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CMECNE

ACOG Response to the JAMA RCT Findings: Immediate or Delayed Pushing for Nulliparous Women with Epidural?

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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

Faculty:

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.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

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

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

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

KEY POINTS:

Summary of the JAMA Publication (Cahill et al., 2018)

Methods

  • Randomized Controlled Trial (RCT)
  • Participants
    • Nulliparous pregnant women ≥37 weeks’ with neuraxial analgesia
    • Admitted for spontaneous or induced labor
    • 6 academic and community medical centers across the United States
    • Exclusion
      • 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
    • Secondary outcomes
      • 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
      • Serious adverse events included maternal death, ICU admission, unplanned hysterectomy, serious neonatal birth injuries

Results

  • 2,414 women (75% of recruitment target) were randomized before the study was stopped following a planned interim analysis by the data and safety monitoring board
    • Stopped due to futility (even if study continued unlikely to show difference) and increased morbidity in the delayed pushing group
  • Rate of spontaneous vaginal delivery was not different between groups
    • Immediate group: 85.9%
    • Delayed group: 86.5%
    • Absolute difference, −0.6%; 95% CI, −3.4% to 2.1%
    • Relative risk (RR) 0.99; 95% CI, 0.96 to 1.03
  • Secondary outcomes
    • There were no significant differences in
      • Composite outcome of neonatal morbidity
      • Perineal lacerations
    • The immediate group had significantly
      • Shorter mean duration of the second stage compared with the delayed group (102.4 vs 134.2 minutes)
      • Lower rate of chorioamnionitis (6.7% vs 9.1%)
      • Fewer postpartum hemorrhages (2.3% vs 4.0%)

Conclusions

  • No significant difference in rate of vaginal delivery between immediate and delayed pushing groups in nulliparous women with neuraxial anesthesia
  • Consistent with a previous meta-analysis of RCTs

Learn More – Primary Sources:

ACOG Committee Opinion 766: Approaches to Limit Intervention During Labor and Birth

Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia

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Related ObG Topics:

Epidural Timing: The Earlier the Better?
Results of the BUMPES Trial: Sitting Up or Lying Down to Promote Vaginal Delivery with an Epidural in the 2nd Stage of Labor?
Cochrane Review: What are the Risks and Benefits of Epidural Analgesia During Labor?
Does Epidural Anesthesia Impact the Second Stage of Labor?

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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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