Two common pushing approaches are used during the second stage of labor: immediate and delayed. Neither has been shown to be superior. A pragmatic, multicenter randomized trial was undertaken to compare the effect of the two methods on rates of spontaneous vaginal delivery and maternal and neonatal morbidities in women receiving neuraxial analgesia.

Nulliparous women who were at or beyond 37 weeks' gestation, admitted for spontaneous or induced labor, and receiving neuroaxial analgesia were eligible for the trial. At complete cervical dilation, the women were randomly assigned to either the immediate or delayed pushing group; those assigned to the delayed group were instructed to wait 60 minutes before pushing. The baseline characteristics of the two groups were similar, and all the women received usual obstetric care. They and their infants were followed for six weeks, and a total of 2,404 women completed the trial.

The trial was stopped early after an interim analysis found no difference in the rate of spontaneous delivery between the two groups and a significantly higher rate of postpartum hemorrhage among women in the delayed pushing group. Those in the immediate pushing group had a significantly shorter mean duration of second stage labor and a significantly longer mean duration of active pushing than those in the delayed pushing group. Rates of operative vaginal delivery and cesarean delivery were low in both groups. Rates of postpartum hemorrhage and chorioamnionitis were significantly lower among women in the immediate pushing group. There was a heightened risk of neonatal acidemia and a higher rate of suspected sepsis in the delayed pushing group. The authors observed that perineal lacerations were common in both groups, but the risk of third-degree perineal lacerations was significantly higher in the immediate pushing group.

The researchers' finding that delayed pushing is associated with a longer second stage of labor is consistent with the results of prior trials. Because delayed pushing was found to increase the risk of maternal and neonatal morbidity, the authors argue against its routine use during labor.-KR

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