R

ESEARCH

JOGNN
A Meta-Analysis of Passive Descent
Versus Immediate Pushing in
Nulliparous Women With Epidural
Analgesia in the Second Stage of Labor
Robyn M. Brancato1, Sara Church2, and Patricia W. Stone3

Correspondence
Robyn M. Brancato, MA, BS,
RN, 270 Fort Washington Avenue
3, New York, NY 10032.
rb2449@columbia.edu

ABSTRACT
Objective: To determine which method of pushingpassive descent or early pushingmost 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.

Keywords
second stage
management
passive descent laboring
downrest and descend
physiologic second stage

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 womans 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.

JOGNN, 37, 4-12; 2008. DOI: 10.1111/J.1552-6909.2007.00205.x

Accepted October 2007

1MA, BS, RN, is a midwifery

student, Columbia University,
New York, NY.

2BS,

n the past 35 years, epidural analgesia has become a

(PD). The practice involves allowing the woman to delay

more common method of pain management used in

pushing until she feels the urge to push or the head is

the hospital setting. One of the negative effects of epidu-

visible at the vaginal introitus (delayed pushing). Re-

RN, is a midwifery student,

Columbia University, New York,
NY.

ral analgesia is that it often decreases a womans lower

search on passive descent has been inconclusive and,

body sensations, thereby inhibiting her natural urge to

indeed, both methods have been equally praised and

push upon full cervical dilation. Obstetrics, with its long

criticized (Beynon, 1957; Crawford, 1983; Manyonda,

3PhD,

history of active management of labor (Brancato, 2006;

Shaw, & Drife, 1990; Peterson & Besuner, 2007). Be-

Roberts, 2002; Rooks, 1997), often compensates for this

cause immediate pushing is an artificial construct of

inhibition by directing women to push immediately upon

obstetrics that gained practice with the development of

MPH, MS, is an associate

professor of nursing, Columbia
University, New York, NY.

full cervical dilation (immediate or early pushing [EP]).

This method may not be evidence based. The natural

epidural analgesia, it is questionable whether this management practice is best for mother and baby.

second stage includes a period of rest and descent

The chief concern from opponents of delayed pushing

(Roberts, 2003) during which the fetus descends pas-

is that it prolongs the second stage of labor. A length-

sively, and when this occurs in the clinical setting, it is

ened second stage can signify impending labor compli-

often termed as laboring down or passive descent

cations and, in the past, was thought to cause adverse

2008, AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

http://jognn.awhonn.org

Brancato, R. M., Church, S., and Stone, P. W.

ESEARCH

consequences to mom and baby; thus, the American

College of Obstetricians and Gynecologists (ACOG) recommended limiting the second stage to 2 hours (ACOG,
1994). However, researchers have recently demonstrated

Epidural analgesia significantly affects second-stage pushing.

When women do not feel the urge, pushing is more difficult for
both women and nurses.

that this limit is null and ACOG has amended its recommendation (1995, 2003). Yet, ACOG does recommend

registered nurses, obstetricians, and midwives base

considering operative delivery when 3 hours have

their decisions during labor on the research data,

elapsed for a nullipara with anesthesia and 2 hours for a

thereby encouraging evidence-based practice and (b)

multipara with anesthesia (Roberts, 2002) due to con-

allow women to have the most optimal childbirth

cerns over maternal and fetal acidosis. Delayed pushing,

experiences.

because it incorporates a rest period between full dilatation and pushing, can prolong the second stage.

Methods

Concerns about adverse consequences associated

Studies were identified by searching MEDLINE, CIN-

with prolonged second stage may be unwarranted, as

HAL, and the Cochrane Register of Controlled Trials; a

researchers suggest that it is the length of active push-

hand search of references was then performed on the

ing, not the length of second stage, that may be delete-

identified articles. The search terms included epidural,

rious; indeed, prolonged active pushing has been

passive descent, laboring down, physiologic 2nd stage,

shown to increase the incidence of fetal and maternal

delayed pushing, spontaneous pushing, passive sec-

acidosis, which is indicated by lactic acid, partial pres-

ond stage, second stage pause, passive fetal descent

sure of carbon dioxide, and pH at the time of birth.

and rest and descend. This review was limited to RCTs

Roberts (2002) suggests that the latter findings should

written in English that compared PD to early or immedi-

cause providers to limit the duration of active pushing,

ate pushing in laboring women who received epidural

not the duration of second stage.

