Pushing/bearing down methods for the second stage of labour

Background Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterine contraction. There is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on the mother and fetus. Objectives To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster‐RCTs were eligible for inclusion, but none were identified. Studies using a cross‐over design and those published in form only were not eligible for inclusion in this review. Data collection and analysis Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. Main results In this updated review, we included 21 studies in total, eight (884 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. Our GRADE assessments of evidence ranged from moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Overall, the included studies varied in their risk of bias; most were judged to be at unclear risk of bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushing There was no clear difference in the duration of the second stage of labour (mean difference (MD) 10.26 minutes; 95% confidence interval (CI) ‐1.12 to 21.64 minutes, six studies, 667 women, random‐effects, I² = 81%) (very low‐quality evidence). There was no clear difference in 3rd or 4th degree perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) (low‐quality evidence), episiotomy (average RR 1.05; 95% CI 0.60 to 1.85, two studies, 420 women, random‐effects, I² = 81%), duration of pushing (MD ‐9.76 minutes, 95% CI ‐19.54 to 0.02; two studies; 169 women; I² = 88%) (ver