“LABORING DOWN”Passive DescentDelayed Pushing

Small Randomised Controlled Trials with Different outcome

measures & variable amounts of “time for delay before pushing”

have created fuel for passionate positions

ACOG PRACTICE BULLETIN2003 No 49

• “A prolonged second stage of labor warrants clinical reassessment of the woman, fetus, and expulsive forces”.

• Diagnosis of prolonged 2 nd stage Nulliparous 3 hours with regional anesthesia 2 hours no regional anesthesia Multiparous 2 hours with regional anesthesia 1 hour no regional

“Laboring Down”WHAT IS THE EVIDENCE

• Two robust/referenced studies to date include:

1) One Large Randomised Controlled Trial (2000)

n = 1,862 (1994-1996)

2) One large Meta Analysis Reviewing 7 Randomised Controlled Trials

n = 2,827

Multicenter, randomized, controlled trial of delayed pushing for Nulliparous women in the second stage of labor with Continuous

Epidural Analgesia.

Am J Obstet Gynecol 2000;182:1165 (n = 1862) (1994-1996)

MEDIAN DELAY ~ 2 HOURS ( 40 % > 2 HRS)• Difficult delivery (operative vaginal delivery) was reduced with

delayed pushing (relative risk, 0.79; 95% CI; 0.66-0.95). • The greatest effect was on midpelvic procedures (relative risk,

0.72; 95% CI 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% CI 1.00-1.18).

• Median Pushing time DECREASED ~ 42min 68 minutes (pd) vs 110 minutes (ep)• Scores for a summary indicator, the Neonatal Morbidity Index, were

similarly distributed in the 2 groups.

Multicenter, randomized, controlled trial of delayed pushing for Nulliparous women in the second stage of labor with Continuous

Epidural Analgesia.

Am J Obstet Gynecol 2000;182:1165 (n = 1862) (1994-1996)

MEDIAN DELAY ~ 2 HOURS ( 40 % > 2 HRS)

• Delayed pushing Increased the duration of the second stage a median of 64 minutes

INCREASE RISK OF CHORIO WITH DELAY > 1 HOUR• With the early pushing group as the reference group, the

relative risks of intrapartum fever ( 38.0 c) were: • 1.14 (95% CI; 0.54-2.38 ) NS for delay of 0 to 59 min• 1.73 (95% CI; 1.10-2.72 ) for delay of 60-119 min• 2.33 (95% CI; 1.54-3.51 ) for delay 120 minutes

• Abnormal umbilical cord blood pH ( <7.10 arterial value) was more frequent in the delayed pushing group (RR 2.45, 95% CI 1.35-4. 43). However, scores for a summary indicator, the Neonatal Morbidity Index, were similarly distributed in the 2 groups.

A Meta-Analysis of passive descent versus immediate pushing in Nulliparous women with Epidural analgesia in the second stage of

labor. J Obstet Gynecol Neonatal Nurs. 2008 Jan-Feb;37(1):4-12.

7 RCT’s with n = 2,827 indicate that passive descent:

1) Increases a woman's chance of having a spontaneous vaginal birth vs operative vaginal delivery

(relative risk: 1.08; 95% CI: 1.01-1.15 (CI of 1.00 Not Significant)

2) Decreases risk of having an instrument-assisted deliveries (relative risk: 0.77; 95% CI : 0.77-0.85 )

3) Decreases pushing time (mean difference: 11 minutes) - Several studies limiting the delay to 1 hour only prolonged 2 nd stage4) Only 1 study evaluated risk of infection & demonstrated RR ~ 2 > 1 hr5) Only one study evaluated variables with a decrease in significant variables

No differences were found in rates of:1) Cesarean births (RR: 0.80; 95% CI: 0.57-1.12 )2) Lacerations (RR: 0.88; 95% CI: 0.72-1.07 ) 3) Episiotomies (RR: 0.97; 95% CI: 0.88-1.06 )

Candidates for Delayed PushingMaximum delay 90 minutes

• The decision to delay pushing should reflect the balance between the need to expedite delivery (eg, in the presence of chorioamnionitis or category III FHT) versus the desire to minimize the requirement for operative vaginal delivery in Nulliparous patients with an Epidural.

• CONSIDER delayed pushing until the woman feels an urge to push ( ie turn down epidural if motor block ) while waiting for the head to descend.

• If the FHR tracing is reassuring and the Head is high (< +2 ) Transverse or Occiput Posterior No maternal urge to push,

• When recurrent variable decelerations are occurring but the tracing is otherwise reassuring (eg, accelerations/moderate variability are present), CONSIDER pushing with every other contraction.

Labor Down Summary• Virtually all studies that did demonstrate any benefit were performed

in Nulliparous patients with epidurals. The only consistent benefit demonstrated was that less operative vaginal deliveries (forceps or vacuum) were performed in the passive descent group

• Not Appropriate for patients who have an indication for expedited second stage ( laboring down increased 2nd stage by ~ 1 hr )

eg Chorioamnionitis eg Category III FHT eg Patients with RISK FOR SHOULDER DYSTOCIAWHO ONLY Recommended for NULLIPAROUS patients with an

Epidural and do not have an urge to push or fetal station < +2 OP or TRANSVERSE or Significant variables with pushing HOW If a motor block is present CONSIDER TURNING DOWN or

TURNING OFF the continuous epidural infusion until the patient perceives pelvic pressure / urge to push / or is crowning

HOW LONG 30 MINUTES TO NO LONGER THAN 90 MINUTES