Variability of clinical practice in the care of the second stage of labor among midwives in Spain

This study was carried out to determine the variability of the different childbirth practices during the second stage of labor, observing that most participating midwives let women choose the position of birth and if the woman does not have any preference, they use side lying positions or lithotomy with foot support. Regarding the use of the Kristeller maneuver, a significant proportion of midwives considered that it was used excessively at their work center. In the case of certain practices, such as the use of lubricant or the decision of whether to allow the woman to drink liquids during this process, there was a great variability in responses.

Furthermore, significant variability was also observed regarding the time allowed by professionals for initiation of active pushing during the second stage of labor and the time allowed to complete this period.

In relation to birthing positions used by mothers, there are publications that have observed that the squatting or chair position reduces pain in the second stage of labor [18], and that perineal trauma is reduced in side lying positions [19]. In a systematic review comparing the supine versus side lying position, it was also observed that the latter was associated with a significant reduction in the duration of labor [20].

In the same vein, a systematic review published in 2017 concluded that the upright position compared to supine positions, was associated with a reduction in the duration of the second stage of labor, as well as a decrease in instrumental births and episiotomies, although a possible increase in second-degree perineal tears was observed (20–22). Despite this, some authors believe that women should not be discouraged from adopting these positions to prevent perineal damage [21] and women should be encouraged to use the position that is most comfortable for her [22].

Nonetheless, no literature has been found to report which position is most frequently used in clinical practice during the third stage of labor. In April 2022, a study describing midwives’ perspectives on culturally appropriate care to support maternal positions highlighted the importance of including women in decision-making regarding their birth preferences [23]. In our study, most of the practitioners offered to allow the woman to assume the position of her choice, and if the woman had no preference, most opted for side lying positions or lithotomy with foot support.

Regarding pushing, the WHO considers that sustained (Valsalva maneuver) and directed pushes are not effective and are also harmful and therefore not a recommended practice [5]. In our study, midwives agreed with these recommendations and when asked about pushing in women without epidurals, most midwives suggested spontaneous pushing. Moreover, in a meta-analysis of randomized trials (21 trials, 3763 participants) comparing different pushing techniques, it was concluded that maternal and neonatal outcomes were similar in women who followed their own pushing instincts (spontaneous pushing) and those who performed directed pushing [24].

In this regard, restrictive policies are still very broad, perhaps because they depend on several professionals (anesthesiologists, gynecologists and midwives), although the WHO recommends fluid intake during labor in low-risk women [14]. Another prospective study with 249 cases supported this recommendation [25]. Despite these recommendations, a significant number of midwives who responded to our study reported that they would be open to give fluids to the pregnant woman however this was against their hospital protocol, and of those who did, many reported that they only give liquids in small amounts.

In the same line, the SEGO (Sociedad Española de Ginecología y Obstetrícia) also recommend encouraging spontaneous urination, and if this is not possible or the amount is insufficient, bladder catheterization should be performed [26]. According to our data, most midwives would do this in a woman without an epidural but not if the mother had epidural analgesia.

Regarding the use of local anesthetic spray, we found only one study with 185 women that concluded that the use of local anesthetic spray is not associated with a decrease in pain during birth, although it may be associated with a reduction in perineal trauma [27]. In our study most midwives do not use it as a means of pain relief at this stage.

Concerning the Kristeller maneuver, there are currently no records in the mother’s clinical history on its use, which makes it difficult to collect data on its incidence. In 2008, the SEGO stated that it should only be used in very specific cases and never to assist in the descent of head planes [26]. The WHO guide for the care of normal childbirth states that it is a practice that entails risks for both the mother and the infant and although there are not many studies on the subject, the general impression is that it is used excessively [5]. The results of our study agree with this statement, since a large number of professionals consider that it is used excessively in their workplace.

There is no standardized definition of duration of labor, nor is there consensus on which guideline is most appropriate for clinical use [28]. The Ministry of Health and Social Policy in 2010 established that the normal duration of the passive phase in nulliparous women is up to two hours whether or not they have epidural anesthesia. The passive phase in multiparous women is up to one hour if they do not have epidural anesthesia and up to two hours if they do. Regarding the duration of the active phase, in nulliparous women it is up to one hour if they do not have epidural anesthesia and up to two hours if they do. In multiparous women it is up to one hour whether or not they have epidural anesthesia [5]. In our study we observed variability regarding the times granted by each professional, this variability is especially marked when the pregnant woman has had a previous cesarean section. This situation of a pregnant woman with a previous cesarean section who attempts vaginal birth is not contemplated in many clinical practice guidelines [29, 30]. These mentioned that this stage should not exceed two hours in nulliparous women and 1.5 h in multiparous women; it does not refer to whether or not they are under epidural analgesia. The Spanish protocol of the Hospital Clinic of Barcelona “Gestational control in pregnant women with previous cesarean section”, states that the expulsion should not last more than three hours [31]. Other authors point out that the duration in these pregnant women should be the same as in women without previous cesarean section although more caution should be exercised and with an even closer follow-up [32]. Finally, a retrospective cohort study involving 198 women concluded that the different practices used by professionals attending the birth influenced the duration of the same [33].

Among the limitations of this study, there is a risk of selection bias, since it is possible that the midwives who participated were more sensitive to the study subject. This could mean that the true results present even greater variability compared to our findings. Moreover, we have also observed that the age of the participants is relatively young, which could give us an insight into the future regarding the trend in the evolution of care during the second stage of labor. However, determining the response rate is challenging due to varying levels of engagement from associations in distributing the questionnaire to their members.

Among the strengths of this study, it is worth highlighting that it is the first study in Spain to evaluate the variability in the clinical practice of midwives during the second stage of labor. We have only found one study in the United Kingdom which sought to research the practices of midwives at the time of birth, which concluded that they additional training was needed on the identification of anal sphincter lesions [34]. The results of this study could serve as a basis for further research, as well as comparative research aimed at raising awareness of the need for adherence to evidence-based recommendations in clinical practice.

A recent study by Soriano-Vidal et al. [35] in Spain highlights certain evidence-based practices—such as support during childbirth, permitting fluid intake, and skin-to-skin contact—that have been shown to significantly enhance maternal satisfaction. Reducing practice variability among midwives by adhering to clinical practice guidelines is crucial for both improving patient safety and enhancing perceptions of care received. However, there has been no data collection to date on professionals’ compliance with these guidelines. This gap underlines the importance of our work in providing insight into current childbirth care practices, identifying areas with the most significant deficiencies, and designing policies for professional training.