Does Delayed Pushing in the Second Stage of Labor Impact Perinatal Outcomes?

Abstract

2-hour recommendation, and evidence would suggest that as many as 60% of women with a 2-hour pause in labor will go on to deliver vaginally (Obstet Gynecol. 2001;98:550Y554).Finally, the data regarding the standards for length of labor in the second stage are antiquated and based on a time when operative vaginal deliveries were performed in the majority if not a large minority of women, and the use of epidural analgesia was rare. Furthermore, there have been recent studies that suggest that the complications from a prolonged second stage of labor arise from obstetric intervention as much as from the length of the second stage itself. This led to recommendations to lengthen the current guidelines for the second stage all by 1 hour. The current standards have been for 1 hour for multiparous women without an epidural, 2 hours for multiparous women with an epidural, 2 hours for nulliparous women without an epidural, and 3 hours for women with an epidural. Thus, the new recommendations are for 2, 3, 3, and 4 hours, respectively. I think these Table 5 recommendations are the crux of this document and am curious to see if all of these changes will be adopted and how long such adoption will take. As each of these aspects of care is responsible for tens and hundreds of thousands of cesarean deliveries, the impact could be enormous. However, I think the most important component of these changes is that they are done in a thoughtful, patient-centric fashion. With the widespread use of VBAC that was encouraged and then declined, certainly 1 factor in the abandonment of VBAC was the initial lack of attention on patient safety. Although I do not think any of these management changes will have such a dramatic impact as a uterine rupture, I also would not want to see broad adoption of guidelines supplants clinical acumen. However, as many of these represent a more thoughtful approach to labor and delivery, hopefully they will encourage a greater focus on clinical skills beyond the simple use of the scalpel, and we can demonstrate a second reduction in cesarean deliveries over the coming decade.VABC) ABSTRACT Delayed pushing in the second stage of labor may facilitate delivery and avoid potential adverse outcomes. This retrospective cohort study was designed to assess the effectiveness of delayed pushing, estimate its effect on delivery mode, assess its relationship with maternal and neonatal well-being, and estimate its effect on the duration of second stage of labor.The study included consecutive women admitted at term who reached the second stage of labor; those who delayed pushing were compared with those who pushed immediately. Data on maternal demographics and outcomes and neonatal outcomes were obtained from medical records. Delayed pushing, used at the practitioner's discretion, was defined as initiation of pushing 60 minutes or greater after complete dilatation. Baseline characteristics were compared between the 2 groups using W 2 analysis and the Student t and Mann-Whitney U tests. Mode of delivery and rates of maternal...

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.…”

“…10 Our data are also in contrast to work by Frey et al, who demonstrated while delayed pushing was associated with a decreased rate of spontaneous vaginal delivery in the total population (N = 5290), in the subgroup analysis of nulliparous women, there was no difference in cesarean delivery based on immediate versus delayed pushing. 16 Our secondary analysis represents a large investigation of delayed pushing and is notable in the finding of a statistically significant increased risk of adverse maternal outcomes. While our data are retrospective in nature, the larger sample increases the power to detect differences and the diverse cohort enhances reliability of these findings.…”

“…The analysis was limited to nulliparous women in order to focus on the most clinically relevant group in which delayed pushing is employed, as multiparous women with a prior vaginal delivery are likely to experience vaginal delivery regardless of second stage characteristics. 8,16 The total length of second stage was defined as the amount of time from when the woman was examined and found to have 10 cm dilation until vaginal delivery, or to decision time for cesarean delivery. Women were designated as having delayed or early pushing based on the difference in time between achievement of 10 cm cervical dilation and time of initiation of active pushing.…”

“…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. 16 The objectives of this analysis were two-fold. First, we aimed to assess the relationship between delayed pushing and perinatal outcomes in a large, diverse national cohort of nulliparous women.…”

Birth Outcomes After Implementing an Evidence-Based Guideline for Managing Delayed Pushing in Second Stage Labor in Women with Epidural Anesthesia

“…More time allowed for descent of the fetus prior to active pushing may reduce the need for operative intervention. Some studies, including a meta-analysis, have reported no significant effect or even lower rates of spontaneous vaginal birth with delayed pushing [7,8]. Interestingly, a standard guideline for when and how delayed pushing should be employed has not been utilized in previous studies, making this a strength of our study.…”