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Cochrane Database of Systematic Reviews

Pushing/bearing down methods for the second stage of labour

Information

DOI:
https://doi.org/10.1002/14651858.CD009124.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 26 March 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Pregnancy and Childbirth Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Andrea Lemos

    Correspondence to: Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil

    [email protected]

  • Melania MR Amorim

    Instituto de Medicina Integral Prof. Fernando Figueira ‐ IMIP, Recife, Brazil

  • Armele Dornelas de Andrade

    Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil

  • Ariani I de Souza

    Instituto de Medicina Integral Prof. Fernando Figueira ‐ IMIP, Recife, Brazil

  • José Eulálio Cabral Filho

    Instituto de Medicina Integral Prof. Fernando Figueira ‐ IMIP, Recife, Brazil

  • Jailson B Correia

    Instituto de Medicina Integral Prof. Fernando Figueira ‐ IMIP, Recife, Brazil

Contributions of authors

For the initial (Lemos 2015) version of this review, Andrea Lemos designed the review, wrote the protocol, and is the guarantor for the review. Melania Amorim designed the review and provided a clinical perspective. Armele Dornelas de Andrade designed the search strategies for the additional searching. Ariani Impieri de Souza provided a clinical perspective. José Eulálio Cabral‐Filho provided general advice on the protocol and designed the search strategies for the additional searching. Jailson Correia provided a methodological perspective, wrote the protocol and provided general advice on the protocol.

For this update, Andrea Lemos assessed the new trials eligibility and built the GRADE tables. Melania Amorim provided a clinical perspective. Armele Dornelas de Andrade provided a methodological perspective. Ariani Impieri de Souza provided a clinical perspective. José Eulálio Cabral‐Filho assessed the new trials eligibility and the quality of evidence. Jailson Correia provided a methodological perspective

Sources of support

Internal sources

  • Universidade Federal de Pernambuco, Physical Therapy Department ‐ Recife‐PE, Brazil.

  • Instituto de Medicina Integral Prof. Fernando Figueira‐ Recife‐PE, Brazil.

External sources

  • UNDP‐UNFPA‐UNICEF‐WHO‐World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.

Declarations of interest

Andrea Lemos ‐ none known.

Melania MR Amorim ‐ none known.

Armele Dornelas de Andrade ‐ none known.

Ariani I de Souza ‐ none known.

José Eulálio Cabral Filho ‐ none known.

Jailson B Correia ‐ received salary from Instituto de Medicina Integral Professor Fernando Figueira and a research scholarship from Conselho Nacional de Desenvolvimento Científico e Tecnológico.

Acknowledgements

We would like to thank Erica Gillesby and Amy Dempsey for providing us with additional information and unpublished data relating to their trial (Gillesby 2010).

This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2017 Mar 26

Pushing/bearing down methods for the second stage of labour

Review

Andrea Lemos, Melania MR Amorim, Armele Dornelas de Andrade, Ariani I de Souza, José Eulálio Cabral Filho, Jailson B Correia

https://doi.org/10.1002/14651858.CD009124.pub3

2015 Oct 09

Pushing/bearing down methods for the second stage of labour

Review

Andrea Lemos, Melania MR Amorim, Armele Dornelas de Andrade, Ariani I de Souza, José Eulálio Cabral Filho, Jailson B Correia

https://doi.org/10.1002/14651858.CD009124.pub2

2011 May 11

Pushing/bearing down methods for the second stage of labour

Protocol

Andrea Lemos, Melania MR Amorim, Armele Dornelas de Andrade, Ariani I de Souza, José Eulálio Cabral Filho, Jailson B Correia

https://doi.org/10.1002/14651858.CD009124

Differences between protocol and review

We followed the pre‐specified protocol, however after an exhaustive reading and examination of the studies we added four more maternal secondary outcomes (duration of pushing, maternal satisfaction, fatigue after delivery and detrusor overactivity, and one more neonatal secondary outcome (need for resuscitation) because we judged them to be clinically important in contributing to the overall evidence. We also add total care costs as a secondary outcome.

