Evidence on: Prolonged Second Stage of Labor

May 23, 2017 by

Summary

In reviewing the evidence on the length of pushing times, several trends become clear:

  • The amount of research on this topic has grown significantly in the past few years!
  • Laboring people who have epidurals have significantly longer pushing times compared to those without epidurals.
  • Not all researchers have taken into account the time of delayed pushing in their studies. This makes it difficult to apply some of the research to people with epidurals who have reached 10 centimeters but waited for some time before pushing.
  • The only randomized trial on this topic found that extending the length of pushing by one hour (in line with the new guidelines) decreased the Cesarean rate from 43% to 20%. This study was too small to determine differences in complications for birthing people or newborns.
  • Observational research has shown that for mothers, longer pushing times are related to higher rates of postpartum hemorrhage, infection, and 3rd and 4th degree tears. Severe tears are more common with longer pushing phases even after adjusting for instrumental birth and episiotomy. Unfortunately, no study has measured what impact “hands-on” intervention to speed up the birth (the care provider using their hands to facilitate a prolonged second stage through perineal massage, etc.) might have on tears.
  • Most people with prolonged pushing times will end up with a vaginal birth. However, longer pushing times are still associated with a higher chance of Cesarean and vacuum or forceps assisted birth.
  • For babies, longer pushing times have been associated with higher rates of low Apgar scores, NICU admissions, birth trauma and other newborn health problems. In one study, researchers found the overall combined rate of newborn complications is around 2.5% for first-time mothers who push 3 or more hours.
  • Some of the health problems associated with longer pushing phases might be related to an underlying reason for the prolonged pushing phase, rather than the length of pushing time alone.
  • All of the researchers who mention the new ACOG/SMFM consensus guidelines state that their data support the new guidelines—that laboring people should have additional time to push, given that rates of vaginal birth are high and overall rates of complications are low.
  • Deciding whether or not to continue pushing at a certain time point is an individualized decision, based on weighing the risks and benefits in that particular individual’s situation.

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