Immediate pushing in second stage offers benefits and is preferable to delayed pushing
Cahill AG, Srinivas SK, Tita AT, 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.
In a randomized trial of 2,414 women, Cahill and colleagues sought to answer a seemingly simple question: What is the best timing for pushing during the second stage of labor--immediate or delayed?
Practical management of the second stage of labor (defined as complete cervical dilation to the delivery of the infant) varies by provider and setting, and previous data on pushing efforts are conflicting. Delayed pushing, or "laboring down," has been suggested to allow passive fetal rotation and to conserve maternal energy for pushing. Older studies have shown that delayed pushing decreases the rate of operative delivery. More recent study data have not demonstrated a difference between immediate and delayed pushing techniques on vaginal delivery rates and have noted that increased maternal and neonatal morbidities are associated with a longer second stage of labor.
The recent trial by Cahill and colleagues was designed to determine the effect of these 2 techniques on spontaneous vaginal delivery rates and on maternal and neonatal morbidities.4
Large study population
This randomized pragmatic trial was conducted at 6 centers in the United States. Study participants (2,404 women completed the study) were nulliparous women at 37 or more weeks' gestation with neuraxial anesthesia who were randomly assigned at complete cervical dilation either to immediate pushing (n = 1,200) or to delayed pushing, that is, instructed to wait 60 minutes before starting to push (n = 1,204). The obstetric provider determined the rest of the labor management.
The primary outcome was the rate of spontaneous vaginal delivery. Secondary outcomes included duration of the second stage of labor, duration of active pushing, operative vaginal delivery, CD, and several maternal assessments (postpartum hemorrhage, chorioamnionitis, endometritis, and perineal lacerations).
Both groups had similar vaginal delivery rates, differences in some measures
There was no difference in the primary outcome between the 2 groups: The spontaneous vaginal delivery rate was 85.9% (n = 1,031) in the immediate pushing group and 86.5% (n = 1,041) in the delayed pushing group (P = .67).
Analysis of secondary outcomes revealed several significant differences:
- decreased total time for the second stage of labor in the immediate pushing group compared with the delayed pushing group (102.4 vs 134.2 minutes) but longer active pushing time (83.7 vs 74.5 minutes)
- a lower rate of postpartum hemorrhage, chorioamnionitis in the second stage, neonatal acidemia, and suspected neonatal sepsis in the immediate pushing group
- a higher rate of third-degree perineal lacerations in the immediate pushing group.
No difference was found between groups in rates of operative vaginal deliveries, CDs, endometritis, overall perineal lacerations, or spontaneous vaginal delivery by fetal station or occiput position.
Authors' takeaway
The authors concluded that since delayed pushing does not increase spontaneous vaginal delivery rates and increases the duration of the second stage of labor and both maternal and neonatal morbidity, immediate pushing may be preferred in this patient population.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
After reviewing the available literature in light of this study’s findings, ACOG released a practice advisory in October 2018 stating that “it is reasonable to choose immediate over delayed pushing in nulliparous patients with neuraxial anesthesia.”5 Nulliparous patients with neuraxial anesthesia should be counseled that delayed pushing does not increase the rate of spontaneous vaginal birth and may increase both maternal and neonatal complications. As this may be a practice change for many obstetrics units, the obstetric nursing department should be included in this education and counseling. In my practice, I would recommend immediate pushing, but it is important to include both the patient and her nurse in the discussion.
After reviewing the available literature in light of this study’s findings, ACOG released a practice advisory in October 2018 stating that “it is reasonable to choose immediate over delayed pushing in nulliparous patients with neuraxial anesthesia.”5 Nulliparous patients with neuraxial anesthesia should be counseled that delayed pushing does not increase the rate of spontaneous vaginal birth and may increase both maternal and neonatal complications. As this may be a practice change for many obstetrics units, the obstetric nursing department should be included in this education and counseling. In my practice, I would recommend immediate pushing, but it is important to include both the patient and her nurse in the discussion.
ACOG aims to optimize postpartum care
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736. Optimizing postpartum care. Obstet Gynecol. 2018;131:e140-e150.
In May 2018, ACOG released "Optimizing postpartum care," a committee opinion that proposes a new model of comprehensive postpartum care focused on improving both short- and long-term health outcomes for women and infants. (This replaces the June 2016 committee opinion No. 666.) Described as "the fourth trimester," the postpartum period is a critical transitional period in which both pregnancy-related and pre-existing conditions may affect maternal, neonatal, and family status; half of pregnancy-related maternal deaths occur during the postpartum period.6
The postpartum visit: Often a lost opportunity
ACOG cites that up to 40% of women in the United States do not attend their postpartum visit.6 Many aspects of the postpartum visit, including follow-up for chronic diseases, mental health screening, and contraceptive counseling, provide opportunities for acute intervention as well as establishment of healthy behaviors. Some studies have shown that postpartum depression, breastfeeding, and patient satisfaction outcomes improve as a result of postpartum engagement.
Continue to: ACOG's recommendations...