Immediate Compared With Delayed Pushing in the Second Stage of Labor

Abstract

Studies to date suggest there are few clinical differences in outcomes with immediate compared with delayed pushing in the second stage of labor, especially when high-quality studies are pooled. Effects on maternal and neonatal outcomes remain uncertain.

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

“…Our data are in contrast to a meta-analysis by Tuuli et al (including 3115 women), which suggested delayed pushing was associated with few clinical differences but decreased amount of active pushing. 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.…”

“…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.…”

“…5 While a long second stage 6,7 and prolonged active pushing in the second stage 8 have been associated with an increased risk of adverse maternal and neonatal outcomes, data on the maternal and neonatal risks associated with delayed pushing are conflicting. Some data suggest delayed pushing is associated with less active pushing time 9,10 and increased likelihood of spontaneous vaginal delivery. 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.…”

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

“…A number of reports have indicated that delayed pushing for properly selected women may improve outcomes and patient satisfaction, especially in second stage labor for women with epidural anesthesia [12][13][14][15][16]. Multiple studies, including one meta-analysis comparing delayed with immediate pushing, have demonstrated significant positive effects, including: less fatigue [11,17], decreased active pushing time [7,11,[13][14][17][18][19], increased vaginal birth rates [12][13]20], and decreased operative delivery [12,13]. In contrast, other studies have found no decrease in operative delivery [11] or even an increase in odds of operative or cesarean delivery and a decreased chance of spontaneous vaginal delivery with a longer second stage with delayed pushing [6,21].…”

“…The notion that complete cervical dilation heralds the initiation of immediate pushing regardless of fetal station, position, maternal urge or the presence of epidural anesthesia, has come under repeated challenge [6][7][8][9][10][11][12][13][14][15][16]. A number of reports have indicated that delayed pushing for properly selected women may improve outcomes and patient satisfaction, especially in second stage labor for women with epidural anesthesia [12][13][14][15][16].…”