Directive versus supportive approaches used by midwives when providing care during the second stage of labor

Although the risks associated with using sustained and forceful maternal bearing-down efforts during the second stage of labor have been well documented, most women who give birth in the United States bear down in response to direction from care providers about when and how to push rather than in response to their own physiologic urges. The purpose of this study was to describe the practices used by certified nurse-midwives/certified midwives (CNMs/CMs) in response to maternal bearing-down efforts when caring for women in second-stage labor and to identify factors associated with the use of supportive approaches to second-stage labor care.

A national survey of 705 CNMs/CMs was conducted using mailed questionnaires. The instrument was an 84-item, fixed-choice questionnaire using Likert type scales that had been validated. A 72.6% response rate was achieved, and 375 of the respondents cared for women during the second stage of labor.

Most CNMs/CMs (82.4%) often or almost always supported women without epidural anesthesia to initiate bearing-down efforts only when the woman felt an urge to do so. When caring for women without an epidural, most of the respondents (67%) reported that they often or almost always supported a woman's spontaneous bearing-down efforts without providing direction. Most participants reported using more directive practices when caring for women with epidural anesthesia. Whether caring for women with or without an epidural, most respondents (77.1% and 79.6%, respectively) often or almost always provided more direction as the fetal head emerged and the final stretching of the perineum was taking place. A change in fetal heart tones that led the midwife to believe the birth needed to occur quickly was the circumstance that had the greatest degree of influence on the participant's (90.6%) decision to provide more direction during bearing-down efforts. Many participants indicated that they also were influenced to provide more direction when women in labor asked for more direction (73.3%) or appeared to be fatigued (74.6%).

The majority of CNMs/CMs use supportive approaches to bearing-down efforts during second-stage labor care and most used directive approaches as an intervention aimed at avoiding potential problems.