We clarified the maternal secondary outcome "mode of delivery" to include spontaneous vaginal delivery, instrumental delivery, rotational or midpelvic or posterior forceps and caesarean delivery in order to allow for clearer analyses. For the maternal primary outcome "perineal trauma", we separated this outcome into two: perineal lacerations of third or fourth degree and episiotomy to show transparency in the findings.

To provide a better understanding of the available evidence we added one subgroup analysis:

  1. parity (nulliparous, primiparous and multiparous with or without epidural analgesia) for three maternal outcomes: duration of the second stage, duration of pushing and spontaneous vaginal delivery.

We changed our inclusion criteria to include randomised controlled trials using a cluster‐randomised design, but none were identified. We added methods to the Unit of analysis issues section to clarify how we will handle such data in future updates, if appropriate.

We also used a statistical method to estimate means and standard deviations from the studies that showed the results as medians (Hozo 2005) and therefore we had to perform a sensitivity analyses for the outcomes that had used this method. A sensitivity analysis was performed for the outcomes "duration of second stage" and "duration of pushing" from Comparison 2: Timing of pushing: delayed pushing versus immediate pushing (all women with epidural analgesia).

We carried out another sensitivity analysis to explore the effect of trial quality for outcomes "duration of second stage" and "duration of pushing". In the review protocol, only quasi‐randomised trials were excluded. For this update, we excluded any trials which were assessed as being at high risk for random sequence generation and allocation concealment as we felt this criteria was more transparent.

We will carry out a further sensitivity analysis in future updates if cluster‐randomised trials are included in meta‐analysis along with individually‐randomised trials.

We planned to carry out a sensitivity analysis to explore the effects of fixed‐effect or random‐effects analyses for outcomes with statistical heterogeneity but instead used random‐effects analysis where we identified substantial heterogeneity.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.10 Instrumental delivery.
Figures and Tables -
Figure 4

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.10 Instrumental delivery.

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.1 Duration of second stage.
Figures and Tables -
Figure 5

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.1 Duration of second stage.

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.7 Duration of Pushing.
Figures and Tables -
Figure 6

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.7 Duration of Pushing.

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.9 Spontaneous vaginal delivery.
Figures and Tables -
Figure 7

Funnel plot of comparison 2: Delayed pushing versus immediate pushing (all women with epidural), outcome: 2.9 Spontaneous vaginal delivery.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 1 Duration of second stage (minutes).
Figures and Tables -
Analysis 1.1

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 1 Duration of second stage (minutes).

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 2 Perineal laceration (3rd or 4th degree).
Figures and Tables -
Analysis 1.2

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 2 Perineal laceration (3rd or 4th degree).

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 3 Episiotomy.
Figures and Tables -
Analysis 1.3

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 3 Episiotomy.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 4 Admission to neonatal intensive care.
Figures and Tables -
Analysis 1.4

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 4 Admission to neonatal intensive care.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 5 Five‐minute Apgar score < seven.
Figures and Tables -
Analysis 1.5

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 5 Five‐minute Apgar score < seven.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 6 Duration of pushing (minutes).
Figures and Tables -
Analysis 1.6

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 6 Duration of pushing (minutes).

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 7 Oxytocin use in second stage after randomisation.
Figures and Tables -
Analysis 1.7

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 7 Oxytocin use in second stage after randomisation.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 8 Spontaneous vaginal delivery.
Figures and Tables -
Analysis 1.8

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 8 Spontaneous vaginal delivery.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 9 Instrumental delivery.
Figures and Tables -
Analysis 1.9

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 9 Instrumental delivery.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 10 Caesarean delivery.
Figures and Tables -
Analysis 1.10

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 10 Caesarean delivery.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 11 Fatigue after delivery.
Figures and Tables -
Analysis 1.11

