Delayed Versus Immediate Pushing: New Study Shows Similar Outcomes

In terms of clinical outcomes, a meta-analysis found that studies to date show few clinical differences between immediate and delayed pushing in the second stage of labor.¹

Researchers analyzed 12 randomized controlled trials that involved 1584 women who pushed immediately after beginning the second stage of labor and 1531 women who delayed pushing. Spontaneous vaginal delivery was the primary outcome, and instrumental delivery, cesarean delivery, duration of the second stage of labor, duration of active pushing, and other maternal and neonatal outcomes were listed as secondary outcomes.

Overall, a higher number of spontaneous vaginal deliveries occurred in the delayed pushing group than in the immediate pushing group (61.5% vs 56.9%, respectively). However, when only high-quality studies were analyzed, this difference-59% for delayed pushing and 54.9% for immediate pushing-was less robust and not statistically significant. When lower-quality studies were analyzed, the difference was greater-81% for delayed pushing and 71% for immediate pushing-and reached statistical significance.

For both groups, the researchers consider the reported rates of operative vaginal delivery to be high, at 33.7% in the delayed group and 37.4% in the immediate group. Delayed pushing increased the second stage of labor by 57 minutes, but women in the delayed group actively pushed for 22 minutes less than those in the immediate pushing group. The authors concluded that there is not enough evidence to determine the effects of either practice on maternal and neonatal outcomes.

Delayed pushing, or the practice of waiting for the baby to passively come through the birth canal, is considered safe and sometimes may make pushing more effective. In clinical practice, this means waiting for the mother to feel a strong urge to push. If an epidural is used, the natural mechanism of labor is altered, and the urge to push generally is reduced or nonexistent. The results of one study showed that delayed pushing for up to 2 hours is safe and may lower the risk of difficult deliveries in nulliparous women who received continuous epidural analgesia.² Another study found that the failure of the head to rotate to an occiput anterior position when an epidural is used often can be overcome by delaying pushing.³ Another benefit of delayed pushing may be more favorable fetal well-being, concluded a study that measured fetal oxygen saturation.⁴ Regardless of whether the patient has an epidural, the urge to push is generally more pronounced the longer “passive descent” ensues.

Pertinent Points:
- Delayed pushing increases the duration of the second stage of labor by 57 minutes but decreases the duration of active pushing by 22 minutes.
- Additional research is needed to determine which practice is associated with better outcomes (tears, pain, etc).

References:

1. Tuuli MG, Frey HA, Odibo AO, et al. Immediate compared with delayed pushing in the second stage of labor: a systematic review and meta-analysis. Obstet Gynecol. 2012;120:660-668.
2. Fraser WD, Marcoux S, Krauss I, et al, for the PEOPLE (Pushihng Early or Pushing Late with Epidural study group). Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. Am J Obstet Gynecol. 2000;182:1165-1172.
3. Roberts CL, Torvaldsen S, Cameron C, et al. Review: delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG. 2004;111:1333-1340.