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Keywords:

  • second stage;
  • management;
  • passive descent laboring;
  • downrest and descend;
  • physiologic second stage

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Objective:  To determine which method of pushing—passive descent or early pushing—most benefits women with epidurals during second-stage labor.

Data sources:  MEDLINE, CINAHL, and Cochrane Database.

Study selection:  Studies limited to randomized controlled trials in English, comparing passive descent to early pushing in women with effective epidural analgesia.

Data extraction:  A hand search was performed. Data included number of instrument-assisted deliveries (forceps and vacuum); noninstrumental or spontaneous vaginal births, cesarean births, pushing time, episiotomies, lacerations; maternal fatigue; and fetal well-being.

Data synthesis:  Seven studies were eligible for a sample size of 2,827 women. Pooled data indicate that passive descent increases a woman’s chance of having a spontaneous vaginal birth (relative risk: 1.08; 95% confidence interval: 1.01-1.15; p = 0.025), decreases risk of having an instrument-assisted deliveries (relative risk: 0.77; 95% confidence interval: 0.77-0.85; p ≤ 0.0001), and decreases pushing time (mean difference: −0.19 hours; 95% confidence interval: −0.27 to −0.12; p ≤ 0.0001). No differences were found in rates of cesarean births (relative risk: 0.80; 95% confidence interval: 0.57-1.12; p = 0.19), lacerations (relative risk: 0.88; 95% confidence interval: 0.72-1.07; p = 0.20), or episiotomies (relative risk: 0.97; 95% confidence interval: 0.88-1.06; p = 0.45).

Conclusions:  Significant positive effects were found indicating that passive descent should be used during birth to safely and effectively increase spontaneous vaginal births, decrease instrument-assisted deliveries, and shorten pushing time.

In the past 35 years, epidural analgesia has become a more common method of pain management used in the hospital setting. One of the negative effects of epidural analgesia is that it often decreases a woman’s lower body sensations, thereby inhibiting her natural urge to push upon full cervical dilation. Obstetrics, with its long history of active management of labor (Brancato, 2006; Roberts, 2002; Rooks, 1997), often compensates for this inhibition by directing women to push immediately upon full cervical dilation (immediate or early pushing [EP]). This method may not be evidence based. The natural second stage includes a period of “rest and descent” (Roberts, 2003) during which the fetus descends passively, and when this occurs in the clinical setting, it is often termed as “laboring down” or “passive descent” (PD). The practice involves allowing the woman to delay pushing until she feels the urge to push or the head is visible at the vaginal introitus (delayed pushing). Research on passive descent has been inconclusive and, indeed, both methods have been equally praised and criticized (Beynon, 1957; Crawford, 1983; Manyonda, Shaw, & Drife, 1990; Peterson & Besuner, 2007). Because immediate pushing is an artificial construct of obstetrics that gained practice with the development of epidural analgesia, it is questionable whether this management practice is best for mother and baby.

The chief concern from opponents of delayed pushing is that it prolongs the second stage of labor. A lengthened second stage can signify impending labor complications and, in the past, was thought to cause adverse consequences to mom and baby; thus, the American College of Obstetricians and Gynecologists (ACOG) recommended limiting the second stage to 2 hours (ACOG, 1994). However, researchers have recently demonstrated that this limit is null and ACOG has amended its recommendation (1995, 2003). Yet, ACOG does recommend considering operative delivery when 3 hours have elapsed for a nullipara with anesthesia and 2 hours for a multipara with anesthesia (Roberts, 2002) due to concerns over maternal and fetal acidosis. Delayed pushing, because it incorporates a rest period between full dilatation and pushing, can prolong the second stage.

Concerns about adverse consequences associated with prolonged second stage may be unwarranted, as researchers suggest that it is the length of active pushing, not the length of second stage, that may be deleterious; indeed, prolonged active pushing has been shown to increase the incidence of fetal and maternal acidosis, which is indicated by lactic acid, partial pressure of carbon dioxide, and pH at the time of birth. Roberts (2002) suggests that the latter findings should cause providers to limit the duration of active pushing, not the duration of second stage.

Epidural analgesia significantly affects second-stage pushing. When women do not feel the urge, pushing is more difficult for both women and nurses.