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 11 Fatigue after delivery.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 12 Maternal satisfaction.
Figures and Tables -
Analysis 1.12

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 12 Maternal satisfaction.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 13 Detrusor overactivity.
Figures and Tables -
Analysis 1.13

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 13 Detrusor overactivity.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 14 Urinary stress incontinence.
Figures and Tables -
Analysis 1.14

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 14 Urinary stress incontinence.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 15 Low umbilical cord blood.
Figures and Tables -
Analysis 1.15

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 15 Low umbilical cord blood.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 16 Delivery room resuscitation.
Figures and Tables -
Analysis 1.16

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 16 Delivery room resuscitation.

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 17 Sensitivity analysis (trial quality): Duration of second stage (minutes).
Figures and Tables -
Analysis 1.17

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 17 Sensitivity analysis (trial quality): Duration of second stage (minutes).

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 18 Sensitivity analysis (trial quality): Duration of pushing (minutes).
Figures and Tables -
Analysis 1.18

Comparison 1 Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing, Outcome 18 Sensitivity analysis (trial quality): Duration of pushing (minutes).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 1 Duration of second stage (minutes).
Figures and Tables -
Analysis 2.1

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 1 Duration of second stage (minutes).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 2 Perineal Laceration (3rd or 4th degree).
Figures and Tables -
Analysis 2.2

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 2 Perineal Laceration (3rd or 4th degree).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 3 Episiotomy.
Figures and Tables -
Analysis 2.3

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 3 Episiotomy.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 4 Admission to neonatal intensive care.
Figures and Tables -
Analysis 2.4

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 4 Admission to neonatal intensive care.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 5 Five‐minute Apgar score < seven.
Figures and Tables -
Analysis 2.5

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 5 Five‐minute Apgar score < seven.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 6 Duration of pushing (minutes).
Figures and Tables -
Analysis 2.6

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 6 Duration of pushing (minutes).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 7 Oxytocin use in second stage after randomisation.
Figures and Tables -
Analysis 2.7

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 7 Oxytocin use in second stage after randomisation.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 8 Spontaneous vaginal delivery.
Figures and Tables -
Analysis 2.8

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 8 Spontaneous vaginal delivery.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 9 Instrumental delivery.
Figures and Tables -
Analysis 2.9

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 9 Instrumental delivery.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 10 Rotational or midpelvic or posterior forceps.
Figures and Tables -
Analysis 2.10

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 10 Rotational or midpelvic or posterior forceps.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 11 Caesarean delivery.
Figures and Tables -
Analysis 2.11

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 11 Caesarean delivery.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 12 Postpartum haemorrhage.
Figures and Tables -
Analysis 2.12

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 12 Postpartum haemorrhage.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 13 Fatigue after delivery.
Figures and Tables -
Analysis 2.13

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 13 Fatigue after delivery.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 14 Maternal satisfaction.
Figures and Tables -
Analysis 2.14

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 14 Maternal satisfaction.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 15 Dyspareunia.
Figures and Tables -
Analysis 2.15

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 15 Dyspareunia.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 16 Fecal incontinence.
Figures and Tables -
Analysis 2.16

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 16 Fecal incontinence.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 17 Low umbilical cord pH.
Figures and Tables -
Analysis 2.17

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 17 Low umbilical cord pH.

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 18 Total care costs (CND$).
Figures and Tables -
Analysis 2.18

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 18 Total care costs (CND$).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 19 Sensitivity analysis (trial quality): Duration of second stage (minutes).
Figures and Tables -
Analysis 2.19

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 19 Sensitivity analysis (trial quality): Duration of second stage (minutes).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 20 Sensitivity analysis (trial quality): Duration of pushing (minutes).
Figures and Tables -
Analysis 2.20

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 20 Sensitivity analysis (trial quality): Duration of pushing (minutes).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 21 Sensitivity analysis (median and IQR): Duration of second stage (minutes).
Figures and Tables -
Analysis 2.21

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 21 Sensitivity analysis (median and IQR): Duration of second stage (minutes).

