title: A cross-sectional survey of policies guiding second stage labor in urban Japanese hospitals, clinics and midwifery birth centers.
abstract: BACKGROUND
  The Japan Academy of Midwifery developed and disseminated the '2012 Evidence-based Guidelines for Midwifery Care (Guidelines for Midwives)' for low-risk births to achieve a more uniform standard of care during childbirth in Japan. The objective of this study was to cross-sectional survey policy implementation regarding care during the second stage of labor at Japanese hospitals, clinics, and midwifery birth centers, and to compare those policies with the recommendations in Guidelines for Midwives.
  
  
  METHODS
  This study was conducted in the four major urbanized areas (e.g. Tokyo) of the Kanto region of Japan. Respondents were chiefs of the institutions (obstetricians/midwives), nurse administrators (including midwives) of the obstetrical departments, or other nurse/midwives who were well versed in the routine care of the targeted institutions. The Guidelines implementation questionnaire comprised 12 items. Data was collected from October 2010 to July 2011.
  
  
  RESULTS
  The overall response was 255 of the 684 institutions (37%). Of the total responses 46% were hospitals, 26% were clinics and 28% were midwifery birth centers. Few institutions reported perineal massage education for 'almost all cases'. Using 'active birth' were all midwifery birth centers, 56% hospitals and 32% clinics. Few institutions used water births. The majority of hospitals (73%) and clinics (80%) but a minority (39%) of midwifery birth centers reported 'not implemented' about applying warm compress to the perineum. Few midwifery birth centers (10%) and more hospitals (38%) and clinics (50%) had a policy for valsalva as routine care. Many hospitals (90%) and clinics (88%) and fewer midwifery birth centers (54%) offered hands-on technique to provide perineal support during birth. A majority of institutions used antiseptic solution for perineal disinfection. Few institutions routinely used episiotomies for multiparas, however routine use for primiparas was slightly more in hospitals (21%) and clinics (25%). All respondents used fundal pressure as consistent with guidelines. Not many institutions implemented the hands and knees position for correcting fetal abnormal rotation.
  
  
  CONCLUSIONS
  This survey has provided new information about the policies instituted in three types of institutions guiding second stage labor in four metropolitan areas of Japan. There existed considerable differences among institutions' practice. There were also many gaps between reported policies and evidence-based Guidelines for Midwives, therefore new strategies are needed in Japan to realign institution's care policies with evidenced based guidelines.
authors.affiliation: St. Luke's International University, Tokyo, Japan. 13DN001-ts@slcn.ac.jp.
authors.forename: Kaori
authors.initials: K
authors.lastname: Baba
authors.affiliation: St. Luke's International University, Tokyo, Japan.
authors.forename: Yaeko
authors.initials: Y
authors.lastname: Kataoka
authors.affiliation: St. Luke's International University, Tokyo, Japan.
authors.forename: Kaori
authors.initials: K
authors.lastname: Nakayama
authors.affiliation: St. Luke's International University, Tokyo, Japan.
authors.forename: Yukari
authors.initials: Y
authors.lastname: Yaju
authors.affiliation: St. Luke's International University, Tokyo, Japan.
authors.forename: Shigeko
authors.initials: S
authors.lastname: Horiuchi
authors.affiliation: Nagasaki University, Nagasaki, Japan.
authors.forename: Hiromi
authors.initials: H
authors.lastname: Eto
mesh_terms: D016550:Birthing Centers / Q000458:organization & administration*; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006284:Health Plan Implementation / Q000706:statistics & numerical data; D006786:Hospitals, Urban / Q000458:organization & administration*; D006801:Humans; D007564:Japan; D007748:Labor Stage, Second; D008880:Midwifery / Q000592:standards*; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011795:Surveys and Questionnaires