title: Management of the second stage of labor in nulliparas with continuous epidural analgesia.
abstract: OBJECTIVE
  To determine if waiting for a strong urge to push in nulliparas with continuous low-concentration epidural analgesia shortens the pushing duration in the second stage.
  
  
  METHODS
  Nulliparas with standardized patient-controlled epidural analgesia (0.0625% bupivacaine with fentanyl 2 microg/mL) were randomly assigned to pushing immediately upon complete cervical dilatation (n = 85) or waiting for a strong urge to push (n = 117). Urge to push and patient satisfaction were quantified on 100-mm visual analogue scales. Duration of pushing and total duration of the second stage were analyzed as survival time data.
  
  
  RESULTS
  Women who delayed pushing and those who pushed immediately were similar with respect to maternal characteristics. Women who delayed pushing had a stronger urge to push (P <.01) and a longer second stage (P <.05) than women who pushed immediately. There was no significant difference in the time spent pushing (median 57 versus 62 minutes, respectively) or the median level of patient satisfaction (80 mm for both groups). There were no significant differences in the overall rates of cesarean delivery (6% versus 12%, respectively), cesarean delivery during the second stage (2% in each group), spontaneous vaginal delivery (70% versus 69%, respectively), or neonatal or maternal morbidity.
  
  
  CONCLUSIONS
  In nulliparas with continuous low-concentration epidural analgesia, delaying pushing until a strong urge is felt does not reduce the duration of pushing in the second stage of labor.
authors.affiliation: Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, USA. p-beth@northwestern.edu
authors.forename: Beth A
authors.initials: BA
authors.lastname: Plunkett
authors.forename: Alex
authors.initials: A
authors.lastname: Lin
authors.forename: Cynthia A
authors.initials: CA
authors.lastname: Wong
authors.forename: William A
authors.initials: WA
authors.lastname: Grobman
authors.forename: Alan M
authors.initials: AM
authors.lastname: Peaceman
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000379:methods*; D016058:Analgesia, Patient-Controlled / Q000379:methods*; D000773:Anesthesia, Obstetrical / Q000379:methods; D002045:Bupivacaine / Q000008:administration & dosage*; D036861:Delivery, Obstetric / Q000379:methods*; D005260:Female; D005865:Gestational Age; D006801:Humans; D007748:Labor Stage, Second; D010147:Pain Measurement / Q000187:drug effects; D010298:Parity; D017060:Patient Satisfaction; D011247:Pregnancy; D011256:Pregnancy Outcome; D011336:Probability; D012016:Reference Values; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D002045:Bupivacaine