Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group.
This study was undertaken to determine whether a policy of delayed pushing for nulliparous women with continuous-infusion epidural analgesia reduces the risk of difficult delivery (cesarean delivery, operative delivery from a midpelvic position, low-pelvic procedures with rotation >45 degrees ). Study Design: In this multicenter, randomized, controlled trial women in the delayed pushing group (n = 936) were advised to wait > or =2 hours after full dilatation before commencement of pushing. Women in the early pushing group (n = 926) were advised to commence pushing as soon as they had been randomly assigned.
Difficult delivery was reduced with delayed pushing (relative risk, 0.79; 95% confidence interval, 0.66-0.95). The greatest effect was on midpelvic procedures (relative risk, 0.72; 95% confidence interval, 0.55-0.93). Although there was little evidence for an effect on low-pelvic procedures, spontaneous delivery was more frequent among women who practiced delayed pushing (relative risk, 1.09; 95% confidence interval, 1.00-1.18). Abnormal umbilical cord blood pH (<7.15 venous value or <7.10 arterial value) was more frequent in the delayed pushing group (relative risk, 2.45, 95% confidence interval, 1.35-4. 43). However, scores for a summary indicator, the Neonatal Morbidity Index, were similarly distributed in the 2 groups.
Delayed pushing is an effective strategy to reduce difficult deliveries among nulliparous women.
Available from: sciencedirect.com
- "Although it was reported to prolong labor by 1 hour, a metaanalysis showed that delayed pushing had significantly positive effects in terms of safely and effectively decreasing instrumentassisted deliveries and shortening pushing time. In addition, the PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group concluded that delayed pushing with epidural anesthesia was an effective strategy to reduce difficult deliveries among nulliparous women. As for episiotomy, its use was met with a variety of different opinions from obstetricians, and many Taiwanese obstetricians view it as necessary. "
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ABSTRACT: Objective: Pleasant and humane childbirth is every mother's wish. The objective of this study was to propose a practicable mother-friendly childbirth model tailored to Taiwanese women in order to improve the quality of perinatal care and maternal satisfaction. Material and methods: In this study, the guidelines of several countries were systematically reviewed, and a standard set of clinical guidelines were established by a focus group. In addition, a total of 172 Taiwanese obstetricians were visited, and a cross-sectional study of these obstetricians' attitudes toward the practicality and effectiveness of the model was performed using questionnaires. Results: A total of 10 suggestions were developed for this woman-friendly childbirth model, including: (1) intermittent fetal monitoring for low-risk pregnancy, (2) no routine enema, (3) no routine perineal shaving, (4) no routine restricted oral intake, (5) no routine parenteral fluid support, (6) no routine elective amniotomy, (7) nonpharmacological pain management, (8) upright position during childbirth, (9) delayed pushing, and (10) restrictive episiotomy. Taiwanese obstetricians approved of no routine oral intake restriction and providing nonmedical pain relief. The majority of obstetricians disagreed that perineal shaving and routine elective amniotomy were necessary, and agreed to modify their practice according to the suggestions. Suggestions were still being debated, such as no routine parenteral fluid support, using an upright position for childbirth, and delayed pushing. Intermittent fetal monitoring for low-risk pregnancy, no routine enema, and restrictive episiotomy were questioned by many Taiwanese obstetricians. Conclusion: Several suggestions were made in this model. However, there was still no consensus of Taiwanese obstetricians. More evidence for the advantages and disadvantages of the various suggestions was needed to convince Taiwanese obstetrician to modify their routine practice.
Available from: sonoma.edu
- "Eight randomized clinical trials (RCTs) have compared the e¡ects of immediate and delayed pushing at the onset of the second stage of labor (Fitzpatrick et al., 2002; Fraser et al., 2000; Hansen, Clark, & Foster, 2002; Kelly et al., 2010; Mayberry et al., 1999b; Plunkett, Lin, Wong, Grobman, & Peaceman, 2003; Simpson & James, 2005; Vause, Congdon, & Thornton, 1998). The majority of the RCTs examined participants between 37 and 42 weeks of gestation with a singleton, vertex presentation in mothers receiving epidural anesthesia. "
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ABSTRACT: Objective: To determine if the use of delayed pushing after the onset of the second stage of labor decreases the time of active pushing and decreases maternal fatigue.
Design: Randomized clinical trial.
Setting: Labor and delivery unit of a not-for-profit community hospital.
Patients/Participants: Convenience sample of nulliparous laboring women with epidural anesthesia.
Interventions: Immediate or delayed pushing (2 hours) during the second stage of labor at the time of complete cervical dilatation.
Main Outcome Measures: The length of pushing, total length of the second stage, and maternal fatigue.
Results: A total of 77 women were studied (immediate pushing group=39; delayed pushing=38). The immediate pushing group averaged 94 (± 57) minutes in active pushing, while the delayed pushing group averaged 68 (± 46) minutes, a statistically significant difference (p=.04). No significant differences were found in fatigue scores between the immediate and delayed pushing groups (p>.05).
Conclusions: We found that by delaying the onset of active pushing for 2 hours after the beginning of the second stage of labor, the time that nulliparous women with epidural anesthesia spent in active pushing was significantly decreased by 27%. Although the delayed pushing group rested for up to 2 hours, the total time in the second stage of labor averaged only 59 minutes longer than the immediate pushing group.
Available from: Bruno Carbonne
- "Angleterre Immédiate 70 108 37 81 28 Retardée 36 189 62 68 26 Gleeson et Griffith 1991  Irlande Immédiate 219 72 30 72 30 Retardée 194 96 48 42 36 Vause et al. 1998  Angleterre Immédiate 67 119 73 43 Retardée 68 214 52 36 Mayberry et al. 1999  USA Immédiate 72 105 73 29 Retardée 81 119 119 24 Fraser et al. 2000  Canada Immédiate 926 123 110 41 Retardée 936 187 68 37 Hansen et al. 2002  USA Immédiate 65 75 41 75 41 29 Retardée 64 171 56 58 44 21 Fitzpatrick et al. 2002  Irlande Immédiate 90 60 60 38 Retardée 88 120 56 44 Plunkett et al. 2003  USA Immédiate 85 69 62 18 Retardée 117 99 62 23 Moyennes 120 58 67 "
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ABSTRACT: The aim of this work is to answer constructively to C. Le Ray and F. Audibert who were surprised that the French guidelines recommended an assisted delivery after 30 min pushing, even if the fetal heart rate is reassuring. We first resumed the definition of “second stage of labor”, this word including the first phase with no pushing efforts and the second phase with active pushing of the mother. With that definition, the length of the second stage is around 60 min for the primipara and 20 min for the multipara, this length being modified by the use of peridural. We then specified the physiological mechanisms influencing the acidobasic equilibrium during the pushing time. Those mechanisms are difficult to consider because foetal heart rate monitoring is often “lost” during that phase. Altogether, these factors bring incertitude about progressive foetal acidosis and incapacity to diagnose it. Finally, the literature analysis teaches us that increasing the second stage of labor (inactive plus active phases) during the normal pregnancy seems to be at low risk for the foetus within the primiparas, but display a risk for the mother and so might be limited. Comparing the delayed pushing with the immediate pushing only lead us to conclude that delayed pushing is dangerous, as is prolonged second stage. In conclusion, we think that prolonging the second stage of labor is possible but must be by increasing the inactive first phase of the second stage, especially as long as we will not get a noninvasive and reliable method allowing assessing the well-being of the foetus.
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