Implementing a Four-Step Evidence-Based Pushing Protocol for Labor and Birth

First, to determine whether implementing an evidence-based practice pushing protocol for pregnant individuals in the second stage of labor with an epidural affects the observed duration of the second stage of labor, the degree of perineal laceration, and the use of operative vaginal birth compared with standard practice. Second, to determine whether implementing an educational session on the protocol increases the frequency of nursing documentation of flexible sacrum positioning, investigation of fetal position, interventions to prevent lower-extremity nerve injury, and use of warm compresses.

The Stanford Medicine Children's Health Methodological Approach to Evidence-Based Practice guided this evidence-based practice project.

An acute care teaching hospital in California that averages 4,000 to 5,000 births per year.

One hundred sixteen labor and birth nurses participated in the documentation and protocol education; 369 medical records of laboring patients were reviewed.

A Four-Step Evidence-Based Pushing Protocol for Labor and Birth was developed that focused on evidence-based nursing interventions. From November 15, 2022, through February 15, 2023, the medical records of 185 patients were reviewed pre-protocol; 184 were reviewed from March 20, 2023, through June 20, 2023, post-protocol. Protocol and documentation guidelines were implemented through unit-based, in-service educational programs and individual teaching sessions with superusers.

No change was observed in the duration of second-stage labor after implementing the pushing protocol. The degree of perineal laceration after birth was significantly less after protocol implementation (p = .028). Use of operative vaginal birth decreased from 8.9% to 3.3%. Documentation by nurses of protocol interventions increased by an average of 23.7% after implementation.

After implementation of the Four-Step Evidence-Based Pushing Protocol for Labor and Birth, perineal tear grades and operative vaginal births decreased. This evidence-based protocol and educational intervention was associated with improvement in observed clinical outcomes.