Introduction
Materials and methods
Search and selection of studies
Eligibility criteria
Population | Primiparous |
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Intervention | Spontaneous pushing, delayed pushing, or uncoached pushing |
Comparison | Directed pushing, immediate pushing, or coached pushing, Valsalva maneuver(pushing) Take a deep breath, hold it and push, or early pushing |
Outcomes | Primary: urinary incontinence at postpartum Secondary: No perineal laceration (intact perineum), Third- or fourth-degree laceration Episiotomy, Length of second stage of labor |
Study design | Randomized controlled trial; RCT |
Study selection
Data analysis
Assessing risk of bias
Results
Search results
Characteristics of included studies
Authors | Year | Location | Study type | Sample size | Intervention group (spontaneous pushing) | Control group (directed pushing) | Outcome reported | Results | |
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Spontaneous pushing | Directed pushing | ||||||||
Ahmadi Z et al. [14] | 2017 | Iran | RCT 166 | Breathing technique group: 83 Valsalva maneuver group: 83 | Breathing techniques (case group): The women were asked to take two deep abdominal breaths and push for 4–5 s with an open mouth while controlling exhalation and then resume the process for the next push as trained | Control group (Valsalva maneuver): pushing was carried out according to delivery room routine by holding the breath | No trauma Perineum lacelation (I–III) Episiotomy | Perineal outcomes n = 83 no trauma 34(41%) Perineal laceration: 12 (14.3%) 1st degree 8 (69%) 2nd degree 4 (31%) 3rd degree 0 Anterior laceration: 22 (26.5%) Episiotomy 15 (18.2%) | Perineal outcomes n = 83 no trauma 16(19.3%) Perineal laceration: 29 (34.9%) 1st degree 12 (41%) 2nd degree 16 (56%) 3rd degree 1 (3%) Anterior laceration: 17 (20.5%) Episiotomy 21 (25.3%) |
Bloom et al. [15] | 2006 | US | RCT 320 | Uncoached group n = 157 Coached group n = 163 | Uncoached group Step 1: Head of bed up 30° Step 2: Position patient, as she desires, on her back or either side Step 3: The patient should be told simply to "do whatever the patient feels the urge to while in bed" | Coached group Step 1: Head to be placed up 30° Step 2: Position patient, as she desires, on her back or either side Step 3: Coach patient to pull back on both knees and tuck her chin while the provider or partner supports the legs Step 4: Coach patient to take a deep breath and hold it during the peak of a contraction then bear down and push for 10 s; repeat this as long as the contraction continues | Length of second stage (min) Perineal laceration Episiotomy | Perineal outcomes n = 157 No or first degree 110 51%) 2nd degree 32 (20%) 3rd degree 13 (8%) 4th degree 2 (1%) Episiotomy 32 (20%) | Perineal outcomes n = 163 No or first degree 105 (45%) 2nd degree 40 (24%) 3rd degree 12 (7%) 4th degree 6 (4%) Episiotomy 42 (26%) |
Hansen et al. [16] | 2002 | US | RCT 129 | Pushing group n = 65 Rest group n = 64 | Rest group: Women in the experimental group began a period of rest and descent at the time of complete dilatation and continued until the head was seen at the introitus, or after 120 min. These women were encouraged not to push. Visualizing the head at the introitus was determined by sightly separating the vulva with two fingers during a contraction, with the woman's legs apart. The introitus was examined in this manner every 30 min, or sooner if signs of imminent delivery occurred. In the experimental group, the nurse determined the station and position at the onset of pushing after the period of rest and decent. | In the control group women were encouraged to begin pushing as soon as they were found to be completely dilated | Length of second stage (min) | Length of second stage of labor Rest group: n = 64 Mean (min) 171 (56.76) | Length of second stage of labor Pushing group: n = 65 Mean (min) 75.77 (41.33) |