analgesia. According to the Oxford-Centre of Evidence-

In fact, investigators found delayed pushing with epidu-

Based Medicine (2001), these RCTs are considered

ral analgesia shortens the duration of active pushing,

strong evidence, with a level 1b rating.

while immediate pushing or EP causes a longer dura-

Data were audited for number of instrumental deliveries

tion of active pushing (Fitzpatrick et al., 2002; Fraser

(forceps and vacuum); noninstrumental, or spontane-

et al., 2000; Hanson, Clark, & Foster, 2002; Manyonda

ous vaginal, births (SVB), cesarean births (CB), episiot-

et al., 1990; Mayberry, Hammer, Kelly, True-Driver, & De,

omies, and lacerations; maternal fatigue; and measures

1999; Peterson & Besuner, 1997; Plunkett, Lin, Wong,

of fetal well-being including accelerations, decelera-

Grobman, & Peaceman, 2003; Roberts, 2002; Simpson

tions, and variability of fetal heart rate, oxygen desatu-

& James, 2005; Vause, Congdon, & Thornton, 1998).

ration, and cord pH. The meta-analysis was conducted

Passive descent may allow for further fetal descent and

using Meta-Analysis with Interactive eXplanations (MIX),

rotation, better situating the fetus in the womans pelvis,

a computer program available for free download (Bax,

and causing further release of oxytocin to augment the

Yu, Ikeda, Tsuruta, Moons, 2006). Relative risk (RR) ratio

progress of labor. These factors may encourage more

(fixed effect) was calculated for SVB, CB, instrumental

forceful contractions, an urge to push, and a smoother

deliveries, lacerations, and episiotomies. Mean differ-

crowning, all of which may lead to fewer instrumental

ence (fixed effect) was calculated for time spent push-

deliveries, less maternal fatigue, and less perineal dam-

ing during second-stage labor. The 95% confidence

age (Roberts, 2002). A physician describes the risks of

interval (CI) for each outcome was analyzed. Mantel-

pushing upon complete dilatation when no urge is felt:

Haenszel weighting method was applied. For pooled

The result will often be a long period of increasing ma-

analyses that were significant, figures were developed

ternal exhaustion, with accompanying metabolic acido-

that display the results from all studies in that analysis.

sis (and thus infusion acidosis of the fetus) culminating

in an instrument-assisted delivery because the patience
and fortitude of all have been dissipated (Crawford,

Results

1983, p. 271).

Methodology of Studies

In an attempt to prevent ineffective patterns of pushing,

Seven RCTs were found and reviewed (see Table 2). All

maternal exhaustion, practitioner frustration, instrumental

of the study samples included healthy women with

deliveries, and other interventions, researchers have

full-term singleton pregnancies who received effective

begun to study immediate versus delayed pushing in

epidural analgesia. While most researchers included

randomized controlled trials (RCTs). This meta-analysis

only nulliparous women, Hanson et al. (2002) included

was conducted to analyze trends in the evidence and

multiparous women stratified into a separate study arm

determine practice implications and aims to (a) help

with both control and experimental groups. Simpson

JOGNN 2008; Vol. 37, Issue 1

ESEARCH

Meta-Analysis of Passive Descent Versus Immediate Pushing

All researchers examined the effects of PD versus ac-

Waiting to push can result in more spontaneous vaginal births, fewer

instrumental deliveries, and less time spent pushing.

tive pushing in the second stage of labor. Women in

delayed pushing groups experienced a delay between full dilation and commencement of active push-

and James (2005) limited inclusion to women with elec-

ing; the fetus passively descended the birth canal

tive inductions, while the other research teams included

during this delay. Women in immediate pushing or EP

spontaneous and induced labors. All but one study

groups began pushing upon full dilation. Six of the in-

(Mayberry et al., 1999) excluded women with nonce-

vestigative teams compared delayed pushing with im-

phalic or nonvertex presentation. Most researchers ex-

mediate pushing at full dilation, whereas Vause et al.

