point out that further study is necessary with larger sample sizes, but that this study is another one that indicates that pacifier use should be encouraged. We should be using this study as a good example for our patients when they ask us about pacifier use.


Comment by Sigridur Sia Jonsdottir

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Making Choices for Childbirth: A Randomized Controlled Trial of a Decision-Aid for Informed Birth After Cesarean

Shorten, A., Shorten, B., Geogh, J., West, S., & Morris, J. (2005). Birth, 32(4), 252-261.


Women who have cesarean deliveries used to be routinely subjected to repeat cesareans. This absolute edict was later followed by a requirement that all women who met specific criteria undergo a trial of labor and attempt vaginal birth after cesarean (VBAC) to reduce the elective cesarean delivery rate. This prospective, multicenter randomized controlled trial had as its objective to determine whether a booklet describing risks and benefits of elective repeat cesarean versus trial of labor would facilitate maternal decision-making in a subsequent pregnancy. This study was conducted in New South Wales, Australia. Women who had a single previous Cesarean birth and who were medically eligible for a trial of labor and vaginal birth after cesarean were recruited between 12 and 18 weeks gestation and randomly assigned to intervention and control groups. Although women who received the educational booklet demonstrated higher knowledge levels, there was no significant difference in birth option preferences between the two groups, even though the preferences expressed by the women did not always correlate with actual birth outcomes. The implications for practice are that the knowledge alone does not lead to informed choice, and healthcare providers need to further examine how they can help empower women to make informed choices.


Comment by Judith A. Lewis


Risks and Protective Factors Associated With Symptoms of Depression in Low-Income African American and Caucasian Women During Pregnancy

Jesse, D. E., Walcott-McQuigg, J., Mariella, A., & Swanson, M. S. (2005). Journal of Midwifery and Women's Health, 50(5), 405-410.


Postpartum depression continues to plague women, and it is essential that nurses and midwives do a better job of finding women with the illness. This study was done to help us discover risk factors and protective factors for postpartum depression. The 130 expectant mothers who participated in the study were recruited while waiting for their prenatal appointment at an urban prenatal clinic. Interviews were done with the women, and the Beck Depression Inventory (BDI-II) was completed, as well as instruments measuring abuse in pregnancy, psychosocial attributes, and spiritual well-being. All the women were English speaking, aged 14-44, and 16-28 weeks pregnant.


Twenty-seven percent of the women scored more than 16 on the BDI-II and were therefore clinically diagnosed with depression. The African American women (24%) were less depressed than the Caucasian women (33%), although this difference was not statistically significant. Adolescents scored significantly higher on the BDI-II than the adults. The risk factors for depression were identified as abuse, stress, and risky behaviors such as smoking, alcohol and other substance abuse. The protective factors were identified as social support, self-esteem, religiosity, and a spiritual perspective. Smoking and substance abuse were not significantly linked to depression. The authors concluded that screening all pregnant women for symptoms of depression would be beneficial in case finding, and encouraged all nurses to do so. I encourage MCN readers to read this interesting study about an important issue in prenatal care.


Comment by Sigridur Sia Jonsdottir

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Five Years to the Term Breech Trial: The Rise and Fall of a Randomized Controlled Trial

Glezerman, M. (2006). American Journal of Obstetrics and Gynecology, 194(1), 20-25. [Context Link]


We have all become aware of the major recent change in practice in which planned cesarean births have become more common. Planned cesareans for full-term breech births are now protocol in many institutions, probably in large part because of the term breech trial (TBT) (Hannah et al., 2000), which concluded that cesarean birth was safer for term breech babies. This interesting article by Glezerman goes back to the original data from the TBT to reanalyze the data. The TBT included 2,183 women from 26 countries at term with a fetus in breech presentation, who were randomly assigned to deliver either by planned cesarean section or planned vaginal delivery. The results, in favor of planned cesarean section, changed medical practice almost immediately. In this article, Glezerman suggests not only that the design, methods, and conclusions were incorrect, but also that the neonatal death and morbidity in the TBT did not actually result from the method of delivery and that analyses of infant outcomes after 2 years have now shown there is no difference between infants in either group. Glezerman concludes that the original TBT recommendation should be withdrawn.


Among Glezerman's concerns is the big variance between participating centers, which he says put planned vaginal deliveries at a disadvantage. The TBT defined 35.2 % of the centers as having a "high standard of care." The remaining 64.8% were defined as having "usual standard of care" including cesarean section within 60 minutes and emergency intubations within 30 minutes. Glezerman contends, however, that this was not the standard of care in most institutions in the Western world. Glezerman also says that inclusion criteria were not clearly followed in all sites. Hodnett and Hannah (2002) have also confirmed that many of the participating centers had no routine access to ultrasound evaluation.


Glezerman's conclusions are very important for all midwives and nurses working in perinatal care. We educate women regarding birth and support them during pregnancy and delivery. If Glezerman is correct, then perhaps vaginal breech birth is safe in some situations. More study is needed about this important topic.


Comment by Sigridur Sia Jonsdottir




Hannah, M., Hannah, W., Hewson, S., Hodnett, E., Saigal, S., & Willan, A. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Term breech trial collaborative group. Lancet, 21, 1375-1383.


Hodnett, E., & Hannah, M. (2002). Term breech trial. Birth, 29, 217-219. [Context Link]