This study reported the most recent policies during the second stage of labor among hospitals, clinics, and midwifery birth centers in the metropolitan areas of Tokyo, Kanagawa, Saitama, and Chiba in Japan, and compared that care with the Guidelines for Midwives . This research not only informs the health care community about the current state of care during second stage of labor, it is also the first research comparing three types of institutions. This research will be useful to enhance the quality of care for low-risk birth in Japan, and for future evaluation of institutions’ adherence to the Guidelines for Midwifery . Considerable differences were reported in these policies among the institutions, although there were some similarities between hospitals and clinics. Important questions to consider are what factors influenced the gap between present care and recommended routine care found in the Guidelines for Midwives  and what are the desired future trends in Japanese antenatal care.
Perineal massage education
Perineal massage during pregnancy is one of the effective self-care strategies used by pregnant women for preventing perineal injury at birth , so perineal massage must be acceptable to institutions. However, only nearly half of institutions responded ‘almost all cases’ or ‘depending on the cases’. According to a Japanese survey, antenatal face-to-face education by midwife was the most influential factor for women to implement perineal self-massage . Dissemination of the Guidelines for Midwives will be a solution strategy to promote perineal massage during pregnancy.
Women’s preferred position during labor and birth
A hallmark of midwifery practice in Japan is the philosophy and practice of ‘active birth’ and ‘expectant management’ , thus it is no surprise that all midwifery birth centers adopted ‘active birth’ during the second stage of labor. The traditional birthing supine position is still in evidence with a small majority of the hospitals and two-thirds of the clinics. Although there are benefits and risks of each position, there is no specific evidence that the supine position is more beneficial for women ; supported by the NICE guidelines , two systematic reviews [24, 25] and two random controlled trials [26, 27]. Another study found significant differences between women who were able to move around and those who were supine for 50 % of the time or more. Women who could assume alternative positions had shorter labors, less pain, lower requests for analgesics, less need for episiotomies and fewer problems with fetal occiput rotation  For that reason, supported by the evidence from Guidelines for Midwives , institutions should consider offering laboring women a choice of positions unless an abnormal labor dictates otherwise.
NICE Guidelines shows that women should be informed that there is insufficient high-quality evidence to either support or discourage giving birth in water , however none of the other guidelines included evidence about water births. In these results, 34 % of midwifery birth centers compared to only one hospital and two clinics implemented water births. Although NICE Guidelines recommended water birth , the institutions with water birth capacity in Japan are limited. Hospitals and clinics with water birth resources would be very cautious in implementing due to the risk of infection and their mixed population of low and high-risk women . For this reason, the rate of implementation was quite low among hospitals and clinics compared to midwifery birth centers that only manage low risk births.
Applying warm compresses to the perineum
According to the Guidelines for Midwives  there was no evidence that applying warm compresses to the perineum was effective for preventing perineal trauma. However, there was evidence that the women receiving warm compress experienced less perineal pain at post-delivery day one and two compared to the control group . A more recent review suggests that warm compresses were associated with a significant decrease in 3rd and 4th degree tears . Moreover, it was shown that no harmful outcomes occurred; therefore, warm compress to the perineum could be applied if clinicians used an appropriate temperature . In this research, with two-thirds of the midwifery birth centers and only a quarter of the hospitals and clinics responding ‘almost all cases or depending on the cases’, it appears to be a widespread practice of midwives and may be more related to promoting comfort. Additional research regarding the lack of using warm compresses in clinics and hospitals should be explored.
Valsalva while pushing
The Guidelines for Midwives  does not provide evidence about using Valsalva maneuver while pushing during the second stage of labor. NICE Guidelines recommends that women be informed that during the second stage they should be guided by their own urge to push . Yet, more than half of clinics, one-third of hospitals, and a small percentage of midwifery birth centers responded that in almost all cases they encouraged women to push even if the women did not have the urge to push. From these results it is apparent that there are still many Japanese institutions, particularly clinics and hospitals, that are using a delivery table and midwives and physicians are encouraging women to deliver in a supine position while pushing regardless of the urge. Because Japanese clinics and hospitals accept both low and high-risk women, clinicians’ attention is necessarily diverted to high-risk patients; the low risk patients are cared for efficiently but not necessarily in a way that honors an ’active birth’.
