ONGOING COLUMNS: Perinatal Patient Safety
Results of a recent well-designed, multicenter randomized controlled trial (RCT) have contributed more evidence to what is known about how to best advise nulliparous women with epidural analgesia when they reach 10 cm cervical dilation (Cahill et al., 2018). Nulliparous women with epidural analgesia were randomized to immediate pushing at 10 cm or delayed pushing for up to 1 hour. There were no differences between groups on cesarean versus vaginal birth or on the composite of neonatal morbidity (Cahill et al.). This study was stopped after a planned interim analysis revealed unlikeliness of finding a difference between groups for the main outcome (spontaneous vaginal birth) and concern for increased risk of postpartum hemorrhage (PPH) in the delayed pushing group. It is important to note that PPH was measured via four variables, three of which used a visual estimation of blood loss and the other the rate of blood transfusions (see Table). A difference between groups was noted in only one of variables that were based on visual estimation. In the quantifiable measure of PPH, blood transfusion, there were no differences between groups. As earlier studies have found, there are advantages and disadvantages to either approach. Review of the full study is required before considering implications for practice. The table summarizes evidence based on RCTs. A meta-analysis of RCTs is included (Tuuli, Frey, Odibo, Macones, & Cahill, 2012). The table includes studies that measured outcomes beyond timing.
There are many articles on managing the second-stage labor. This is an opportunity to move beyond managing and include the woman as a full partner in her care by offering her information based on the most recent evidence. The conversation should include the context of her individual clinical situation (maternal–fetal condition such as maternal vital signs, fetal heart rate tracing, risk of PPH, maternal fatigue, urge to push, fetal station/position etc.), answering any questions, and encouraging her to discuss options for timing of pushing with the other members of the healthcare team. The woman's preferences can be informed by a thoughtful, thorough discussion led by the obstetric provider and should be the basis for her care.
Cahill A. G., Srinivas S. K., Tita A. T. N., Caughey A. B., Richter H. E., Gregory W. T., ..., Tuuli M. G. (2018). Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: A randomized clinical trial. Journal of the American Medical Association
, 320(14), 1444–1454. doi:10.1001/jama.2018.13986
Fraser W. D., Marcoux S., Krauss I., Douglas J., Goulet C., Boulvain M. (2000). Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group. American Journal of Obstetrics and Gynecology
, 182(5), 1165–1172.
Hansen S. L., Clark S. L., Foster J. C. (2002). Active pushing versus passive fetal descent in the second stage of labor: A randomized controlled trial. Obstetrics and Gynecology
, 99(1), 29–34.
Simpson K. R., James D. C. (2005). Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: A randomized clinical trial. Nursing Research
, 54(3), 149–157.
Tuuli M. G., Frey H. A., Odibo A. O., Macones G. A., Cahill A. G. (2012). Immediate compared with delayed pushing in the second stage of labor: A systematic review and meta-analysis. Obstetrics and Gynecology
, 120(3), 660–668. doi:10.1097/AOG.0b013e3182639fae