cluded women with obstetric complications such as

(1998) compared delayed pushing with EP or pushing

pregnancy-induced hypertension, diabetes, fetal anom-

within 1 hour of complete dilation. This difference in in-

alies, or indications that medically necessitated shorten-

terventions could have been clinically significant. Most

ing the second stage. The analgesia medications, doses

of the studies included in this review reported that

and concentrations appear to be standard (Table 1), es-

women in the delayed pushing group began to push

sentially comparable and unlikely to account for any

within 1 hour after full dilatation. Therefore, if Vause et

variability in results. However, protocols for epidural

al.s EP group commenced pushing at a time similar to

care may have varied per site and differences in these

the delayed pushing groups, the Vause et al. control

factors could potentially have affected the results.

group may have had a second stage similar to those in

All studies were nonblinded, RCTs with an intention to

treat analysis and had at least 80% completion. Randomization was computer generated for all studies;
women were randomized upon enrollment in four of the
studies (Vause et al.; Hanson et al.; Plunkett et al.;
Mayberry et al.) and at the time of complete dilation in
the remaining three (Fitzpatrick et al., 2002; Fraser et al.,
2000; Simpson & James, 2005). Baseline characteristics
were similar in both groups with the exception of Simpson et al. who reported their control group to be slightly
older than the experimental group. Plunkett et al. reported

the experimental groups. However, Vause et al. did report a significant difference in time between pushing
and full dilation in the early versus delayed groups
(median of 52 vs. 168 minutes; p < 0.002). Similarly,
Plunkett et al. (2003) reported that women in the delayed pushing group waited on average only 10 minutes
more than the immediate pushing group, but the researchers did not feel this to have a profound effect on
the clinical experience. Additionally, all studies reviewed
limited the length of time from full dilation to pushing
(PD) in the intervention groups to 2 hours or less.

that, despite computer-generated randomization, control

Maternal fatigue was measured in only two studies;

and experimental groups were unevenly distributed, with

therefore, meta-analysis was not computed for this out-

85 participants assigned to immediate pushing and 117

come. Fraser et al. (2000) used the self-administered

participants assigned to delayed pushing. In addition,

Birth Experience Rating Scale to assess perception of

more women were induced in Plunketts immediate push-

control during the labor and birth experience. Significantly,

ing group and this could have inadvertently influenced

more women in the immediate pushing group moder-

the management of labor.

ately or strongly agreed that I feel that I pushed for a

Table 1: Comparison of Epidural Anesthesia Among Studies

Study

Type of Anesthesia

Dosage

Administration

Vause et al. (1998)

Not specified

Not specified

Not specified

Mayberry et al. (1999)

0.12-0.25 mg bupivacaine with only

slightly differing amounts
of fentanyl

Not specified

Continuous infusion

Fraser et al. (2000)

0.12-0.25 mg bupivacaine with only

slightly differing amounts of fentanyl

Not specified

Continuous infusion

Fitzpatrick et al. (2002)

0.1% bupivacaine and 2 m/ml

fentanyl citrate

8-10 ml/hr

Continuous infusion

Hanson et al. (2002)

In over 95% of cases bupivacaine

was the agent. No subdural
component was used

Not specified

Continuous infusion

Plunkett et al. (2003)

0.0625% bupivacaine with

2 g/ml fentanyl

Basal infusion rate 15 ml/hr, 5 mL

patient-controlled bolus
(maximum 30 ml/hr)

Continuous infusion/patient
controlled

Simpson and James (2005)

0.125% bupivacaine with

2 g/ml fentanyl

6-12 ml/hr

Continuous infusion

JOGNN, 37, 4-12; 2008. DOI: 10.1111/j.1552-6909.2007.00205.x

http://jognn.awhonn.org

Brancato, R. M., Church, S., and Stone, P. W.

ESEARCH

Table 2: Characteristics of Included Studies

Setting

Intervention Groups

Outcome Measures

Significant Findingsa

Vause et al.
(1998)

135

Leeds General
Infirmary, U.K.

Pushing within 1 hr of
full dilatation; delayed
pushing: rest until urge
to push, vertex visible,
or maximum 3 hr

Length of second stage (min);

length of pushing time (min);
incident of laceration;
instrument delivery;
5-min Apgar score

In delayed pushing group: - length of

second stage; length of pushing time

Mayberry et al.
(1999)

153

Multisite:
four U.S.
tertiary-level
labor and
delivery
units

Immediate pushing;
delayed pushing:
rest until urge to
push or maximum
1 hr

Length of second stage (min);

1-min Apgar score; 5-min
Apgar score; arterial cord
pH; maternal fatigue;
incident of lacerations;
instrument delivery;
perineal lacerations

