Dissertationen zum Thema „The second stage of labor simulation“

Cette thèse a développé une approche originale pour quantifier les incertitudes liées aux propriétés hyperélastiques des tissus mous, en utilisant à la fois des probabilités précises et imprécises. Le protocole de calcul a été étendu pour quantifier les incertitudes dans les contractions utérines actives lors des simulations du deuxième stade du travail. De plus, une simulation de la descente foetale a été créée, intégrant des données de contraction utérine active basées sur l'IRM et une quantification d'incertitude associée. L'étude a révélé que l'Expansion du Chaos Polynomial (PCE) non intrusif est plus efficace que les simulations directes de Monte Carlo.Ce travail met en évidence l'importance de quantifier et de propager les incertitudes dans les propriétés hyperélastiques des tissus utérins lors des simulations de travail, améliorant ainsi la fiabilité des résultats de simulation. Pour la première fois, il aborde la quantification des incertitudes des contractions utérines actives pendant le travail, assurant des résultats de simulation fiables et valides. La simulation de la descente foetale, cohérente avec les données théoriques et IRM, valide la précision des modèles en reflétant les processus physiologiques, soulignant la nécessité d'inclure les contractions utérines actives pour des résultats plus réalistes. L'étude souligne également l'importance d'évaluer la sensibilité globale des paramètres, l'incertitude et les résultats de simulation pour des applications cliniques fiables. En conclusion, cette recherche fait progresser de manière significative les simulations de l'accouchement en fournissant un cadre robuste pour la quantification des incertitudes, améliorant ainsi la fiabilité des résultats de simulation et soutenant une meilleure prise de décision clinique.Les travaux futurs étendront le processus à un modèle complet du système pelvien, incluant l'os du bassin, les ligaments et d'autres organes (comme la vessie, le rectum) pour simuler l'ensemble du processus de délivrance. Des comportements plus complexes des tissus mous pelviens seront étudiés pour mieux décrire l'interaction foetale pendant le travail. L'utilisation de données IRM 3D, si disponibles, permettra une meilleure évaluation, notamment pour la rotation foetale lors de l'expulsion. Un modèle complet du bassin maternel sera couplé à l'apprentissage par renforcement pour identifier les mécanismes de délivrance. De plus, une combinaison plus complexe d'orientations de fibres sera envisagée. Pour améliorer la méthode de Monte Carlo, des techniques de réduction de la variance et des stratégies d'optimisation telles que l'échantillonnage par importance, l'échantillonnage hypercube latin et les méthodes de Monte Carlo par chaînes de Markov seront utilisées pour réduire la taille des échantillons tout en maintenant la précision. Des méthodes pour une convergence plus rapide et une précision accrue dans la quantification des incertitudes, comme discuté par Hauseux et al. (2017), seront explorées. D'autres formulations de la méthode des éléments finis stochastiques (SFEM), comme la méthode SFEM spectrale stochastique (SSFEM), seront considérées pour la quantification des incertitudes, et des méthodes intrusives comme le stochastique-Galerkin seront utilisées pour leurs avantages computationnels. Ces approches pourraient améliorer la quantification des incertitudes dans les études futures.Enfin, l'approche développée pourrait être adaptée à la modélisation spécifique au patient et aux simulations de complications de la délivrance, permettant d'identifier les risques et les solutions thérapeutiques potentielles pour des interventions médicales personnalisées et des résultats améliorés pour les patients
Approximately 0.5 million deaths during childbirth occur annually, as reported by the World Health Organization (WHO). One prominent cause is complicated obstructed labor, also known as labor dystocia. This condition arises when the baby fails to navigate the birth canal despite normal uterine contractions. Therefore, understanding this complex physiological process is essential for improving diagnosis, optimizing clinical interventions, and defining predictive and preventive strategies. Currently, due to the complexity of experimental protocols and associated ethical issues, computational modeling and simulation of childbirth have emerged as the most promising solutions to achieve these objectives. However, it is crucial to quantify the significant influence of inherent uncertainties in the parameters and behaviors of the human pelvic system and their propagation through simulations to establish reliable indicators for clinical decision-making. Specifically, epistemic uncertainties due to lack of knowledge and aleatoric uncertainties due to intrinsic variability in physical domain geometries, material properties, and loads are often not fully understood and are frequently overlooked in current literature on childbirth computational modeling and simulation.This PhD thesis addresses three original contributions aimed at overcoming these challenges: 1) development and evaluation of a computational workflow for the uncertainty quantification of hyperelastic properties of the soft tissue using precise and imprecise probabilities; 2) extrapolation of the developed protocol for the uncertainty quantification of the active uterine contraction during the second stage of labor simulation; and 3) development and evaluation of a fetus descent simulation with the active uterine contraction using MRI-based observations and associated uncertainty quantification process.This thesis pays the way to a more reliable childbirth modeling and simulation under passive and active uterine contractions. In fact, the developed computational protocols could be extrapolated into a patient-specific modeling and simulation to identify the risk factors and associated strategies for vaginal delivery complications in a straightforward manner. Finally, the investigation of stochastic finite element formulation will allow to improve the computational cost for the uncertainty quantification process

