Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial

doi:10.1016/S0029-7844(01)01642-8

Obstetrics & Gynecology

Volume 99, Issue 1, January 2002, Pages 29-34

https://doi.org/10.1016/S0029-7844(01)01642-8 Get rights and content

Abstract

OBJECTIVE: To compare perinatal outcomes among women with epidural anesthesia who were encouraged to push at complete dilatation with those who had a period of rest before pushing began.

METHODS: After a power analysis to determine appropriate sample size (based upon an α error rate of .05% and 80% power), a prospective randomized trial of 252 women with epidural anesthesia was conducted. Patients were randomized to a rest period or immediate pushing at complete dilatation. Variables measured included rate of fetal descent, length of time of pushing, the number and type of fetal heart rate decelerations, Apgar scores, arterial cord pH values, perineal injuries, type of delivery, length of second stage, maternal fatigue, and endometritis.

RESULTS: When a period of rest was used before pushing, we found a longer second stage, decreased pushing time, fewer decelerations, and, in primiparous women, less fatigue compared with control patients. Apgar scores, arterial cord pH values, rates of perineal injury, instrument delivery, and endometritis were similar in both groups.

CONCLUSION: Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit.

Section snippets

Materials and methods

Patients were enrolled in this study at the time of admission to labor and delivery with the diagnosis of spontaneous or induced labor at term. Care was provided at LDS Hospital, a regional tertiary care teaching center.

Exclusion criteria included refusal of epidural, first epidural dose after complete dilatation, known fetal anomaly, multiple gestation, nonvertex presentation, gestational age less than 37 weeks or over 42 weeks, and pregnancy complicated by pregnancy-induced hypertension,

Results

Of the 312 women initially randomized, 60 were removed. The reasons for withdrawal were physician request without medical indication (16 patients), physician request for medical complication (eight patients), patient request (one patient), cesarean before the second stage of labor (12 patients), cesarean for abnormal FHR pattern in the second stage of labor (three patients), nursing protocol error (nine patients), and unknown (11 patients).

Our population consisted of 96% white, non-Hispanic

Discussion

Our data suggest that although the second stage of labor may be prolonged (up to 4.9 hours) in women allowed to rest and descend, such lengthening of labor is not associated with any discernable adverse maternal or fetal outcomes in women with functioning epidural anesthesia. Among women undergoing a protocol of rest and descend compared with the more traditional second-stage labor management, there was no difference with respect to Apgar scores, umbilical arterial cord pH, perineal injuries,

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Cited by (122)

