When to stop pushing: effects of duration of second-stage expulsion efforts on maternal and neonatal outcomes in nulliparous women with epidural analgesia.
OBJECTIVE
The purpose of this study was to assess the influence of the duration of active second-stage labor on maternal and neonatal outcomes.


METHODS
Secondary analysis of the Pushing Early Or Pushing Late with Epidural trial that included 1862 nulliparous women with epidural analgesia who were in the second stage of labor. According to duration of active second-stage labor, we estimated the proportion of spontaneous vaginal deliveries (SVD) with a newborn infant without signs of asphyxia (5-minute Apgar score > or =7 and arterial pH >7.10). We also analyzed maternal and neonatal outcomes according to the duration of expulsive efforts.


RESULTS
Relative to the first hour of expulsive efforts, the chances of a SVD of a newborn infant without signs of asphyxia decreased significantly every hour (1- to 2-hour adjusted odds ratio, 0.4; 95% confidence interval [CI], 0.3-0.6; 2- to 3-hour adjusted odds ratio, 0.1; 95% CI, 0.09-0.2; >3-hour adjusted odds ratio, 0.03; 95% CI, 0.02-0.05). The risk of postpartum hemorrhage and intrapartum fever increased significantly after 2 hours of pushing.


CONCLUSIONS
Faced with a decreasing probability of SVD and increased maternal risk of morbidity after 2 hours, we raise the question as to whether expulsive efforts should be continued after this time.
Le Ray
Camille
C
Department of Obstetrics and Gynecology, Sainte Justine Hospital, University of Montréal, Montreal, QC, Canada. camille.leray@gmail.com
Audibert
François
F
Goffinet
François
F
Fraser
William
W
D000328:Adult; D015360:Analgesia, Epidural; D016362:Analgesia, Obstetrical; D036861:Delivery, Obstetric; D005260:Female; D005334:Fever / Q000453:epidemiology; D006801:Humans; D007748:Labor Stage, Second; D015999:Multivariate Analysis; D010298:Parity; D006473:Postpartum Hemorrhage / Q000453:epidemiology; D011247:Pregnancy; D011256:Pregnancy Outcome; D012307:Risk Factors; D013997:Time Factors; D055815:Young Adult