Non-Directed Pushing as An Evidence-Based Practice in Second Stage Labor

Tuesday, 13 July 2010: 11:10 AM

Patricia A. Heale, DNP, RN, CNS
Women's Services, Texas Children's Hospital, Houston, TX

Learning Objective 1: ...contrast the merits of directed and non-directed pushing during the second stage of labor as related to maternal and fetal well-being.

Learning Objective 2: identify the specific barriers to implementation of non-directed pushing as reported by labor and delivery nurses.

Purpose: Over the past 20 years evidence-based practice (EBP) has become key to providing quality nursing care. However, implementation of EBP in perinatal nursing has been inconsistent and many practices are not evidence-based. One practice is directed pushing during the second-stage of labor. Research has provided no evidence that directed pushing is either safe or effective and there is evidence of adverse maternal and neonatal outcomes. Understanding why labor and delivery nurses have not adopted non-directed pushing is necessary for planning a successful change in practice. While researchers have identified barriers to EBP in general the nurse-reported barriers to implementation of non-directed pushing have not been previously studied.


A qualitative descriptive method was utilized involving six focus groups with 36 participants. The particpants were recruited from major metropolitan areas in the north-east and the southern United States through AWHONN.


The participants reported several barriers to utilization of non-directed pushing. Every participant in each of the seven focus groups identified the concept of individual as a barrier. The participants further categorized the concept of the individual into categories. Three categories emerged from the data related to the concept of the individual: physician, nurse, and the patient/family unit. Subcategories were found in the data relating to each of the main categories. These subcategories were identified across all seven of the focus groups and included: control, change, education, time, and noise.


Understanding the specific nurse-reported barriers to implementation of non-directed pushing will provide opportunities to facilitate a nursing practice change. The barriers show the importance of managing change, providing education, team-building, addressing issues related to time, and negotiating unit culture.