Effect Of Immediate Vs Delayed Pushing On Rates Of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia A Randomized Clinical Trial. Cahill AG, Srinivas SK, Tita ATN, et al. JAMA. 2018 Oct 9;320(14):1444-1454.
SUMMARY
There is inadequate evidence on the management of the second stage of labor, that is the time from complete cervical dilation to delivery of the baby.
A common strategy is to “labor down,” or wait a while after complete dilation to start pushing. The alternative is start pushing immediately with each uterine contraction.
The authors feel old studies on this topic, which were equivocal anyway, are outdated because delivery techniques have changed.
2414 nulliparous patients at 6 academic centers with epidurals were randomized to immediate pushing after complete cervical dilation or pushing after waiting 60 minutes.
Half of the labors were spontaneous, half were induced.
Patients were half private insurance, half Medicaid
Almost half were delivered by residents
Outcomes
Primary outcome: No difference in spontaneous vaginal delivery (85.9% vs. 86.5%) (No use of vacuum, forceps, or c-section)
Secondary outcomes
Second stage of labor shorter in immediate pushing by 32 minutes but actual time of pushing longer 9 minutes.
Postpartum hemorrhage more common in delayed pushing group NNH=58,
Chorioamnionitis more common in delayed pushing group NNH=40
EDITOR’S COMMENTARY - Steve Brown MD Yes apparently we still don’t know when to tell a nulliparous woman with complete cervical dilation to push her baby out when she has an epidural. This RCT shows either waiting 60 minutes or pushing immediately are reasonable options. Neither increases the chance of a successful vaginal delivery. It does seem pushing sooner decreases time to delivery, unsurprisingly, and secondary outcomes seem to indicate it decreases the chance of excessive bleeding or infection.
BOTTOM LINE: In nulliparous patients with epidural delivery outcomes are similar if pushing immediately or delaying pushing. Other maternal and neonatal outcomes may need to be considered in your guidance to patients. Immediate pushing seems a reasonable option in most patients.
