Pushing/bearing down methods for the second stage of labour

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

doi:10.1002/14651858.CD009124.pub3

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Figure 4

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

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Figure 5

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

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Figure 6

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

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Figure 7

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

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Analysis 1.1

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

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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).

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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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Analysis 1.6

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

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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.

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Analysis 1.8

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

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Analysis 1.9

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

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Analysis 1.10

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

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Analysis 1.11

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

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Analysis 1.12

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

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Analysis 1.13

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

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Analysis 1.14

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

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Analysis 1.15

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

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Analysis 1.16

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

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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).

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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).

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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).

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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).

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Analysis 2.3

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

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Analysis 2.15

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

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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.

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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.

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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$).

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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).

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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).

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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).

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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).

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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)

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

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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)

Summary of findings 2. Delayed pushing compared to immediate pushing (all women with epidural) for the second stage of labour (timing of pushing)

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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]

Comparison 1. Analysis 1. Comparison 1: types of pushing: spontaneous pushing versus directed pushing

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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]

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

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