Spontaneous vaginal delivery rates similar for immediate versus delayed pushing in second stage of labor

1. In this randomized controlled trial, the rates of operative vaginal deliveries and cesarean sections did not differ between immediate versus delayed pushing groups.

2. The rates of postpartum hemorrhage and chorioamnionitis were significantly lower in the immediate pushing group compared to the delayed pushing group.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: For women in the second stage of labor, there are two common approaches to labor management, immediate or delayed pushing. However, the optimal second stage labor management strategy remains undetermined. Among full-term, nulliparous women who received neuraxial anesthesia, there were no differences in spontaneous vaginal delivery rates among immediate and delayed pushing groups. Furthermore, the rates of operative vaginal deliveries and cesarean deliveries did not differ between groups. Women who immediately pushed in the second stage of labor were significantly less likely to have postpartum hemorrhage and chorioamnionitis. However, those in the immediate pushing group were significantly more likely to sustain third-degree perineal lacerations. There were no neonatal fatalities in either of the randomized groups.

One drawback to this study is that it could not feasibly be blinded to patients nor care team, which may have introduced bias. Additionally, this study only included nulliparous women, therefore the results cannot be generalized to multiparous women. Future studies could include multiparous women in addition to varied timing in the delayed pushing group.

Click to read the study in JAMA

Relevant Reading: Immediate compared with delayed pushing in the second stage of labor: A systematic review and meta-analysis

In-Depth [randomized controlled trial]: This study enrolled nulliparous women who received neuraxial anesthesia at or beyond 37-weeks gestation among six US medical centers from May 2014 to December 2017. At complete cervical dilation, women were randomized to immediate pushing (n= 1200) or delayed (= 60 mins, n= 1204) pushing. The primary outcome measured was rate of spontaneous vaginal delivery. 85.9% of women in the immediate pushing group and 86.5% of women in the delayed pushing group had a spontaneous vaginal delivery (RR 0.99; CI95 0.96-1.03). The rates of operative vaginal or cesarean deliveries did not differ between the groups (p = 0.75; p = 0.55, respectively). The rates of postpartum hemorrhage and chorioamnionitis were significantly lower in the immediate pushing group compared to the delayed pushing group (p = 0.03; p = 0.005, respectively). Neonates born in the immediate pushing group, were significantly less likely to have acidemia and suspected sepsis (p = 0.01, p = 0.003, respectively). There were no reported neonatal deaths in either group.

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