California College of Midwives
3889 Middlefield Road ** Palo Alto, CA 94303
650/328-8491 goodnews@best.com


Comparative Study
Midwifery Management of Expulsive Labor

Purpose of study -- to compare outcomes between standard hospital-based protocols and the traditional midwifery management of second stage in unmediated and unanesthesized mothers experiencing normal spontaneous labors without pre-existing fetal distress or major medical problems (either mother or fetus).

Background: Standard hospital management for most of the last century has not directly addressed the psyco-social/sexual aspect of childbearing and resulting needs of mother in regard to privacy and emotional comfort. Standard obstetrical textbooks and journal articles generally do not make a distinction between 2nd stage and the perineal phase. Typically the obstetrical patient is not encouraged to be mobile during active labor, permitted to sit on the toilet for prolonged periods of time during expulsive stage or instructed to assume a vertical posture for delivery. In contrast, midwifery management has traditionally acknowledged the psychological, social and sexual aspects of labor, the influence of gravity, the advantages of maternal mobility and upright postures, birth-specific positions such as squatting and the benefit of facilitating the fetal ejection reflex when possible.

Methods: Comparison of 10 healthy hospitalized obstetrical patients, five in each category matched for parity and assigned at the onset of complete dilation to one of the two groups

Outcome criteria: This study is to contrast the use of these diverse styles of intrapartum management as measured by (1) the total length of time between onset of spontaneous expulsive efforts by the mother and physiological birth, (2) development of fetal distress including thick mec, (3) use of episiotomy, (4) 2rd, 3rd & 4th degrees perineal lacerations, (5) complaints by the mother expressing inability to complete 2nd stage spontaneously (6) necessity for vacuum extraction or forceps due to maternal fatigue, soft-tissue dystocia or fetal distress -- identify reason for operative intervention, (7) Cesarean surgery -- identify reason.

Instructions for Study -- standard hospital management consists of maintaining normal routines. Midwifery management implies the use of the methods listed below.

Definitions of Traditional Midwifery Management for purposes of the study

1) Mother mobile with vertical postures 70% of the time after onset of spontaneous expulsive efforts; squatting or quasi-squatted positions as the baby descends to the perineum

2) Early Second Stage -- encouraged to spend 10-30 minutes on the toilet -- timing due to maternal preference or as soon as good spontaneous urges to push manifest

3) Perineal Phase -- encouraged to maintain maternal mobility and vertical posture in various forms of squatting or crouching positions or birth stool until perineal cleft flattens and 2-4 cms of caput visible

4) Crowning -- position of choice is mother’s choice unless it entails weight bearing on sacrum. Squat on bed (with s. bar) or floor (but not on birth stool) OR side-lying in bed with caregiver either at end of bed or directly behind mother (Dr. DeLee’s delivery position)

Study to be published in the on-line, peer-reviewed International Journal of Domiciliary Midwifery


Comparative Study -- Report Form
Midwifery Management of Expulsive Labor

Date: ______ Caregiver Name ___________________ Practitioner Status ______

Patient #___ age____; parity ____; wks. gestation ___ length of 1st stage _____

Category assigned: Standard Ob management _____ time limit permitted for second stage _______; Mother labors mainly in bed ______; pushing in prone / semi-flowlers _____: directed pushing _____; breath-holding ______; internal perineal massage/stretching ______; mother in lithotomy position for delivery _______; crowning - hands off ________; maintained flexion of fetal head ______; Ritgen maneuver _______; episiotomy _________; vaginal operative ______; for _________; Cesarean _______ reason __________________________

Midwifery Management _______;

Mother mobile with vertical postures 70% of the time after onset of spontaneous expulsive efforts ________; 1st half of Second Stage -- encouraged to spend 10-30 minutes on the toilet _______; squatting or quasi-squatted positions as the baby descends to the perineum ________; Perineal Phase -- maintained maternal mobility and vertical posture in various forms of squatting or crouching positions ______; or birth stool ______ until perineal cleft flattens and 2-4 cms of caput visible ______; Crowning -- no weight bearing on sacrum _______. Squat (on floor or bed with s. bar but not on birth stool) ________; &/OR side-lying in bed with caregiver either at end of bed ________; or directly behind mother (Dr. DeLee’s delivery position) ________; crowning - hands-off ______; maintained flexion of fetal head ______; perineal support during delivery of head ________; perineal support during delivery of shoulders ______; operative intervention ________; reason _______; Cesarean ______; reason ___________________________________________________________________

Outcome statistics and comments:

(1) length of time between spontaneous expulsive efforts & spontaneous birth ___________________________________________________________________

(2) development of fetal distress including thick me_________________________

(3) use of episiotomy / reason _________________________________________

(4) 2rd, 3rd & 4th degrees perineal lacerations _____________________________

(5) complaints by the mother expressing inability to complete 2nd stage spontaneously ____________________________________________________

(6) necessity for vacuum extraction or forceps due to maternal fatigue, soft-tissue dystocia or fetal distress (state reason) ________________________________

(7) Cesarean for ____________________________________________________

Remarks about the study, for instance, any strong opinions about the two methods, did the study change any of your opinions about management techniques? Did the mother express any relative opinions about her birth experience? Were hospital staff helpful or not?

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Thank you for your efforts. Please keep copies for yourself and mail originals to above address