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 22 Sensitivity analysis (median and IQR): Duration of pushing (minutes).
Figures and Tables -
Analysis 2.22

Comparison 2 Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural), Outcome 22 Sensitivity analysis (median and IQR): Duration of pushing (minutes).

Summary of findings for the main comparison. Spontaneous pushing compared to directed pushing for the second stage of labour (types of pushing)

Spontaneous pushing compared to directed pushing for the second stage of labour (types of pushing)

Patient or population: women in the second stage of labour
Settings: labour ward. Trials conducted in Turkey, Iran, UK, US and Hong Kong
Intervention: types of pushing: spontaneous pushing versus directed pushing

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with directed pushing

Risk with spontaneous pushing

Duration of second stage (minutes)

The mean duration of second stage (minutes) was 0

MD 10.26 higher
(1.12 lower to 21.64 higher)

667
(6 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2 3

Perineal laceration (3rd or 4th degree)

Study population

RR 0.87
(0.45 to 1.66)

320
(1 RCT)

⊕⊕⊝⊝
LOW 3 4

110 per 1000

96 per 1000
(50 to 183)

Admission to neonatal intensive care

Study population

RR 1.08
(0.30 to 3.79)

393
(2 RCTs)

⊕⊝⊝⊝
VERY LOW 1 5

20 per 1000

21 per 1000
(6 to 75)

Hypoxic ischaemic encephalopathy

Study population

(0 study)

Outcome not reported in the included studies under this comparison.

see comment

see comment

5‐minute Apgar score < 7

Study population

RR 0.35
(0.01 to 8.43)

320
(1 RCT)

⊕⊝⊝⊝
VERY LOW 4 5

6 per 1000

2 per 1000
(0 to 52)

Duration of pushing (minutes)

The mean duration of pushing (minutes) was 0

MD 9.76 lower
(19.54 lower to 0.02 higher)

169
(2 RCTs)

⊕⊝⊝⊝
VERY LOW 2 6 7

Spontaneous vaginal delivery

Study population

RR 1.01
(0.97 to 1.05)

688
(5 RCTs)

⊕⊕⊕⊝
MODERATE 8 9

922 per 1000

932 per 1000
(895 to 969)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Most studies contributing data had design limitations, with more than 40% of weight from studies with serious design limitations. (‐2)

2 Statistical Heterogeneity (I2>60%). Variation in size of effect. (‐1)

3 Wide confidence intervals crossing the line of no effect. (‐1)

4 One study with design limitations. (‐1)

5 Wide confidence intervals crossing the line of no effect and few events. (‐2)

6 One study contributing >40% of data had serious design limitations. One other study had design limitations. (‐2)

7 Wide confidence intervals just crossing the line of no effect and small sample size. (‐2)

8 Study contributing most data (46.9%) has design limitations, other studies have design limitations or serious design limitations. (‐1)

9 Although confidence intervals cross the line of no effect, the effect estimate is precise. (not downgraded)

Figures and Tables -
Summary of findings for the main comparison. Spontaneous pushing compared to directed pushing for the second stage of labour (types of pushing)
Summary of findings 2. Delayed pushing compared to immediate pushing (all women with epidural) for the second stage of labour (timing of pushing)

Delayed pushing compared to immediate pushing (all women with epidural) for the second stage of labour (timing of pushing)

Patient or population: women in the second stage of labour with epidural in situ
Settings: labour wards in hospital settings. Trials were carried out in Ireland, US, UK, Canada
Intervention: timing of pushing: delayed pushing versus immediate pushing (women with epidural only)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with immediate pushing (all women with epidural)

Risk with delayed pushing

Duration of second stage (minutes)

The mean duration of second stage (minutes) was 0

MD 56.40 higher
(42.05 higher to 70.76 higher)

3049
(11 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2

1 trial contributing data for multiparous women, 1 trial included both nulliparous and multiparous women.

