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Knowledge to Action: Implementing a Guideline for Second Stage Labor

Sprague, Ann E. PhD, RN; Oppenheimer, Lawrence MD, FRCOG, FRCSC; McCabe, Linda BN, RN, PNC(C); Graham, Ian D. PhD; Davies, Barbara L. PhD, RN

MCN, The American Journal of Maternal/Child Nursing: May-June 2008 - Volume 33 - Issue 3 - p 179–186
doi: 10.1097/01.NMC.0000318354.00859.41
feature article

Purpose To quantify practice changes associated with implementing a clinical practice guideline for the second stage of labor in term nulliparous women with epidural anesthesia and to describe the lessons learned about knowledge translation. The main clinical practice guideline recommendation was waiting up to 2 hours before pushing after full dilatation.

Design and Methods Pre- and post-evaluation of clinical outcomes and knowledge translation strategies associated with implementing the second stage of labor clinical practice guideline at two birthing units within a large teaching hospital.

Results The implementation of the clinical practice guideline resulted in a significant increase in median waiting time before pushing of 33 minutes at Site 1. This change was also reflected in the twofold increase in the proportion of women waiting longer than 120 minutes before pushing at this site. There was no change in waiting time at Site 2. The duration of the second stage did not change significantly at either site. The median pushing time decreased at both sites but was only statistically significant at Site 1.

Clinical Implications Bringing about practice change in obstetrics is complex. The measured change in this study was less than we expected. Greater success might have been achieved by enhancing feedback to care providers and more frequent audits of practice. We need to better understand the subtle influences in attitude and culture that prevented successful implementation in one site. For units considering a similar process, we recommend a commensurately greater level of presence in the units to encourage compliance with the clinical practice guideline in order to achieve the desired level of practice change.

This interdisciplinary team worked to change the way second stage labor was managed. What worked? What didn't?

Ann E. Sprague is a Perinatal Coordinator, Perinatal Partnership Program of Eastern and Southeastern Ontario, Canada. She can be reached via e-mail at

Lawrence Oppenheimer is an Associate Professor, Obstetrics and Gynecology, University of Ottawa, Canada.

Linda McCabe is a Nurse Educator, Birthing Unit, The Ottawa Hospital, Civic Campus, Canada.

Ian D. Graham is Vice President for Knowledge Translation, Canadian Institutes of Health Research, Ottawa Hospital, Canada.

Barbara L. Davies is an Associate Professor, School of Nursing, University of Ottawa, Canada.

The authors of this article have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

© 2008 Lippincott Williams & Wilkins, Inc.