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To examine the relationship between delayed pushing and perinatal outcomes in nulliparas with singleton term gestations.
Cohort study of data from deliveries at 25 U.S. hospitals from 2008-2011. Nulliparous women with singleton, cephalic, term births who achieved 10 cm cervical dilation were included for analysis. Women in whom pushing was delayed by ≥60 minutes (delayed group) were compared to those who initiated pushing within 30 minutes (early group). Multivariable regression analyses were used to assess the independent association of delayed pushing with mode of delivery, length of second stage and other maternal and perinatal outcomes.
Of 21,034 analyzable women, pushing was delayed in 18.4% (N=3870). Women who were older, privately insured, or non-Hispanic white, as well as those who had induction or augmentation of labor, gestational diabetes, or epidural analgesia were more likely to have delayed pushing. Delayed pushing was more common when the second stage began during daytime hours or in hospitals with dedicated 24-hour obstetrical anesthesia. It occurred less commonly in hospitals with a 24-hour in-house attending obstetrician or neonatologist. After adjusting for differences in baseline characteristics, women in the delayed group had longer adjusted mean durations of the second stage (192 vs. 84 min, p<0.001) and of active pushing (86 vs. 76 min, p<0.001). Delayed pushing also was associated with a greater odds of cesarean delivery (11.2% vs 5.1%, p<0.001), operative vaginal delivery (16.2% vs 11.2%, p<0.001) and NICU admission (8.8% vs 6.8%, p<0.001), without an increase in risk of major perineal laceration, compared with early pushing (Table).
In this large birth cohort, delayed pushing was associated with a longer duration of pushing, increased odds of cesarean delivery and NICU admission.