No difference in outcomes

1,862b

Multisite: 12
medical
centers
(1 United
States,
10 Canada,
and 1
Switzerland)

Immediate pushing;
delayed pushing:
rest at least 2 hr
unless urge to push,
medical indication for
shortened second
stage or fetal head
was visible at introitus

Second-stage cesarean
delivery; forceps delivery;
vacuum delivery;
spontaneous vaginal
delivery; perineal or
cervical tears; intrapartum
or postpartum febrile
morbidity; length of second
stage (min); length of pushing
(min); neonatal morbidity
index; birth experience

In delayed pushing group: difficult

delivery; midpelvic procedures; spontaneous vaginal birth; length of
pushing time; - length of second
stage; - intrapartum fever, related to
length of delay: delays 0-59 min = 14%
-, 60-119 min = 73% -, 120+ min =
133% -; - abnormal cord pH

Study

Fraser et al.
(2000)

Sample

Fitzpatrick
et al. (2002)

178

Tertiary teaching
hospital, Dublin,
Ireland

Immediate pushing;
delayed pushing:
rest for 1 hr

Spontaneous vaginal
delivery; forceps delivery;
vacuum delivery;
vacuum/forceps delivery;
cesarean delivery; fetal
cord pH; incidence of
laceration; incidence of
episiotomy; incidence of
dyspareunia; perineal
pain; patient satisfaction
with management of labor;
preferred mode of delivery

In delayed pushing group: - length of

second stage

Hanson et al.
(2002)

252

Tertiary
regional
hospital,
Salt Lake
City, Utah

Immediate pushing;
delayed pushing:
rest until head
seen at introitus
or 2 hr

Length of second stage

(min); pushing time (min);
1-min Apgar score; 5-min
Apgar score; arterial
cord pH; maternal fatigue;
combined decels/min;
mild variables/min; moderate
variables/min; severe
variables/min; prolonged
decels/min; incidence of
laceration; instrument delivery

In delayed pushing group: - length of

second stage; length of pushing
time; maternal fatigue; combined
decels/min; mild and moderate
variables/min; prolonged decels/min;
- average uterine contraction rate/min;
- number of pushes each uterine
contraction/min; number of position
changes/min

Plunkett et al.
(2003)

202

Tertiary
academic
medical center,
Chicago,
Illinois

Immediate pushing;
delayed pushing:
rest until urge to
push or maximum
1.5 hr

Length of second stage (min);

pushing time (min); 5-min
Apgar score; arterial cord
pH; incidence of laceration;
instrument delivery

In delayed pushing group: - length of

second stage

Simpson
and James
(2005)

45

Tertiary hospital,
St. Louis,
Missouri

Immediate,
closed-glottis
pushing; delayed,
open-glottis
pushing: rest until
urge to push or
maximum 2 hr

Length of 2nd stage (min);

length of active pushing
(min); fetal oxygen
desaturations; FRH patterns;
1-min Apgar score;
5-min Apgar score; fetal
cord gases: arterial and
venous pH, O2, CO2; rate
of fetal descent; instrument
delivery; perineal lacerations

In delayed pushing group: in perineal

lacerations; - length of second stage;
time spent pushing; epochs of fetal
oxygen desats less than 30% for less
than 1 min 59 s; variable decels;
prolonged decels

Note. = decrease; - = increase; FHR = fetal heart rate; decels = FRH decelerations; decels/min = FRH decelerations per minute.
aSignificant findings, p 0.05. bThe study enrolled 1,864 participants, with a 99.9% completion rate. cThe study enrolled 312 participants, with an 81% completion rate.

JOGNN 2008; Vol. 37, Issue 1

ESEARCH

Meta-Analysis of Passive Descent Versus Immediate Pushing

Table 3: Results of Meta-Analysis by Outcome Measure

With the exception of Fraser et al., there were no

differences in outcomes (Fitzpatrick et al., 2002;
Hanson et al., 2002; Mayberry et al., 1999; Plunkett

Outcome Measure18

Studies

Pooled Meta-Analysis

Spontaneous
vaginal births

Vause et al. (1998); Fitzpatrick et al. (2002);

Mayberry et al. (1999); Plunkett et al.
(2003); Fraser et al. (2000); Simpson and
James (2005); Hanson et al. (2002)

RR: 1.08 (95%

CI: 1.01-1.15)

Use of interventions

Vause et al.; Fitzpatrick et al.; Mayberry

et al.; Plunkett et al.; Fraser et al.;
Simpson and James; Hanson et al.