Maternal outcomes using delayed pushing versus immediate pushing in the second stage of labour: An umbrella review
2024, International Journal of Nursing Studies
Different systematic reviews have been developed in the last decades about maternal risks of immediate pushing and delayed pushing, depending on the duration of the second stage of labour, but they do not provide conclusive evidence.
The main aim of this overview of systematic reviews was to assess the maternal outcomes using delayed pushing and immediate pushing in the second stage of labour in women receiving epidural analgesia.
We searched systematically in PubMed (Medline), EMBASE, CINAHL, and Scopus (October 26th, 2023). Methodological quality was analysed using AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. The outcome measures were the duration of the second stage of labour, duration of active pushing, caesarean section, instrumental vaginal birth, spontaneous vaginal birth, fatigue score, perineal lacerations, postpartum haemorrhage, and rate of episiotomy. Seven systematic reviews with and without meta-analysis were included.
Results showed that delayed pushing increases the total time of the second stage of labour, although delayed pushing decreases the duration of active pushing with moderate quality of evidence. Mixed results were found with respect to the variables instrumental vaginal birth, spontaneous vaginal birth, and fatigue score although the results favour delayed pushing or show no statistically significant differences with respect to immediate pushing. No favourable results were ever found for immediate pushing with respect to delayed pushing, with a limited quality of evidence. Even so, delayed pushing seems to be associated with a significant increase in spontaneous vaginal birth rates. The results found no significant differences between the immediate pushing and delayed pushing groups in the caesarean section rates, perineal lacerations, postpartum haemorrhage, and episiotomy ratio, with a limited quality of evidence.
This study shows that delayed pushing during the second stage of labour produces at least the same maternal outcomes as immediate pushing, although we note that delayed pushing produces an increase of the duration of the second stage of labour, a shorter duration of the active pushing and a tendency to increase spontaneous vaginal birth and to reduce the instrumental vaginal birth rates and fatigue scores. This should be considered clinically.
This review was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42023397616).
Management of the active second stage of labor in waterbirths compared with conventional births – a prospective cohort study
2022, Midwifery
The management of the active second stage in labor and perineal protection varies between countries and is rarely described regarding waterbirths. The objective of this study was to describe how midwives manage the active second stage of labor in waterbirths compared to conventional births. A secondary aim was to compare clinical outcomes between the two groups.
A prospective cohort study, based on 323 women who gave birth at three clinics in Sweden, between Dec 2015-May 2019. The women were both primiparous and multiparous; 153 gave birth in water and 170 had a conventional uncomplicated birth. A protocol was completed by the attending midwife after birth, describing characteristics and management of the active second stage of labor as well as perineal protection.
The active second stage of labor differed in several aspects between waterbirths and conventional births. Maternal pushing was spontaneous to a higher extent among women giving birth in water and the use of manual perineal protection was lower. The technique of manual perineal protection differed as well as birth positions. Giving birth in water was associated with less second-degree tears among primiparous women but with no differences among multiparas.
In waterbirth, the midwife took the role of a more watchful attendee, making less interventions. Waterbirths were associated with less directed pushing and less manual perineal protection. However, there was still a widespread use of manual perineal protection, showing it is possible to use in the same way as in conventional births if needed.
Delayed versus immediate pushing in the second stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials
2020, American Journal of Obstetrics and Gynecology
The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effect of delayed versus immediate pushing in the second stage of labor on mode of delivery and other outcomes in women with neuraxial analgesia.
The research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and the Cochrane Library as electronic databases, from the inception of each database to August 2019. No restrictions for language or geographic location were applied.
Selection criteria included only randomized controlled trials in pregnant women randomized to either delayed or immediate pushing during the second stage of labor.
The primary outcome was mode of delivery. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I² (Higgins I²) value of greater than 0% was used to identify heterogeneity.
Twelve randomized controlled trials, including 5445 women with neuraxial analgesia randomized to delayed versus immediate pushing during the second stage of labor, were included in the meta-analysis. Of the 5445 women included in the meta-analysis, 2754 were randomized to the delayed pushing group and 2691 to the immediate pushing group. No significant difference between delayed and immediate pushing was found for spontaneous vaginal delivery (80.9% versus 78.3%; relative risk, 1.05; 95% confidence interval, 1.00−1.10; 12 randomized controlled trials, 5540 women), operative vaginal delivery (12.8% versus 14.6%; relative risk, 0.89; 95% confidence interval, 0.75−1.08; 11 randomized controlled trials, 5395 women), and cesarean delivery (6.9% versus 7.9%; relative risk, 0.89; 95% confidence interval, 0.73−1.07; 11 randomized controlled trials; 5395 women). Women randomized to the delayed pushing group had a significantly shorter length of active pushing (mean difference, −27.54 minutes; 95% confidence interval, −43.04 to −12.04; 7 randomized controlled trials, 4737 women) at the expense of a significantly longer overall duration of the second stage of labor (mean difference, 46.17 minutes; 95% confidence interval, 32.63−59.71; 8 studies; 4890 women). The incidence of chorioamnionitis (9.1% versus 6.6%; relative risk, 1.37, 95% confidence interval, 1.04−1.81; 1 randomized controlled trial, 2404 women) and low umbilical cord pH (2.7% versus 1.3%; relative risk, 2.00; 95% confidence interval, 1.30−3.07; 5 randomized controlled trials, 4549 women) were significantly higher in the delayed pushing group.
In women with spontaneous or induced labor at term with neuraxial analgesia, delayed pushing in the second stage does not affect the mode of delivery, although it reduces the time of active pushing at the expense of a longer second stage. This prolongation of labor was associated with a higher incidence of chorioamnionitis and low umbilical cord pH. Based on these findings, delayed pushing cannot be routinely advocated for the management of the second stage.
Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives’ experiences in Northern Italy
2019, Midwifery
To explore midwives’ experiences of the management of the second stage of labour in women with epidural analgesia.
Descriptive qualitative study using semi-structured face-to-face interviews.
Purposive sample of twelve midwives working in three Obstetric Units. Among them six were senior midwives with more than five years’ experience on labour ward and six were junior midwives with less than five years’ experience on labour ward.
The findings included four themes: a) timing of second stage of labour and maternal pushing; b) maternal positions and mobility; c) perspectives on epidural boluses; d) midwifery presence and support. The time ‘allowed’ by midwives for the passive phase of the second stage of labour ranged from zero to two hours, with some of them avoiding vaginal examinations to delay the recorded starting time of active pushing. The semi-sitting and the lithotomy positions were the most used respectively in labour and at birth. Some midwives encouraged the kneeling position or the lateral position. Regarding the management of the epidural bolus during the second stage of labour, the interviewees’ opinions were divided between favourable and unfavourable to the administration of analgesic boluses after the full cervical dilatation. Midwives reported their experiences of providing different care to women with epidural analgesia when compared to women without epidural, mainly due to a more medicalised approach and the midwives’ sense of ‘usefulness’ when caring for women not experiencing labour pain.
To our knowledge, this was the first study on this topic conducted in an Italian setting. Despite the consistent body of evidence on the effects of epidural analgesia in the second stage on birth outcomes, the lack of clear guidelines, the presence of different hospital protocols and Obstetricians’ opinion, introduce uncertainty in midwifery practice and lead midwives with feelings of ‘uselessness’. Across the four themes, midwives frequently had to negotiate a space for their professional autonomy with other healthcare professionals, whilst adhering to the Obstetric Units’ protocols. An influencing factor on the care provided to women with epidural was the years of midwife's experience on labour ward. Further research and the development of comprehensive midwifery care guidelines on the management of the second stage of labour in women with an epidural analgesia appears essential.
On the effect of labour durations using an anisotropic visco-hyperelastic-damage approach to simulate vaginal deliveries
2018, Journal of the Mechanical Behavior of Biomedical Materials
Injuries sustained by the pelvic floor muscles during childbirth are one of the major risk factors for the development of pelvic floor dysfunctions. The ability to predict the loss of the tissue integrity and the most affected regions prior to the childbirth would represent a compelling difference in choosing the appropriate management of labour.
Previous biomechanical studies, using the finite element method, were able to simulate a vaginal delivery and analyse the mechanical effects on the pelvic floor muscles during the passage of the foetus. Complementing these studies, the aim of this work is to improve the characterization of the pelvic floor muscles, by using an anisotropic visco-hyperelastic constitutive model, including a continuum mechanics damage model. Viscoelasticity is a key feature to obtain more realistic results since biological tissues present relaxation effects that allow larger deformations without damage. This work analyses the reaction forces and the loss of tissue integrity sustained by the pelvic floor and evaluates the effects of different durations of labour. A delaying pushing technique of rest and descend is also studied in this work.
The results obtained showed that the reaction forces vary with the duration of labour, with higher force levels associated with higher stretch rates. The pubovisceral muscle is the most affected of the levator ani, presenting an affected region of approximately 30%. The relaxation properties of the tissue contribute to diminish the damage levels, supporting the theory of delayed pushing applied in the second stage of labour.
Practices used by midwives during the second stage of labor to facilitate birth – Are they related to perineal trauma?
2018, Sexual and Reproductive Healthcare
The second stage of labor is considered to be the most stressful part of the process of childbirth for the woman and her unborn child, and consequently for the midwife. Midwives use different methods to enhance maternal bearing-down efforts and to ascertain the progress during the second stage. The aim of this study was to describe methods used by midwives during the second stage of labor and to assess potential associations with perineal trauma.
A secondary analysis with data from an experimental study with a cohort design, conducted at two maternity wards. Data from 704 primiparous women were available for the analysis. Outcome variables were second-degree tears, and severe perineal trauma. Descriptive statistics and multivariable logistic regression analysis adjusting for known risk factors were performed to compute incidence and adjusted odds ratios.
The most common techniques used during the second stage were directed pushing (57.1%), digital stretching of the vagina (levator pressure) (29.8%), and manual stretching of the perineum (21.9%). The birth-seat was the most common birth position (30.3%). 77.3% of the women sustained a second-degree tear and 3.1% had an episiotomy performed. None of the methods used by the midwives were associated with second-degree tears or severe perineal trauma.
The practices used by the midwives were not associated with second-degree tears, or severe perineal trauma and were used in both upright and supine birth positions, except fundal pressure.

