Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia

Cahill, Alison G.; Srinivas, Sindhu K.; Tita, Alan T.N.; Caughey, Aaron B.; Richter, Holly E.; Gregory, W. Thomas; Liu, Jingxia; Woolfolk, Candice; Weinstein, Debra F.; Mathur, Amit M.; Macones, George A.; Tuuli, Methodius G.

doi:10.1001/jama.2018.13986

Cited by 87 publications

(51 citation statements)

References 31 publications

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“…The duration of second stage did not account much in the total stage, but more attention should be pay to it. Some harmless measures should be taken to make it shorter, such as upright position or immediate pushing [ 24 , 25 ]. It was important to assess the fetal position in second stage, occiput posterior position and transverse position were associated with more pain and prolonged stage of labor.…”

Section: Discussionmentioning

confidence: 99%

The impact of stage of labor on adverse maternal and neonatal outcomes in multiparous women: a retrospective cohort study

Wang

et al. 2020

BMC Pregnancy Childbirth

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Background The correlation between stage of labor and adverse delivery outcomes has been widely studied. Most of studies focused on nulliparous women, it was not very clear what impact the stage of labor duration had on multiparous women. Methods A retrospective cohort study was conducted among all the multiparous women of cephalic, term, singleton births, who planned vaginal delivery. The total stage of labor covered the first stage and the second stage in this study, and they were divided into subgroups. Adverse maternal outcomes were defined as referral cesarean delivery, instrumental delivery, postpartum hemorrhage, perineal laceration (III and IV degree), hospitalization stay ≥90th, and adverse neonatal outcomes as NICU, shoulder dystocia, Apgar score ≤ 7(5 min), neonatal resuscitation, assisted ventilation required immediately after delivery. Results There were 7109 parturients included in this study. The duration of first stage was 6.2(3.6–10.0) hours, the second stage was 0.3(0.2–0.7) hour, the total stage was 6.9(4.1–10.7) hours in multiparous women. At the first stage, the rates of overall adverse outcome were 21, 23.4, 28.8, 35.5, 38.4% in subgroups < 6 h, 6–11.9 h, 12–17.9 h, 18–23.9 h, ≥24 h, which increased significantly (X2 = 57.64, P < 0.001), and ARR (95% CI) were 1.10 (0.92,1.31), 1.33 (1.04,1.70), 1.80 (1.21,2.68), 2.57 (1.60,4.15) compared with subgroup < 6 h (ARR = 1); At the second stage, the rates of overall adverse outcome were 20.0, 30.7, 38.5, 61.2, 69.6% in subgroups < 1 h, 1–1.9 h, 2–2.9 h, 3–3.9 h, ≥4 h (X2 = 349.70, P < 0.001), and ARR (95% CI) were 1.89 (1.50, 2.39), 2.22 (1.55, 3.18), 10.64 (6.09, 18.59), 11.75 (6.55, 21.08) compared with subgroup < 1 h (ARR = 1)). At the total stage, the rates of overall adverse outcome were 21.5, 30.8, 42.4% in subgroups < 12 h, 12–23.9 h, ≥24 h (X2 = 84.90, P < 0.001), and ARR (95% CI) were 1.41 (1.16,1.72), 3.17 (2.10,4.80) compared with subgroup < 12 h (ARR = 1). Conclusions The prolonged stage of labor may lead to increased adverse outcomes in multiparous women, it was an independent risk factor of adverse maternal and neonatal outcomes.

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Section: Discussionmentioning

confidence: 99%

The impact of stage of labor on adverse maternal and neonatal outcomes in multiparous women: a retrospective cohort study

Wang

et al. 2020

BMC Pregnancy Childbirth

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“…We did not specifically explore the effects of delayed pushing. Although reports indicate that delayed pushing results in a decrease in the time pushing, 22,23 it remains to be determined if it reduces the number of pushing contractions required. We did not assess the adequacy or strength (i.e., Montevideo units) of uterine contractions in the second stage as intrauterine pressure transducer measurements are elevated in response to maternal pushing efforts.…”

Section: Discussionmentioning

confidence: 99%

“…21 Although delayed pushing has been advocated for patients, particularly those with epidural analgesia, there appears to be an increase in several adverse outcomes (chorioamnionitis, postpartum hemorrhage) with this procedure. 22,23 Consequently, controversy remains as to how to best manage the second stage of labor to optimize the rate of successful vaginal delivery and minimize maternal and infant morbidity.…”