Kelly et al. [17] | 2010 | US | RCT 59 | Delayed: 26 Immediate: 33 | Delayed pushing group: After dilatation of 10 cm was reached, the VAS was completed, and subjects randomized were told to rest for 90 min or until they felt an uncontrollable urge to push (whichever came first) before they began pushing. A 90-min rest period was selected based on a review of recent publications on delayed pushing, which found that the delay interval ranged from 60 to 120 min. Pushing was allowed to begin before and after the 90-min rest period if the subjects felt an unconfortable urge to push or if the fetal head was visualized at the intoroitus. Instructions for pushing were provided in the same manner as for the immediate pushing group, subjects used a variety of positions during second stage of labor | Immediate pushing group: After dilatation of 10 cm was reached, the subjects were then directed to begin pushing. The subjects were instructed to push three to four times during each contruction by bearing down in a manner similar to the bearing-down effort used to have a bowel movement. No provider counting during pushing occurred. Both open and glottis methods were used, depending on subject's preference and effectiveness of pushing effort as determined by progressive fetal decent. Subjects used a variety of positions during the second stage of labor | Length of second stage of labor perineal lacelation (3rd degree, 4th degree) | Delayed pushing n = 26 Perineal laceration 3rd degree: 1 (7%) 4th degree: 0 (0%) Length of second stage of labor Delayed pushing n = 16 Mean (min): 117.6 (12.1) | Immediate pushing n = 33 Perineal laceration 3rd degree: 2 (8%) 4th degree: 0 (0%) Length of second stage of labor Immediate pushing n = 28 Mean (min): 87.1 (8.6) |
Low et al. [18] | 2013 | US | RCT 73 | Spontaneous pushing: 34 Direct pushing: 39 | Spontaneous pushing: with instruction provided prenatally via a standardized training video. This method included instructing the woman to follow her bodily sensation and push as she felt the urge | Directed pushing or coached pushing: using a closed glottis Valsalva maneuver, which was routine care provided at the recruitment hospital | Change in urine leakage between baseline and 12 months postpartum Second stage length (min) | Spontaneous pushing: n = 34 Change of urine leakage: 0.35 (1.95) Second stage length: 151.69 (133.26) | Directed pushing: n = 39 Change of leakage: 0.84 (1.94) Second-stage length: 131.12 (91.08) |
Parnell et al. [19] | 1993 | Denmark | RCT 306 | Spontaneous pushing: 151 Forced group 155 | Spontaneous method: the woman was encouraged to use her own urge to push, so long and so many times during each contraction as she felt necessary | Forced method: the woman was encouraged to push using the Valsalva maneuver, i.e., to take a deep breath, hold it, and push for as long as hard as possible, i.e., 2–3 times during each contraction | Second stage of labor | Spontaneous group: n = 151 Second stage of labor: 57 (35.6) | Forced group: n = 155 Second stage of labor: 54 (33.8) |
Schaffer et al. [20] | 2005 | US | RCT 128 | Uncoached group: 61 Coached group: 67 | Uncoached group Step 1: Head of bed up 30º Step 2: Position patient, as she desires, on her back or either side Step 3: The patient should be told simply to "do whatever the patient feels the urge to while in bed" | Coached group Step 1: Head to be placed up 30° Step 2: Position patient, as she desires, on her back or either side Step 3: Coach patient to pull back on both knees and tuck her chin while the provider or partner supports the legs Step 4: Coach the patient to take a deep breath and hold during the peak of a contraction then bear down and push for 10 s; repeat this as long as the contraction continues | Urodynamic stress incontinence Episiotomy | Uncoached group: 61 Urodynamic stress incontinence: 7 Episiotomy: 13 | Coached group: 67 Urodynamic stress incontinence: 11 Episiotomy: 15 |
Simpson et al. [21] | 2005 | US | RCT 45 | Delayed pushing group: 23 Immediate pushing group: 22 | Delayed pushing group: Women were assisted to a felt lateral position at 10-cm cervical dilatation where they remained as they felt the urge to push or the second stage had lasted for 2 h (whichever came first). When they reported an urge to push or the second stage had lasted for 2 h, they were encouraged by the nurse to bear down with the contractions without holding their breath (open glottis) for no more than 6–8 s and continue bearing down no more than three times with each contraction until birth. The L lateral position was used during passive fetal descent to control for potential differences in ESpO2 related to maternal position | Immediate pushing group: Women were coached by the nurse to use closed-glottis pushing three to four times during each contraction immediately when cervical dilation reached 10 cm and to continue pushing using this method with each contraction until birth. The nurse counted to 10 during each pushing effort to assist the woman in holding her breath at least 10 s | Length of second stage of labor Perineal laceration | Delayed pushing: n = 23 Length of second stage: 139 (39) Perineal laceration: 5 No laceration: 18 | Immediate pushing n = 22 Length of second stage of labor: 101 (55.9) Perineal laceration: 13 No laceration: 9 |