Perineal laceration (3rd or 4th degree)

Study population

RR 0.94
(0.78 to 1.14)

2775
(7 RCTs)

⊕⊕⊕⊝
MODERATE 1 3

1 of the studies contributing data reported all lacerations (i.e. did not specify 3rd or 4th degree)

122 per 1000

115 per 1000
(95 to 139)

Admission to neonatal intensive care

Study population

RR 0.98
(0.67 to 1.41)

2197
(3 RCTs)

⊕⊕⊝⊝
LOW 4 5

49 per 1000

48 per 1000
(33 to 69)

Hypoxic ischaemic encephalopathy

Study population

(0 study)

Outcome not reported in the included studies under this comparison.

see comment

see comment

5‐minute Apgar score < 7

Study population

RR 0.15
(0.01 to 3.00)

413
(3 RCTs)

⊕⊝⊝⊝
VERY LOW 6 7

Only 1 trial contributing data.

10 per 1000

2 per 1000
(0 to 31)

Duration of pushing (minutes)

The mean duration of pushing (minutes) was 0

MD 19.05 lower
(32.27 lower to 5.83 lower)

2932
(11 RCTs)

⊕⊝⊝⊝
VERY LOW 1 2

1 trial contributing data for multiparous women, 1 trial included both nulliparous and multiparous women.

Spontaneous vaginal delivery

Study population

RR 1.07
(1.03 to 1.11)

3114
(12 RCTs)

⊕⊕⊕⊝
MODERATE 1

713 per 1000

762 per 1000
(734 to 791)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 All studies have design limitations, two studies contributing <40% have serious design limitations. (‐1)

2 Heterogeneity (I2>60%). Considerable variation in size of effect. (‐2)

3 Although confidence intervals cross the line of no effect, the effect estimate is precise. (not downgraded)

4 All studies have design limitations. (‐1)

5 Wide confidence intervals crossing the line of no effect. (‐1)

6 One study contributing data has design limitations. (‐1)

7 Wide confidence intervals crossing the line of no effect and very few events. (‐2)

Figures and Tables -
Summary of findings 2. Delayed pushing compared to immediate pushing (all women with epidural) for the second stage of labour (timing of pushing)
Comparison 1. Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Duration of second stage (minutes) Show forest plot

6

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Nulliparous

6

667

Mean Difference (IV, Random, 95% CI)

10.26 [‐1.12, 21.64]

2 Perineal laceration (3rd or 4th degree) Show forest plot

1

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.45, 1.66]

3 Episiotomy Show forest plot

2

420

Risk Ratio (M‐H, Random, 95% CI)

1.05 [0.60, 1.85]

4 Admission to neonatal intensive care Show forest plot

2

393

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.30, 3.79]

5 Five‐minute Apgar score < seven Show forest plot

1

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.01, 8.43]

6 Duration of pushing (minutes) Show forest plot

2

169

Mean Difference (IV, Random, 95% CI)

‐9.76 [‐19.54, 0.02]

6.1 Mixed parity

2

169

Mean Difference (IV, Random, 95% CI)

‐9.76 [‐19.54, 0.02]

7 Oxytocin use in second stage after randomisation Show forest plot

1

128

Risk Ratio (M‐H, Fixed, 95% CI)

2.20 [0.80, 6.07]

8 Spontaneous vaginal delivery Show forest plot

5

688

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.97, 1.05]

9 Instrumental delivery Show forest plot

2

393

Risk Ratio (M‐H, Random, 95% CI)

0.56 [0.06, 5.10]

10 Caesarean delivery Show forest plot

3

583

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.14, 4.39]

11 Fatigue after delivery Show forest plot

2

142

Std. Mean Difference (IV, Random, 95% CI)

‐1.14 [‐3.29, 1.02]

12 Maternal satisfaction Show forest plot

1

31

Mean Difference (IV, Fixed, 95% CI)

0.91 [‐1.30, 3.12]

13 Detrusor overactivity Show forest plot

1

128

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.18, 1.36]