The purpose of this thesis was to develop best practice recommendations to care for women in the second stage of labor. Evidence suggests that care of women during the second stage of labor using upright positioning, delayed pushing, application of warm compresses to the perineum, and perineal massage can improve maternal and neonatal outcomes (Aasheim et al., 2011; Brancato et al., 2008; Chang et al., 2011; Dahlen et al., 2007; Dahlen et al., 2009; Gillesby et al., 2010; Gupta et al., 2012; Kelly et al., 2010; Sanders et al., 2005; Schaub et al., 2008; Simpson & James, 2005; Terry et al., 2006; Thies-Lagergren et al., 2013). A theoretical plan for implementation and evaluation of best practice recommendations for the second stage of labor was discussed in this paper. Registered nurses implementing evidence-based recommendations within the hospital setting for pregnant women regarding delayed pushing, upright labor positions, and interventions to reduce perineal trauma and pain, would provide women care that may improve second stage of labor outcomes.

OBJECTIVE: To evaluate whether the fetal head-symphysis distance measured by three-dimensional transperineal ultrasound during the active second stage predicts operative delivery. DESIGN: Prospective observational study. SETTING: University hospital, Bologna, Italy. POPULATION: Seventy-one nulliparous women at term in active second stage of labor. METHODS: We acquired a series of sonographic volumes at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5, T6) until delivery. All volumes were retrospectively analyzed and head-symphysis distance was measured for each acquisition. We compared head-symphysis distance between women with spontaneous vaginal delivery and those with operative delivery. Receiver operator characteristic curves were constructed to estimate the accuracy of head-symphysis distance in the prediction of operative delivery. Logistic regression was used to identify independent variables associated with operative delivery. MAIN OUTCOME MEASURES: Operative delivery (vacuum or cesarean). RESULTS: Of the women included, 81.7% had a spontaneous vaginal delivery and 18.3% underwent operative delivery. Women with spontaneous vaginal delivery had shorter head-symphysis distance than women in the operative delivery group at T1 (p < 0.001), T2 (p < 0.001) and T3 (p = 0.025), whereas no significant differences were recorded thereafter. Receiver operator characteristic curves revealed accuracy values of 81.0%, 87.9% and 77.6% in the prediction of operative delivery at T1, T2 and T3, respectively. At multivariate logistic regression head-symphysis distance and epidural analgesia were the only independent predictors of operative delivery among ultrasonographic, maternal and intrapartum variables. CONCLUSIONS: Ultrasonographic measurement of head-symphysis distance in the second stage of labor can be used to predict operative delivery.

O risco de traumatismos no parto vaginal pode incorrer em disfunções do pavimento pélvico, com impacto negativo na qualidade de vida da mulher. Este relatório centra-se num projeto de melhoria da qualidade de cuidados, desenvolvido no Centro Hospitalar Barreiro-Montijo, com o objetivo de promover a implementação de medidas protetoras de traumatismo se disfunção do pavimento pélvico, em mulheres de baixo risco obstétrico, no 2ºestadio do trabalho de parto. Consideraram-se medidas protetoras: posições verticalizadas, esforços expulsivos espontâneos, técnicas suporte perineal (“hands-off” e “hands-on),episiotomia seletiva, não realização da manobra de Kristeller e aplicação de calor. As intervenções foram avaliadas na equipa de enfermagem e num grupo de parturientes, através da aplicação de questionários. As necessidades identificadas determinaram as atividades desenvolvidas. Constatou-se uma adesão crescente na implementação das medidas referidas, refletindo-se em ganhos na preservação da integridade perineal. A implementação destas medidas constitui-se uma área de intervenção da autonomia e responsabilidade do Enfermeiro Obstetra, devendo ser um cuidado na sua prática. Abstract: The risk of trauma to vaginal delivery may lead to pelvic floor dysfunction, with a negative impact on the quality of life of the woman. This report focuses on a project to improve the quality of care, developed at Centro Hospitalar Barreiro-Montijo, with the objective of promoting the implementation of protective measures for trauma and pelvic floor dysfunction in low-risk obstetric women in the 2nd labor. Protective measures were considered: vertical positions, spon-taneous expulsive efforts, techniques perineal (hands-off and hands-on), selective epi-siotomy, non-performance of the Kristeller maneuver and heat application. The interventions were evaluated in the nursing team and in a group of parturients, through the application of questionnaires. The identified needs determined the activities developed. Increased adherence was observed in the implementation of these measures, reflected in gains in the preservation of perineal integrity. The implementation of these measures constitutes an intervention area of the auto-nomy and responsibility of the Midwife, and should be a care in its practice.