RR: 0.77 (95%

CI: 0.71-0.85)

ing group (RR: 2.54; 95% CI: 1.35-4.43). The authors

Time spent pushing

Vause et al.; Fitzpatrick et al.; Fraser

et al.; Plunkett et al.; Hanson et al.;
Simpson and James

MD: 0.19 (95%

CI: 0.27 to 0.12)

cance because Neonatal Morbidity Index scores

Vause et al.; Fitzpatrick et al.; Mayberry

et al.; Plunkett et al.; Fraser et al.;
Simpson and James; Hanson et al.

RR: 0.8 (95%

CI: 0.57-1.12)

significant differences in fetal decelerations between

Vause et al.; Fitzpatrick et al.; Mayberry

et al.; Plunkett et al.; Fraser et al.;
Simpson and James; Hanson et al.

RR: 0.88 (95%

CI: 0.72-1.07)

rous delayed pushing groups experienced fewer

Episiotomies

Vause et al.; Fitzpatrick et al.; Fraser et al.;

Simpson and James

RR: 0.97 (95%

CI: 0.88-1.06)

fewer prolonged decelerations per minute than the im-

Fetal well-being

Vause et al.; Fitzpatrick et al.; Mayberry

et al.; Plunkett et al.; Fraser et al.;
Simpson and James; Hanson et al.

Not applicable

Fraser et al.; Hanson et al.

Not applicable

Cesarean births

Lacerations

Maternal fatigue

et al., 2003; Simpson & James, 2005; Vause et al.,

1998). Fraser et al. measured a difference in abnormal umbilical cord pH (venous value less than 7.15
or arterial value less than 7.10) for the delayed pushargue that this finding is of uncertain clinical signifiwere similar in both groups, despite the difference in
pH. Hanson et al. and Simpson et al. demonstrated
groups. Hanson et al. found that fetuses of nullipacombined decelerations per minute (p = 0.001),
fewer mild variable decelerations (p = 0.006), and
mediate pushing group (p = 0.011); Simpson et al.s
delayed pushing group showed fewer variable fetal
heart rate decelerations, with a mean of 15.6 in
the delayed group and 22.4 in the immediate group
(p = 0.03).

Note. RR = relative risk; CI = confidence interval; MD = mean difference.

Results of Meta-Analyses
long time (40.4% vs. 31.4%; p < 0.001). Hanson et al.
(2002) used the Modified Fatigue Symptom Checklist
and a visual analog scale. Nulliparous women in this immediate pushing group reported significantly more
overall fatigue (p = 0.017).

The results of the analyzed outcomes are reported in

Table 3. Women who labored with PD compared to EP
were found to have an increased chance of having an
SVB (RR: 1.08; CI: 1.01-1.15), 23% decreased risk of
having an instrumental delivery (RR: 0.77; CI: 0.71-0.85),
and lower mean time spent pushing during second stage

The data on fetal well-being were also too disparate

(mean difference: 0.19 hours; CI: 0.27 to 0.12). Thus,

to be pooled into a meta-analysis. Fetal well-being

immediate pushing decreased a womans chance to

was measured by both umbilical cord pH and Apgar.

have an SVB, increased her risk of having an instrumental

Figure 1. Spontaneous vaginal births with delayed pushing versus immediate pushing.
Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

JOGNN, 37, 4-12; 2008. DOI: 10.1111/j.1552-6909.2007.00205.x

http://jognn.awhonn.org

Brancato, R. M., Church, S., and Stone, P. W.

ESEARCH

Figure 2. Risk of instrument-assisted delivery with delayed pushing versus immediate pushing.
Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

delivery, and resulted in longer time spent pushing

evidence aids in drawing conclusions on PD versus im-

during second stage. No significant differences were

mediate pushing during second-stage labor.

found related to risk of CB, risk of lacerations, or risk of

episiotomy (Figures 4 through 6).
The study by Fraser et al. (2000) had the largest weight
for SVBs (66.2%), as shown in Figure 1. Similarly, this
study had the largest weight in instrumental deliveries
(78%; Figure 2) and in time spent pushing during
second-stage labor (74.1%; Figure 3).