14 Urinary stress incontinence Show forest plot

1

128

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.29, 1.69]

15 Low umbilical cord blood Show forest plot

1

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.24, 2.29]

15.1 Arterial umbilical cord pH < 7.2

1

320

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.24, 2.29]

15.2 Venous umbilical cord < 7.3

0

0

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

16 Delivery room resuscitation Show forest plot

2

352

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.40, 1.75]

17 Sensitivity analysis (trial quality): Duration of second stage (minutes) Show forest plot

4

Mean Difference (IV, Random, 95% CI)

Subtotals only

17.1 All studies

4

494

Mean Difference (IV, Random, 95% CI)

17.62 [5.28, 29.95]

18 Sensitivity analysis (trial quality): Duration of pushing (minutes) Show forest plot

1

69

Mean Difference (IV, Random, 95% CI)

‐15.22 [‐21.64, ‐8.80]

18.1 Mixed parity

1

69

Mean Difference (IV, Random, 95% CI)

‐15.22 [‐21.64, ‐8.80]

Figures and Tables -
Comparison 1. Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing
Comparison 2. Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Duration of second stage (minutes) Show forest plot

11

3049

Mean Difference (IV, Random, 95% CI)

56.40 [42.05, 70.76]

1.1 Nulliparous

10

2885

Mean Difference (IV, Random, 95% CI)

56.12 [39.29, 72.96]

1.2 Multiparous

1

123

Mean Difference (IV, Random, 95% CI)

38.80 [29.16, 48.44]

1.3 Mixed parity

1

41

Mean Difference (IV, Random, 95% CI)

91.0 [50.37, 131.63]

2 Perineal Laceration (3rd or 4th degree) Show forest plot

7

2775

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.78, 1.14]

3 Episiotomy Show forest plot

5

2320

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.87, 1.04]

4 Admission to neonatal intensive care Show forest plot

3

2197

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.67, 1.41]

5 Five‐minute Apgar score < seven Show forest plot

3

413

Risk Ratio (M‐H, Fixed, 95% CI)

0.15 [0.01, 3.00]

6 Duration of pushing (minutes) Show forest plot

11

2932

Mean Difference (IV, Random, 95% CI)

‐19.05 [‐32.27, ‐5.83]

6.1 Nulliparous

10

2768

Mean Difference (IV, Random, 95% CI)

‐21.30 [‐36.87, ‐5.73]

6.2 Multiparous

1

123

Mean Difference (IV, Random, 95% CI)

‐11.35 [‐18.19, ‐4.51]

6.3 Mixed parity

1

41

Mean Difference (IV, Random, 95% CI)

‐2.0 [‐30.35, 26.35]

7 Oxytocin use in second stage after randomisation Show forest plot

2

177

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.79, 1.27]

8 Spontaneous vaginal delivery Show forest plot

12

3114

Risk Ratio (M‐H, Fixed, 95% CI)

1.07 [1.02, 1.11]

8.1 Nulliparous

11

2953

Risk Ratio (M‐H, Fixed, 95% CI)

1.07 [1.03, 1.12]

8.2 Multiparous

1

120

Risk Ratio (M‐H, Fixed, 95% CI)

1.11 [1.00, 1.24]

8.3 Mixed parity

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.22, 1.03]

9 Instrumental delivery Show forest plot

10

3007

Risk Ratio (M‐H, Random, 95% CI)

0.89 [0.74, 1.07]

10 Rotational or midpelvic or posterior forceps Show forest plot

5

2151

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.61, 1.10]

11 Caesarean delivery Show forest plot

9

2783

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.65, 1.05]

12 Postpartum haemorrhage Show forest plot

3

2199

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.86, 1.26]

13 Fatigue after delivery Show forest plot

1

73

Mean Difference (IV, Fixed, 95% CI)

‐6.40 [‐21.00, 8.20]

14 Maternal satisfaction Show forest plot

1

73

Mean Difference (IV, Fixed, 95% CI)