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confidence: 99%

Redefining Second Stage of Labor: Number of Pushing Contractions

Bok

Carmona

Crawford

et al. 2020

AJP Rep

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Introduction Despite time standards for second stage labor, “delayed pushing,” uterine contraction frequency, and alternate contraction pushing may alter the effective maternal effort. We sought to quantify the number of pushing contractions needed for a spontaneous vaginal delivery (SVD) among primipara and multipara patients. Methods Deliveries at Harbor-UCLA Medical Center in 2017 were selected for SVD of singleton, term newborns. The first 100 primipara and 100 multipara deliveries were analyzed and monitor tracings quantified for pushing contractions. Results Significantly more pushing contractions were required by primiparas versus multiparas (17.3 ± 1.7 vs. 5.5 ± 0.7; p < 0.001) in accord with a longer second stage (86.7 ± 7.8 vs. 27.2 ± 4.9 min; p < 0.001) and epidural was associated with greater number of pushing contractions among both primipara (18.5 ± 1.8 vs. 10.8 ± 0.8) and multipara women (6.1 ± 0.8 vs. 4.1 ± 0.3). Newborn weight (<3000, 3000–3500, >3500 g) demonstrated a trend for increased pushing contractions among primipara (16.9, 16.5, 19.8 pushes, respectively) though not multiparas. Conclusion Although correlated with the absolute duration of the second stage, the number of pushing contractions eliminates ambiguities of “delayed pushing,” pushing every-other, and frequency of contractions. Examination of larger databases and patients with second stage “arrest disorders” may provide pushing contraction criteria predictive of SVD and prevention of morbidity.

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“…The duration of second stage is very important for labor, even though it does not account for much longer of total stage. We should pay more attention to the management of the second stage of labor, taking some harmless measures to make it shorter by upright position or immediate pushing [21,22].…”

Section: Discussionmentioning

confidence: 99%

The Impact of Labor Stage Duration on Adverse Maternal and Neonatal Outcomes in Multiparous Women: A Retrospective Cohort Study

wang

Wang

et al. 2020

Preprint

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Background The duration of first and second stages of labor was increased in the consensus that American College of Obstetricians and Gynecologists (ACOG) published 2014. Studies showed increased adverse maternal and neonatal outcomes in nulliparous women with prolonged second stage of labor. It is not very clear that the impact of labor stage duration on multiparous women.Methods A retrospective cohort study was performed. Cephalic, term, singleton multiparous women were included, who planned for vaginal delivery. Adverse maternal outcomes were defined as referral cesarean delivery, instrumental delivery, postpartum hemorrhage, perineal laceration (3rd and 4th degree), hospitalization stay ≥ 90%th, and adverse neonatal outcomes as NICU, shoulder dystocia, Apgar score ≤ 7(5 min), neonatal resuscitation, assisted ventilation required immediately after delivery. We defined the total stage included the first and second stage of labor.Results There were 7109 parturients included, The duration of first stage was 6.2(3.6–10.0) hours in multiparous women, the second stage was 0.3(0.2–0.7) hours, the total stage was 6.9(4.1–10.7) hours. In the first stage, the rate of overall adverse outcomes was 21%, 23.4%, 28.8%, 35.5%, 38.4% in < 6 h, 6-11.9 h, 12-17.9 h, 18-23.9 h, ≥ 24 h, increased significantly (X2 = 57.64, P๤0.001). Compared with < 6 h, ARR(95%CI) were 1.10(0.92,1.31), 1.33(1.04,1.70), 1.80(1.21,2.68), 2.57(1.60,4.15);In the second stage, the rate of overall adverse outcomes increased from 20.0%, 30.7%, 38.5%, to 61.2%, 69.6% in < 1 h, 1-1.9 h, 2-2.9 h, 3-3.9 h, ≥ 4 h (X2 = 349.70, P๤0.001). Compared with < 1 h, ARR (95% CI) were 1.89 (1.50, 2.39), 2.22 (1.55, 3.18), 10.64 (6.09, 18.59), 11.75 (6.55, 21.08); In the total stage, the rate of overall adverse outcomes were 21.5%, 30.8%, 42.4% in < 12 h, 12-23.9 h, ≥ 24 h (X2 = 84.90, P๤0.001). Compared with < 12 h, ARR (95% CI) were 1.41(1.16,1.72), 3.17 (2.10,4.80).Conclusions The prolonged labor stage may lead to increased adverse outcomes in multiparous women, even in the first stage. The duration of labor stage was an independent risk factor for adverse maternal and neonatal outcomes.

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Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia

Cited by 87 publications

References 31 publications

The impact of stage of labor on adverse maternal and neonatal outcomes in multiparous women: a retrospective cohort study

The impact of stage of labor on adverse maternal and neonatal outcomes in multiparous women: a retrospective cohort study

Redefining Second Stage of Labor: Number of Pushing Contractions

The Impact of Labor Stage Duration on Adverse Maternal and Neonatal Outcomes in Multiparous Women: A Retrospective Cohort Study

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