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The model of obstetric and neonatal care at the national level, is experiencing important changes regarding the qualification and humanization of care. The importance of the insertion of obstetrical nurses in this scenario and the carrying out of research based on scientific evidence are highlighted. The objective was to perform a systematic review with meta-analysis to investigate whether the adoption of vertical positions by the woman, in childbirth, compared to the lithotomic position, prevents perineal lacerations. The first manuscript was an integrative review of literature, by searching the bases PubMed and Lilacs, on methods for prevention of perineal lacerations. The final sample consisted of 16 articles and emerged three thematic categories: factors related to the practice of episiotomy and the occurrence of perineal lacerations and indications for the performance, approach of the professional that provides assistance to normal delivery and strategies for prevention of perineal lacerations.The second manuscript concerns a systematic review. For this study, the Lilacs, Pubmed, Cinahl, Cochrane Library, Web of Science, Science Direct, Scopus, Google Schoolar and Open Gray databases were delineated as the main descriptors in english and portuguese: posture, second stage labor, posição and segunda fase de trabalho de parto. Moreover, only primary studies were carried out, which included parturients in active labor, who adopted vertical positions or lithotomic position at the time of delivery, and the prevention or not of perineal lacerations when adopting these positions. No temporal or language cut of studies was delimited. The relevance tests I and II were performed by two independent reviewers. The quality of the evidence was evaluated, according to the GRADE System, and meta-analysis of the results. Scientific evidence has emerged that it is not possible to say with certainty that vertical positions prevent perineal lacerations, compared to the lithotomic position. The product resulting from the research process is a systematic review with meta-analysis, which, based on evidence-based practice, is the best evidence available for clinical decision-making.
O modelo de assistência obstétrica e neonatal em âmbito nacional, está vivenciando mudanças importantes, referentes a qualificação e humanização da assistência. Destaca-se a importância da inserção de enfermeiras obstétricas nesse cenário e a realização de pesquisas baseadas em evidências científicas. Objetivou-se realizar uma revisão sistemática com metanálise, para investigar se a adoção de posições verticalizadas pela mulher, no parto, comparada à posição litotômica, previne lacerações perineais. Emergiram dois artigos da dissertação. O primeiro manuscrito realizado foi uma revisão integrativa de literatura, elaborada a partir do projeto de pesquisa. Foi realizada busca nas bases Pubmed e Lilacs, sobre métodos para prevenção de lacerações perineais. A amostra final foi composta de 16 artigos e emergiram três categorias temáticas quais sejam: fatores relacionados à prática da episiotomia e ocorrência de lacerações perineais e indicações para a realização; abordagem do profissional que presta assistência ao parto normal e estratégias para prevenção de lacerações perineais. O segundo manuscrito diz respeito a uma revisão sistemática. Para esse estudo foram elencadas as bases de dados Lilacs, Pubmed, Cinahl, Cochrane Library, Web of Science, Science Direct, Scopus, Google Schoolar e Open Gray e delimitados como principais descritores em inglês e português: posture, second stage labor, posição e segunda fase de trabalho de parto. Ainda, selecionou-se apenas estudos primários, que contemplassem parturientes em trabalho de parto ativo, que adotaram posições verticalizadas ou posição litotômica, no momento do parto, e a prevenção ou não de lacerações perineais ao adotarem essas posições. Não foi delimitado recorte temporal ou idioma dos estudos. Os testes de relevância I e II foram realizados por dois revisores independentes. Foi avaliada a qualidade da evidência científica dos estudos, de acordo com o Sistema GRADE, e realizada metanálise dos resultados. Emergiu a evidência científica de que não é possível afirmar com certeza, que as posições verticalizadas previnem lacerações perineais, quando comparadas à posições horizontais. O produto resultante do processo da pesquisa configura-se como revisão sistemática com metanálise, a qual, mediante a prática baseada em evidências, se fundamenta como a melhor evidência disponível para a tomada de decisão clínica.