View all citing articles on Scopus

^☆: Research funded by The Deseret Foundation.

¹: Standards for Different Types of Articles: Guidelines for three different types of articles have been adopted by Obstetrics & Gynecology as policy: • CONSORT guidelines for randomized trials • QUORUM guidelines for meta-analyses and systematic reviews of randomized trials • MOOSE guidelines for meta-analyses and systematic reviews of observational studies; Investigators who are planning, conducting, or reporting randomized trials or meta-analyses of randomized trials or meta-analyses of observational studies should be thoroughly familiar with these sets of standards. Summaries of them may be obtained by contacting the Editorial Office (P.O. Box 70410, Washington, DC 20024-0410; FAX: (202) 479-0830; E-mail: [email protected]).

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Original researchActive pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial1☆,

Abstract

Section snippets

Materials and methods

Results

Discussion

Obstet Gynecol

The effect of delayed pushing in the second stage of labor with continuous lumbar epidural analgesia

Acta Obstet Gynecol Scand

The management of the second stage of labour in primiparae with epidural analgesia

Br J Clin Pract

Delayed pushing with lumbar epidural analgesia in labour

Br J Obstet Gynaecol

Continuous lumbar epidural analgesia in labour — Does delaying ‘pushing’ in the second stage reduce the incidence of instrumental delivery?

Br J Obstet Gynaecol

The influence of maternal bearing-down efforts during second stage on fetal well-being

Birth Fam J

Original research
Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial¹☆,