Midwives' approaches to early pushing urge in labour

The objectives of this mixed-methods study were: a) to investigate midwives' approaches to early pushing urge (EPU); and b) to explore midwives' perspectives and experiences of helping women cope with EPU. A quantitative observational methodology was adopted to investigate midwives' approaches to EPU in 60 cases. A qualitative phenomenological approach was carried out in order to gain more in-depth understanding of midwives' views and experiences of EPU management strategies. It was found that midwives mainly adopt two approaches in the case of EPU: letting the woman do what she feels, and a stop-pushing technique. The findings are presented as four main domains: a) midwives' approaches to EPU; b) drivers guiding midwives' approaches to EPU; c) influencing factors in helping women cope with EPU; d) variation of midwives' approaches to EPU over time.


INTRODUCTION
Early pushing urge (EPU) is defined as the perception of the irresistible urge to push by the labouring woman before full cervical dilatation, documented by vaginal examination. Although different incidence rates are reported in the literature (from 7.6% to 54%), a significant minority of childbearing women seem to be experiencing the EPU phenomenon during labour (Roberts et al., 1987;Downe, 2008;Borrelli et al., 2013). Midwives are consequently often called to help labouring women cope with this event (Petersen and Besuner, 1997). The EPU has been traditionally considered as a pathological event, with a number of authors highlighting the increased risk of cervical damage and maternal exhaustion (Berkeley and Fairbairn, 1931;Benyon, 1957;Gaskin, 1990). More recently, researchers have reconsidered EPU as a physiological phenomenon when good maternal and fetal conditions are present (Enkin et al., 2000;Downe, 2008;Borrelli et al., 2013). However, the real incidence of EPU, the nature of the phenomenon and the optimum approach to management remain controversial areas. Moreover, despite EPU appearing to be a common event occurring in a number of labouring women, international recommendations (NICE, 2014), national guidelines (SNLG-ISS, 2014) and local protocols seem to be incomplete in this area.
Given the evidence gaps, the objectives of this study were: a) to investigate midwives' approaches to early pushing urge; b) to explore midwives' perspectives and experiences of helping women cope with EPU. The findings discussed in this paper are part of a larger research project, which investigated the prevalence, characteristics and management of EPU through a prospective observational methodology and explored women's and midwives' experiences of EPU using a phenomenological design. This study aims at informing local midwifery practice and contributing to international debates around the topic.

Design
According to the aims of the study, a mixed-method approach was undertaken. A quantitative observational methodology was adopted to investigate midwives' approaches to early pushing urge in 60 EPU cases. A qualitative phenomenological approach was carried out in order to gain a more in-depth understanding of midwives' views and experiences of EPU management strategies.

Setting
The study setting was a large tertiary referral public maternity hospital with approximately 3000 births per year located in Northern Italy. In regard to the intrapartum care provided in the research site, the midwives are responsible for caring for low-risk women with physiological childbirth. Whenever possible, one-to-one inlabour care is guaranteed. According to local guidelines, a vaginal examination is done by the midwife every two hours and recorded on the partogram. There is not a dedicated section in the woman's case history for the recording of the appearance of EPU. In the absence of local guidelines or protocols specifically on EPU, the midwives' practices in response to the phenomenon may vary. Women are routinely admitted to the hospital postnatal ward for 2-3 days following birth.

Sample
For the quantitative observational part of the study, the sample included 60 EPU cases from women who manifested the event in labour at term pregnancy, with single fetus in cephalic presentation. Exclusion criteria were fetal malformations and women under 18. For the qualitative part of the project, a purposeful sampling was used in order to include participant midwives with in-depth knowledge of the phenomenon under research (Carpenter, 2007;Smith et al., 2009). The midwives working in the hospital labour ward for at least 18 months were eligible for the study. The sample included 25 midwives with a mix of clinical expertise, with a range from 18 months to 30 years of experience. All the midwives interviewed had witnessed the phenomenon of early pushing urge in labouring women during their work experience.