碩士
國立台北護理學院
護理助產研究所
93
The purpose of this study is to assess the advantage of upright position pushing during second stage of labor. We studies 66 lower risk vertex presentation primigravida women during 37 - 42 weeks of gestation age, who had urge sensation in pusing baby out of their womb during second stage of labor. The second stage duration of labor, birth fatigure, labor pushing experience, perineal laceration after episiotomy, newborn Apgar Score of women who received either upright position ( 33 women ) or smi-flowers position ( 33 women)were analysed with independent t-test, χ2 , Mann - Whitney U test. The result revealed upright position could be effective in shorted 54 minutes the duration of second stage of labor ( p < .05 ), decrease birth fatigue ( p < .05 ), and pushing experi ence ( p < .05 ), labor pain ( p < .01 ), decrease perineal laceration after episiotomy ( p < .05 ) in second stage of labor improved with upright pushing position. This upright position program could be promoted and be used by other hospitals in order to gain the satisfaction by women in laboring.

碩士
國立臺北護理健康大學
助產及婦女健康照護系護理助產研究所
105
Background Reducing pain during labor and delivery is an important issue in maternity care. Studies have indicated that applying a hot compress to the perineum during the second stage of labor may effectively reduce postpartum perineal pain, perineal laceration severity, and urinary incontinence and thus improve the birth satisfaction of new mothers. Purpose The present study explores the effect of applying a hot compress to the perineum during the second stage of labor on perineal laceration severity, postpartum perineal pain, and patient-perceived comfort and birth satisfaction. Methods This quasi-experimental study used continuous convenience sampling to recruit qualified cases from a regional research hospital in northern Taiwan between May 2016 and February 2017. Forty-seven cases were assigned based on stated preference to the intervention group and to the control group, respectively, with 94 cases in total. The intervention group completed the pretest at the start of the second stage of labor, with the researcher or a maternity nurse first assessing patient perineal pain and physical comfort and then administering the initial hot compress application to the perineal region. The control group received standard maternity care only. Changes in perineal pain and physical comfort were then assessed and recorded at the following intervals: immediately after, 30-minutes after, and 60-minutes after the application and at 24-hours postpartum. Perineal laceration severity and birth satisfaction were also assessed and recorded at 24-hours postpartum. A structured questionnaire that included a demographic and obstetrics datasheet, visual analogue scales for pain and comfort, a childbirth satisfaction scale, and a perineal wound assessment scale was used to gather data. Data were managed and analyzed on SPSS 20.0 using inferential statistics, including descriptive statistics, the independent samples t test, the chi-square test, and the GEE. Results A total of 94 participants completed the present study. The control group had fewer cases of surgical suturing (t=3.51, p<.05), a shorter average suture time (t=4.25, p<.01), a lower average REEDA scale score (t=6.31, p<.01), and lower average perineal laceration severity (t=3.32, p<.05). Significant differences between the two groups were observed in terms of level of perineal pain at pretest (full dilation; t=2.02, p<.05), immediately after the time of hot compress application (t=4.17, p<.01), 30 minutes after the time of hot compress application (t=10.08, p<.01), 60 minutes after the time of hot compress application (t=16.86, p<.01), and at 24-hours postpartum (t=5.42, p<.01). No difference was observed between the two groups in terms of perceived perineal comfort at pretest (t=-0.75, p=.46). However, significant intergroup differences for this variable were recorded at all post-application observation time points (immediately after [t=-6.31, p<.01], 30-mins after [t=-16.96, p<.01], 60-mins after [t=-27.34, p<.01], and 24-hrs after [t=-6.56, p<.01]. Finally, the experimential group had a higher average birth satisfaction scores (t=-4.46, p<.05). The findings discerned the interaction effects of both group and time. Not only did the intervention group earn lower perineal pain scores than the control group, this intergroup difference increased over time as pain scores for the former gradually decreased and those for the latter gradually increased. Additionally, the posttest intergroup difference in perineal comfort also increased over time, with scores reaching their highest at 60-minutes posttest for the intervention group and decreasing steadily over time for the control group. Conclusions and Clinical Applications Demographic and obstetrics variables, including age, education level, duration of second-stage labor, total pushing time, weeks of pregnancy, and infant head circumference, had no significant effect on either perineal pain or comfort. Degree of perineal laceration was found to have the most significant effect on perineal pain, with higher degrees of laceration associated with greater perineal pain and reduced perineal comfort. Results support that applying the perineal hot compress intervention during the second stage of labor significantly reduces perineal laceration severity and perineal pain while improving perineal comfort. Furthermore, the intervention group required fewer perineal stitches and thus less stitching time. The perineal hot compress is a low-cost, noninvasive intervention that may be performed by staffs without special training. The authors hope that the present article provides maternity-ward personnel with the basic skills necessary to perform this intervention in clinical settings in order to reduce the perineal laceration severity and perineal pain and to improve the perineal comfort and birth satisfaction of new mothers. Moreover, the authors hope to help focus greater medical community attention on this non-pharmacological method of pain control as a way to further enhance patient autonomy, promote positive perspectives on the birth process, and achieve optimal birth outcomes.

