title: A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence.
abstract: OBJECTIVE
  To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function.
  
  
  METHODS
  Prospective, randomised, controlled trial.Tertiary referral maternity teaching hospital.
  
  
  METHODS
  One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing.
  
  
  METHODS
  A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound.
  
  
  METHODS
  Mode of delivery; altered faecal continence.
  
  
  RESULTS
  Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group (P = 0.005). Eighty-four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty-one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies.
  
  
  CONCLUSIONS
  Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing.
authors.affiliation: Department of Obstetrics and Gynaecology, National Maternity Hospital, University College Dublin, Ireland.
authors.forename: Myra
authors.initials: M
authors.lastname: Fitzpatrick
authors.forename: Rosemary
authors.initials: R
authors.lastname: Harkin
authors.forename: Katherine
authors.initials: K
authors.lastname: McQuillan
authors.forename: Conor
authors.initials: C
authors.lastname: O'Brien
authors.forename: P Ronan
authors.initials: PR
authors.lastname: O'Connell
authors.forename: Colm
authors.initials: C
authors.lastname: O'Herlihy
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000379:methods; D016362:Analgesia, Obstetrical / Q000379:methods*; D036861:Delivery, Obstetric / Q000379:methods*; D005113:Extraction, Obstetrical / Q000706:statistics & numerical data; D005242:Fecal Incontinence / Q000209:etiology*; D005260:Female; D006801:Humans; D007748:Labor Stage, Second / Q000502:physiology*; D010298:Parity; D011247:Pregnancy; D011446:Prospective Studies; D011644:Puerperal Disorders / Q000209:etiology*; D013997:Time Factors