These findings are significant to laboring women. In

respect to risk of having an instrumental delivery, it is
of note that difficult (e.g., instrumental) deliveries are
correlated with significant maternal morbidity, such as
perineal damage, fecal incontinence, anal sphincter
injury, and pudendal nerve damage (Fitzpatrick et al.,
2002; Fraser et al., 2000), that may last a lifetime and

Discussion

strongly affect a womans health and quality of life.

This meta-analysis included only RCTs. Positive results

risk of experiencing a difficult delivery, as does imme-

were found with PD in three important outcomes (SVB,

diate pushing, may increase her risk of maternal

instrumental deliveries, and time spent pushing). This

morbidity.

Therefore, any procedure that increases a womans

Figure 3. Time spent pushing during second-stage labor in delayed versus immediate pushing.
Note. CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

JOGNN 2008; Vol. 37, Issue 1

ESEARCH

Meta-Analysis of Passive Descent Versus Immediate Pushing

Figure 4. Risk of cesarean birth with delayed pushing versus immediate pushing.
Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

Figure 5. Risk of laceration with delayed pushing versus immediate pushing.

Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

Figure 6. Risk of episiotomy with delayed pushing versus immediate pushing.

Note. RR = relative risk; CI = confidence interval. Size of the square indicates weight of study, as determined using Mantel-Haenszel weighting method.

10

JOGNN, 37, 4-12; 2008. DOI: 10.1111/j.1552-6909.2007.00205.x

http://jognn.awhonn.org

Brancato, R. M., Church, S., and Stone, P. W.

ESEARCH

Of great importance in this meta-analysis is the finding

that PD significantly decreases pushing time in women
with epidural analgesia, whereas immediate pushing
resulted in longer time spent pushing. Roberts (2002)

Passive descent is recommended in healthy women with

uncomplicated labors and effective epidural analgesia. Women should
begin to push when they feel the urge.

stated that time spent actively pushing may be directly

related to maternal morbidity, by increasing the risk of
difficult deliveries, and neonatal morbidity, by increasing fetal pH. Furthermore, less time spent pushing may

cated labors and with a singleton fetus should be

correlate with decreased maternal fatigue. While more

allowed to labor with PD for as long as 2 hours, until

data are needed on the latter measure, the evidence

the head is visible at the introitus or until they have an

that exists supports this finding and suggests that

irresistible urge to push.

women may be more fatigued when immediate pushing

is implemented than if PD is allowed.
This meta-analysis was limited to only RCTs. Data included a total of 2,827 women, and the studies were conducted in multiple countries, including Europe, Canada,
and the United States. While seven RCTs met the criteria,

Acknowledgment
Funded in part by the Jonas Center for Nursing Excellence and the Registered Nurse Division of 1199 Service
Employees International Union (SEIU).

the sample sizes of most of these studies were small and

the meta-analytic results were weighted heavily by Fra-

REFERENCES

ser et al. (2000). The pushing method was not consistent

American College of Obstetricians and Gynecologists. (1994).

among studies and, as Roberts (2002) indicates, method

Operative vaginal delivery (ACOG Technical Bulletin No. 196).

of pushing has been shown to affect neonatal cord pH.

Washington, DC: Author.

All studies limited the length of PD to 2 hours or less;

thus, this review cannot determine the effects of PD lasting longer than 2 hours. Additionally, epidural protocols
were not described in the studies and variations in these

American College of Obstetricians and Gynecologists. (1995). Dystocia and the augmentation of labor (ACOG Technical Bulletin
No. 218). Washington, DC: Author.
American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics. (2003). Dystocia and augmentation of

factors could potentially have affected the results. Large-

labor (ACOG Practice Bulletin No. 49). Obstetrics and Gyne-

scale studies that control the above issues are needed to

cology, 102, 1445-1454.

confirm the results of this meta-analysis.

Bax, L., Yu, L. M., Ikeda, N., Tsuruta, N., & Moons, K. G. M. (2006).
MIX: Comprehensive free software for meta-analysis of causal

However, current research indicates that immediate

pushing can increase birth complications, whereas

research dataVersion 1.54. Retrieved October 25, 2006,

from http://www.mix-for-meta-analysis.info/

PD can prevent birth complications. Further research

Beynon, C. L. (1957). The normal second stage of labour: A plea for

is needed that includes much larger sample sizes,

reform in its conduct. Journal of Obstetrics and Gynaecology

more control of confounders such as method of pushing (coached vs. noncoached and open glottis vs.

of the British Commonwealth, 64, 815-820.