In fact, investigators found delayed pushing with epidural analgesia shortens the duration of active pushing, while immediate pushing or EP causes a longer duration of active pushing (Fitzpatrick et al., 2002; Fraser et al., 2000; Hanson, Clark, & Foster, 2002; Manyonda et al., 1990; Mayberry, Hammer, Kelly, True-Driver, & De, 1999; Peterson & Besuner, 1997; Plunkett, Lin, Wong, Grobman, & Peaceman, 2003; Roberts, 2002; Simpson & James, 2005; Vause, Congdon, & Thornton, 1998). Passive descent may allow for further fetal descent and rotation, better situating the fetus in the woman’s pelvis, and causing further release of oxytocin to augment the progress of labor. These factors may encourage more forceful contractions, an urge to push, and a smoother crowning, all of which may lead to fewer instrumental deliveries, less maternal fatigue, and less perineal damage (Roberts, 2002). A physician describes the risks of pushing upon complete dilatation when no urge is felt: “The result will often be a long period of increasing maternal exhaustion, with accompanying metabolic acidosis (and thus infusion acidosis of the fetus) culminating in an instrument-assisted delivery because the patience and fortitude of all have been dissipated” (Crawford, 1983, p. 271).

In an attempt to prevent ineffective patterns of pushing, maternal exhaustion, practitioner frustration, instrumental deliveries, and other interventions, researchers have begun to study immediate versus delayed pushing in randomized controlled trials (RCTs). This meta-analysis was conducted to analyze trends in the evidence and determine practice implications and aims to (a) help registered nurses, obstetricians, and midwives base their decisions during labor on the research data, thereby encouraging evidence-based practice and (b) allow women to have the most optimal childbirth experiences.

Methods

  1. Top of page
  2. ABSTRACT
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Studies were identified by searching MEDLINE, CINHAL, and the Cochrane Register of Controlled Trials; a hand search of references was then performed on the identified articles. The search terms included epidural, passive descent, laboring down, physiologic 2nd stage, delayed pushing, spontaneous pushing, passive second stage, second stage pause, passive fetal descent and rest and descend. This review was limited to RCTs written in English that compared PD to early or immediate pushing in laboring women who received epidural analgesia. According to the Oxford-Centre of Evidence-Based Medicine (2001), these RCTs are considered strong evidence, with a level 1b rating.

Data were audited for number of instrumental deliveries (forceps and vacuum); noninstrumental, or spontaneous vaginal, births (SVB), cesarean births (CB), episiotomies, and lacerations; maternal fatigue; and measures of fetal well-being including accelerations, decelerations, and variability of fetal heart rate, oxygen desaturation, and cord pH. The meta-analysis was conducted using Meta-Analysis with Interactive eXplanations (MIX), a computer program available for free download (Bax, Yu, Ikeda, Tsuruta, Moons, 2006). Relative risk (RR) ratio (fixed effect) was calculated for SVB, CB, instrumental deliveries, lacerations, and episiotomies. Mean difference (fixed effect) was calculated for time spent pushing during second-stage labor. The 95% confidence interval (CI) for each outcome was analyzed. Mantel-Haenszel weighting method was applied. For pooled analyses that were significant, figures were developed that display the results from all studies in that analysis.

Results

  1. Top of page
  2. ABSTRACT
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Methodology of studies

Seven RCTs were found and reviewed (see Table 2). All of the study samples included healthy women with full-term singleton pregnancies who received effective epidural analgesia. While most researchers included only nulliparous women, Hanson et al. (2002) included multiparous women stratified into a separate study arm with both control and experimental groups. Simpson and James (2005) limited inclusion to women with elective inductions, while the other research teams included spontaneous and induced labors. All but one study (Mayberry et al., 1999) excluded women with noncephalic or nonvertex presentation. Most researchers excluded women with obstetric complications such as pregnancy-induced hypertension, diabetes, fetal anomalies, or indications that medically necessitated shortening the second stage. The analgesia medications, doses and concentrations appear to be standard (Table 1), essentially comparable and unlikely to account for any variability in results. However, protocols for epidural care may have varied per site and differences in these factors could potentially have affected the results.

