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Recording available 2/16-5/2
Recording available 2/16-5/2
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Abstract Award
Abstract Award
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Foundation Awardee

Poster Session 2

Category: Obstetric Quality and Safety

Poster Session 2

(570) Delayed pushing in second stage: Variation in de-implementation in real world clinical settings

Wednesday, February 11, 2026
3:30 PM - 5:00 PM  
Objective:
The American College of Obstetricians and Gynecologists (ACOG) recommends that pushing commence when complete cervical dilation is achieved, rather than delaying pushing or “laboring down,” particularly when an epidural is in place. In a statewide quality collaborative, we assess the use of this evidence-based practice in a nulliparous term, singleton, vertex (NTSV) population

Study Design:

Retrospective cohort study of NTSV births from 1/1/2020- 12/31/2024 in the clinical registry of the Obstetrics Initiative, a state-wide quality collaborative supported by Blue Cross Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program. We included births with an epidural in place, preceded by spontaneous or induced labor progressing to the 2nd stage. Our primary exposure was delayed pushing, defined as active pushing initiated at > 60 minutes after complete cervical dilation. Descriptive statistics characterized delayed pushing rates over time and across individual hospitals, and generalized linear mixed models evaluated associations between delayed pushing and maternal and neonatal outcomes, controlling for covariates.

Results:
Among 84,771 births at 72 hospitals, the collaborative-wide rate of delayed pushing decreased from a high of 16.8% in 2020 to 12.8% (p< 0.05) in 2024 (Figure 1, A). Individual hospital rates of delayed pushing still varied widely in 2024 (range: 2.3% to 31.9%; Figure 1, B). After adjusting for covariates, births after delayed vs. immediate pushing had significantly increased odds of multiple maternal complications, including cesarean (OR 1.66, 95% CI 1.56 to 1.77), hemorrhage (OR 1.23, 95% CI 1.14 to 1.33), and operative vaginal birth (OR 1.19, 95% CI 1.11 to 1.27; Table 1), consistent with findings in earlier clinical trials.

Conclusion:

Delayed pushing remains a common practice associated with harm in real-world maternity settings. Given the established risks of delayed pushing, quality improvement interventions are urgently needed to increase use of immediate pushing in the second stage.