How do midwives facilitate women to give birth during physiological second stage of labour? A protocol for a systematic review
Midwives’ practices during the second stage of labour vary nationally and internationally. We aim to retrieve evidence that supports high-quality intrapartum care by conducting a systematic review of the literature.
Electronic bibliographic databases including PubMed, EMBASE.com, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Maternity and Infant Care Database (through MIDIRS), and The Cochrane Library will be searched to identify studies that meet the inclusion criteria. No language or publication date constraints will be applied. Articles that pass the two-stage screening process will then be assessed for risk of bias and have their reference lists hand searched.
A midwife’s practice can be influenced by education and cultural practices but ultimately it should be informed by up-to-date research evidence. By analysing and synthesising the results of the studies, this systematic review will provide valuable insight into high-quality evidence-based midwifery care, which can inform practice, education and future research.
Systematic review registration
KeywordsIntrapartum care Midwifery Physiological birth Second stage of labour
Confidence in the Evidence from Reviews of Qualitative research
Grading of Recommendations Assessment, Development and Evaluation
Population, Exposure, Outcomes
Patient or Population, Intervention, Comparison, Outcome
Preferred Reporting Items for Systematic Reviews and Meta-Analysis
International Prospective Register of Systematic Reviews
World Health Organization
Labour and birth constitute significant and memorable life events for a woman and her wider family. How a woman experiences birth has both short- and long-term effects on health and wellbeing for both herself and her baby [2, 4, 5, 9, 10, 14]. Experiencing a physiological labour and birth may contribute to positive outcomes: “The health and well-being of a mother and child at birth largely determines the future health and wellness of the entire family” .
As far back as 1997, the WHO defined physiological birth as spontaneous onset, low risk at the commencement of labour and continuing so for the remainder of labour and birth. The infant is born spontaneously, between 37 and 42 weeks of pregnancy with a cephalic presentation. Following birth, both mother and infant are in good condition (World Health Organization, 1997). Labour can be divided into three stages: the first, second and the third stage of labour. The WHO (2018) have recently defined the first stage of labour as the time period characterised by regular painful uterine contractions until full dilatation of the cervix and the second stage of labour as the time period between full dilatation of the cervix and the birth of the baby, whilst the woman is experiencing an involuntary urge to bear down, due to expulsive uterine contractions. The third stage is recognised as the period after the birth of the baby ending with the birth of the placenta and fetal membranes .
Midwives can facilitate the process of physiological labour and birth by enabling the interplay of reproductive hormonal and neuro-hormonal mechanisms by their kind and respectful caring practices, which promote oxytocin release for effective uterine contractions during labour and the relaxation of the birth canal [12, 13]. However, there is little explanation or description of the variety of physical and emotional actions the midwife does when “being with” a woman during birth of the baby, in particular, how they facilitate this physiological process. Furthermore, Kennedy et al. emphasised the priority of research that “identifies and describes aspects of care that optimise, and those that disturb, the biological/physiological processes for healthy childbearing women and fetus/newborn infants and those who experience complications” ( p e777).
Therefore, we plan to undertake a systematic review to identify pertinent evidence related to intrapartum midwifery care, focusing specifically on care during the second stage of labour.
This leads to our structured research questions which were formulated using the PICO (Patient or Population, Intervention, Comparison, Outcome) framework for quantitative research and the PEO (Population, Exposure, Outcomes) question format for qualitative research questions: “How do midwives facilitate women to give birth during physiological second stage of labour?” and “What evidence supports good quality intrapartum care during the second stage of labour?”
The aim of the systematic review is to collate, analyse and synthesise the international evidence that supports high-quality intrapartum care during the second stage, which will inform midwifery practice, education and future research and positively influence this aspect of midwifery care for women.
Study identification and selection
Criteria for considering studies for review
All studies describing midwives’ care or practice during second stage of physiological birth or normal birth will be included. Both relevant quantitative and qualitative studies will be eligible for review.
