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Delayed versus early pushing in women with epidural analgesia: a systematic review and meta‐analysis
Author(s) -
Roberts Christine L.,
Torvaldsen Siranda,
Cameron Carolyn A.,
Olive Emily
Publication year - 2004
Publication title -
bjog: an international journal of obstetrics and gynaecology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.157
H-Index - 164
eISSN - 1471-0528
pISSN - 1470-0328
DOI - 10.1111/j.1471-0528.2004.00282.x
Subject(s) - public health , library science , research centre , medicine , media studies , sociology , nursing , computer science
Epidural analgesia is highly effective in relieving the pain of labour and childbirth, but it also interferes with the normal mechanism of labour. Trials of delayed pushing have occurred in response to concerns about the association between epidural analgesia and unwanted and potentially harmful outcomes, particularly instrumental delivery. Instrumental deliveries, especially forceps, have been associated with increased risk of urinary and faecal incontinence, sexual problems and organ prolapse. The mechanism for the association between epidural analgesia and increased instrumental deliveries is likely to be multifactorial but may include a weakened desire to push due to diminution of the bearing down reflex, reduced uterine activity and altered clinical practice. Contemporary obstetric practice has women begin pushing as soon as the cervix is fully dilated. Delaying the onset of pushing has been proposed as an alternative that may allow spontaneous descent and rotation of the fetal head, thereby reducing the instrumental delivery rate. On the other hand, delayed pushing prolongs the second stage of labour and this too has been implicated in pelvic floor trauma and subsequent maternal morbidity. Further, second stage is considered to be a time of particular risk to the fetus. A systematic review and meta-analysis of three small studies published in 1992 found both a tendency towards decreased perineal trauma and a decrease in rotational forceps with a policy of delayed pushing, however, there were insufficient data on infant outcomes and no data on pelvic floor morbidity. Since then several more trials of delayed pushing have been published and we undertook to update the systematic review and metaanalysis with the aim of assessing the effectiveness of delayed pushing among women with epidural analgesia in reducing instrumental deliveries and on other measures of maternal and infant morbidity. We aimed to compare the potential benefits and harms of a policy of delayed pushing among women with uncomplicated pregnancies and effective epidural analgesia established in the first stage of labour.