Using outcomes as an indicator of quality in maternity care is challenging because large samples are required to detect any significant differences or changes using traditional quantitative measures. This challenge is in part due to the relative good health and young age of childbearing women; thus, adverse outcomes in this population are rare. Quality experts have attempted to overcome these measurement limitations by developing composites of maternal and newborn complications and evaluating processes of care and near-miss events such as severe maternal morbidity as surrogates of and in addition to specific patient outcomes. These strategies have been successful with large datasets but are not always easily applicable to perinatal services in the individual hospital setting. Clinicians need methods to evaluate care at the local level that have immediate and realistic implications for enhancing clinical practice and promoting perinatal teamwork and safety.

An Apgar score of less than 7 at 5 minutes of life for a baby born at term is sometimes used as an indicator of a case that requires further review; however, Apgar scores less than 7 at 1 minute of life generally do not prompt more scrutiny if the 5-minute Apgar score is 7 or higher. Apgar scores indicate status of the newborn after birth and response to neonatal resuscitation if needed (American College of Obstetricians and Gynecologists [ACOG] & American Academy of Pediatrics [AAP], 2015). Individual scores are not predictive of outcomes (ACOG & AAP).

Despite its limitations, an Apgar score as an indicator of the condition of the newborn at 1 minute after vaginal birth may be useful as a screening measure to identify cases that warrant closer evaluation of the quality of care during the active phase of the second stage of labor. Several factors are amendable to clinician control during second-stage maternal pushing efforts including positioning, encouragement of the woman about how to push and how often to push, management of uterine activity, and accurate assessment and attention to fetal well-being. Each of these factors can influence how well the baby transitions to extrauterine life.

Common issues during the active pushing phase of the second stage of labor that can contribute to depressed fetal status at birth are static maternal positioning rather than frequent repositioning, lithotomy positioning, pushing in stirrups, forcing women's legs back against their abdomen, excessive uterine activity via continued and sometimes increases in an intravenous oxytocin infusion, and coached pushing with sustained breath-holding several times with every contraction in the context of one or more of the following: recurrent fetal heart rate (FHR) decelerations, a rising FHR baseline, and minimal variability. Recording of the maternal heart rate as the FHR and lack of awareness of the source of the data as maternal is another practice frequently involved in second-stage pushing. Sometimes clinicians are so focused on imminent birth that they are unable to realize that their continued efforts are at the expense of fetal well-being.

A low Apgar score at 1 minute can be considered a near miss. Case review by the perinatal team, including the electronic fetal monitoring tracing, can be helpful in revealing aspects of second-stage labor care that could benefit from change. Consider including cases in the multidisciplinary review process of Apgar scores less than 7 at 1 minute for babies born vaginally as a method to promote quality second-stage labor care. Apply the lessons learned to clinical practice and make changes as needed to make care safer for mothers and babies. The majority of the care during the second stage of labor is provided by the labor nurse in most settings. This is an opportunity to focus on a quality care initiative directly related to nursing practice that can be modified as necessary by perinatal nurses to improve care.

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