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NIHR Signal Delaying pushing in labour has no benefit for women with an epidural and/or spinal for pain relief

Published on 12 February 2019

doi: 10.3310/signal-000730

For women having their first baby with an epidural and/or spinal anaesthetic for pain-relief, the timing of pushing after full dilatation of the cervix does not affect the numbers that achieve normal vaginal delivery.

The best management for the second stage of labour is still debated. In the UK epidurals are by far the most widely used regional anaesthetic technique for pain relief in labour.

In this large trial, women either pushed immediately or delayed pushing by waiting for 60 minutes. Women in the immediate group ended up pushing for slightly longer, but their labour was 30 minutes shorter overall. They also had a lower risk of bleeding and infection.

Although this was a USA-based study the findings may help to inform practice in the UK.

Share your views on the research.

Why was this study needed?

Labour is divided into the first stage when regular contractions start, and the second and third stages. The second stage of labour begins at complete cervical dilatation and is also known as the pushing stage. It ends when the baby is born.

Some evidence suggests that in women who have epidural and/or spinal anaesthesia, delayed pushing may encourage spontaneous vaginal delivery and reduce the need for interventional delivery. Other evidence suggests that there is no difference in spontaneous vaginal delivery rates between immediate and delayed pushing.

Up to 1 in 5 women in England have an epidural for pain management during labour. Instrumental delivery and prolonged labour can both lead to adverse outcomes, and so it is important to have good research to address the issue. This large trial was designed to provide stronger evidence to resolve the practical question of when the ideal time to start pushing in these circumstances.

What did this study do?

This randomised controlled trial was conducted at six centres across the United States. It included 2,414 women having their first baby, who had gone into either spontaneous or induced labour and had received epidural (+/- spinal) anaesthesia. Once reaching full cervical dilation (10cm), they were randomised to begin pushing immediately or to delay for 60 minutes (unless they had an irresistible urge or were instructed otherwise). Other aspects of care were unchanged.

The target recruitment was 3,184, but the trial terminated early due to safety concerns in the delayed group in the face of no apparent benefit.

Around two-thirds of eligible women invited to the study declined participation. Management of labour and technique of pushing were not measured. Some aspects of practice, such as the rate of epidural, may not be applicable to the UK.

What did it find?

  • Rates of spontaneous vaginal delivery were similar in the immediate pushing group (85.9%) and delayed pushing group (86.5%). Neither was there difference in the rates of assisted deliveries (forceps or ventouse) or caesarean.
  • The second stage of labour was on average 31.8 minutes shorter (95% confidence interval [CI] -36.7 to -26.9 minutes) shorter in the immediate group at 102.4 minutes compared with 134.2 minutes in the delayed group. The duration of active pushing was 9.2 minutes longer in the immediate group (95% CI +5.8 to +12.6 minutes).
  • Immediate pushing was associated with lower rates of postpartum haemorrhage at 2.3% compared with 4.0% in the delayed group (relative risk [RR] 0.6, 95% CI 0.3 to 0.9), and infection of fetal membranes (chorioamnionitis) at 6.7% compared with 9.1% (RR 0.70, 95% CI 0.66 to 0.90).
  • There was no difference between groups in the rate of neonatal morbidity (7.3% immediate vs 8.9% delayed; RR 0.8, 95% CI 0.6 to 1.1).  Neither was there difference in the overall rate of perineal tears, which were common and affected 46% of both groups. However, third-degree tears (extending to the anal muscle) were borderline more common in the immediate pushing group (5.3% vs 4.3% delayed group; RR 1.2, 95% CI 1.0 to 1.4).
  • Patient satisfaction with the second stage of labour did not differ between groups, and both groups similarly reported feeling in control.

What does current guidance say on this issue?

The NICE guideline on care during labour (updated 2017) advises that in women who have an epidural (and combined spinal-epidural), pushing should be delayed for at least one hour after full cervical dilation and longer if the woman wishes. Women without an epidural should be guided by their own urge to push.

The Royal College of Obstetricians and Gynaecologists guideline on assisted (operative) delivery (2011) state that delayed pushing in women with an epidural can reduce the need for deliveries that require forceps to rotate the baby’s head or because the head is too high in the birth canal.    

What are the implications?

This large study raises a question regarding current practice that recommends delayed pushing in women having their first baby and who are receiving epidural and or spinal anaesthesia. It wasn’t found to reduce risk of assisted delivery.

The study may be less reliable for detecting a difference in other outcomes, such as postpartum haemorrhage and chorioamnionitis. However, there is a possibility that prolonging the second stage of labour is associated with adverse maternal and neonatal outcomes.  

It is worth noting that many women, when asked, declined to participate in this trial. It’s unclear how management factors, such as positioning, may affect outcomes which may also vary between the US and the UK.

This study suggests no benefit from delayed pushing, but further research is needed to improve our understanding of this issue in UK practice. 