Hands-on technique to support fetal expulsion
Guidelines for Midwives shows that there is no evidence for the effectiveness of two different methods of perineal support (hands-poised and hands-on) used to prevent perineal tears during delivery in the lateral position, however further study is needed to take other factors into consideration such as labor positions, race, and delivery environment . This is based on NICE Guidelines  and a systematic review . In Japan, midwives traditionally apply perineal support during the birth of a baby; there are some reports, but no research, about techniques of perineal support . In this study, hospitals and clinics had a high rate of implementing perineal support. On the other hand, about half of midwifery birth centers answered almost all cases, and one-third answered depending on the cases, indicating a lower implementation rate. The ‘hands-poised’ support is often understood as part of ‘active birth’. An area for further research is to document the extent to which hands-poised is associated with expectant birth practices and the subsequent outcomes.
According to the Guidelines for Midwives , there is no evidence supporting the effectiveness of disinfecting the perineum prior to delivery because the infection sites for women and newborns were no different from when disinfectant like benzalkonium chloride or chlorhexidine was used compared to tap water . In this research, a large majority of all institutions disinfected the perineum. Various disinfectants were used. Due to these results, it was evident that there was little diffusion of knowledge about water as an acceptable disinfectant for the perineum and this was particularly evident in hospitals and clinics. From the point of view of women’s comfort, tap water would be more than adequate. Furthermore, because expensive disinfectants are not necessary, institutions would have the benefit of cost cutting. For these reasons tap water for disinfecting the perineum should be promoted.
Use of episiotomies for primiparas and multiparas
Guidelines for Midwives shows that there is evidence that restrictive use of episiotomies is more beneficial to women and babies when compared to those women in the routine episiotomy group . This is based on NICE Guidelines , Guidelines for comfortable pregnancy and childbirth  and a systematic review . These guidelines and research recommend use of an episiotomy when it is needed for an instrumental delivery or for fetal abnormality, but not for routine use [4, 5, 31]. In this study, a minority of hospitals and clinics and an even a smaller percentage of midwifery birth centers answered ‘almost all cases’ for using an episiotomy for primiparas. The majority of hospitals and clinics responded that ‘it depended on the case’. The small percentage of midwifery birth centers that responded ‘it depended on the case’ was not surprising, as midwives generally do not perform episiotomies . It is possible that hospitals and clinics are performing more instrumental deliveries related to the mixed patient load of low and high-risk mothers. However, the rate of ‘almost all cases’ meant that routine use of episiotomy was higher than expected. This result might be related to conventional enforcement of episiotomies, or lack of doctors. Because it is clear that the routine use of episiotomy is unnecessary, it is important that the spread of knowledge include both midwives and doctors.
Moreover, for multiparas, most of the hospitals and clinics performed episiotomies ‘depending on the case’. From these results, the routine use for multiparas was very small compared to primiparas hence both hospitals and clinics are in accordance with the Guidelines for Midwives . Furthermore, almost all institutions performed episiotomies under the appropriate circumstances such as, severe distress of fetus, to prevent severe perineal injury, and use of vacuum, or forceps. The midwifery birth clinics reported not using episiotomies for multiparas. That approach is in line with the philosophy of expectant management in midwifery.
Fundal pressure during the second stage
Guidelines for Midwives found that there was no robust evidence available for the effects of manual fundal pressure . This conclusion was based on one high quality study regarding the efficacy of using fundal pressure  and on the Guidelines for obstetrical practice in Japan . The authors concluded that not enough high quality research has been conducted to either recommend or not recommend using fundal pressure . Moreover, there is a risk of uterine rupture , anal sphincter damage  and severe perineal lacerations [35, 36]. However, the Guidelines for Obstetrical Practice in Japan recommended complementary use of fundal pressure for vacuum extraction or forceps but with caution ; therefore, fundal pressure should not be practiced for normal delivery. In the results of this study, only one hospital and no clinics or midwifery birth centers answered ‘used fundal pressure in almost all cases’. The vast majority of the hospitals and clinics and about one-third of the midwifery birth centers used fundal pressure depending on the case. It seems apparent that the danger of routine fundal pressure during the second stage is widely known at these institutions. However, one hospital continued to enforce routine fundal pressure during the second stage so that the current evidence has to be more widely disseminated. One would expect hospitals and clinics to use fundal pressure, depending on the case, because of instrument delivery or fetal abnormality. Specifics about the conditions under which it was used varied but all were related to complications of delivery.
