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Delivery update: Delayed pushing might do more harm than good

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Having a baby is hard work. Fifteen years ago, the “too posh to push” movement emerged with women believing that it might be better to go straight to a cesarean delivery (C-section) and skip the work of the second stage of labor. This trend contributed to C-section rates as high as 80 to 90 percent in some private obstetrics practices in Brazil.

Fortunately, the idea of opting for C-sections without good reason hasn’t become routine in the U.S. Here, C-sections account for less than 32 percent of births. Still, there are differences of opinion about how doctors should manage timing of pushing in the second stage of labor, especially in women who are having their first babies and choose to have epidurals for pain relief. However, a 2018 study published in The Journal of the American Medical Association (JAMA) has shed some light on whether delayed pushing can reduce the need for C-section – and whether the technique is safe for mothers and babies.

‘Laboring down’ vs. immediate pushing

The practice of “laboring down” or delayed pushing is common among OB providers. Once a woman’s cervix is fully dilated to 10 centimeters, she rests for one to two hours before she starts pushing with contractions. Proponents of this practice suggest that by taking a break before pushing begins can allow the baby’s head to rotate and descend naturally through the birth canal, potentially reducing the need for C-section at the end of labor. 

The JAMA study is a randomized clinical study involving more than 2,400 women who were having their first babies and who opted for epidurals. Once fully dilated, they were randomly assigned to one of two groups: the first group started pushing immediately, and the second labored down for an hour before starting to push.

Data from the study indicated that laboring down did not make a difference in vaginal delivery success. In both groups, nearly 9 out of 10 women achieved a vaginal delivery and the C-section rate was similar. However, the study found some important differences in pushing duration and mother/baby health. 

"Having a baby is hard work. Fifteen years ago, the 'too posh to push' movement emerged with women believing that it might be better to go straight to a cesarean delivery (C-section) and skip the work of the second stage of labor. "

– Robyn Horsager-Boehrer, M.D.

Differences in pushing duration, postpartum health

The women in the immediate pushing group pushed about 9 minutes longer than their counterparts. But overall, their second stage of labor was shorter, and they met their new babies about 32 minutes earlier than the delayed pushing group. Another bit of good news is that patients in both groups reported feeling highly satisfied with their labor management and felt in control of their childbirth experiences

More concerning was the finding that women in the delayed pushing group developed intrauterine infections (chorioamnionitis) and excessive postpartum bleeding more frequently than other women. Babies born to the delayed pushing group also had higher rates of acidemia and suspected sepsis at birth.

The findings of this study suggest there are no clear benefits in waiting to push after the cervix is fully dilated. If a woman is considering this option, the American Congress of Obstetricians and Gynecologists suggests that OB providers discuss potential risks to mothers and babies. 

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