Table 2. characteristics of included studies
StudySampleSettingIntervention GroupsOutcome MeasuresSignificant Findingsa
  1. Note. [DOWNWARDS ARROW]= decrease; [UPWARDS ARROW]= increase; FHR = fetal heart rate; decels = FRH decelerations; decels/min = FRH decelerations per minute.

  2. a Significant findings, p ≤ 0.05. bThe study enrolled 1,864 participants, with a 99.9% completion rate. cThe study enrolled 312 participants, with an 81% completion rate.

Vause et al. (1998)135Leeds General Infirmary, U.K.Pushing within 1 hr of full dilatation; delayed pushing: rest until urge to push, vertex visible, or maximum 3 hrLength of second stage (min); length of pushing time (min); incident of laceration; instrument delivery; 5-min Apgar scoreIn delayed pushing group: [UPWARDS ARROW] length of second stage; [DOWNWARDS ARROW] length of pushing time
Mayberry et al. (1999)153Multisite: four U.S. tertiary-level labor and delivery unitsImmediate pushing; delayed pushing: rest until urge to push or maximum 1 hrLength of second stage (min); 1-min Apgar score; 5-min Apgar score; arterial cord pH; maternal fatigue; incident of lacerations; instrument delivery; perineal lacerationsNo difference in outcomes
Fraser et al. (2000)1,862bMultisite: 12 medical centers (1 United States, 10 Canada, and 1 Switzerland)Immediate pushing; delayed pushing: rest at least 2 hr unless urge to push, medical indication for shortened second stage or fetal head was visible at introitusSecond-stage cesarean delivery; forceps delivery; vacuum delivery; spontaneous vaginal delivery; perineal or cervical tears; intrapartum or postpartum febrile morbidity; length of second stage (min); length of pushing (min); neonatal morbidity index; birth experienceIn delayed pushing group: [DOWNWARDS ARROW] difficult delivery; [DOWNWARDS ARROW] midpelvic procedures; [UPWARDS ARROW] spontaneous vaginal birth; [DOWNWARDS ARROW] length of pushing time; [UPWARDS ARROW] length of second stage; [UPWARDS ARROW] intrapartum fever, related to length of delay: delays 0-59 min = 14% [UPWARDS ARROW], 60-119 min = 73% [UPWARDS ARROW], 120+ min = 133% [UPWARDS ARROW]; [UPWARDS ARROW] abnormal cord pH
Fitzpatrick et al. (2002)178Tertiary teaching hospital, Dublin, IrelandImmediate pushing; delayed pushing: rest for 1 hrSpontaneous vaginal delivery; forceps delivery; vacuum delivery; vacuum/forceps delivery; cesarean delivery; fetal cord pH; incidence of laceration; incidence of episiotomy; incidence of dyspareunia; perineal pain; patient satisfaction with management of labor; preferred mode of deliveryIn delayed pushing group: [UPWARDS ARROW] length of second stage
Hanson et al. (2002)252Tertiary regional hospital, Salt Lake City, UtahImmediate pushing; delayed pushing: rest until head seen at introitus or 2 hrLength of second stage (min); pushing time (min); 1-min Apgar score; 5-min Apgar score; arterial cord pH; maternal fatigue; combined decels/min; mild variables/min; moderate variables/min; severe variables/min; prolonged decels/min; incidence of laceration; instrument deliveryIn delayed pushing group: [UPWARDS ARROW] length of second stage; [DOWNWARDS ARROW] length of pushing time; [DOWNWARDS ARROW] maternal fatigue; [DOWNWARDS ARROW] combined decels/min; [DOWNWARDS ARROW] mild and [DOWNWARDS ARROW] moderate variables/min; [DOWNWARDS ARROW] prolonged decels/min; [UPWARDS ARROW] average uterine contraction rate/min; [UPWARDS ARROW] number of pushes each uterine contraction/min; [DOWNWARDS ARROW] number of position changes/min
Plunkett et al. (2003)202Tertiary academic medical center, Chicago, IllinoisImmediate pushing; delayed pushing: rest until urge to push or maximum 1.5 hrLength of second stage (min); pushing time (min); 5-min Apgar score; arterial cord pH; incidence of laceration; instrument deliveryIn delayed pushing group: [UPWARDS ARROW] length of second stage
Simpson and James (2005)45Tertiary hospital, St. Louis, MissouriImmediate, closed-glottis pushing; delayed, open-glottis pushing: rest until urge to push or maximum 2 hrLength of 2nd stage (min); length of active pushing (min); fetal oxygen desaturations; FRH patterns; 1-min Apgar score; 5-min Apgar score; fetal cord gases: arterial and venous pH, O2, CO2; rate of fetal descent; instrument delivery; perineal lacerationsIn delayed pushing group: [DOWNWARDS ARROW] in perineal lacerations; [UPWARDS ARROW] length of second stage; [DOWNWARDS ARROW] time spent pushing; [DOWNWARDS ARROW] epochs of fetal oxygen desats less than 30% for less than 1 min 59 s; [DOWNWARDS ARROW] variable decels; [DOWNWARDS ARROW] prolonged decels
Table 1. Comparison of Epidural Anesthesia Among Studies
StudyType of AnesthesiaDosageAdministration
Vause et al. (1998)Not specifiedNot specifiedNot specified
Mayberry et al. (1999)0.12-0.25 mg bupivacaine with “only slightly differing amounts of fentanyl”Not specifiedContinuous infusion
Fraser et al. (2000)0.12-0.25 mg bupivacaine with only slightly differing amounts of fentanylNot specifiedContinuous infusion
Fitzpatrick et al. (2002)0.1% bupivacaine and 2 μm/ml fentanyl citrate8-10 ml/hrContinuous infusion
Hanson et al. (2002)“In over 95% of cases bupivacaine was the agent. No subdural component was used”Not specifiedContinuous infusion
Plunkett et al. (2003)0.0625% bupivacaine with 2 μg/ml fentanylBasal infusion rate 15 ml/hr, 5 mL patient-controlled bolus (maximum 30 ml/hr)Continuous infusion/patient controlled
Simpson and James (2005)0.125% bupivacaine with 2 μg/ml fentanyl6-12 ml/hrContinuous infusion