0.40 [‐7.34, 8.14]

15 Dyspareunia Show forest plot

1

162

Risk Ratio (M‐H, Fixed, 95% CI)

1.15 [0.63, 2.10]

16 Fecal incontinence Show forest plot

1

178

Risk Ratio (M‐H, Fixed, 95% CI)

1.47 [0.94, 2.29]

17 Low umbilical cord pH Show forest plot

4

2145

Risk Ratio (M‐H, Fixed, 95% CI)

2.24 [1.37, 3.68]

17.1 Arterial umbilical cord pH < 7.2

2

244

Risk Ratio (M‐H, Fixed, 95% CI)

1.84 [0.55, 6.16]

17.2 Venous umbilical cord pH < 7.3

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

1.70 [0.44, 6.66]

17.3 Arterial < 7.2 and/or venous < 7.3 umbilical cord pH

1

1860

Risk Ratio (M‐H, Fixed, 95% CI)

2.45 [1.35, 4.43]

18 Total care costs (CND$) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

18.1 Total hospital costs

1

1862

Mean Difference (IV, Fixed, 95% CI)

81.35 [‐80.27, 242.97]

18.2 Intrapartum care costs

1

1862

Mean Difference (IV, Fixed, 95% CI)

68.22 [55.37, 81.07]

18.3 Postnatal care costs

1

1862

Mean Difference (IV, Fixed, 95% CI)

13.13 [‐145.27, 171.53]

19 Sensitivity analysis (trial quality): Duration of second stage (minutes) Show forest plot

10

2973

Mean Difference (IV, Random, 95% CI)

53.46 [38.82, 68.10]

19.1 Nulliparous

9

2809

Mean Difference (IV, Random, 95% CI)

52.54 [35.14, 69.93]

19.2 Multiparous

1

123

Mean Difference (IV, Random, 95% CI)

38.80 [29.16, 48.44]

19.3 Mixed parity

1

41

Mean Difference (IV, Random, 95% CI)

91.0 [50.37, 131.63]

20 Sensitivity analysis (trial quality): Duration of pushing (minutes) Show forest plot

10

2856

Mean Difference (IV, Random, 95% CI)

‐21.30 [‐34.97, ‐7.63]

20.1 Nulliparous

9

2692

Mean Difference (IV, Random, 95% CI)

‐24.25 [‐40.43, ‐8.07]

20.2 Multiparous

1

123

Mean Difference (IV, Random, 95% CI)

‐11.35 [‐18.19, ‐4.51]

20.3 Mixed parity

1

41

Mean Difference (IV, Random, 95% CI)

‐2.0 [‐30.35, 26.35]

21 Sensitivity analysis (median and IQR): Duration of second stage (minutes) Show forest plot

7

684

Mean Difference (IV, Random, 95% CI)

56.48 [34.24, 78.72]

21.1 Nulliparous

6

520

Mean Difference (IV, Random, 95% CI)

55.17 [25.33, 85.01]

21.2 Multiparous

1

123

Mean Difference (IV, Random, 95% CI)

38.80 [29.16, 48.44]

21.3 Mixed parity

1

41

Mean Difference (IV, Random, 95% CI)

91.0 [50.37, 131.63]

22 Sensitivity analysis (median and IQR): Duration of pushing (minutes) Show forest plot

6

531

Mean Difference (IV, Random, 95% CI)

‐17.22 [‐28.92, ‐5.52]

22.1 Nulliparous

5

367

Mean Difference (IV, Random, 95% CI)

‐22.51 [‐41.53, ‐3.50]

22.2 Multiparous

1

123

Mean Difference (IV, Random, 95% CI)

‐11.35 [‐18.19, ‐4.51]

22.3 Mixed parity

1

41

Mean Difference (IV, Random, 95% CI)

‐2.0 [‐30.35, 26.35]

Figures and Tables -
Comparison 2. Analysis 2. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)