Outcomes/Effectiveness Research

Delaying the urge to push during second-stage labor offers no benefit for women who receive low-dose epidural analgesia

There is an ongoing debate about optimal management of the second stage of labor in women who are given epidural analgesia. Women who receive epidural analgesia and concomitant sensory blockade may not feel a strong urge to push upon reaching the second stage of labor. Thus, some doctors believe that these women should begin pushing immediately upon reaching complete cervical dilation to decrease the length of the second stage and the potential for infection. Other doctors argue that waiting for a strong urge to push maximizes the efficiency of pushing efforts and reduces the risk of maternal exhaustion and delivery by cesarean section.

According to a recent study supported by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00078), women giving birth for the first time who receive low-concentration epidural analgesia do not benefit from delaying pushing efforts until there is a strong urge to push. Such a delay did not reduce the duration of pushing in the second stage of labor or increase maternal satisfaction, explains lead author, Beth A. Plunkett, M.D., of Northwestern University. Dr. Plunkett and her colleagues randomly assigned women at one hospital giving birth for the first time who received low-dose, continuous epidural analgesia (0.0625 percent bupivacaine with fentanyl 2 ng/mL) to either pushing immediately upon complete cervical dilation (85 women) or waiting for a strong urge to push (117 women).

Women who delayed pushing (typically by a clinically insignificant 10 minutes) had a strong urge to push and a longer second stage than women who pushed immediately, and they spent a similar amount of time pushing (median of 57 versus 62 minutes). There were no significant differences in median level of satisfaction or in the overall rates of cesarean delivery (6 vs. 12 percent), cesarean delivery during the second stage (2 percent in each group), spontaneous vaginal delivery (70 vs. 69 percent), or neonatal or maternal problems.

See "Management of the second stage of labor in nulliparas with continuous epidural analgesia," by Dr. Plunkett, Alex Lin, M.D., Cynthia A. Wong, M.D., and others, in the July 2003 Obstetrics & Gynecology 102(1), pp. 109-114.

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