Brancato, R. M. (2006). Does the elective primary cesarean section
reflect a lack of body-trust in women of contemporary society?

closed glottis) and length of delay, and longer follow-

Unpublished masters thesis, University of South Florida,

up times. These studies should follow-up on neonatal

Tampa, FL.

and infant health, as well as maternal perineal trauma

including urinary and anal incontinence and sexual
health, and the degree to which any such trauma affects the quality of life of women. More research is
needed on maternal fatigue and on womens perceptions of their labor and birth experiences, as this can
greatly enhance womens experiences of childbirth.

Crawford, J. S. (1983). The stages and phases of labour: An outworn

nomenclature that invites hazard. Lancet, 2, 271-272.
Fitzpatrick, M., Harkin, R., McQuillan, K., OBrien, C., OConnell, P.R.,
OHerlihy, C. (2002). A randomized clinical trial comparing the
effects of delayed versus immediate pushing with epidural
analgesia on mode of delivery and faecal incontinence. British
Journal of Obstetrics and Gynaecology, 109, 1359-1365.
Fraser, W. D., Marcoux, S., Krauss, I., Douglas, J., Goulet, C., &
Boulvain, M. (2000). Multicenter, randomized, controlled

The research concludes that allowing the fetus to pas-

trial of delayed pushing for nulliparous women in the second

sively descend the birth canal, instead of pushing im-

stage of labor with continuous epidural analgesia. American

mediately upon full dilation, is a safe and effective

Journal of Obstetrics and Gynecology, 182, 1165-1172.

method of increasing SVBs, decreasing instrumental

Hanson, S. L., Clark, S. L., & Foster, J. C. (2002). Active pushing

deliveries, and shortening pushing time. This review

versus passive fetal descent in the second stage of labor:

recommends the use of PD during the second stage of

labor in healthy women with effective epidural analgesia

A randomized controlled trial. Obstetrics and Gynecology, 99,

29-34.
Manyonda, T., Shaw, D. E., & Drife, J. O. (1990). The effect of delayed

to promote better birth experiences and outcomes for

pushing in the second stage of labor with continuous lumbar

mother and baby. Based on the criteria of the studies

epidural analgesia. Acta Obstetricia et Gynecologica Scandi-

reviewed in this article, healthy women without compli-

navica, 68, 291-295.

JOGNN 2008; Vol. 37, Issue 1

11

ESEARCH

Meta-Analysis of Passive Descent Versus Immediate Pushing

Mayberry, L. J., Hammer, R., Kelly, C., True-Driver, B., & De, A. (1999).

Roberts, J. E. (2002). The push for evidence: Management of the sec-

Use of delayed pushing with epidural anesthesia: Findings

from a randomized, controlled trial. Journal of Perinatology, 19,

ond stage. Journal of Midwifery & Womens Health, 47, 2-15.

Roberts, J. E. (2003). A new understanding of the second stage of

26-30.

labor: Implications for nursing care. Journal of Obstetric,

Oxford-Centre of Evidence-Based Medicine. (2001). Levels of evidence. Retrieved November 15, 2006, from http://www.cebm.

Gynecologic, and Neonatal Nursing, 32, 794-801.

Rooks, J. P. (1997). Midwifery and childbirth in America. Philadelphia:

net/levels_of_evidence.asp#levels

Temple University Press.

Peterson, L., & Besuner, P. (1997). Pushing techniques during labor:

Simpson K. R., & James, D. C. (2005). Effects of immediate versus

Issues and controversies. Journal of Obstetric, Gynecologic,

delayed pushing during second stage labor on fetal well-being.

and Neonatal Nursing, 26, 719-726.

12

Nursing Research, 54, 149.

Plunkett, B. A., Lin, A., Wong, C. A., Grobman, W. A., & Peaceman, A.

Vause, S., Congdon, H. M., & Thornton, J. G. (1998). Immediate and

M. (2003). Management of the second stage of labor in nullipa-

delayed pushing in the second stage of labour for nulliparous

ras with continuous epidural anesthesia. Obstetrics and Gyne-

women with epidural analgesia: A randomized controlled trial.

cology, 102, 109-114.

BJOG, 105, 186-188.

JOGNN, 37, 4-12; 2008. DOI: 10.1111/j.1552-6909.2007.00205.x

http://jognn.awhonn.org