Pregnancy SmartShop formulas

Is it safe? · Pregnancy Smart

Delayed pushing with an epidural: risks and evidence

Assigned clinical reviewerMichael Yuzefovich· MD, FACOGDraft · pending clinical reviewUpdated

What does the evidence say about delayed pushing with an epidural during pregnancy?

  1. Current ACOG guidance says the newer evidence supports beginning pushing once full dilation is reached. It cites no spontaneous-delivery advantage with delay and links delayed pushing with a longer second stage and adverse maternal outcomes. 1
  2. A six-center U.S. randomized trial assigned 2,414 first-time mothers at term with neuraxial analgesia to immediate pushing or a one-hour delay. Spontaneous vaginal birth did not differ significantly, while delayed pushing shortened active effort but lengthened the full second stage. 2
  3. In that trial, delayed pushing had higher chorioamnionitis and postpartum-hemorrhage rates. Recruitment stopped early for futility on the primary outcome, so the trial does not show that immediate pushing improves every newborn or maternal outcome. 2
  4. A meta-analysis of 12 randomized trials involving more than 5,400 women found no significant difference in spontaneous vaginal, operative vaginal, or cesarean birth. Delayed pushing reduced active pushing time but prolonged the second stage and was associated with more chorioamnionitis and low cord pH. 3
  5. International guidance is not uniform. WHO's 2018 guideline conditionally supported a one-to-two-hour delay where a longer second stage and perinatal hypoxia can be adequately managed, while newer U.S. ACOG guidance incorporated later trial findings and favors immediate pushing. 4

Is delayed pushing with an epidural safe in each trimester?

  • First trimester. Delayed pushing is a second-stage labor decision, not a first-trimester intervention. Early pregnancy is better used to identify the hospital, labor support, and any medical factors that may affect delivery planning.
  • Second trimester. Ask how the planned birth setting defines the second stage and whether it routinely uses immediate or delayed pushing with neuraxial analgesia. Guidelines differ internationally, so local practice may not be identical.
  • Third trimester. At full dilation, the team weighs fetal descent, urge to push, parity, fetal monitoring, labor progress, and maternal status. Current U.S. guidance generally starts pushing then rather than using a routine one-hour delay.

Frequently asked questions

What does delayed pushing with an epidural mean?

Delayed pushing means waiting after the cervix is fully dilated before actively bearing down, often to allow passive fetal descent or the urge to push to return. Trial protocols have used delays of one, two, or more hours, so the term does not describe one fixed method.

Does delayed pushing increase the chance of vaginal birth?

The large U.S. randomized trial found no significant spontaneous-vaginal-birth difference between immediate pushing and a one-hour delay. A later meta-analysis also found no significant difference in spontaneous vaginal, operative vaginal, or cesarean birth.

Does delayed pushing shorten the time spent actively pushing?

Yes, delayed pushing generally shortens active bearing-down time. That tradeoff comes with a longer total second stage, meaning less active effort does not equal a shorter interval from full dilation to birth.

What risks were higher with delayed pushing?

In the large 2018 U.S. trial, the delayed group had higher rates of chorioamnionitis and postpartum hemorrhage. A 2020 meta-analysis also found more chorioamnionitis and low umbilical-cord pH with delayed pushing, although some findings came from relatively few trials.

Why do some guidelines still mention waiting to push?

WHO's 2018 guidance considered older trials that suggested a modest spontaneous-birth advantage and supported delay only where a longer second stage and perinatal hypoxia could be managed. Current U.S. ACOG guidance incorporated the later large U.S. trial and favors pushing at full dilation.

Does an epidural always remove the urge to push?

No. Sensation varies with the medication, dose, catheter position, and individual response. Some people still feel pressure or an urge to bear down, while others need coaching. The presence or absence of an urge is one part of the bedside plan.

Does an epidural delay delivery?

Epidural analgesia can be associated with a longer second stage, but delayed pushing is a separate management choice made after full dilation. A routine delay further lengthens the full second stage even though it can reduce minutes of active pushing.

Can pushing timing be individualized?

Yes. Immediate pushing is the current U.S. default supported by ACOG, but fetal descent, fetal heart tracing, parity, maternal condition, urge, and patient preferences still matter. A medical reason to expedite birth overrides a planned waiting period.

Related in the library

References

  1. First and Second Stage Labor Management

    ACOG · https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.