Citation and Funding

Cahill AG, Srinivas SK, Tita AT et al. Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: a randomized clinical trial. JAMA. 2018;320(14):1444-54.

This trial was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and by funding from the Department of Obstetrics and Gynaecology, School of Medicine, Washington University in St Louis.

Bibliography

NHS Digital. NHS maternity statistics, England 2017-2018. London: NHS Digital; 2018.

NHS Digital. NHS maternity statistics, England 2016-17. London: NHS Digital; 2017.

NICE. Intrapartum care for healthy women and babies. CG190. London: National Institute for Health and Care Excellence; 2014, updated 2017.

RCOG. Operative vaginal delivery. London: Royal College of Obstetricians and Gynaecologists; 2011.

Why was this study needed?

Labour is divided into the first stage when regular contractions start, and the second and third stages. The second stage of labour begins at complete cervical dilatation and is also known as the pushing stage. It ends when the baby is born.

Some evidence suggests that in women who have epidural and/or spinal anaesthesia, delayed pushing may encourage spontaneous vaginal delivery and reduce the need for interventional delivery. Other evidence suggests that there is no difference in spontaneous vaginal delivery rates between immediate and delayed pushing.

Up to 1 in 5 women in England have an epidural for pain management during labour. Instrumental delivery and prolonged labour can both lead to adverse outcomes, and so it is important to have good research to address the issue. This large trial was designed to provide stronger evidence to resolve the practical question of when the ideal time to start pushing in these circumstances.

What did this study do?

This randomised controlled trial was conducted at six centres across the United States. It included 2,414 women having their first baby, who had gone into either spontaneous or induced labour and had received epidural (+/- spinal) anaesthesia. Once reaching full cervical dilation (10cm), they were randomised to begin pushing immediately or to delay for 60 minutes (unless they had an irresistible urge or were instructed otherwise). Other aspects of care were unchanged.

The target recruitment was 3,184, but the trial terminated early due to safety concerns in the delayed group in the face of no apparent benefit.

Around two-thirds of eligible women invited to the study declined participation. Management of labour and technique of pushing were not measured. Some aspects of practice, such as the rate of epidural, may not be applicable to the UK.

What did it find?

  • Rates of spontaneous vaginal delivery were similar in the immediate pushing group (85.9%) and delayed pushing group (86.5%). Neither was there difference in the rates of assisted deliveries (forceps or ventouse) or caesarean.
  • The second stage of labour was on average 31.8 minutes shorter (95% confidence interval [CI] -36.7 to -26.9 minutes) shorter in the immediate group at 102.4 minutes compared with 134.2 minutes in the delayed group. The duration of active pushing was 9.2 minutes longer in the immediate group (95% CI +5.8 to +12.6 minutes).
  • Immediate pushing was associated with lower rates of postpartum haemorrhage at 2.3% compared with 4.0% in the delayed group (relative risk [RR] 0.6, 95% CI 0.3 to 0.9), and infection of fetal membranes (chorioamnionitis) at 6.7% compared with 9.1% (RR 0.70, 95% CI 0.66 to 0.90).
  • There was no difference between groups in the rate of neonatal morbidity (7.3% immediate vs 8.9% delayed; RR 0.8, 95% CI 0.6 to 1.1).  Neither was there difference in the overall rate of perineal tears, which were common and affected 46% of both groups. However, third-degree tears (extending to the anal muscle) were borderline more common in the immediate pushing group (5.3% vs 4.3% delayed group; RR 1.2, 95% CI 1.0 to 1.4).
  • Patient satisfaction with the second stage of labour did not differ between groups, and both groups similarly reported feeling in control.

What does current guidance say on this issue?

The NICE guideline on care during labour (updated 2017) advises that in women who have an epidural (and combined spinal-epidural), pushing should be delayed for at least one hour after full cervical dilation and longer if the woman wishes. Women without an epidural should be guided by their own urge to push.

The Royal College of Obstetricians and Gynaecologists guideline on assisted (operative) delivery (2011) state that delayed pushing in women with an epidural can reduce the need for deliveries that require forceps to rotate the baby’s head or because the head is too high in the birth canal.    

What are the implications?

This large study raises a question regarding current practice that recommends delayed pushing in women having their first baby and who are receiving epidural and or spinal anaesthesia. It wasn’t found to reduce risk of assisted delivery.

The study may be less reliable for detecting a difference in other outcomes, such as postpartum haemorrhage and chorioamnionitis. However, there is a possibility that prolonging the second stage of labour is associated with adverse maternal and neonatal outcomes.  

It is worth noting that many women, when asked, declined to participate in this trial. It’s unclear how management factors, such as positioning, may affect outcomes which may also vary between the US and the UK.

This study suggests no benefit from delayed pushing, but further research is needed to improve our understanding of this issue in UK practice. 

Citation and Funding

Cahill AG, Srinivas SK, Tita AT et al. Effect of immediate vs delayed pushing on rates of spontaneous vaginal delivery among nulliparous women receiving neuraxial analgesia: a randomized clinical trial. JAMA. 2018;320(14):1444-54.

