Maternal outcomes using delayed pushing versus immediate pushing in the second stage of labour: An umbrella review

Introduction: Different systematic reviews have been developed in the last decades about maternal risks of immediate pushing and delayed pushing, depending on the duration of the second stage of labour, but they do not provide conclusive evidence. Aim: The main aim of this overview of systematic reviews was to assess the maternal outcomes using delayed pushing and immediate pushing in the second stage of labour in women receiving epidural analgesia. Methods: We searched systematically in PubMed (Medline), EMBASE, CINAHL, and Scopus (October 26th, 2023). Methodological quality was analysed using AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. The outcome measures were the duration of the second stage of labour, duration of active pushing, caesarean section, instrumental vaginal birth, spontaneous vaginal birth, fatigue score, perineal lacerations, postpartum haemorrhage, and rate of episiotomy. Seven systematic reviews with and without meta-analysis were included. Results: Results showed that delayed pushing increases the total time of the second stage of labour, although delayed pushing decreases the duration of active pushing with moderate quality of evidence. Mixed results were found with respect to the variables instrumental vaginal birth, spontaneous vaginal birth, and fatigue score although the results favour delayed pushing or show no statistically significant differences with respect to immediate pushing. No favourable results were ever found for immediate pushing with respect to delayed pushing, with a limited quality of evidence. