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Am Fam Physician. 2006;73(10):1819-1820

Clinical Question: During the second stage of labor, is coaching to push more beneficial than not coaching to push?

Setting: Inpatient (ward only)

Study Design: Randomized controlled trial (nonblinded)

Allocation: Concealed

Synopsis: The benefit of the routine practice of coaching to push during the second stage of labor is debated. In this study, 325 women with uncomplicated term pregnancies in spontaneous active labor for the first time were randomized to coached pushing or uncoached pushing during the second stage of labor. Women were excluded if the estimated fetal weight was more than 8.2 lb (4,000 g), if they had a diagnosis of chorioamnionitis, or if oxytocin (Pitocin) or epidural analgesia was used.

Coaching consisted of asking women to bear down with a closed glottis and legs pulled back for 10-second intervals during contractions. Women who were not coached to push were told to “do what comes naturally.” All women were asked to assume a recumbent or lateral position and were attended by certified nurse-midwives. The midwives were trained to be compliant with the instructions for the corresponding arm of the study. Forceps delivery was considered only if there was a prolonged second stage (more than two hours) or a fetal heart rate abnormality.

Mean duration of second-stage labor was 46 minutes in the coached group and 59 in the uncoached group (P = .014). There were no differences in mode of delivery, perineal trauma, or episiotomy use. There were no differences in neonatal Apgar scores, need for resuscitation, sepsis work-up, or neonatal intensive care unit admission. There were more infants with meconium-stained f luid in the coached group, but in most cases, it was noted before the second stage of labor. It also appears unlikely that a larger study would have detected clinically important differences.

Bottom Line: Pushing time is reduced by an average of 13 minutes when women are coached to push during the expulsive phase of labor. Other than that, coached pushing demonstrated neither benefit nor harm. The choice is a matter of preference. This study included only women who were not receiving epidural analgesia or oxytocin. (Level of Evidence: 1b)

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

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Copyright © 2006 by the American Academy of Family Physicians.

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