Moderate pushing strategy during labor safe for neonates, saves episiotomies

According to a study published in the American Journal of Obstetrics & Gynecology, moderate pushing had no impact on neonatal morbidity but may still be advantageous due to its association with a decreased rate of episiotomies.

Regardless of the method of delivery, childbirth by its very nature entails potential risks for the mother and her child. It is challenging to pinpoint the morbidity directly brought on by the delivery method.

The authors stated that there was "no agreement on an ideal method for managing the active portion of the second stage of labor."

This study sought to determine whether "moderate" pushing or "intense" pushing had a greater impact on newborn morbidity.

The research involved 1710 nulliparous women who were in the second stage of labor with an epidural and had a singleton cephalic fetus who was full-term and had a normal fetal heart rate. There were 2 groups established: (1) the moderate pushing group, in which women pushed for an unlimited amount of time, twice during each contraction, and observed regular periods without pushing; and (2) the intensive pushing group, in which women attempted to push three times during each contraction and the healthcare professional called an obstetrician to analyze operative delivery after 30 minutes of pushing (standard care). The main result was a composite neonatal morbidity criterion that included a 5-minute Apgar score of 7, an umbilical arterial pH of 7.15, a base excess of >10 mmol/L, lactate levels of >6 mmol/L, and severe neonatal trauma. Mode of birth, episiotomy, obstetrical anal sphincter injury, postpartum hemorrhage, and maternal satisfaction were the secondary endpoints.

Conclusive points of the study:

• In the moderate pushing group, the infant morbidity rate was 18.9%, whereas in the intense pushing group, it was 20.6% (P=.38).
• Pushing lasted for an extended period of time in the moderate group compared to the intensive group (38.826.4 vs. 28.617.0 minutes; P.001), and its rate of operational delivery was lower in the moderate group (21.1% vs. 24.8%; P=.08).
• The moderate pushing group saw a notably lower rate of episiotomies than the intensive pushing group (13.5% vs. 17.8%; P=.02).
• There was no discernible difference in maternal satisfaction, postpartum hemorrhage, or obstetrical anal sphincter injury.

In addition to shortening the length of pushing, intensive pushing may also result in abnormally high fetal heart rates due to cord compression and decreased placental perfusion and oxygenation brought on by the interaction of uterine contractions and maternal expulsive forces, concluded the investigators.

They continued, "As a result, it may raise the possibility of neonatal acidosis and the requirement for operational vaginal delivery."

REFERENCE

Le Ray C, Rozenberg P, Kayem G, et al. Alternative to intensive management of the active phase of the second stage of labor: a multicenter randomized trial (PASST trial) among nulliparous women with an epidural. Am J Obstet Gynecol 2022;227:639.e1-15.