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

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 < or = 0.0001), and decreases pushing time (mean difference: -0.19 hours; 95% confidence interval: -0.27 to -0.12; p < or = 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.