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

描述（由申请人提供）：分娩会增加女性终生经历与尿失禁相关的盆底不良变化的风险，对其生活质量产生负面影响。第二产程的处理是与盆底健康相关的可改变因素。女性在第二阶段的分娩方式，无论是自发的还是引导的，都可能影响这种风险。随机临床试验PERL：尿失禁预防：降低分娩风险（R01-NR4007）的结果表明，自发推法并不能显著减少产后尿漏。然而，对一组参与者（N=58）的第二阶段分娩录音的回顾表明，由于提供者和参与者的原因，对小组分配（自发或定向）的忠诚并没有始终保持。在这个亚群中，对评估实际推压方法的录音带的分析趋向于表明自发推压对减少产后漏的好处（p= 0.048），但动力不足。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骨盆底改变的科学证据。因此，将使用定性和定量方法对162盘代表17,929分钟第二产程的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分娩情况。利用录音劳动互动的片段，针对30个床边产科护理提供者的焦点小组将完成调查实施第二阶段战略的临床考虑。目的1：探讨第二产程实际推入方式与产后尿失禁风险的关系。H1：我们假设在第二产程和H2期间，通过随机分配的原始分配和实际推动努力之间会发生显著的交叉效应。与随机分组相比，使用实际推尿方式进行分组分配，自发性组在产后12个月的尿漏严重程度明显低于定向组。目的2：调查产科护理提供者的基本原理和临床指标的描述，这些指标影响他们如何管理第二产程，并记录提供者的口头指导如何在第二产程过程中响应产妇的推动努力而改变。H3：我们假设产科护理提供者鼓励的推法（直接或自发）是动态的；受时间、顶点可见度和产妇反应的影响。这项研究将为前瞻性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盆底不良改变奠定基础。在每年分娩的近300万妇女中，即使减少5%的失禁，每年也能消除超过14万妇女的这种负担。

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.