Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Delayed Pushing & Spontaneous Vaginal Delivery

JAMA; 2018 Oct 9; Cahill, Srinivas, et al

Among nulliparous women receiving neuraxial anesthesia, the timing of second stage pushing efforts (immediate vs delayed) did not affect the rate of spontaneous vaginal delivery, a recent study found. The randomized clinical trial included 2,414 women (mean age, 26.5 years) at or beyond 37 weeks’ gestation admitted for spontaneous or induced labor with neuraxial anesthesia between May 2014 and December 2017 at 6 US medical centers. Randomization occurred when participants reached complete cervical dilation. Immediate group participants (n=1,200) began pushing immediately. Delayed group participants (n=1,204) were instructed to wait 60 minutes. Researchers found:

  • Immediate vs delayed pushing did not result in a significant difference in the rates of spontaneous vaginal delivery (85.9% vs 86.5%, respectively).
  • There was no significant difference in 5 of the 9 prespecified secondary outcomes reported, including the composite outcomes of neonatal morbidity and perineal lacerations.
  • The immediate group had significantly short mean duration of the second stage vs the delayed group.


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(14):1444–1454. doi:10.1001/jama.2018.13986.

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Maternal Position in Women with Epidural Anesthesia, Cochrane Library; ePub 2018 Nov 9; Walker, et al

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