Use of Delayed Pushing in Nulliparous Birthing Patients With an Epidural

Should delayed pushing be recommended in nulliparous birthing patients with an epidural?

Clinicians should use shared decision-making with the pregnant patient to decide whether to delay pushing in the second stage of labor. Delayed pushing in the second stage among nulliparous pregnant patients with an epidural is associated with increased risks of postpartum hemorrhage, chorioamnionitis, and neonatal acidemia. (Strength of Recommendation [SOR]: B, randomized controlled trial [RCT], meta-analysis.) Compared with immediate pushing, delayed pushing leads to a longer second stage of labor but less time spent pushing. (SOR: A, multiple meta-analyses.) There is conflicting evidence about whether delayed pushing results in increased rates of vaginal delivery or decreased rates of assisted vaginal delivery.

A 2020 systematic review and meta-analysis of 12 RCTs found that delayed pushing led to a longer second stage of labor (mean difference = 46.2 minutes; 95% CI, 32.6–59.7; eight RCTs; n = 4,890) and a shorter time pushing (mean difference = −27.5 minutes; 95% CI, −43.0 to −12.0; seven RCTs; n = 4,737) compared with immediate pushing. Patients in the delayed pushing group were instructed to rest for 90 minutes or until there was an uncontrollable urge to push. Patients in the immediate pushing group began pushing as soon as the cervix was completely dilated. No differences were noted in the risk of spontaneous vaginal delivery. The delayed pushing group had higher rates of chorioamnionitis (relative risk [RR] = 1.37; 95% CI, 1.04–1.81; one RCT; n = 2,404) and low umbilical cord pH (RR = 2.00; 95% CI, 1.30–3.07; five RCTs; n = 4,549). The authors recommend against delayed pushing in the second stage of labor.¹

A 2018 multicenter RCT compared 1,200 nulliparous birthing patients who started pushing immediately at complete dilation with 1,204 patients who started pushing 60 minutes after. Each patient had an epidural. The immediate pushing group had a shorter second stage of labor (−31.8 minutes; 95% CI, −36.7 to −26.9) with an increase in time spent pushing (mean difference = 9.2 minutes; 95% CI, 5.8–12.6). The study ended early due to increased risks of postpartum hemorrhage, chorioamnionitis, and neonatal acidemia in the delayed pushing group. The immediate pushing group had decreased risks of postpartum hemorrhage (2.3% vs 4.0% in the delayed pushing group; RR = 0.6; 95% CI, 0.3–0.9; number needed to harm [NNH] = 59), chorioamnionitis (6.7% vs 9.1%; RR = 0.70; 95% CI, 0.66–0.90; NNH = 42), and neonatal acidemia (umbilical cord arterial pH less than 7.1; 0.8% vs 1.2%; RR = 0.7; 95% CI, 0.5–0.9; NNH = 250). There were no differences in rates of vaginal delivery, neonatal morbidity, or perineal lacerations.²

A 2021 systematic review and meta-analysis of 15 RCTs with 6,121 participants found that delayed pushing compared with immediate pushing (using the same definitions as the previous study) resulted in a longer second stage of labor (40.9 minutes; 95% CI, 23.6–58.2) and shorter length of time spent pushing (25.4 minutes; 95% CI, 13.9–37.0). Delayed pushing was also associated with a lower rate of assisted vaginal deliveries in Western countries (RR = 0.85; 95% CI, 0.74–0.97) and a lower postpartum fatigue score (−0.67; 95% CI, −1.09 to −0.26). The authors suggest that delayed pushing may save the birthing patient energy during labor.³