Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article

Second Stage Pushing with Epidural: Early Versus Delayed Pushing

Epidural analgesia has become a prevalent method of pain management in labor. Epidurals give most women excellent pain relief, but are associated with numerous untoward events, including a higher risk of an instrumental vaginal birth, which is associated with more perineal injury.[20] During the 1990s, several research groups assessed whether delaying pushing until fetal descent would lower the rate of instrumental birth and perineal trauma in women using epidurals, compared with the usual policy of encouraging the woman to begin pushing at complete cervical dilatation.

A recent review summarized the studies that assessed the effect of immediate versus delayed pushing in women using epidurals on the likelihood of an instrumental delivery.[21] Nine studies of 2953 healthy, childbearing women were pooled in a meta-analysis. Delayed pushing was associated with a longer second stage but a shorter phase of active pushing. The incidence of instrumental births was lower in women who delayed pushing (RR = 0.92; 95% CI, 0.84-1.01), as were rotational or mid-pelvic instrumental deliveries (RR = 0.69; 95% CI, 0.55-0.87). No statistically significant differences were noted in episiotomies or spontaneous lacerations; however, in this meta-analysis, only 4 of the 9 included studies reported on episiotomy as a key outcome, and only 5 reported on spontaneous lacerations. Because each of these are common covariates with instrumental births, this can be viewed as a limitation of the meta-analysis. Any reduction in instrumental deliveries would be clinically significant in reducing the incidence of genital tract trauma and subsequent postdelivery pain.


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