The practice issue is whether standing or squatting while in the 2nd stage of labor assist with the delivery of a baby more efficiently than laying in a supine position with the HOB elevated to 45-90 degree angle. The safe delivery procedures are well-meant and will go a long way in protecting mother and child (Barrington & Finer, 2010). However, they might also ruin the very beginning of the life-long social and cultural journey of motherhood. Further, available primary research have shown that procedural variations relating to the mother’s position do not per se have an adverse effect on the safety of mother and child during the delivery process. Based on the above, the practice change recommendation herein is to the effect that unless a social or cultural practice is injurious to either mother or child during stage-two of delivery, it should be allowed in honor of the mother’s cultural affiliation.
Change Model Overview
The ACE Star model Evidence-Based Practice Process is a five step transitional process created to ensure smooth development of better clinical processes. Step one happens when the novel concept is realized. Step two is the summarization of the evidence relating to the new concept while step three is the breaking down of the new concept into applicable steps within the affected processes (Nilsen, 2015). The next step is the integration of the new concept, as broken down, into existing practice procedures. The last step is the evaluation of the outcomes of both the concept as applied and the integration process itself. The ACE Star model Evidence-Based Practice Process is critical for a variety of reasons. The first is that care and clinical practice procedures keep on constantly improving due to innovation and increasing understanding of related subjects. Secondly, some of these inventions and improvements may be wrong, half-baked, premature or with unknown adversities. Finally, care and clinical practice never stops, hence it is critical for incorporation of new ideas to happen without affecting the continuity of service proviso. The ACE star process enables betterment without inordinate interruptions (Nilsen, 2015).
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Define the Scope of the EBP
The EBP, as stated above is, does standing or squatting while in the 2nd stage of labor assist with the delivery of a baby more efficiently than laying in a supine position with the HOB elevated to 45-90 degree angle. The problem canvassed within it is that clinical procedures often fail to canvass social and cultural considerations to the detriment of patients. In this regard, the mother might want to stand or squat during the 2 nd stage of labor but the same will not be allowed by the attending practitioners. Whereas the practitioners mean well, their instructions may have serious cultural and psychological ramifications on the mother, and perhaps even in the mother-child relationship in future. These extreme ramifications should be avoided unless their avoidance harms the child or the mother during delivery.
Stakeholders
The stakeholders include the charge nurse, gynaecologists, an advanced practice nurse for midwifery, a representative from the legal/administrative department, the surgical resident involved in delivery, and the physician resident involved in delivery.
Determine Responsibility of Team Members
Team leader will organize and coordinate the EBP process and also assemble and coordinate the EBP team. The charge nurse will be available for guidance, direction, and relevant permissions during the process. The gynaecologists will be the consultant of the technical elements of the EBP from the perspective of genecology. The midwifery APN will also play a consultative role. The two residents will assist the team leader in the evaluation of evidence and also the breaking down of the EBP into an implementable state. The legal or administrative representative will provide guidance on non- clinical aspects of the EBP.
Evidence
Available evidence definitively shows that the position within which a mother stays in during the 2 nd stage of delivery is based on convenience for the practitioners as opposed to the mother’s preferences. Most mothers are allowed discretion during the first stage but the moment the second stage begins, a lot of limitations are introduced. 57% of women who have vaginal births in America report that they lay in their backs through the last process according to Declercq, Sakala, Corry and Applebaum (2007). 35% used a semi-sitting position and 4% lying on their side. Finally, only 3% were either squatting or sitting and 1% on their hands and knees. No cases of standing births were reported. The research above shows a high preference to the lying down position was over 90% yet without any reference to the mother’s preferences. All available quality improvement instructions, position statements, data and statistics relate to safety issues and not preferences (Declercq et al., 2007). The information provided herein is reliable and valid having been realized through a research carried out by the Harris Interactive® in partnership with Lamaze International.
