Although more than 3 million women give birth in the United States each year, there is no consensus regarding the optimal timing of maternal pushing during the second stage of labor (defined as the time from complete cervical dilation to delivery of the fetus). The two most common approaches are to either initiate pushing immediately upon entry into the second stage, or to delay pushing to allow time for spontaneous descent of the fetus. In this randomized controlled trial, 2,414 nulliparous women at or beyond 37 weeks gestation in spontaneous or induced labor with neuraxial analgesia were assigned to either immediate pushing or delayed pushing (instructed to wait 60 minutes after randomization) once they had reached complete cervical dilation. The primary outcome was the rate of spontaneous vaginal delivery without the use of forceps, vacuum, or cesarean delivery. The trial was stopped early due to futility and concern for increased morbidity in the delayed pushing group. Researchers found that there was no difference in the rate of spontaneous vaginal delivery between the two groups (85.9% in the immediate pushing group vs. 86.5% in the delayed pushing group, RR 0.99, 95% CI 0.96 to 1.03, p=0.67). The immediate pushing group experienced a significantly shorter mean duration of the second stage of labor as compared with the delayed group (102.4 vs. 134.2 minutes, mean difference -31.8 minutes, 95% CI -36.7 to -26.9 minutes, p<0.001). Furthermore, the immediate pushing group had significantly lower rates of chorioamnionitis (6.7% vs. 9.1%, RR 0.70, 95% CI 0.66 to 0.90, p=0.005) and postpartum hemorrhage (2.3% vs. 4.0%, RR 0.60, 95% CI 0.3 to 0.9, p=0.03) than the delayed pushing group. Therefore, this trial supports the practice of immediate pushing upon entry into the second stage of labor in nulliparous women at full term.
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