October 23, 2018

Delayed pushing doesn’t help during labor

At a Glance

  • Women who pushed earlier during labor were as likely to have a vaginal birth as those who delayed pushing, and had fewer complications.
  • These results may change recommendations made to many women giving birth to their first child.
Doctor examines the abdomen of pregnant woman during childbirth Large clinical studies can examine notions about childbirth that may not be based on sound research. olesiabilkei/iStock/Thinkstock

Despite millions of women giving birth in the U.S. every year, many recommendations for labor and delivery aren’t based on results from large research studies. One unanswered question has been whether a successful vaginal birth is more likely when the mother pushes as soon as possible or delays pushing.

Researchers led by Dr. Allison Cahill at Washington University in St. Louis designed a study to directly compare immediate versus delayed pushing. Women at or beyond 37 weeks of pregnancy with their first child were recruited to participate at six medical centers nationwide. The women recruited were admitted to the hospital for either spontaneous or induced labor. Participants had to have chosen to receive an epidural—pain medicine delivered into the spinal canal.

Participants were randomly assigned once labor progressed to the second stage of labor. This is when the cervix—the entry to the womb—has completely dilated (expanded enough to allow delivery of the baby). Women assigned to the immediate pushing group started pushing right away. Women assigned to the delayed pushing group were told to wait an hour, unless they felt an irresistible need to push or were told to push by a doctor. All other labor and delivery decisions were made on an individual basis.

The researchers compared the rate of spontaneous vaginal delivery between the groups. These are deliveries that don’t require the use of forceps, a vacuum, or cesarean section. They also compared the occurrence of complications between the groups. The study was funded in part by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Results were published on October 9, 2018 in JAMA.

More than 2,400 women were enrolled. Overall, the rate of spontaneous vaginal delivery was virtually identical between the groups: 86% in the immediate pushing group compared to 87% in the delayed pushing group. Women in the immediate pushing group actively pushed for an average of 9 minutes longer during delivery. However, they had an overall shorter second stage of labor: 102 minutes, versus 134 minutes for the delayed pushing group.

Women in the immediate pushing group had a lower risk of severe bleeding (2.3% vs 4%) and of a type of infection that can happen after delivery (6.7% vs. 9.1%). Other potentially serious complications were the same between the groups.

The team had planned to enroll more than 3,000 women. However, the safety board monitoring the results recommended that the study be stopped early. No difference in spontaneous vaginal deliveries had been observed, and concern had arisen about the potential for severe bleeding in the delayed pushing group.

“Our findings can guide providers to better manage the second stage of labor for optimal health for moms and their babies. This means avoiding delayed pushing for the sake of increasing the chance of vaginal delivery since it is associated with longer labor time and higher health risks to mothers and babies,” Cahill says.

Related Links

References: Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial. Cahill AG, Srinivas SK, Tita ATN, Caughey AB, Richter HE, Gregory WT, Liu J, Woolfolk C, Weinstein DL, Mathur AM, Macones GA, Tuuli MG. JAMA. 2018 Oct 9;320(14):1444-1454. doi: 10.1001/jama.2018.13986. PMID: 30304425.

Funding: NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and Washington University in St. Louis.