OBJECTIVE:To compare outcomes between women receiving epidural anesthesia assigned to a group following either a 1-hour "delayed" pushing protocol or directed to initiate pushing at full cervical dilation. STUDY DESIGN:Using a randomized, controlled design, multivariate analyses were used to evaluate second stage labor duration and Apgar scores. An estimated odds ratio equation evaluated fetal descent progress. RESULTS:A 13.68-minute difference occurred in second stage labor length (p ϭ 0.225). No differences were found in Apgar scores (p Ͼ 0.09). An estimated odds ratio, that progress in terms of one fetal station unit would occur for control group subjects as compared with subjects with similar progress in the experimental group, was 1.51 (95% confidence interval: 1.16, 1.95). CONCLUSION:Second stage labor was not significantly lengthened, and a similar rate of fetal descent occurred in the absence of directed pushing. Findings support further research on the potential advantages of minimizing the duration of pushing in labor.Women receiving epidural anesthesia are thought to experience prolonged labor in comparison to those of nonanesthetized women because of relaxation of the pelvic floor musculature causing a delay in rotation of the fetal head. Also, diminishing the bearing-down reflex, which results in a decrease in the efficiency of the maternal pushing efforts, in combination with less uterine contractility, have been associated with the anesthetic effect.1,2 In an attempt to compensate for these presumed effects and shorten the length of labor, conventional care management for anesthetized women typically includes promotion of strong, sustained, and directed valsalva or closed glottis pushing efforts.It has been suggested that this type of directed pushing may actually impede the progress of second stage due to tightening of the pelvic floor muscles and wedging of the fetal head behind the symphysis, particularly when pushing with the curved spine position of the commonly used semi-Fowler position.3,4 Research findings also suggest that fetal intolerance to a prolonged labor (often a concern of practitioners) may be less related to time actually spent in labor and more related to the stress of excessive and prolonged pushing efforts that decrease cerebral oxygenation and blood volume, and result in fetal heart rate deceleration patterns a cesarean delivery indication. [5][6][7] Therefore, the assumptions underlying concerns about prolonged labors may actually be less important than focusing on the limitation of both the intensity and duration of pushing efforts. This is particularly important given the potential maternal fatigue (another common indication for cesarean delivery) induced by long-term pushing efforts and for the increased likelihood of perineal tearing associated with sustained breath holding due to excessive perineal pressure and stretching that is thought to be aggravated by the semisitting or reclining position often used by women during the second stage. 8 -12 Recently, it is has b...

Interest in purchasing and installing a perinatal computerized patient record (CPR) and archiving system is growing in the United States as a result of increased patient satisfaction demands, cost containment, and quality improvement. Perinatal nurses are commonly charged with researching available computer software and hardware, making purchasing decisions, developing menus and forms, orienting users, and maintaining and upgrading systems. The decision to chart and archive by computer as well as installation and maintenance issues mandate that nurses increase their computer-related knowledge. The article reviews information related to CPR capabilities and rationales for purchase decisions, implementation and staff development issues, ergonomic and maintenance considerations, and realistic expectations of a CPR to provide perinatal nurses who are involved in purchasing, implementing, and maintaining these systems with a timely understanding of important elements that they need to know to make this effort successful.