This trial was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and by funding from the Department of Obstetrics and Gynaecology, School of Medicine, Washington University in St Louis.

Bibliography

NHS Digital. NHS maternity statistics, England 2017-2018. London: NHS Digital; 2018.

NHS Digital. NHS maternity statistics, England 2016-17. London: NHS Digital; 2017.

NICE. Intrapartum care for healthy women and babies. CG190. London: National Institute for Health and Care Excellence; 2014, updated 2017.

RCOG. Operative vaginal delivery. London: Royal College of Obstetricians and Gynaecologists; 2011.

Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial

Published on 12 October 2018

Cahill, A. G.,Srinivas, S. K.,Tita, A. T. N.,Caughey, A. B.,Richter, H. E.,Gregory, W. T.,Liu, J.,Woolfolk, C.,Weinstein, D. L.,Mathur, A. M.,Macones, G. A.,Tuuli, M. G.

Jama Volume 320 Issue 14 , 2018

Importance: It is unclear whether the timing of second stage pushing efforts affects spontaneous vaginal delivery rates and reduces morbidities. Objective: To evaluate whether immediate or delayed pushing results in higher rates of spontaneous vaginal delivery and lower rates of maternal and neonatal morbidities. Design, Setting, and Participants: Pragmatic randomized clinical trial of nulliparous women at or beyond 37 weeks' gestation admitted for spontaneous or induced labor with neuraxial analgesia between May 2014 and December 2017 at 6 US medical centers. The interim analysis suggested futility for the primary outcome and recruitment was terminated with 2414 of 3184 planned participants. Follow-up ended January 4, 2018. Interventions: Randomization occurred when participants reached complete cervical dilation. Immediate group participants (n = 1200) began pushing immediately. Delayed group participants (n = 1204) were instructed to wait 60 minutes. Main Outcomes and Measures: The primary outcome was spontaneous vaginal delivery. Secondary outcomes included total duration of the second stage, duration of active pushing, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, chorioamnionitis, endometritis, perineal lacerations (>/=second degree), and a composite outcome of neonatal morbidity that included neonatal death and 9 other adverse outcomes. Results: Among 2414 women randomized (mean age, 26.5 years), 2404 (99.6%) completed the trial. The rate of spontaneous vaginal delivery was 85.9% in the immediate group vs 86.5% in the delayed group, and was not significantly different (absolute difference, -0.6% [95% CI, -3.4% to 2.1%]; relative risk, 0.99 [95% CI, 0.96 to 1.03]). There was no significant difference in 5 of the 9 prespecified secondary outcomes reported, including the composite outcome of neonatal morbidity (7.3% for the immediate group vs 8.9% for the delayed group; between-group difference, -1.6% [95% CI, -3.8% to 0.5%]) and perineal lacerations (45.9% vs 46.4%, respectively; between-group difference, -0.4% [95% CI, -4.4% to 3.6%]). The immediate group had significantly shorter mean duration of the second stage compared with the delayed group (102.4 vs 134.2 minutes, respectively; mean difference, -31.8 minutes [95% CI, -36.7 to -26.9], P < .001), despite a significantly longer mean duration of active pushing (83.7 vs 74.5 minutes; mean difference, 9.2 minutes [95% CI, 5.8 to 12.6], P < .001), lower rates of chorioamnionitis (6.7% vs 9.1%; between-group difference, -2.5% [95% CI, -4.6% to -0.3%], P = .005), and fewer postpartum hemorrhages (2.3% vs 4.0%; between-group difference, -1.7% [95% CI, -3.1% to -0.4%], P = .03). Conclusions and Relevance: Among nulliparous women receiving neuraxial anesthesia, the timing of second stage pushing efforts did not affect the rate of spontaneous vaginal delivery. These findings may help inform decisions about the preferred timing of second stage pushing efforts, when considered with other maternal and neonatal outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02137200.

Expert commentary

In the UK, it is recommended practice to delay directed pushing for at least one hour for women with epidural pain relief entering the second stage of labour, unless there is a clinical indication to expedite birth or birth is imminent.

This US, pragmatic randomised clinical trial compared immediate with one hour delayed pushing for nulliparous women with neuraxial (epidural/spinal) analgesia. The study found that there was no difference in the rate of instrumental birth, and was stopped early due to the increased rates of postpartum haemorrhage and chorioamnionitis in the delayed group. 

These findings should be read acknowledging the different healthcare context in the US compared with the UK, including higher regional analgesia use (71% in the US vs <40% in the UK) and the high oxytocin augmentation rates in this study (~80%). However, given that sepsis and haemorrhage remain two of the leading causes of maternal death in the UK, these findings warrant attention. Further study in the UK context is required to determine best practice.

Dr Helen White, Midwifery Lecturer, University of Manchester

The commentator declares no conflicting interests