Improvement Stories

Adaptation and Implementation
of a Guideline for Second Stage
Labor for Women with
Epidural Analgesia

Samantha A. Sommerness, DNP, RN, CNM
Melissa D. Avery PhD, CNM, FACNM, FAAN
Becky L. Gams, RN, MS, CNP

What did you set out to change or improve?

Management of second stage labor is a topic of interprofessional importance in perinatal quality improvement (Association of Women’s Health and Neonatal Nurses, [AWHONN], 2008). Available evidence supports the safety of delayed pushing for at least two hours following complete cervical dilatation in healthy women with epidural anesthesia and no urge to push and has been associated with reduction in active pushing time, perineal lacerations and operative vaginal birth.

We set out to revise and implement a standardized evidenced-based guideline for the management of second stage labor for women with epidural analgesia. We hoped that implementing a standardized guideline would result in a decrease in operative vaginal birth (forceps and vacuum use), 3rd and 4th degree lacerations, cesarean section, and maternal and neonatal adverse outcomes in our setting where the rate of labor induction is high.

How did you change it? What new policy, process, or practice did you put in place?
Our goal was to implement a prototype guideline that could be effective and useful for women with epidural analgesia. An evidence-based guideline identified in the literature was modified (permission obtained) to meet the needs of both nulliparous and parous women in labor with epidural analgesia and within most risk categories. This guideline was piloted at a Midwest community hospital from April – July, 2011. Records of women at term with single vertex fetus, epidural analgesia, and normal fetal heart rate, with or without urge to push upon complete dilatation were reviewed retrospectively from 403 records prior to guideline implementation. Outcomes for 428 women and their newborns were compared to retrospective records.

Who was involved in making the change and what was each person’s role?
The project team included members of the Zero Birth Injury Initiative (ZBII) an existing maternity care quality improvement steering committee consisting of two practicing OB/GYNs, the FHS System Director of Clinical Safety, a Quality and Patient Safety Manager, a Family Practice Physician, a Certified Nurse-Midwife (CNM), two Neonatologists, two Maternal Fetal Medicine (MFM) physicians and two Perinatal Advanced Practice Nurse Leaders (APNL's). All members were involved in the full project from the needs assessment survey to determine current practice to the approval of the final guideline. Particular members of the team developed a computer-based learning module to support education for the nurses. The physician co-lead provided education and facilitated discussion for the various physician groups at staff meetings. Copies of both the guideline and algorithm were laminated and placed at work stations on the labor unit for reference. Two labor and delivery staff nurses were co-leaders during the implementation. The staff nurse co-leaders, the unit’s APNL, physician co-lead and nurse educators provided concentrated bedside education and support on the labor and delivery unit with the staff nurses during all shifts to ensure that nurses were familiar with the guideline strategies.

How did you determine if the change worked? What data did you collect? How did you define “success”? How did you ensure your change didn’t have any unintended negative consequences?
Almost immediately the nursing staff began reporting how the guideline benefitted their patients, especially since the guideline calls for encouraging active pushing when the patient has an urge to bear down rather than encouraging the patient to push because the cervix is completely dilated. Nurses reported their approval of the documentation of cervical dilation and assessments times on an hourly basis and this commitment benefitted them as well due to their deep desire to not push too soon. Within the first month, we observed fewer vacuum assisted births and less active pushing time. These improved results in a short time frame motivated more the nursing and physician staff to use the guideline. Data collected included maternal demographics such as gravid and para, whether the labor was spontaneous, induced, or augmented and how induced or augmented, mode of delivery including use of vacuum extractor or forceps, type of laceration or episiotomy, birth weight, apgar scores, length of active pushing and the length of second stage.

Success was defined in terms of completion and utilization of the guideline by nurses and providers as well as a reduction in the outcomes we were trying to improve. Daily monitoring usage of the guideline and outcomes helped ensure the change being proposed did not have any unintended consequences.

What was the biggest barrier to making the change?
The biggest barrier was working with some physicians who believed that implementing the guideline would result in longer second stage labors. Physicians also voiced concerns that patients would reach complete dilation and would not be continuously assessed between complete dilation and the urge to bear down as present. They wanted to ensure that the nurses continued to assess patients and to notify them of patient progress. Nurses had to overcome the misunderstanding that the only patients who were in the guideline were those without an urge to push. All women with an epidural infusion with a single vertex fetus are included in the guideline and must have care managed according to the parameters in the guideline.

How did you overcome that barrier?
Education was provided to all provider groups so that the guideline and issues could be reviewed and discussed prior to implementation. Physicians who resisted the guideline were encouraged to try it with a couple of patients to see how well it could work. These physicians only needed a few personal deliveries to understand the positive impact the guideline was for their patients. Particulary resistant physicians were reassured when the option of “immediate pushing per provider preference” was added to the guideline. This gave them an out if needed and a feeling of personal control over the patient’s plan of care. However, very few physicians have used this “opt out” option. Some physicians who desired more data were offered personal meetings to further walk through the guideline, to understand data collection and analysis process.

If you have data or other evidence that your change was successful, please provide that data.
At this time, we cannot share specific information regarding the precise impact the guideline has had for our patient population. However, success was defined in terms of comparing a retrospective group of patients with a guideline used group of patients. In the guideline used group, the length of active pushing was decreased, and both the 3rd degree laceration rate and the use of VE was reduced at a statistically significant levels. There was no statistical change to Apgars, Cesarean Sections, and overall length of second stage.


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