JOGNN: Effect of Timing of Second-Stage Pushing on Pelvic Floor Morbidity After Birth

Effect of Timing of Second-Stage Pushing on Pelvic Floor Morbidity After Birth

Tuuli, M. G., Gregory, W. T., Arya, L. A., Lowder, J. L., Woolfolk, D., Caughey, A. B.,…Richter, H. E. (2023). Effect of second-stage pushing timing on postpartum pelvic floor morbidity. Obstetrics & Gynecology 141(2), 245-252. DOI:

An important goal of the intrapartum nurse is to provide effective care to prevent maternal and neonatal morbidities. The labor and birth processes typically occur without complications, but maternal morbidities such as perineal lacerations, stress urinary incontinence, anal incontinence, and pelvic organ prolapse may occur. Maternal pelvic floor morbidities are typically non-life threatening but can be life-altering.

Tuuli et al., 2023

 conducted a multicenter, randomized controlled trial in six health care centers to examine the effect of the timing of second-stage pushing (immediate pushing at complete dilation vs. delayed pushing beginning 60 minutes following complete dilation) on pelvic floor morbidity after birth. This was a secondary aim of a larger clinical trial (N = 2414). Participants were recruited after birth and were nulliparous women at 37 weeks or greater gestation with neuraxial analgesia (N = 941) who were randomized at complete dilation to one of the second-stage pushing methods. This sample size exceeded the calculated requirement to detect significant differences, and in an editorial, 

Corton, 2023

 identified this study as the largest randomized controlled trial on pelvic floor morbidity outcomes.

Tuuli et al. identified three categories of pelvic floor morbidity: second-degree or greater perineal lacerations; pelvic organ prolapse; and scores on validated, symptom-specific distress and quality-of-life questionnaires. Perineal lacerations were diagnosed at birth by the birth attendant using standardized criteria. Birth attendants identified the degree of pelvic organ prolapse with the pelvic organ prolapse quantification (POP-Q) system, which is used to quantify pelvic organ descent in relation to the introitus. The POP-Q measures were obtained at two time points: 6 weeks and 6 months after birth. The validated, symptom-specific, distress and quality-of-life questionnaires included the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ), the Fecal Incontinence Severity Index (FISI), and the Modified Manchester Health Questionnaire (MMHQ). The questionnaires included items related to pelvic distress; urinary incontinence; anal incontinence; and the effect of pelvic symptoms on role, relationships, and sleep. Tuuli et al. used the questionnaires to measure symptoms at baseline (1-5 days after birth) and 6 weeks and 6 months after birth. Participants were asked after birth to recall pelvic floor symptoms from the antepartum period.


Participant Characteristics

A total of 941 women participated in the pelvic floor assessments at baseline: 452 in the immediate pushing group and 489 in the delayed pushing group. After loss to follow up, 831 (88%) participants (398 immediate, 433 delayed) and 767 (82%) participants (371 immediate pushing, 396 delayed pushing) participated in the pelvic floor assessments at 6 weeks and 6 months after birth respectively. Tuuli et al. found no significant differences in the characteristics of the participants. The mean age of the participants was 24.8 years, and 93.4% had vaginal births. Fewer than 6% of the participants had forceps-assisted or vacuum-assisted vaginal births. A small number of participants had cesarean births after pushing (5.8% of the immediate pushing group and 7.4% of the delayed pushing group). Still, there was not a significant difference in birth mode between the two groups. The total active pushing time was not significantly different between groups.

Outcome Measures

Rates of second-degree or greater perineal lacerations at birth and pelvic organ prolapse at 6 weeks and 6 months after birth were not significantly different between groups. All pelvic organ prolapses in this study were categorized as stage 1 or 2.

Any changes from baseline scores for the PFDI-20, the PFIQ, and the MMHQ were not significantly different at 6 weeks or 6 months after birth. The FISI scores were statistically higher in the immediate pushing group at 6 months; however, the participant scores in this group were below a score of 4, which demonstrates clinical significance in fecal incontinence.


Tuuli et al., 2023

 concluded that among their participants, the method and timing of pushing during the second stage of labor did not affect the frequency or severity of perineal lacerations, degree of pelvic organ prolapse, or subjective report of pelvic floor symptoms. They suggested that the early postpartum period may be an ideal opportunity to assess pelvic floor morbidities and to implement measures to prevent further complications. Further, 

Tuuli et al., 2023

 supported immediate pushing in lieu of delayed pushing because there were no significant pelvic floor morbidities related to the timing of pushing.

Critical Interpretation