碩士
國防大學理工學院
機械工程碩士班
105
In the SCUBA diving equipment, the most important part is the air supply system. The compressed air is stored in the tank, and then it is adjusted to a lower pressure by the first-stage regulator. The second-stage regulator supplies required air with a suitable pressure for divers. The quality of a second-stage regulator affects the efficiency during breathing. In this study, a pneumatically balanced second-stage regulator is selected for analysis. The mathematical model of the mechanism is setup first. Matlab programming is used for simulation. The sensitivity and optimization analysis are also applied on the model. Finally, the experiments are performed to obtain the air pressure in the first-stage and second-stage regulators. The experimental results can be used to construct and verify the mathematical model.

碩士
國立臺北護理健康大學
護理助產研究所
104
Research background The delivery process is an important stage connecting the time before delivery and the time after delivery. The fatigue resulting from the delivery can last to the time after delivery, even affecting the healthy indexes such as postpartum recovery, mother’s comfort, and the living quality. Furthermore, it can affect the milk secretion of the delivery woman, the willingness and effect of breastfeeding. And it should be noted that the pushing skill of the second stage labor duration can effectively reduce postpartum fatigue, and enhance the birth satisfaction. Research purpose The main purpose was to explore the differences between different pushing skills and pushing perception, postpartum fatigue and the birth satisfaction of the delivery woman. In addition, it aimed to study the correlation between the pushing perception of the second stage labor duration, postpartum fatigue, and the birth satisfaction. Methodology This was a descriptive research design. Using a convenient sampling, we have recluded 382 women at the postpartum unit of a medical center hospital in northern Taiwan from November 2014 to October 2015. The structured questionnaire was used to collect data. And the research tools included the data of basic demography and obstetrics, Pushing Perception Scale, Fatigue Scale(Modified Fatigue Symptoms Checklist‚ MFSC), and the scale of birth satisfaction(Mackey Childbirth Satisfaction Rating Scale). SPSS 18.0 statistical software was used to conduct data management and analysis.In addition, the statistical methods included descriptive statistics, independent sample t test, Pearson product moment correlation analysis, multiple linear regression, hierarchical multiple regression analysis, all of which were inferential statistics. Results The satisfaction level of the delivery woman using the upright position in the second stage labor duration was higher than that of the delivery woman using a lying position in terms of birth satisfaction (t= 2.28, p＜.05), overall satisfaction (t = 2.64, p<.01), the satisfaction of the nursing staff (t = 3.06, p< .01), and the satisfaction of the doctors (t = 2.07, p＜.05). The self-satisfaction of the delivery women using delayed push (t = -1.98, p＜.05) was higher than that of the delivery women using immediate push. The time the delivery women pushing with their glottis open during the second stage labor duration spent was 17.67 minutes less than the time the delivery women pushing with their glottis closed did (t = 5.46, p＜.001).Regarding the correlation between pushing perception experiences, birth satisfaction, and postpartum fatigue, it showed that the higher the birth satisfaction of the delivery women, the better the pushing experience perception (r = .46, p<.05), and that the higher the birth satisfaction, the lower the postpartum fatigue ( r = -.16, p<.05), and that the higher the pushing experience perception, the lower the postpartum fatigue perception (r= -.22, p<.05). The better the pushing experience perception (β = -.22, p<.05), and the higher the age (β = -.19, p<.05), the lower the fatigue perception.Compared to the delivery women who were jobless, the fatigue perception of the delivery women who were employed (β = .13, p < .05) was higher. Regarding the related factors relating birth satisfaction, the better the pushing experiences (β = .45, p<.05) and the longer the second stage labor duration (β = .15, p<.05), the higher the birth satisfaction. The higher the education degree (β = -.13, p<.05), the lower the birth satisfaction. The pushing