All studies were nonblinded, RCTs with an intention to treat analysis and had at least 80% completion. Randomization was computer generated for all studies; women were randomized upon enrollment in four of the studies (Vause et al.; Hanson et al.; Plunkett et al.; Mayberry et al.) and at the time of complete dilation in the remaining three (Fitzpatrick et al., 2002; Fraser et al., 2000; Simpson & James, 2005). Baseline characteristics were similar in both groups with the exception of Simpson et al. who reported their control group to be slightly older than the experimental group. Plunkett et al. reported that, despite computer-generated randomization, control and experimental groups were unevenly distributed, with 85 participants assigned to immediate pushing and 117 participants assigned to delayed pushing. In addition, more women were induced in Plunkett’s immediate pushing group and this could have inadvertently influenced the management of labor.

All researchers examined the effects of PD versus active pushing in the second stage of labor. Women in delayed pushing groups experienced a delay between full dilation and commencement of active pushing; the fetus passively descended the birth canal during this delay. Women in immediate pushing or EP groups began pushing upon full dilation. Six of the investigative teams compared delayed pushing with immediate pushing at full dilation, whereas Vause et al. (1998) compared delayed pushing with EP or pushing within 1 hour of complete dilation. This difference in interventions could have been clinically significant. Most of the studies included in this review reported that women in the delayed pushing group began to push within 1 hour after full dilatation. Therefore, if Vause et al.’s EP group commenced pushing at a time similar to the delayed pushing groups, the Vause et al. control group may have had a second stage similar to those in the experimental groups. However, Vause et al. did report a significant difference in time between pushing and full dilation in the early versus delayed groups (median of 52 vs. 168 minutes; p < 0.002). Similarly, Plunkett et al. (2003) reported that women in the delayed pushing group waited on average only 10 minutes more than the immediate pushing group, but the researchers did not feel this to have a profound effect on the clinical experience. Additionally, all studies reviewed limited the length of time from full dilation to pushing (PD) in the intervention groups to 2 hours or less.

Waiting to push can result in more spontaneous vaginal births, fewer instrumental deliveries, and less time spent pushing.

