A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence

Abstract

Objective To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function. Design Prospective, randomised, controlled trial.Setting Tertiary referral maternity teaching hospital.Population One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing. Methods A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound. Main outcome measures Mode of delivery; altered faecal continence.Results Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group ( P ¼ 0.005). Eighty-four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty-one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies. Conclusions Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing.

Maternal and Neonatal Outcomes With Early Compared With Delayed Pushing Among Nulliparous Women

“…These time intervals were chosen as surrogates for intent regarding management of the second stage; sixty minutes was felt to be an amount of time in which it was likely that the patient or provider intentionally waited to initiate pushing, rather than delayed for logistical or personnel reasons. This definition of delayed pushing is consistent with prior published reports on this topic 14,16 and with the definition used in a current National Institutes of Health-sponsored multicenter randomized trial of immediate versus delayed pushing. 18 Women who initiated pushing between 31 and 59 minutes after achieving the second stage were excluded from the primary analysis due to lack of information about the reason why pushing was intermediately delayed; this population was included in a sensitivity analysis.…”

“…9 In contrast, a meta-analysis of twelve randomized controlled trials reported delayed pushing was not associated with increased spontaneous vaginal delivery when the analysis was limited to high quality studies. 10 Randomized trials also have reported conflicting results, with some reporting decreases in time spent actively pushing, 11,12 others with no difference in time spent actively pushing or mode of delivery, 13,14 and another with a decrease in "difficult" deliveries but no difference in "nondifficult" vaginal deliveries. 15 A retrospective analysis by Frey et al reported delayed pushing to be associated with longer active pushing time, no change in or lower spontaneous vaginal delivery rate, and worse perinatal outcomes, including maternal fever and lower cord arterial pH.…”

Incidence and Predictors of Anal Incontinence After Obstetric Anal Sphincter Injury in Primiparous Women

“…In one randomized trial of delayed pushing versus immediate pushing, where there was a significant (p<0.001) decrease in the length of second stage (median [range], 120 [57-255] vs 60 [0-148] minutes, respectively), there was no significant difference in the proportion of women with postpartum fecal continence. [20] In a retrospective study, 360 primiparous women were queried regarding anal incontinence symptoms and those with a prolonged second stage of labor (n=197, >90 minutes) were compared to those with a short second stage (n=163, <30 min). With a response rate of 51%, flatal incontinence was noted in 9.1% of subjects in the prolonged second stage group compared to 15.6% in the shorter second stage group (p=0.18).…”

First Do No Harm: Interventions During Childbirth

“…Episiotomy and/or perineal lacerations increase the mother's risk of pain, infection, and hemorrhage, and prolong recovery time (MacLeod et al, 2008). The long-term risks of fecal incontinence or pudendal nerve damage ( Fitzpatrick et al, 2002), urinary incontinence, and dyspareunia (Hall, McCraken, Osterwell, & Guise, 2003;Liebling et al, 2004) are also increased with instrumental vaginal birth.…”