Guidelines for Midwives recommends ’active birth’ at delivery and that a woman should be informed about both the benefits and risks of the various birthing positions; she should be able to choose the position . Almost all of the midwifery birth centers practiced ’active birth’ at the delivery compared to a minority of hospitals and clinics. Given that hospitals and clinics are also caring for high-risk women with complications it is assumed that staff do not have the time to provide the extra explanation for alternative birthing positions. Other factors may also be influencing the decisions such as convention, lack of experience with the positions and lack of cooperation. Future research should investigate the reasons why few hospitals and clinics implement women’s chosen position at delivery.
Hands and knees position to correct fetal abnormal rotation
In this study a minority of institutions implemented hands and knee position in all cases but with midwifery leading by twice as much. The tendency was to offer hands and knee position depending on the case or not at all; for example more than half of the clinics did not offer it at all. Guidelines for Midwives  shows that there is no obvious evidence that the hands and knees position resolves the abnormal rotation of the fetus or that it is effective in relieving the back pain that comes from abnormal rotation . However, there are not so many studies of this issue so more research is needed in the future. This was the conclusion of the Guidelines for Midwives  based on the NICE Guidelines  and a systematic review . NICE Guidelines, which used only one study, indicated that there was no significant difference in the number of fetuses presenting as occipitoposterior to transition to an occipitoanterior presentation . A more recent study concluded that alternate positions positively and significantly influenced fetal occiput presentation . Therefore, although it is necessary to conduct more research about the effects of taking hands and knees position for correcting fetal abnormal rotation during the second stage of labor it could be safely encouraged for low-risk women.
The gap between the care policies of institutions and the Guidelines
We found some gaps between the care policies of institutions and the Guidelines. Therefore, we explored the possible reasons. Three reasons were noted: (1) differences in staff scope of practice and needs among institutions; (2) persistence of Japanese traditional practice; (3) evidence which was not supported and more research needed.
There were differences about staff scope of practice and needs among institutions. For example, doctors, midwives, and nurses work within a hospital, however their scope of practice is very different (e.g. episiotomy and suturing are restricted to physicians). Midwifery birth centers supported expectant or physiological management of labor and active birth. Also, because Japanese hospitals need to care for both high-risk and low-risk births, the responsibility and complexity of care within hospitals is greater , and hospitals tend to conduct excessive medical interventions (e.g. valsalva, episiotomy, fundal pressure). To reduce this first gap, institutions, especially hospitals need to work out systematic countermeasures so that staff resources are used to greatest advantage.
The gap made by Japanese traditional treatment (perineal disinfection, and hands-on technique to support fetal expulsion), or non-traditional treatment (applying warm compress to the perineum). Although the majority of hospitals, clinics and midwifery birth centers attempted to cleanse the perineum, there was a wide variation in methods. Needed is systematic diffusion of information to physicians, nurses and infection prevention committees about using only water for perineal disinfection. Applying warm compresses to the perineum is easy and not harmful to women and newborns therefore it can confidently be adopted as usual care. It is likely that if more clinicians knew of the relaxing effects of warm compresses to the perineum this care would be adopted.
There was no strong evidence to support water birth, and taking hands and knees position for correcting fetal abnormal rotation and more research is needed. Accumulating additional research in the Japanese context may be necessary to provide the evidence that will support building a consensus.
Study Limitations. This research has a number of limitations; first, the survey targeted only occupations or positions that knew about the care policy among hospitals, clinics, and midwifery birth centers. Therefore we cannot assume that the results of this survey indicate that all policies were translated into practice. Surveys that compare actual practice are needed. While the high response rate of the midwifery birth centers provided higher generalizability for that group, the low response rate particularly of the clinics was a limitation. Moreover, the respondents were not required to add their profession such as physicians or midwives; therefore we were unable to determine whether or not profession itself influenced the response. There is some possibility that these data reflected policies of many independent midwives. The survey tool should be subjected to additional psychometric development beyond face validity and updated, as new Cochrane reviews are available. The Midwifery Guidelines  will be revised, as newer research is available (e. g. NICE updated in 2014  to replace the 2007 NICE , and the Clinical Guidelines for Obstetrical Practice in Japan were updated in 2014 ). In addition, a national survey is needed to understand antenatal care for the second stage of labor in the various regions of Japan.