Maternal fatigue was measured in only two studies; therefore, meta-analysis was not computed for this outcome. Fraser et al. (2000) used the self-administered Birth Experience Rating Scale to assess perception of control during the labor and birth experience. Significantly, more women in the immediate pushing group moderately or strongly agreed that “I feel that I pushed for a long time” (40.4% vs. 31.4%; p < 0.001). Hanson et al. (2002) used the “Modified Fatigue Symptom Checklist” and a visual analog scale. Nulliparous women in this immediate pushing group reported significantly more overall fatigue (p = 0.017).

The data on fetal well-being were also too disparate to be pooled into a meta-analysis. Fetal well-being was measured by both umbilical cord pH and Apgar. With the exception of Fraser et al., there were no differences in outcomes (Fitzpatrick et al., 2002; Hanson et al., 2002; Mayberry et al., 1999; Plunkett et al., 2003; Simpson & James, 2005; Vause et al., 1998). Fraser et al. measured a difference in abnormal umbilical cord pH (venous value less than 7.15 or arterial value less than 7.10) for the delayed pushing group (RR: 2.54; 95% CI: 1.35-4.43). The authors argue that this finding is of uncertain clinical significance because Neonatal Morbidity Index scores were similar in both groups, despite the difference in pH. Hanson et al. and Simpson et al. demonstrated significant differences in fetal decelerations between groups. Hanson et al. found that fetuses of nulliparous delayed pushing groups experienced fewer combined decelerations per minute (p = 0.001), fewer mild variable decelerations (p = 0.006), and fewer prolonged decelerations per minute than the immediate pushing group (p = 0.011); Simpson et al.’s delayed pushing group showed fewer variable fetal heart rate decelerations, with a mean of 15.6 in the delayed group and 22.4 in the immediate group (p = 0.03).

Results of meta-analyses

The results of the analyzed outcomes are reported in Table 3. Women who labored with PD compared to EP were found to have an increased chance of having an SVB (RR: 1.08; CI: 1.01-1.15), 23% decreased risk of having an instrumental delivery (RR: 0.77; CI: 0.71-0.85), and lower mean time spent pushing during second stage (mean difference: −0.19 hours; CI: −0.27 to −0.12). Thus, immediate pushing decreased a woman’s chance to have an SVB, increased her risk of having an instrumental delivery, and resulted in longer time spent pushing during second stage. No significant differences were found related to risk of CB, risk of lacerations, or risk of episiotomy (Figures 4 through 6).

Table 3. Results of Meta-Analysis by Outcome Measure
Outcome Measure18StudiesPooled Meta-Analysis
  1. Note. RR = relative risk; CI = confidence interval; MD = mean difference.

Spontaneous vaginal birthsVause et al. (1998); Fitzpatrick et al. (2002); Mayberry et al. (1999); Plunkett et al. (2003); Fraser et al. (2000); Simpson and James (2005); Hanson et al. (2002)RR: 1.08 (95% CI: 1.01-1.15)
Use of interventionsVause et al.; Fitzpatrick et al.; Mayberry et al.; Plunkett et al.; Fraser et al.; Simpson and James; Hanson et al.RR: 0.77 (95% CI: 0.71-0.85)
Time spent pushingVause et al.; Fitzpatrick et al.; Fraser et al.; Plunkett et al.; Hanson et al.; Simpson and JamesMD: −0.19 (95% CI: −0.27 to −0.12)
Cesarean birthsVause et al.; Fitzpatrick et al.; Mayberry et al.; Plunkett et al.; Fraser et al.; Simpson and James; Hanson et al.RR: 0.8 (95% CI: 0.57-1.12)
LacerationsVause et al.; Fitzpatrick et al.; Mayberry et al.; Plunkett et al.; Fraser et al.; Simpson and James; Hanson et al.RR: 0.88 (95% CI: 0.72-1.07)
EpisiotomiesVause et al.; Fitzpatrick et al.; Fraser et al.; Simpson and JamesRR: 0.97 (95% CI: 0.88-1.06)
Fetal well-beingVause et al.; Fitzpatrick et al.; Mayberry et al.; Plunkett et al.; Fraser et al.; Simpson and James; Hanson et al.Not applicable
Maternal fatigueFraser et al.; Hanson et al.Not applicable
image

Figure 4. Risk of cesarean birth with delayed pushing versus immediate pushing. Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

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Figure 5. Risk of laceration with delayed pushing versus immediate pushing. Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

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Figure 6. Risk of episiotomy with delayed pushing versus immediate pushing. Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

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The study by Fraser et al. (2000) had the largest weight for SVBs (66.2%), as shown in Figure 1. Similarly, this study had the largest weight in instrumental deliveries (78%; Figure 2) and in time spent pushing during second-stage labor (74.1%; Figure 3).

