Advertisement

Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia

      Abstract

      Objective: This study was undertaken to determine whether a policy of delayed pushing for nulliparous women with continuous-infusion epidural analgesia reduces the risk of difficult delivery (cesarean delivery, operative delivery from a midpelvic position, low-pelvic procedures with rotation >45°). Study Design: In this multicenter, randomized, controlled trial women in the delayed pushing group (n = 936) were advised to wait ≥2 hours after full dilatation before commencement of pushing. Women in the early pushing group (n = 926) were advised to commence pushing as soon as they had been randomly assigned. Results: Difficult delivery was reduced with delayed pushing (relative risk, 0.79; 95% confidence interval, 0.66-0.95). The greatest effect was on midpelvic procedures (relative risk, 0.72; 95% confidence interval, 0.55-0.93). Although there was little evidence for an effect on low-pelvic procedures, spontaneous delivery was more frequent among women who practiced delayed pushing (relative risk, 1.09; 95% confidence interval, 1.00-1.18). Abnormal umbilical cord blood pH (<7.15 venous value or <7.10 arterial value) was more frequent in the delayed pushing group (relative risk, 2.45, 95% confidence interval, 1.35-4.43). However, scores for a summary indicator, the Neonatal Morbidity Index, were similarly distributed in the 2 groups. Conclusion: Delayed pushing is an effective strategy to reduce difficult deliveries among nulliparous women. (Am J Obstet Gynecol 2000;182:1165-72.)

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Harrison RF
        • Shore M
        • Woods T
        • Mathews G
        • Gardiner J
        • Unwin A.
        A comparative study of transcutaneous electrical nerve stimulation (TENS), entonox, pethidine + promazine and lumbar epidural for pain relief in labor.
        Acta Obstet Gynecol Scand. 1987; 66: 9-14
        • Howell CJ.
        Epidural vs non-epidural analgesia in labour.
        in: The Cochrane library. issue 4. Update Software, Oxford1998 ([computer program])
        • Niehaus L
        • Chaska B
        • Nesse R.
        The effects of epidural anesthesia on type of delivery.
        Am J Fam Pract. 1988; 1: 238-244
        • Paterson CM
        • Saunders NS
        • Wadsworth J.
        The characteristics of the second stage of labour in 25,069 singleton deliveries in the North West Thames Health Region, 1988.
        Br J Obstet Gynaecol. 1992; 99: 377-380
        • Thorp JA
        • Parisi VM
        • Boylan PC
        • Johnston DA.
        The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women.
        Am J Obstet Gynecol. 1989; 161: 670-675
        • Ramin SM
        • Gambling DR
        • Lucas MJ
        • Sharma SK
        • Sidawi JE
        • Leveno KJ.
        Randomized trial of epidural versus intravenous analgesia during labor.
        Obstet Gynecol. 1995; 86: 783-789
        • Sharma SK
        • Sidawi JE
        • Ramin SM
        • Lucas MJ
        • Leveno KJ
        • Cunningham FG.
        Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor.
        Anesthesiology. 1997; 87: 487-494
        • Cyr RM
        • Usher RH
        • McLean FH.
        Changing patterns of birth asphyxia and trauma over 20 years.
        Am J Obstet Gynecol. 1984; 148: 490-498
        • Nicodem VC.
        Early versus late pushing with epidural anaesthesia in the second stage of labor.
        in: Pregnancy and childbirth module of the Cochrane database of systematic reviews, 1995 [computer program]. BMJ Publishing Group, London1995
        • American College of Obstetricians and Gynecologists, Committee on Obstetrics, Maternal and Fetal Medicine
        Obstetrics forceps.
        in: The College, Washington1988: 59
        • Hannah ME
        • Hannah WJ
        • Hellmann J
        • Hewson S
        • Milner R
        • Willan A.
        Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group [published erratum appears in N Engl J Med 1992;327:368].
        N Engl J Med. 1992; 326: 1587-1592
        • Hodnett E
        • Simmons-Tropea A.
        The labor agentry scale: psychometric properties of an instrument measuring control during childbirth.
        Res Nurs Health. 1987; 10: 301-310
        • Mantel N
        • Haenszel W.
        Statistical aspects of the analysis of data from retrospective studies of disease.
        J Natl Cancer Inst. 1959; 22: 741-748
        • Hagadorn-Freathy A
        • Yeomans E
        • Hankins G.
        Validation of the 1988 ACOG forceps classification system.
        Obstet Gynecol. 1991; 77: 356-360
        • Haddad B
        • Abirached F
        • Calvez G
        • Cabrol D
        La rotation manuelle des présentations du sommet en occipito-iliaque postérieure ou transverse.
        J Gynecol Obstet Biol Reprod. 1995; 24: 181-188
        • Tkacz J.
        Skull depression in newborn infants.
        J Clin Proc Child Hosp (Wash). 1960; 16: 45-50
        • Bofill JA
        • Rust OA
        • Schorr SJ
        • Brown RC
        • Martin RW
        • Martin Jr, JN
        • et al.
        A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor.
        Am J Obstet Gynecol. 1996; 175: 1325-1330
        • Dell DL
        • Sightler SE
        • Plauché WC
        Soft cup vacuum extraction: a comparison of outlet delivery.
        Obstet Gynecol. 1985; 66: 624-628
        • Robertson PA
        • Laros RK
        • Zhao RL.
        Neonatal and maternal outcome in low-pelvic and midpelvic operative deliveries.
        Am J Obstet Gynecol. 1990; 162: 1436-1441
        • Piquard F
        • Schaefer A
        • Hsiung R
        • Dellenbach P
        • Habery P.
        Are there two biological parts in the second stage of labor?.
        Acta Obstet Gynecol Scand. 1989; 68: 713-718
        • Winkler CL
        • Hauth JC
        • Tucker JM
        • Owen J
        • Brumfield CG.
        Neonatal complications at term as related to the degree of umbilical artery acidemia.
        Am J Obstet Gynecol. 1991; 164: 637-641
        • Low J.
        The relationship of asphyxia in the mature fetus to long-term neurologic function.
        Clin Obstet Gynecol. 1993; 36: 82-90
        • Lieberman E
        • Lang J
        • Frigoletto F
        • Richardson D
        • Ringer S
        • Cohen A.
        Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation.
        Pediatrics. 1997; 99: 415-418
        • Donnelly V
        • Fynes M
        • Campbell D
        • Johnson H
        • O’Connell R
        • O’Herlihy C
        Obstetric events leading to anal sphincter damage.
        Obstet Gynecol. 1998; 92: 995-1961