Summarize the Evidence
Available research shows that the position in which the mother stays at may have an effect in the duration of the delivery process but not the health of either the mother or the child. Koyucu and Demirci (2017) is a randomized controlled trial that compared different pushing techniques by two groups of mothers, one controlled and the other based on the mother’s preferences. The controlled format led to a faster delivery but did not improve the health outcomes of either the mother or the infant. Similarly, Vaziri et al. (2016) report on a randomized clinical trial that compared the use of the Valsalva maneuver in a supine position with free styling in a lateral positon during stage-two labor. The outcome of the research showed that the Valsalva maneuver in a supine position speeded up the process of delivery and also made the mother more comfortable. However, the relative safety of mother and child was congruent in both groups. Based on the above research, the position in which a mother stays on only has an effect in the process, not the clinical outcomes of the delivery process.
Develop Recommendations for Change Based on Evidence
Based on the research above, it is recommended that mothers be allowed discretion and freedom to choose the position that they would want to remain in during the second phase of labor as long as the preferred position does not endanger, either the mother or the child. If the mother prefers squatting or standing, the same should be allowed, subject to mother and child safety.
Translation
Action Plan
The recommendation herein will be taken through the ACE Star Model.
Step 1: First, the concept and available evidences will be re-evaluated by the team indicated above. (10 days)
Step 2: The team leader and the two residents will then translate it into workable guides. (15 days)
Step 3: Through permission, advice and direction from the experts in the team, the guides will be incorporated into the already available rules and procedure relating to the 2 nd stage of labor. (45 days)
Step 5: Finally, monitoring and evaluation will be undertaken on implementation success. The duration of evaluation and monitoring will include the 45 days of the implementation process, then continue for another 90 days after full implementation to check for success or need for amendments. The team should meet twice a week during the evaluation process to assess evaluation results.
Process, Outcomes Evaluation and Reporting
The primary desired outcome for the process is an elevated level of patient satisfaction based on the ability to adhere to personal preferences during what is arguably the most important minutes of their lives. The outcomes can be assessed through a patient satisfaction assessment questionnaire.
Identify Next Steps
Implementation of the recommendation can only be carried out once it has been successfully implemented and undergone successful monitoring and evaluation. To have it implemented widely, advocacy and campaigning will be undertaken to sensitize on the issue and also spearhead change of policy.
Disseminate Findings
Within the organization, the findings will be communicated electronically through a cover letter emanating from the administrative office. Externally, the findings will be reduced into a journal article which can be published after undergoing the necessary reviews.
Conclusion
The delivery of a child is a critical clinical process that places the life of both the child and mother at risk, but it is also a fundamental social and cultural process. Seeking to protect the mother and child at all cost has sometimes come at the cost of the social and cultural preferences of the mother. Available research has shown that many of the extreme 2 nd stage of delivery rules do not directly relate to the safety of the mother or child, but rather to comfort and expediency. This has led to the recommendation that unless the mother or child is placed in danger, then the mother should be allowed to retain the position of preference. The recommendation, however, will need to be taken through the ACE Star Model for proper implementation before being recommended for wider application.
References
Barrington, K. J., & Finer, N. (2010). Cochrane review: Inhaled nitric oxide for respiratory failure in preterm infants. Evidence‐Based Child Health: A Cochrane Review Journal , 5 (1), 301-336
Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2007). Listening to mothers II: report of the second national US survey of women's childbearing experiences: conducted January–February 2006 for childbirth connection by Harris Interactive® in partnership with Lamaze International. The Journal of Perinatal Education , 16 (4), 9-14.
Koyucu, R. G., & Demirci, N. (2017). Effects of pushing techniques during the second stage of labor: A randomized controlled trial. Taiwanese Journal of Obstetrics and Gynecology , 56 (5), 606-612
Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science , 10 (1), 53
Vaziri, F., Arzhe, A., Asadi, N., Pourahmad, S., & Moshfeghy, Z. (2016). Spontaneous pushing in lateral position versus valsalva maneuver during second stage of labor on maternal and fetal outcomes: A randomized clinical trial. Iranian Red Crescent Medical Journal , 18 (10). doi: 10.5812/ircmj.29279.
