Immediate or delayed pushing in the second stage of labor?
Is there any advantage to delaying pushing in the second stage of labor for nulliparous women receiving epidural analgesia?
PRACTICE CHANGER
Recommend immediate, rather than delayed, pushing in the second stage of labor for nulliparous women receiving epidural analgesia. The rate of spontaneous vaginal delivery is the same, and there is a lower risk of postpartum hemorrhage and chorioamnionitis.
STRENGTH OF RECOMMENDATION
B: Based on an individual randomized controlled trial. 1
Cahill AG, Srinivas SK, Tita ATN, et al. Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: a randomized clinical trial. JAMA. 2018;320:1444-1454.
WHAT’S NEW
There’s no good reason to delay pushing
Delaying pushing once the cervix is completely dilated is not indicated, even for nulliparous women receiving epidural analgesia, as it does not decrease the rate of spontaneous vaginal delivery. It does, however, increase the length of second stage labor and the risk of postpartum hemorrhage and chorioamnionitis.
CAVEATS
Study was stopped early, and groups were unblinded
This study was stopped early, so it is not known if it was underpowered for some of the secondary outcomes. Also, it was not possible to blind the groups, so it is not clear if any bias in patient management or diagnosis resulted.
CHALLENGES TO IMPLEMENTATION
Will current practice and culture pose obstacles?
Although the overt challenges to enacting a policy of immediate pushing are minimal, the inertia of current practice and culture could affect the implementation of this strategy.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