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Figure 1. Spontaneous vaginal births with delayed pushing versus immediate pushing. Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

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Figure 2. Risk of instrument-assisted delivery with delayed pushing versus immediate pushing. Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

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Figure 3. Time spent pushing during second-stage labor in delayed versus immediate pushing. Note. CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

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Discussion

  1. Top of page
  2. ABSTRACT
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

This meta-analysis included only RCTs. Positive results were found with PD in three important outcomes (SVB, instrumental deliveries, and time spent pushing). This evidence aids in drawing conclusions on PD versus immediate pushing during second-stage labor.

These findings are significant to laboring women. In respect to risk of having an instrumental delivery, it is of note that difficult (e.g., instrumental) deliveries are correlated with significant maternal morbidity, such as perineal damage, fecal incontinence, anal sphincter injury, and pudendal nerve damage (Fitzpatrick et al., 2002; Fraser et al., 2000), that may last a lifetime and strongly affect a woman’s health and quality of life. Therefore, any procedure that increases a woman’s risk of experiencing a difficult delivery, as does immediate pushing, may increase her risk of maternal morbidity.

Of great importance in this meta-analysis is the finding that PD significantly decreases pushing time in women with epidural analgesia, whereas immediate pushing resulted in longer time spent pushing. Roberts (2002) stated that time spent actively pushing may be directly related to maternal morbidity, by increasing the risk of difficult deliveries, and neonatal morbidity, by increasing fetal pH. Furthermore, less time spent pushing may correlate with decreased maternal fatigue. While more data are needed on the latter measure, the evidence that exists supports this finding and suggests that women may be more fatigued when immediate pushing is implemented than if PD is allowed.

This meta-analysis was limited to only RCTs. Data included a total of 2,827 women, and the studies were conducted in multiple countries, including Europe, Canada, and the United States. While seven RCTs met the criteria, the sample sizes of most of these studies were small and the meta-analytic results were weighted heavily by Fraser et al. (2000). The pushing method was not consistent among studies and, as Roberts (2002) indicates, method of pushing has been shown to affect neonatal cord pH. All studies limited the length of PD to 2 hours or less; thus, this review cannot determine the effects of PD lasting longer than 2 hours. Additionally, epidural protocols were not described in the studies and variations in these factors could potentially have affected the results. Large-scale studies that control the above issues are needed to confirm the results of this meta-analysis.

However, current research indicates that immediate pushing can increase birth complications, whereas PD can prevent birth complications. Further research is needed that includes much larger sample sizes, more control of confounders such as method of pushing (coached vs. noncoached and open glottis vs. closed glottis) and length of delay, and longer follow-up times. These studies should follow-up on neonatal and infant health, as well as maternal perineal trauma including urinary and anal incontinence and sexual health, and the degree to which any such trauma affects the quality of life of women. More research is needed on maternal fatigue and on women’s perceptions of their labor and birth experiences, as this can greatly enhance women’s experiences of childbirth.

Passive descent is recommended in healthy women with uncomplicated labors and effective epidural analgesia. Women should begin to push when they feel the urge.

The research concludes that allowing the fetus to passively descend the birth canal, instead of pushing immediately upon full dilation, is a safe and effective method of increasing SVBs, decreasing instrumental deliveries, and shortening pushing time. This review recommends the use of PD during the second stage of labor in healthy women with effective epidural analgesia to promote better birth experiences and outcomes for mother and baby. Based on the criteria of the studies reviewed in this article, healthy women without complicated labors and with a singleton fetus should be allowed to labor with PD for as long as 2 hours, until the head is visible at the introitus or until they have an irresistible urge to push.

Acknowledgments

  1. Top of page
  2. ABSTRACT
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Funded in part by the Jonas Center for Nursing Excellence and the Registered Nurse Division of 1199 Service Employees International Union (SEIU).

References

  1. Top of page
  2. ABSTRACT
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References
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