CLINICAL QUESTION

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

EVIDENCE-BASED ANSWER

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.

EVIDENCE SUMMARY

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