Thomson [22] | 1993 | UK | RCT 32 | Spontaneous pushing group: 15 control group: 17 | Experimental (spontaneous pushing) group: The woman was to be encouraged only in spontaneous pushing activity | Control (take a deep breath, hold it and push) group: The women were to be told to 'take a deep breath, hold it and push for as long as possible.' Should the push run out before the contraction ceased, the woman was to repeat the exercise | Duration of second stage (min) Perineal trauma: need for repair | Experimental group: n = 15 Duration of second stage: 121.4 (58.4) Perineal trauma: need for repair: 11 No need for repair: 4 | Control group: n = 17 Duration of second stage: 58 (42) Perineal trauma: need for repair: 10 No need for repair: 7 |
Yildirim et al. [23] | 2008 | Turkey | RCT 100c | Spontaneous pushing: 50 Valsalva pushing: 50 | The members of the spontaneous pushing group were encouraged and supported to push spontaneously in the second stage of labor, breathing down in response to contractions | The members of the Valsalva pushing group were encouraged and supported in using Valsalva-type pushing in the second stage of labor | Duration of second stage (min) No tear Episiotomy | Duration of second stage (min): 40.8 (19.1) Perineal outcomes No tear: 1 (2.0) Episiotomy: 39 (78.0) | Duration of second stage (min): 50.1 (26.3) Perineal outcome No tear: 1 (2.0) Episiotomy: 29 (58.0) |
Fitzpatrick et al. [24] | 2002 | Ireland | RCT 178(170) | Delayed pushing: 88(85) Immediate pushing: 90(85) | No description | No description | Duration of second stage (min) Perineum Episiotomy Second degree Third degree | n = 88 Duration of second stage: 120 (57-225) (interquartile rage) n = 85 Perineum Episiotomy: 61 Second degree: 8 Third degree: 6 | n = 90 Duration of second stage: 60 (0-148) (interquartile rage) n = 85 Perineum Episiotomy: 66 Second degree: 7 Third degree: 9 |
Fraser et al. [25] | 2000 | Canada | RCT 1862 | Delayed pushing: 936 Early pushig: 926 | Delayed pushing: advised to avoid voluntary explulsive efforts for ≥ 2 h unless: (1) she felt an irresistible urge to push (2) the fetal head was visualized during the course of rutine inspection of the perineum, or (3) a medical indication to shorten the second stage of labor developed | Early pushing: encouraged to commence pushing immediately on random assignment | Episiotomy Third- or fourth-degree perineal tear | n = 936 Episiotomy: 380 Third- or fourth-degree perineal tear: 87 | n = 926 Episiotomy: 387 Third- or fourth-degree perineal tear: 88 |
Gillesby et al. [26] | 2010 | U.S | RCT 77 | Delayed pushing: 38 Immediate pushing: 39 | Delayed pushing: delayed the onset of pushing for 2 h or until the patient experienced an irresistible urge to push or until spontaneous delivery was imminent | Immediate pushing: began pushing within 15 min of the time the cervix was determined to be completely dilated | Length of second stage of labor Perineal injuries None First degree Second degree Third degree Fourth degree Episiotomy | n = 36 Length of second stage of labor: 166.3 (64.2) n = 38 Perineal injuries None: 6 First degree: 7 Second degree:19 Third degree: 0 Fourth degree: 0 Episiotomy: 4 | n = 37 Length of second stage of labor: 107.2 (56.3) n = 39 Perineal injuries None: 6 First degree: 11 Second degree:12 Third degree: 2 Fourth degree: 1 Episiotomy: 7 |