experience perception was the mediator (β = .45, p<.001) by which the postpartum fatigue affected the birth satisfaction. Different pushing positions, timing, methods had no adjusting effect on how postpartum fatigue affected the birth satisfaction. Different pushing methods were the moderator (β = -.15, p<.001) by which pushing experience perception affected the birth satisfaction. And different pushing postures and timing had no adjusting effect on how postpartum fatigue affected the birth satisfaction. Conclusion and application The results showed that the pushing skills in the second stage labor duration (including upright position, delayed pushing) can enhance the birth satisfaction. And the method of an open glottis can shorten the time of the second stage labor duration. The better the pushing experience perception, the lower the postpartum fatigue, and the higher the birth satisfaction. In addition, the lower the postpartum fatigue, the higher the birth satisfaction. The obstetrics professionals are expected to understand related knowledge and skills about the timing of the pushing skills in the second stage labor duration, and to practically help and teach the delivery women with correct pushing skills, and to help the delivery women enhance the natural delivery abilities. In this way, the obstetrics physicians, midwives and nursing staff can provide proper and helpful care to the women in the second stage labor duration, and help them to enjoy a positive birth satisfaction. Key words: second stage labor, duration, pushing skill, pushing experience perception, postpartum fatigue, birth satisfaction.

碩士
國立臺北護理健康大學
護理助產研究所
103
Objective: To compare the pushing experiences and birth outcomes of three different pushing positions during the second stage of labor. The three positions were: semi-recumbent, squatting, and squatting with the aid of ergonomically designed ankle supports. Methods: A randomized controlled trial was conducted at a regional teaching hospital in northern Taiwan. Data were collected from 168 primiparous women in their 38th to 42nd gestational week. None of the participants received epidural analgesia during labor and all were free of pregnancy and labor-related complications. Intervention: During labor, after full cervical dilation and when the fetal head had descended to at least the +1 station and had turned to the occiput anterior position, the experimental group was asked to push in the squatting position while wearing the ergonomically designed ankle supports; comparison group A was asked to push in the squatting position without the use of these supports; and comparison group B was asked to push in a standard semi-recumbent position. Measures: The participants completed a demographic and obstetrics datasheet, the Short Form McGill Pain Questionnaire (MPQ-SF), and the Labor Pushing Experience scale within 4-hours postpartum. Conclusion: In terms of delivery time, the duration between the start of pushing to crowning for the experimental group (squatting with ankle supports) averaged 25.52 minutes less (F =6.02, p< .05) than the time for comparison group B (semi-recumbent). Furthermore, the duration between the start of pushing to infant birth averaged 25.21 minutes less for the experimental group than for comparison group B (F =6.14, p< .05). Moreover, the experimental group had a lower average VAS pain score (5.053.22) than comparison group B and the average McGill pain score for the experimental group was lower than both comparison groups (F=18.12, p< .001). In summary, the participants in the group that delivered from a squatting position with ankle supports had better labor pushing experiences than their peers in the comparison groups. Results: In comparison to both unsupported squatting and semi-recumbent pushing, squatting with the aid of ergonomically designed ankle supports reduced pushing times, ameliorated labor pain, and improved the pushing experience. Clinical application and suggestion: The squatting with ankle-support intervention introduced in the present study may significantly reduce tiredness and difficulties in maintaining balance as well as increase pushing efficiency. Thus, this intervention may reduce the caring needs of women during the second stage of labor. This intervention may be introduced in midwifery education programs and in clinical practice as a method to improve the care of women during the second stage of labor.

