Transcript Implications of Delayed Versus Immediate Pushing in the

Denise M. Bourassa, RNC, MSN
Hartford Hospital
Second stage of labor – what is it?
Begins with full dilation (10 cm) and full
effacement (100%) of the cervix
Ends with birth of baby
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Why are we managing it?
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How are we managing it?
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Should we manage it?
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First epidural – 1898
1970’s – first widely used in obstetrics with
problems
1975 – 20% chose epidural
Current epidural in labor rate…75-85% ?
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Relaxation of the pelvic floor musculature
Along came “Time – an important variable in
normal delivery” (Wood et al, 1973)
Leading to prolonged second stage and need
for intervention (Maresh,Choong,Beard, 1983)
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Coached or directed pushing
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Closed glottis pushing
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Early pushing or pushing without urge
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Immediate pushing at 10 cm, regardless of
urge to push
Breath holding, counting for 10 seconds,
repeat x 3
PUSH, PUSH, PUSH !!!!!
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Aka “purple pushing”
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More like “red in the face” pushing
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Usually the result of pushing without urge to
push
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Many different names
◦ Passive descent
◦ Delayed pushing
◦ Physiologic second stage
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When patient feels urge to push, will
instinctively push, breathe when necessary,
not when told.
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Authored by: Maresh, Choong and Beard
Published in: British Journal of Obstetrics and
Gynaecology, 1983
Design of Study
76 primigravidae with epidurals
Delayed pushing group (n=40)
Early pushing group (n=36)
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Authored by: Reynolds and Yukin
Published in: Canadian Medical Association
Journal, 1987
Authored by: Vause, Congdon, Thronton
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Published in: British Journal of Obstetrics and
Gynaecology, 1998
135 nulliparous with effective epidural
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Authors: Mayberry, Hammer, Kelly, TrueDriver and De
Journal of Perinatology – 1999
Pilot study designed to evaluate the use of
delayed pushing in relation to five areas.
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Length of second stage
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Change in fetal station first hour after full
dilation
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Apgar scores
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Arterial umbilical cord gases
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Perineal integrity
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Study suggests time limits could be more
flexible because of improved fetal monitoring
and better ability to identify fetus not
tolerating labor
Suggests redefinition of prolonged labor or
failure to progress
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Clinical Management Guidelines for
Obstetrician-Gynecologists
Indications for operational Vaginal Delivery
when fetal head is engaged and cervix fully
dilated:
Prolonged second stage: Redefinition
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Authored by: Fraser, Marcoux, Krauss,
Douglas, Goulet, Boulvain, for the PEOPLE
(pushing early or pushing late with epidural)
study group
Published in: American Journal of Obstetrics
and Gynecology, 2000
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Multicenter, Randomized Controlled trial
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1864 total participants
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Delayed pushing = waiting 2 hours (n=936)
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Early pushing = as soon as randomly
assigned (n=926)
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Authored by: Hansen, Clark and Foster
Published in: The American College of
Obstetricians and Gynecologists, 2002
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Length of Second stage
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Length of time pushing
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Apgars
Cord pH
Episiotomies/lacerations
Endometritis
Rate of fetal descent
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Fatigue scores
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Authored by: Plunkett, Lin, Wong, Grobman,
and Peaceman
Published in: The American College of
Obstetricians and Gynecologists, 2003
Randomized 202 total subjects
◦ Delayed pushing (n=117)
◦ Early pushing (n=85)
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Authored by: Simpson and James
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Published in: Nursing Research, 2005
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45 nulliparous women in second stage
◦ Delayed pushing (n=23)
◦ Early pushing (n=21)
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Authored by: DiFranco, J.T, Romano, A.M.,
and Keen,R.
Published in: Journal of Perinatal Education,
2007
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Authored by: Brancato, R.M., Church, S., and
Stone, P.W.
Published in: Journal of Obstetric,
Gynecologic and Neonatal Nursing, 2008
Objective: to determine which method of
pushing most benefits women with epidurals
during second-stage
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Authored by: Kelly, M., Johnson, E., Lee, V.,
Massey, L., Purser, D., Ring, K., Sanderson, S.,
Styles, J., and Wood,D.
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Published in: Maternal Child Nursing, 2010
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Randomized clinical trial
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Sample size 44
◦ Delayed pushing (n=28)
◦ Early pushing (n=16)
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Nature of labor is a mystery even today
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No two are the same
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Hold your breath, count, push, push!
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Google search
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The debate continues
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The past 30 years
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The future