Spontaneous vs. Directed Pushing: Analysis of Audiotapes of 2nd stage Labor and A

自发与定向推动：第二产程和 A 期录音带分析

• 批准号: 8113508
• 负责人: Lisa Kane Low
• 金额: $ 7.76万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-03-01 至 2013-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8113508
• 关键词: Adherence; Adverse event; Affect; Audiotape; Birth; Caring; Childbirth; Clinical; Clinical assessments; Code; Communication; Conflict (Psychology); Extravasation; Focus Groups; Foundations; Genetic Crossing Over; Goals; Health; Health Benefit; Health Personnel; Incontinence; Instruction; Intention; Intervention Trial; Investigation; Investments; Language; Link; Literature; Measures; Methods; Muscle; Nerve; Outcome; Participant; Pelvic floor structure; Phase; Postpartum Period; Prevention; Prevention strategy; Process; Provider; Public Health; Quality of life; Randomized; Randomized Clinical Trials; Risk; Science; Second Labor Stage; Severities; Staging; Stretching; Testing; Time; Translations; United States National Institutes of Health; Urinary Incontinence; Urine; Vaginal delivery procedure; Woman; Women' s Health; base; child bearing; design; evidence base; experience; lifetime risk; prevent; prospective; response; standard care; standard of care; symposium; trend; urinary

DESCRIPTION (provided by applicant): Childbirth is implicated in increasing a woman's lifetime risk of experiencing adverse pelvic floor changes associated with incontinence, negatively impacting her quality of life. Management of 2nd stage labor is a modifiable factor related to pelvic floor health. How a woman pushes during 2nd stage, either spontaneously or directed, may affect this risk. Findings from the randomized clinical trial PERL: Urinary Incontinence Prevention: Reducing Birthing Risk (R01-NR4007) suggests spontaneous pushing method does not significantly decrease urinary leakage post partum. However, review of a subset of participants (N=58) using audiotapes from their 2nd stage labor indicate fidelity to group assignment (spontaneous or directed) was not consistently maintained due to provider and participant reasons. In this subset, analysis of audiotapes assessing actual pushing method trends towards significance indicating benefit of spontaneous pushing to reduce post partum leakage (p= 0.048) but is under powered. The need to reduce incontinence risk in childbearing women demands we expand the scientific evidence available regarding 2nd stage and prevention of adverse pelvic floor changes. Therefore a secondary analysis of 162 audiotapes representing 17,929 minutes of 2nd stage labor will be done using qualitative and quantitative methods to determine actual pushing compared to randomized assignment and associated provider communication. Using segments of audio taped labor interaction, focus groups targeting 30 bedside maternity care providers will be completed investigating clinical considerations in implementing 2nd stage strategies. The AIMS of this project are to: Aim 1: Investigate the relationship between actual pushing method used during 2nd stage labor and risk for incontinence post partum. H1: We hypothesize there will be a significant cross over effect that occurs between original assignment through randomization and actual pushing effort during 2nd stage labor and H2. Using actual pushing type for group assignment compared to random group assignment, severity of urine leakage at 12 months post partum will be significantly less in the spontaneous compared to directed group. AIM 2: Investigate maternity care providers' rationale and description of clinical indicators that influence how they manage 2nd stage labor and document how provider verbal instruction may change in response to maternal pushing efforts over the course of 2nd stage labor. H3: We hypothesize that pushing method (directed or spontaneous) encouraged by maternity care providers is dynamic; influenced by time, visibility of the vertex and response of the laboring woman. This investigation will be the foundation for a prospective trial testing provider use of evidence based 2nd stage management strategies and prevention of adverse pelvic floor changes. Reducing incontinence in even 5% of the almost 3 million women who give birth annually removes this burden in over 140,000 women annually. PUBLIC HEALTH RELEVANCE: Childbirth have been implicated as increasing a woman's lifetime risk of experiencing pelvic floor changes, including incontinence, that negatively impact a woman's quality of life. The second stage of labor resulting in vaginal birth is the most important modifiable factor related to pelvic floor changes and how a woman pushes during this phase, either spontaneously or as directed by a health care provider is hypothesized to affect this risk. Our goal in this project is to determine the linkage between how a woman pushes and her risk of incontinence so that we can aid health care providers in the prevention of incontinence associated with childbirth representing a wise public health investment in prevention of a critical women's health condition.

描述（由申请人提供）：分娩涉及增加女性一生中经历与失禁相关的不利盆底变化的风险，对她的生活质量产生负面影响。第二产程的管理是一个与骨盆底健康相关的可变因素。女性在第二阶段如何推动，无论是自发的还是直接的，都可能影响这种风险。来自随机临床试验PERL：尿失禁预防：降低分娩风险（R 01-NR 4007）的结果表明，自发推动法不会显著减少产后尿漏。然而，使用第二阶段分娩的录音带对一部分参与者（N=58）进行的审查表明，由于提供者和参与者的原因，对组分配（自发或指导）的忠诚度没有得到一致的保持。在该子集中，评估实际推动方法的录音带分析趋向于显著性，表明自发推动对减少产后渗漏的益处（p= 0.048），但把握度不足。减少育龄妇女尿失禁风险的需要要求我们扩大关于第二阶段和预防不利的盆底变化的科学证据。因此，将使用定性和定量方法对代表17，929分钟第二产程的162个录音带进行二次分析，以确定与随机分配和相关提供者沟通相比的实际推压。使用录音劳动互动的片段，焦点小组针对30床旁产科护理提供者将完成调查的临床考虑，在实施第二阶段的战略。本项目的目的是：目的1：调查在第二产程中使用的实际推动方法与产后尿失禁风险之间的关系。H1：我们假设在第二产程和H2期间，通过随机化的原始分配和实际推动努力之间将发生显著的交叉效应。与随机组分配相比，使用实际推动类型进行分组分配，自发组产后12个月时的漏尿严重程度显著低于定向组。目标2：调查产妇护理提供者的理由和临床指标的描述，影响他们如何管理第二阶段的劳动和文件如何提供口头指示可能会改变响应产妇推动努力在第二阶段的劳动过程中。H3：我们假设，推动的方法（直接或自发）鼓励产妇护理提供者是动态的，受时间，顶点的可见性和反应的劳动妇女。这项调查将是一个前瞻性的试验测试提供者使用基于证据的第二阶段管理策略和预防不利的骨盆底变化的基础。在每年分娩的近300万名妇女中，减少尿失禁的比例仅为5%，每年可减轻超过14万名妇女的负担。 公共卫生相关性：分娩被认为增加了妇女一生中经历骨盆底变化的风险，包括失禁，这对妇女的生活质量产生了负面影响。导致阴道分娩的第二产程是与骨盆底变化相关的最重要的可改变因素，并且假设女性在此阶段如何推动，无论是自发还是由医疗保健提供者指导，都会影响这种风险。我们在这个项目中的目标是确定妇女如何推动和她的尿失禁风险之间的联系，以便我们可以帮助医疗保健提供者预防与分娩相关的尿失禁，这是预防关键妇女健康状况的明智公共卫生投资。