RESEARCH
Comparison of Delayed Versus Immediate Pushing During Second Stage of Labor for Nulliparous Women With Epidural Anesthesia

https://doi.org/10.1111/j.1552-6909.2010.01195.xGet rights and content

ABSTRACT

Objective:

To determine if the use of delayed pushing after the onset of the second stage of labor decreases the time of active pushing and decreases maternal fatigue.

Setting:

Labor and delivery unit of a not‐for‐profit community hospital.

Patients/Participants:

Convenience sample of nulliparous laboring women with epidural anesthesia.

Interventions:

Immediate or delayed pushing (2 hours) during the second stage of labor at the time of complete cervical dilatation.

Main Outcome Measures:

The length of pushing, total length of the second stage, and maternal fatigue.

Results:

A total of 77 women were studied (immediate pushing group=39; delayed pushing=38). The immediate pushing group averaged 94 (± 57) minutes in active pushing, while the delayed pushing group averaged 68 (± 46) minutes, a statistically significant difference (p=.04). No significant differences were found in fatigue scores between the immediate and delayed pushing groups (p>.05).

Conclusions:

We found that by delaying the onset of active pushing for 2 hours after the beginning of the second stage of labor, the time that nulliparous women with epidural anesthesia spent in active pushing was significantly decreased by 27%. Although the delayed pushing group rested for up to 2 hours, the total time in the second stage of labor averaged only 59 minutes longer than the immediate pushing group.

Section snippets

Methods

This study was conducted from September 2007 to July 2008 in a 409‐bed not‐for‐profit hospital in the Midwest with 2,800 deliveries per year. The Institutional Review Board of the health system reviewed and approved the study.

Results

A total of 85 participants consented to participate in the study. Eight participants were excluded from the study before the beginning of the second stage of labor for the following reasons: did not meet one or more study entry criteria [Cesarean section: 4], participant requested withdrawal from study (2), and provider request to withdraw participant from study—1 with fetal variable decelerations and the other for manual rotation (2). Of the 85 participants who consented to participate in the

Discussion

The current study found that, by delaying the onset of active pushing for up to 2 hours after the beginning of the second stage of labor, the time that nulliparous women with epidural anesthesia spent actively pushing was decreased by 27%. Women in the delayed group pushed an average of 26 minutes fewer than women in the immediate group. Furthermore, despite the addition of up to a 2‐hour delay in active pushing for the delayed pushing group, the total time in the second stage of labor averaged

Clinical Implications

Our most important finding was a 27% reduction in the time spent actively pushing during the second stage of labor for those in the delayed pushing group. Those women who delayed pushing for 2 hours or until they felt an irresistible urge to push actually pushed an average of 26 minutes fewer than those women who began pushing immediately at complete dilation.

There are a number of possibilities as to why delayed pushing is associated with less time actively pushing. Most likely, it is because

Limitations of the Study

The current study did not control the positions used by participants in either group during the second stage of labor or techniques used during active pushing (e.g., open‐glottis vs. closed‐glottis pushing, intensity of pushing), any of which may have affected the progress of fetal descent. A variety of clinicians provided interventions to our laboring patients, and the different practices among clinicians may have affected the outcome data.

For example, when fetal decelerations were noted, some

Conclusions

Our results indicate a benefit of delayed pushing in nulliparous women with epidural analgesia. Active pushing was decreased by 27% in the delayed pushing group, despite a 2‐hour delay in active pushing and a 59‐minute increase in total time of the second stage of labor.  We encourage further research in the area of second stage, especially related fetal outcomes and women's perceptions of their experience. We also recommend research on management of the second stage for the obese patient

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    • Delayed versus immediate pushing in the second stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials

      2020, American Journal of Obstetrics and Gynecology
      Citation Excerpt :

      At the post hoc subgroup analysis on SVD by duration of pushing delay, we found a significantly higher rate of SVD (81.1% vs 75.7%; RR, 1.07; 95% CI, 1.02−1.12) when pushing was delayed for 2 hours, whereas no difference was found when assessing other durations of delay (Table 4). In subgroup analyses including only the 10 trials that enrolled only nulliparous women,5,9,11–14,16–19 delayed pushing compared to immediate pushing was associated with similar rates of SVD (81.0% vs 78.6%; RR, 1.03; 95% CI, 1.00 −1.06) and CD (7.3% vs 8.2%; RR, 0.90; 95% CI, 0.76−1.08). A post hoc sensitivity analysis for only US trials5,12,15–19 showed that delayed pushing compared to immediate pushing was associated with similar rates of SVD (84.1% vs 82.2%; RR, 1.05; 95% CI, 0.99−1.11) and CD (6.5% vs 7.5%; RR, 0.88; 95% CI, 0.68−1.14).

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