Data collection
For quantitative data collection, the collaboration of midwives working in the hospital labour ward was sought in order to collect data about EPU cases on a data collection sheet. The data collected included demographical information; maternal and fetal/neonatal variables; birth outcomes; intrapartum midwifery practice (including EPU management strategies) and interventions in response to EPU.
For qualitative data collection, face-to-face tape-recorded semi-structured interviews were conducted with the participants. Midwives were interviewed before, during or after the working shift. Interview guides were used in order to cover the main topics to answer the research questions. However, the researcher remained also open to investigate areas that seemed appropriate to the individual concerned (Rose, 1994).
Four vignettes reporting clinical cases of EPU were used to facilitate the understanding 6 of the midwives' practices in response to the phenomenon. These were elaborated from the ones developed by Downe (2008). The vignettes ( Figure 1) included different cases of EPU occurring in physiological labours, with variations in women's parity (nulliparous or multiparous) and cervical dilatation at the diagnosis of EPU (5 cm and 9 cm). VIGNETTE 1 -Maria is a 30-year-old nulliparous woman with a physiological pregnancy (single fetus in cephalic presentation). Her labour started spontaneously five hours ago. The membranes are broken, the amniotic fluid is clear and the fetus is healthy. One hour ago the dilatation of the cervix was 4 cm, with a fetal occiput in the anterior position. Now she describes an important pushing urge and cervical dilatation is 5 cm.

VIGNETTE 2 -Laura is a 30-year-old nulliparous woman with a physiological pregnancy (single fetus in cephalic presentation). Her labour started spontaneously five hours ago.
The membranes are broken, the amniotic fluid is clear and the fetus is healthy. One hour ago the dilatation of the cervix was 8 cm, with a fetal occiput in the anterior position. Now she describes a strong pushing urge and cervical dilatation is 9 cm.

VIGNETTE 3 -Sofia is a 30-year-old multiparous woman with a physiological pregnancy (single fetus in cephalic presentation). Her labour started spontaneously five hours ago.
The membranes are broken, the amniotic fluid is clear and the fetus is healthy. One hour ago the dilatation of the cervix was 4 cm, with a fetal occiput in the anterior position. Now she refers an important pushing urge and cervical dilatation is 5 cm.

VIGNETTE 4 -Rebecca is a 30-year-old multiparous woman with a physiological pregnancy (single fetus in cephalic presentation). Her labour started spontaneously five hours ago. The membranes are broken, the amniotic fluid is clear and the fetus is healthy.
One hour ago the dilatation of the cervix was 8 cm, with a fetal occiput in the anterior position. Now she describes a strong pushing urge and cervical dilatation is 9 cm.

Data analysis
A descriptive statistical analysis was performed using Epi-Info 3.5.1 for quantitative data. In this paper, we included only data about midwives' approaches to EPU as other 7 quantitative data have been discussed in a previously published article (Borrelli et al., 2013). All the interviews were digitally recorded, listened/re-listened to, fully transcribed and analysed using an interpretive phenomenological approach (Smith et al., 2009). A line by line analysis was undertaken to identify emergent concepts. The development of core themes was discussed by all the members of the research group.
The data analysis was conducted in Italian in order to maintain language nuances.
Only relevant quotes were translated in English for data dissemination. Triangulation of quantitative and qualitative data was performed.

Ethical approval
The study protocol was approved by the local Ethics Committee. All procedures were performed in compliance with relevant laws and institutional guidelines. Potential participants were given the study information sheet which explained the research objectives and what their involvement would implicate. Informed consent was obtained from all participants prior to participation. Confidentiality and anonymity of data were guaranteed. Participants were free to choose not to take part or to withdraw at any time. For quantitative data, women's informed consent was obtained.

