Nursing Critique

Delayed Pushing

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Delayed Pushing

Yee et al (2015) Conducted a secondary analysis of research on the maternal and neonatal outcomes with early compared with delayed pushing among nulliparous women. Based on the rating system for the Hierarchy of Evidence coined by Melnyk and Fineout-Overholt, this research falls under Level IV described as Evidence from a well-designed case-control or cohort study. This research was conducted to find out the best evidence on the factors associated with delayed pushing, and the impact of delayed pushing on perinatal outcomes in nulliparous women. The analysis was on data collected by the Eunice Kennedy Shrive National Institute of Child Health and Human Development

Validity. The researchers described in detail how they carried out secondary analysis of data from a large observational study carried out in twenty five hospitals in the United States of America. The researchers gave a description of the research which was carried out between 2008 and 2011, and consisted of a cohort of 115,502 women and their neonates who delivered in the hospitals where the study was conducted in this three year period. Based on the target population, the cohort provides a representative and well-defined sample of patients for the study. The follow up period of mothers from 23 weeks of gestation to delivery and the outcomes in the original study was sufficient.

Unbiased and objective outcome criteria was used since the outcomes of each member of the cohort were noted prior to presentation of results. The researchers utilized multivariable regression analysis to assess the independent association of delayed pushing with the mode of delivery, length of second stage and other maternal and perinatal outcomes, with significance defined as p<05. The study provides information for both unadjusted analyses and that in which center and potential confounding factors were adjusted. This proved statistically significant. The researchers provided an inclusion and exclusion criteria to select women who qualify for the study from the cohort.

Results. The researchers indicate that 23,732 women from the cohort of 115, 502 met inclusion for overall analysis, while only 21, 034 of these were included in the primary analysis. A sensitivity analysis was done whereby a sub group of 2,698 women with a delay of between 31 and 59 minutes was included. The researchers found out that out of the 21,034 women in the primary analysis, pushing was delayed in 18.4 %( n=3,870). Older women, privately insured or non-Hispanic Whites and those who had induction or augmentation of labor, diabetes or epidural analgesia were more likely to have delayed pushing. It was evident from the research that delayed pushing was more common when second stage of labor commenced during the day more in hospitals with dedicated 24-hr obstetric anesthesia.

Post adjustment for differences in baseline and labor characteristics, women in the delayed group and longer mean durations of second stage of labor and of active pushing. There were greater rates of cesarean delivery associated with delayed pushing (11.2% compared with 5.1%; adjusted odds ratio 1.86, 95% confidence interval1.63-2.12), operative vaginal delivery (adjusted odds ratio 1.26, 95% confidence interval 1.14-1.40), postpartum hemorrhage (adjusted odds ratio 1.43, 95% confidence interval 1.05–1.95), and blood transfusion (adjusted odds ratio 1.51, 95% confidence interval 1.04–2.17). There was no association between delayed pushing with increased odds of adverse neonatal outcomes as compared with early pushing.

Applicability, Strengths and Weaknesses. This research incorporates follow up of women up to delivery. It is therefore applicable in the field of nursing as it provides insights in caring for mothers during delivery. The evidence provided in the study about factors that increased the chances of delayed pushing and the outcomes associated with delayed pushing is relevant and applicable in the medical field. The results of this study are useful to various professionals in the medical field including but not limited to nurses, obstetricians and anesthetists. The strengths of this study is that it has a large cohort and is therefore easy to generalize to the population. The study was carried out in several hospitals and this makes comparison of various settings and their impact of these settings on the subject matter. The weakness of this study is that the research was conducted over a period of three years. This makes the subjects vary and conditions in various hospitals may have changed greatly over this time period.

References

Fineout-Overholt, E., & Melnyk, B. (2015). Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice (3rd ed). Philadelphia: Wolters Kluwer/ Lippincot Williams & Wilkins.

Yee, L. M., Sandoval, G., Bailit, J., Reddy, U. M., Wapner, R. J., Varner, M. W., . . . Tolosa, J. E. (2016). Maternal and Neonatal Outcomes with Early Compared with Delayed Pushing Among Nulliparous Women. Wolters Kluwer Health, Inc.

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