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Background: Labor and delivery nurses and obstetric practitioners currently manage second stage of labor by either instructing women to actively push at the time of complete dilation or by delaying pushing for up to two hours or until the patient feels an irresistible urge to push. Labor and delivery nurses at our community hospital have not seen a change in practice based on the recent published studies addressing this topic. Therefore, our group of labor and delivery nurses conducted their own randomized trial comparing the two methods of managing second stage. Fatigue and satisfaction have not been concepts addressed in previous published studies, but were included in this trial. Impact to the fetus was also included.

Objective: The purpose of this study was to determine the impact of delayed and immediate pushing on length of active pushing during second stage of labor in nulliparous women with epidural anesthesia.

Sample: The study had a convenience sample of 77 nulliparous laboring women with epidural anesthesia admitted for delivery to a community hospital.

Methods: In a randomized clinical trial, nulliparous laboring mothers with epidural anesthesia were randomly assigned when cervical dilatation was 10 cm to one of two methods for supporting second stage of labor: immediate or delayed pushing (up to 120 minutes). The primary outcome variable was length of pushing during second stage of labor, with secondary variables of maternal fatigue, maternal satisfaction, length of second stage of labor, and fetal well-being. Maternal fatigue and satisfaction were measured with a visual analog scale (VAS). Fetal well-being was measured using APGAR scores (1 & 5 minute). Data was analyzed with Analysis of Variance (ANOVA), with p < 0.05 significance.

Results: The immediate pushing group averaged 94 (± 57) minutes in active pushing while the delayed pushing group averaged 68 (± 46) minutes; a statistically significant difference (p = 0.04). The immediate pushing group had a mean one minute APGAR score of 7.5 and the delayed pushing group had a mean one minute APGAR of 7.9; this result is also statistically significant (p=0.0493). The difference in groups for the five minute APGAR score was not statistically different. Maternal fatigue scores after delivery increased slightly in both groups from scores at the beginning of second stage of labor. No significant differences were found in fatigue scores between the immediate and delayed pushing groups (p > 0.05). No differences were found in maternal satisfaction scores.

Implications for Practice: This study found that when cervical dilatation is complete, the practice of delayed pushing statistically and clinically decreases the time that patients spend pushing during the second stage of labor. In an effort to preserve maternal energy and decrease impact to the fetus during active pushing, we believe that delayed pushing has significant practical application in the labor and delivery setting. We also believe that a more sensitive tool or subjective method of study would better to evaluate fatigue and satisfaction associated with pushing in second stage and would recommend this for further study.