Delayed Pushing Okay in Nulliparous Women.

BEAVER CREEK, COLO. -- Nulliparous women in labor can be allowed to delay pushing with a relative degree of safety, Dr. Michael P. Nageotte said at a perinatal conference sponsored by the University of California, Irvine.

Although the issue of whether early pushing is preferable to delayed pushing has not been resolved, the evidence suggests there is no harm in allowing a nulliparous woman to stay on her epidural a little longer and push only when she feels the urge, said Dr. Nageotte of the university, and Memorial Women's Hospital, Long Beach, Calif.

"Some patients might be tired, some might not be real good pushers, and it is probably okay--with all the continuous monitoring--to leave them alone and let them stay on the epidural," he said.

In general, studies that have compared early with delayed pushing have found little difference, Dr. Nageotte said. A metaanalysis he performed of six trials indicates that there is no difference in either cesarean or instrument-assisted delivery rates. Moreover, in one study, there was a difference of only 14 minutes in the average length of second-stage labor (106 minutes versus 120 minutes) when pushing was started immediately at 8 cm of dilation or delayed for 1 hour (J. Perinatol. 19[1]:26-30, 1999).

That study also found no difference in perineal trauma, he noted.

Fetal outcome does not appear to be affected either, he said. According to historical data and data from countries where labors can go on for very extended periods of time without intervention, there is an increase in adverse fetal events with protracted labor. But in studies done with fetal monitoring, duration of labor is not related to fetal Apgar scores or acid-based status (Br. J. Obstet. Gynaecol. 90[7]:623-27, 1983).

The sole exception to his conclusion is a recent study that he did not include in his ...