Abstract

The Royal College of Obstetricians and Gynaecologists/National Institute for Health and Clinical Excellence guidelines for care of women in the second stage of labour impose time limits on duration. While long second stages are associated with poorer maternal/neonatal outcomes, however, there is little evidence that limiting second stage duration artificially is of physical benefit and the effects on maternal satisfaction are unknown. In this prospective cohort study, the authors compared emotional and physical outcomes when woman-centred second stage guidelines were adopted in place of time-limited guidelines. Thus, advice to offer intervention after passage of a specific amount of time was replaced with advice to offer intervention if progressive descent of the fetal head was not evident throughout the second stage, with no time limit imposed.

Data were collected from 1981 women before and after guideline change, using electronic systems and validated questionnaires. After woman-centred care was adopted, women felt less overwhelmed (p<0.001), less out of control (p<0.001), less powerless (p<0.05) and less detached (p<0.05). The authors measured a decrease in emergency Caesareans in the second stage from 16.6% to 12.1% (p=0.01), an increase in forceps rate from 7.6% to 10.4% (p<0.0001) but a fall in ventouse rate from 9.9% to 6.6% (p<0.0001). Women reported less severe pain (p<0.001) despite the second stage duration increasing by 25 min on average.

There was an unexpected 16% increase in the hospital's birth rate after the guideline change. The benefits described were therefore achieved despite a fall in provision of 1:1 midwifery care during labour from 90% to 79% (p<0.001).