Studies examining midwifery practice of women that focused only on care during the first or third stage of labour are not eligible. Those studies which include women with an epidural, spinal or instrumental/operative vaginal birth or caesarean section birth will not be included. Furthermore, studies that include women who have not reached full-term pregnancy, have had their pregnancy induced or labour augmented with intravenous oxytocin will not be eligible.
Study quality assessment
Study quality assessment will be performed by two reviewers independently. The tool utilised to assess the quality of evidence will depend on each study’s methodological approach. To assess the risk of bias in randomised controlled trials, the Cochrane Collaboration’s tool for assessing risk of bias will be used . For all other study types, the Critical Appraisal Skills Programme (CASP) criteria will be used . The Grading of Recommendations Assessment, Development and Evaluation (GRADE), Cochrane’s recommended approach for grading the body of evidence, will be used for quantitative studies. Confidence in the Evidence from Reviews of Qualitative research (CERQual) will be used for grading the confidence in the evidence of qualitative studies.
Depending on the findings, a meta-analysis and/or a meta-synthesis will be undertaken.
A midwife’s practice can be influenced by education and cultural practices, but ultimately it should be informed by up-to-date research evidence. This systematic review will comprehensively collate, analyse and synthesise the available evidence relating to what midwives do to facilitate physiological birth. This will help to formulate midwifery practice, education and future research recommendations that support high-quality intrapartum care during the second stage of labour.
This article is based upon work from COST Action IS1405 BIRTH: “Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth” (https://www.cost.eu/actions/IS1405/#tabs|Name:overview), supported by COST (European Cooperation in Science and Technology).
The authors gratefully thank Mary Dharmachandran (subject librarian at the Royal College of Midwives, UK) for her valuable contribution to this systematic review.
Finally, they thank the School of Nursing and Midwifery, Queen’s University Belfast, who funded access to Covidence, the web-based systematic review software package recommended by Cochrane.
This systematic review will be conducted as part of the COST Action IS1405 “Building Intrapartum Research Through Health (BIRTH) – an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth”. Furthermore, the School of Nursing and Midwifery, Queen’s University Belfast, funded access to Covidence, the web-based systematic review software package recommended by Cochrane.
Availability of data and materials
CV and MH designed the study. All authors (CV, DS, VN, RO and MH) contributed in writing the manuscript and critically revised earlier drafts of the paper. All authors read and approved the final manuscript. As the guarantor of the review, MH accepts official responsibility for the overall integrity of the manuscript (including ethics, data handling, reporting of results and study conduct).
Ethics approval and consent to participate
This is a protocol for a systematic review which utilises published data, and as such, ethical approval is not required for this study. Wide dissemination of the findings of this study will be undertaken via peer-reviewed publications and conference presentations.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- 1.Begley CM, Gyte GM, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2015;3:CD007412 DOI: 10.1002/14651858.CD007412.pub4. Review.Google Scholar
- 3.Critical Appraisal Skills Programme 2018. CASP Checklists. Available at https://casp-uk.net/casp-tools-checklists/.
- 5.Dahlen HG, Dowling H, Tracy M, Schmied V, Tracy S. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery. 2013;29(7):759–64. https://doi.org/10.1016/j.midw.2012.07.002.CrossRefPubMedGoogle Scholar
- 8.Kennedy HP, Yoshida S, Costello A, Declercq E, Dias MA, Duff E, Gherissi A, Kaufman K, McConville F, McFadden A, Michel-Schuldt M, Moyo NT, Schuiling K, Speciale AM, Renfrew MJ. Asking different questions: research priorities to improve the quality of care for every woman, every child. Lancet Glob Health. 2016;4(11):e777–9. https://doi.org/10.1016/S2214-109X(16)30183-8 Epub 2016 Sep 20.CrossRefPubMedGoogle Scholar
- 12.Uvnäs-Moberg K. The hormone of closeness: the role of oxytocin in relationships. London: Pinter & Martin Ltd; 2012.Google Scholar
- 13.Uvnäs-Moberg K. How kindness, warmth, empathy and support promote the progress of labour: a physiological perspective. In: Byrom S, Downe S, editors. The Roar Behind the Silence. London: Pinter & Martin Ltd; 2015.Google Scholar
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