A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor

Abstract

Objective: To determine which method of pushing-passive descent or early pushing-most benefits women with epidurals during second-stage labor. Data sources: MEDLINE, CINAHL, and Cochrane Database. Study selection: Studies limited to randomized controlled trials in English, comparing passive descent to early pushing in women with effective epidural analgesia. Data extraction: A hand search was performed. Data included number of instrument-assisted deliveries (forceps and vacuum); noninstrumental or spontaneous vaginal births, cesarean births, pushing time, episiotomies, lacerations; maternal fatigue; and fetal well-being. Data synthesis: Seven studies were eligible for a sample size of 2,827 women. Pooled data indicate that passive descent increases a woman's chance of having a spontaneous vaginal birth (relative risk: 1.08; 95% confidence interval: 1.01-1.15; p = 0.025), decreases risk of having an instrument-assisted deliveries (relative risk: 0.77; 95% confidence interval: 0.77-0.85; p ≤ 0.0001), and decreases pushing time (mean difference: -0.19 hours; 95% confidence interval: -0.27 to -0.12; p ≤ 0.0001). No differences were found in rates of cesarean births (relative risk: 0.80; 95% confidence interval: 0.57-1.12; p = 0.19), lacerations (relative risk: 0.88; 95% confidence interval: 0.72-1.07; p = 0.20), or episiotomies (relative risk: 0.97; 95% confidence interval: 0.88-1.06; p = 0.45). Conclusions: Significant positive effects were found indicating that passive descent should be used during birth to safely and effectively increase spontaneous vaginal births, decrease instrument-assisted deliveries, and shorten pushing time. © 2008, AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.