ACOG Response to the JAMA RCT Findings: Immediate or Delayed Pushing for Nulliparous Women with Epidural?
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. State ACOG’s response to the Cahill study (JAMA, 2018) that compares immediate to delayed pushing following an epidural 2. Describe why the safety and monitoring board stopped the study after the 75% enrollment interim analysis
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Oct 29 2018 through Oct 29 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.
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Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
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ACOG addressed via committee opinion (endorsed by ACNM) the JAMA publication that assessed immediate vs delayed pushing in women who have opted for neuraxial analgesia.
Previous ACOG guidelines recommended that in the 2nd stage of labor
Women can be offered a period of rest for 1-2 hours before pushing
Delayed pushing is only appropriate in the absence of a reason for ‘expeditious’ delivery
Resting can be offered ‘particularly’ in nulliparous patients with neuraxial anesthesia
However, in light of the JAMA publication, ACOG now states that
Collectively, and particularly in light of recent high-quality study findings, data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia
Delayed pushing has not been shown to significantly improve the likelihood of vaginal birth and risks of delayed pushing, including infection, hemorrhage, and neonatal acidemia, should be shared with nulliparous women receiving neuraxial analgesia who consider such an approach
Summary of the JAMA Publication (Cahill et al., 2018)
Randomized Controlled Trial (RCT)
Nulliparous pregnant women ≥37 weeks’ with neuraxial analgesia
Admitted for spontaneous or induced labor
6 academic and community medical centers across the United States
Multiparous patients | Scheduled cesarean deliveries | Multiple gestations | Major fetal anomalies | Nonreassuring fetal status
Patients randomized (after 10 cm dilation) to
Immediate pushing: Told to start pushing at randomization
Delayed pushing: Told to wait 60 minutes prior to pushing unless instructed to do otherwise or ‘irresistible’ urge to push
Follow up: To 6 weeks postpartum (mothers and infants)
Primary outcome: Spontaneous vaginal delivery
Total duration of the second stage |Duration of active pushing | Operative vaginal delivery | Cesarean delivery | Several individual maternal morbidity assessments | A composite outcome of neonatal morbidity
Adverse Events (prespecified by the data and safety monitoring board)
Neonatal acidemia | Chorioamnionitis during the second stage of labor | Severe postpartum hemorrhage NICU admission for>12 hours
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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