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 2^nd 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

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?