FINDINGS
The findings are presented as four main domains. These are: a) midwives' approaches to EPU; b) drivers guiding midwives' approaches to EPU; c) influencing factors in helping women cope with EPU; d) variation of midwives' approaches to EPU over time.

Midwives' approaches to EPU
Both quantitative and qualitative data suggested that the midwives adopted mainly two approaches in the case of an EPU. These were letting the woman do what she feels and a stop pushing technique. Within the 60 EPU cases analysed, the latter was the most used approach by midwives, with a percentage of 87% (n=52/60). A small number of midwives suggested to the woman to go along with the pushes (13%, n=8/60), mainly in the case of an EPU diagnosed at a higher cervical dilatation (8-9 centimetres).
In the qualitative interviews, the midwives similarly reported that they usually suggest   The choice of suggesting alternatives to avoid the pushes appeared to be often guided by the fear of cervical damage such as tears, oedema and thickness, which may result in a prolonged or arrested labour: Midwives that would let the woman do what she feels stressed the importance of the presence of physiological signs such as good progression of labour, soft cervix and normal fetal parameters (e.g. presenting part, heart-beat, development and weight).
The idea of respecting physiological times appeared to be a constant guide for the midwives' decision-making, irrespective of parity and dilatation at the appearance of EPU: 'I think it's important to respect physiological times, trying to avoid those precipitous descents that are harmful to both the mother and the baby' (M10)

Influencing factors in helping women cope with EPU
The influencing factors in helping labouring women cope with EPU reported by the participants were: woman's personality; woman-midwife trusting relationship; team working; knowledge of the physiology of childbirth.
The interviewees referred to the woman's personality and the woman-midwife relationship as two of the main influencing aspects. The midwives raised the importance of being able to establish a trusting relationship with each mother, providing an individualised and woman-centred care:

Variation of midwives' approaches to EPU over time
The majority of the participants reported that their approach to EPU evolved within the course of their professional career. In particular, the midwives felt they have acquired increased professional competence, self-confidence and awareness of physiology of childbirth. They also mentioned their increased ability to establish a stronger woman-

CONCLUSION
This paper provides original insights into the midwives' approaches to EPU, including their perceptions and experiences of helping women cope with EPU.
According to both the existing literature (Enkin et al., 2000;Downe, 2003;Borrelli et al., 2013) and our findings, midwives might suggest techniques to alleviate the urge to push and to help the woman cope with it, such as change of maternal position, breathing techniques, vocalisation, lumbar back massage and use of bath. Epidural analgesia could be proposed by midwives when the woman is strongly struggling to cope with EPU after alternative non-pharmacological techniques are suggested.
However, there is no available evidence supporting that early pushes are harmful in physiological conditions and no data are available in the literature about the incidence of cervical damage occurring in the case of EPU. Moreover, the midwives referred to the presence of physiological signs when helping women cope with EPU. This supports the idea of recent researchers about the physiology of EPU in the presence of good maternal and fetal conditions (Enkin et al., 2000;Downe, 2008;Borrelli et al., 2013). In light of this, the question that arises is whether midwives should let the woman do what she feels and go along with the pushes. This remains an open question as there is not enough evidence to determine the optimum response to EPU.
Independently from the undertaken approach, it is recommended that midwives need to work with each individual woman in the context of each labour to determine the best approach in the specific case (Downe, 2008). Midwives should acknowledge that women often strongly struggle to cope with EPU; provide women with explanations and information on EPU; empower mothers; offer individualised woman-centred care and emotional support.
Factors that may facilitate midwives in helping women cope with EPU are: models of care considering one-to-one care and continuity of carer stimulating the establishment of a trusting woman-midwife relationship; supportive working environments promoting normality of labour and birth; observing a number of women experiencing EPU in labour; good team working and peer support.
The optimum approach to EPU needs to be further studied and a work of larger-scale, including several contexts, should be considered. In particular, the association between midwives' approaches at different cervical dilatation and maternal/neonatal outcomes should be investigated.