Effect of delayed pushing on postpartum blood loss in nulliparous women with epidural analgesia

Objective:

To evaluate the association between time until pushing (TUP) after full dilatation of the cervix and blood loss in nulliparous women with epidural analgesia in a prospective observational study.

Methods:

TUP was defined by the time from complete cervical dilatation to the initiation of active pushing. Inclusion criteria were nulliparous women with a planned vaginal delivery after 36 completed weeks of gestation, with epidural analgesia and guided active pushing. The primary outcome was blood loss, which was assessed by drop of hemoglobin after delivery (ΔHb, in g/l), estimated blood loss (EBL, in ml) and rate of ΔHb> 30 g/l as clinically relevant blood loss. In a subgroup analysis, women were divided into three groups based on TUP (group 1: < 60 minutes, group 2: 60 – 120 minutes, group 3: > 120 minutes). Furthermore, secondary maternal and neonatal outcomes were assessed.

Results:

223 women were included in the study. A significant positive correlation between TUP and increased hemoglobin drop was found (ρ= 0.14, p = 0.03). Consistently, rate of ΔHb> 30 g/l was significantly associated with increasing TUP (p < 0.01). The proportion of ΔHb> 30 g/l increased from 15.4% in group 1 to 21.8% in group 2 to 40.7% in group 3. Composite of adverse maternal or neonatal outcomes were not affected by TUP.

Conclusion:

Delayed initiation of active pushing in nulliparous women with epidural analgesia is associated with increased blood loss. To conclude, in contrast to the current FIGO-guideline, delayed pushing in nulliparous women with epidural analgesia is not advisable with respect to maternal blood loss.