Should Moms Wait to Push During Delivery?

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Women in labor face a myriad of options and decisions they must discuss with their doctors, including when to start pushing. But the question remains, can the timing of when a woman begins to push affect the outcome of the birth?
According to a new study in JAMA, there are two common approaches as to when to push. Both advise waiting until full dilation at 10 centimeters.
The first method is to start pushing when fully dilated along with uterine contractions; the other is to delay pushing to allow for the fetus to spontaneously descend.
Researchers wanted to know if waiting leads to disadvantages for mother or child and started a study looking at more than 2,000 women giving birth.
What did the study find?
Dr. Alison G. Cahill, division chief of maternal-fetal medicine at the Washington University School of Medicine in St. Louis, Missouri, led a randomized clinical trial and found that it did not appear to matter statistically whether women push upon full dilation or wait.
But waiting did appear to have some disadvantages in certain cases.
The study included about 2,400 women who were given an epidural. All of the women were giving birth for the first time.
About half of the women in the study began pushing immediately after dilation, and the rest waited at least one hour. Statistically, there was not much difference between the groups.
However, they did note that women who delayed pushing had slightly higher rates of hemorrhage and infection.
In a related editorial in JAMA, Dr. Jeffrey D. Sperling and Dr. Dana R. Gossett from the University of California, San Francisco, said the recent study gave more context for risks and benefits of delayed pushing. This information could help parents and doctors make and plan for the delivery.
They pointed out that delayed pushing does not reduce the risk of cesarean delivery. But it also lengthens the duration of the second stage of labor without evidence of benefit to mother or infant, they wrote.
Sperling and Gossett also brought up a new technology that could improve outcomes no matter when mom starts to push. They referenced recent International Society of Ultrasound in Obstetrics and Gynecology guidelines for using ultrasonography during labor. They say the tool could help better gauge the infant’s position to better assess the feasibility of vaginal delivery. It could also give physicians critical insights to help determine when a patient should begin to push.
“This technique could also minimize unnecessary clinical examinations and improve maternal satisfaction,” they wrote.
Push or pause?
So what does this mean for expectant parents worried about a difficult delivery?
Dr. Chloe A. Zera, an obstetrician at Beth Israel Deaconess Medical Center in Boston who was not affiliated with the research, said the study implies that there’s not much evidence delaying pushing has benefits. Also pushing earlier means ending that second stage of labor earlier and giving moms a break.
Currently, doctors recommend a woman push when fully dilated, but older research found some women preferred to wait.
“Delaying pushing is not an effective strategy to decrease the likelihood of a cesarean or operative vaginal delivery and may increase the risk for infection,” she noted.
Dr. Lynn Yee, an assistant professor of maternal-fetal medicine at Northwestern Medicine in Chicago also not related to the research, thought that the findings were interesting.
“These findings from a very high-quality study demonstrate that waiting to push does not improve a woman’s likelihood of having a spontaneous vaginal delivery, and in fact, some risks appear to be greater when women wait to push,” Yee said.
Women who wait to push experience a longer second stage of labor, and we know that longer time in labor is associated with complications, she said.
Yee noted that women and their doctors must discuss how to best manage labor, but this information may be helpful in guiding decisions about when to push.
“Ultimately, obstetric care always needs to be individualized,” Yee added.