Knauth et al. [27] | 1986 | US | RCT 27 | Exhalation group: 17 Breath-holding group: 10 | Exhalation pushing group: 1. With the onset of contraction, begin to take a normal, relaxing breath. Continue until an urge to push is felt 2. At this point take a normal breath, hold it for a few seconds (2–3), assume a pelvic tilt position, bend the head to the chest 3. As you slowly exhale through pursed lips consciously pull in abdominal muscles 4. Continue to exhale slowly in a controlled manner with a crescendo effect, increasing the volume exhaled gradually. Practice exhaling into a fist as if blowing a trumpet 5. During this time continue to assume a pelvic tilt position, contract the abdominal muscles, and relax the pelvic floor muscles\keep the chin forward and jaw relaxed 6. At the end of exhalation, quickly inhale and repeat the previous pattern as long as an urge to push is felt 7. At end of contraction, take two normal breaths, then relax | Breath-holding group: 1. Take two deep breaths with the onset of each contraction. (Allows contraction to build toward its peak) 2. Inhale deeply once more, let out a small amount of air, hold the breath, close the mouth 3. Raise the head, round the shoulders, bring the chin forward, place the hands underneath the knees letting the legs abduct and relax, keep the elbows out, and bear down forcefully, consciously tightening the abdominal muscles 4. While pushing, keep the pelvis tilted and concentrate on relaxing the pelvic floor and leg muscles 5. Push as long and as hard as you can (about 10-15 s) 6. When you can no longer hold your breath, release your breath, inhale again, and repeat the technique as long as the contraction continues 7. At the end of the contraction, take two deep breaths and relax | Length of the second stage of labor: min (range) | n = 17 Length of second stage of labor: 45.6 (12–100) | n = 10 Length of second stage of labor: 45.6 (24–89) |
Plunkett et al. [28] | 2003 | US | RCT 202 | Delayed pushing: 117 Immediate pushing: 85 | Women in the delayed pushing group were instructed to wait until they felt a strong urge to push, defined as ≥ 50 min on an unmarked 100-min visual analog scale | Women in the immediate pushing group were encouraged to begin pushing efforts upon reaching complete dilatation | Duration of second stage Third- or fourth-degree laceration | n = 117 Duration of the entire second stage: 99 (48–160) Third- or fourth-degree laceration: 11 | n = 85 Duration of the entire second stage: 69 (42–135) Third- or fourth-degree laceration: 10 |
Vause et al. [29] | 1998 | US | RCT 135 | Delayed: 68 Early: 67 | Women in the delayed pushing group were encouraged to rest without pushing for a maximum of 3 h from the time of full dilatation, unless the vertex was visible at the introuitus earlier | Early pushing: It was intended that pushing would commence within 1 h of full dilation, whether the vertex was visible or not | Full dilatation to delivery (median) (IQR) Second-degree tear Episiotomy | n = 60 Full dilatation to delivery: 214 (149–252) n = 68 Second-degree tear: 8 Episiotomy: 40 | n = 63 Full dilatation to delivery: 119 (89–155) n = 67 Second-degree tear: 13 Episiotomy: 42 |
Tuuli et al. [30] | 2020 | US | RCT 767 | Immediate pushing: 371 Delayed pushing: 396 | No description | No description | PFDI:Pelvic Floor Distress Inventry (1–300 points) UDI:Urogenital Distress Inventory (1–100 points) POPDI:Pelvic Organ Prolapse Distress Inventory CRADI:Colorectal Anal Distress Inventory | Delayed pushing n = 396 Change from baseline at 6 months UDI: -5.10 ± 23.9 PFDI: -10.22 ± 44.5 | Immediate pushing n = 371 Change form baseline at 6 months UDI: -1.00 ± 24.3 PFDI: -2.02 ± 47.6 |
Risk of bias in included studies
Effects of interventions
Outcomes | Anticipated absolute effects (95%CI) | Relative effect (95%CI) | No. of participants(studies) | Quality of the evidence(GRADE) | |
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Risk with directed pushing | Risk with spontaneous pushing | ||||
Change in urinary scores | Mean change in urine scores was 0 | SM D – 0.18 lower (–0.31 lower to –0.04 higher) | – | 867 (2 RCT) | ⊕○○○ 134 Low |
Urodynamic stress incontinence | 164 per 1000 | 115 per 1000 (48 to 277) | RR 0.70 (0.29 to 1.69) | 128 (1 RCT) | ⊕○○○12 Very low |
No suturing | 134 per 1000 | 245 per 1000 (156 to 385) | RR 1.83 (1.17 to 2.88) | 341 (3 RCTs) | ⊕⊕⊕○ 4 Moderate |
Third or fourth degree laceration | 93 per 1000 | 82 per 1000 (66 to 105) | RR 0.89 (0.71 to 1.13) | 2856 (7 RCTs) | ⊕⊕⊕○ 1 Moderate |
Episiotomy | 420 per 1000 | 404 per 1000 (370 to 437) | RR 0.96 (0.88 to 1.04) | 2830 (7 RCTs) | ⊕⊕⊕○ 1 Moderate |
Length of second stage of labor | Mean length of second stage of labor was 0 | M D 33.41 higher (14.04 higher to 52.78 higher | – | 1122 (9 RCTs) | ⊕⊕○○ 15 Low |