Risk of operative vaginal delivery lower with open-glottis pushing compared to closed-glottis pushing among parous women: Study

The impact of closed- or open-glottis active second-stage pushing on obstetric outcomes is unclear for both women who have and haven't given birth before. Consequently, global recommendations advocate for women to have the freedom to choose their preferred pushing technique due to the absence of substantial evidence. Recent study examined the association between open- or closed-glottis pushing and obstetrical outcomes among women with an attempted singleton vaginal birth at or near term. It was an ancillary planned cohort study of the TRAAP randomized controlled trial, conducted in 15 French maternity units.

Key Objectives and Data Collection

The key objectives were to assess the association between open- or closed-glottis pushing and mode of delivery, maternal morbidity, and maternal satisfaction. The study design involved prospective data collection on labor and delivery characteristics, with a specific focus on active second-stage pushing. Women were classified into two groups based on the recorded assessment of the attending provider: open-glottis pushing (n=578, 19.0%) or closed-glottis pushing (n=2463, 81.0%). The main findings were: - Among nulliparous women, the risk of operative vaginal delivery did not differ between the open- and closed-glottis pushing groups, after adjusting for confounders. - Among parous women, the risk of operative vaginal delivery was significantly lower in the open-glottis pushing group compared to the closed-glottis group (adjusted OR 0.43, 95% CI 0.19-0.90). - Other maternal and neonatal outcomes, including severe perineal laceration, episiotomy, postpartum hemorrhage, and severe neonatal morbidity, did not differ between the two pushing groups in either nulliparous or parous women. - Maternal satisfaction and psychological status at 2 months postpartum were also similar between the two pushing groups.

Summary and Implications

In summary, this study suggests that the risk of operative vaginal delivery may be lower with open-glottis pushing compared to closed-glottis pushing among parous women, while no difference was observed among nulliparous women. The findings will help inform shared decision-making regarding the mode of pushing during the second stage of labor.

Key Points

1. This was an ancillary planned cohort study of the TRAAP randomized controlled trial, conducted in 15 French maternity units. The study examined the association between open-glottis pushing and closed-glottis pushing with obstetrical outcomes among women attempting singleton vaginal birth at or near term.

2. The key objectives were to assess the association between open- or closed-glottis pushing and mode of delivery, maternal morbidity, and maternal satisfaction. Women were classified into two groups based on the recorded assessment of the attending provider: open-glottis pushing (n=578, 19.0%) or closed-glottis pushing (n=2463, 81.0%).

3. Among nulliparous women, the risk of operative vaginal delivery did not differ between the open- and closed-glottis pushing groups after adjusting for confounders. However, among parous women, the risk of operative vaginal delivery was significantly lower in the open-glottis pushing group compared to the closed-glottis group (adjusted OR 0.43, 95% CI 0.19-0.90).

4. Other maternal and neonatal outcomes, including severe perineal laceration, episiotomy, postpartum hemorrhage, and severe neonatal morbidity, did not differ between the two pushing groups in either nulliparous or parous women.

5. Maternal satisfaction and psychological status at 2 months postpartum were also similar between the two pushing groups.

6. The findings suggest that the risk of operative vaginal delivery may be lower with open-glottis pushing compared to closed-glottis pushing among parous women, while no difference was observed among nulliparous women. These results will help inform shared decision-making regarding the mode of pushing during the second stage of labor.

Reference -

Froeliger A, Deneux-Tharaux C, Madar H, Bouchghoul H, Le Ray C, Sentilhes L; TRAAP study group. Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study. Am J Obstet Gynecol. 2024 Mar;230(3S):S879-S889.e4. doi: 10.1016/j.ajog.2023.07.017. Epub 2023 Aug 24. PMID: 37633725.