Prolonged second stage of labor, excessive gestational weight gain and cesarean delivery has been associated with adverse maternal and fetal outcomes. Physical activity during pregnancy is a modifiable risk factor which has never been studied among Hispanic women. Gestational weight gain, another modifiable risk factor has only been evaluated as a risk factor for cesarean delivery in two studies among women induced for labor. To date, no study has examined the effect of duration of second stage of labor on intra-ventricular hemorrhage in very preterm births. We examined these maternal risk factors for prolonged second stage of labor, rate of cesarean delivery and fetal outcomes. The first study evaluated the association between physical activity and duration of second stage of labor. Prior studies regarding physical activity and duration of second stage of labor have been conflicting and none have examined the Hispanic population. During pregnancy, activities such as household chores, childcare, sports and women's occupation constitute a significant proportion of physical activity but have not been considered in prior studies. We examined the association between total physical activity (occupational, sport/exercise, household/care giving, and active living) during pre, early and mid-pregnancy and duration of second stage of labor in a prospective cohort of 1,231 Hispanic participants. Physical activity was quantified using the Kaiser Physical Activity Survey administered during pregnancy. Using multivariate linear regression we did not find statistically significant association between pre, early and mid-pregnancy physical activity and duration of second stage of labor. The second study focused on the effect of gestational weight gain on the cesarean delivery rate after induction of labor. The rate of induction of labor (IOL) has more than doubled from 9.5% in 1990 to 22.5% in 2006. Cesarean delivery usually follows a failed IOL and is associated with maternal and fetal morbidity. One of the two studies evaluating the effect of gestational weight gain on the rate of cesarean section in patients undergoing IOL was restricted to women with normal Body Mass Index (BMI) and the other was subjected to bias because more than half of the patients were missing BMI data. Therefore, we evaluated the effect of gestational weight gain on the rate of cesarean delivery after labor induction. In a retrospective cohort study design, using data from May 2005 to June 2008 and a multivariate logistic regression we found a 13% increase in risk of cesarean delivery with 5 kg increase in gestational weight gain. Finally, we evaluated the effect of mode of delivery and duration of second stage of labor on intra-ventricular hemorrhage (IVH) among early preterm births. IVH is a serious complication associated with preterm birth and important predictors of cerebral palsy and neurodevelopmental delays. Prior studies on this relationship in early preterm births are sparse. In a retrospective cohort study of newborns born less than 30 weeks or less than 1500 g between May 2003 and August 2008, we found an increase in risk of IVH after vaginal delivery. However, duration of second stage of labor had no significant effect on risk of IVH.

碩士
國立台北護理學院
護理助產研究所
96
This paper aims to study the effects of pushing immediately and delaying pushing during the second stage of labor on post-delivery tiredness as well as on delivery outcomes. Relevant data were collected from primiparous women over 37 weeks pregnant who were not given epidural analgesia during labor and did not have any complications in pregnancy. Surveys were conducted at a medical center and a regional hospital. A total of 72 responders were selected by convenient sampling and divided into an experimental group and a control group after the research purposes were explained. The Modified Fatigue Symptom Checklist (MFSC) was used, 1 hour and 24 hours after delivery, to measure the responders’ levels of fatigue (from 1 to 10 on the scale). Delivery outcomes of the experimental and control groups were analyzed according to their case histories. The SPSS 12.0 and SAS 9.1 statistics software were used to analyze the variables, and the findings are:Fatigue/ 1 hour after delivery: experimental group 2.08±1.87 minutes; control group 4.17±2.6 minutes; p<.01 referring to a significant difference. Fatigue/ 24 hours after delivery: experimental group 1.47±1.66 minutes; control group 3.36±2.13 minutes; p<.01 referring to a significant difference. Duration of second-stage labor/ experimental group 70.31±37.17 minutes; control group 129.06±75.69 minutes; p<.01 referring to a significant difference. Duration of push-off phase/ experimental group 47.53±30.85 minutes; control group 123.19±73.93 minutes; p<.01 referring to a significant difference. In addition, when the Generalized Estimating Equations method (GEE) was used to control the three variables that indicated significant statistical differences according to SPSS results, i.e. fundal height, duration of second-stage labor, and duration of push-off phase, the two groups varied only in the level of post-delivery tiredness (with a difference of 1.54 minutes, p<0.01). Other results showed no significant differences. As for delivery outcomes, the findings suggested no significant differences (p>.05) in terms of operative vaginal delivery, the rate of caesarean section, perineal wound, severe postpartum hemorrhage, fever, meconium aspiration syndrome, and the Apgar score.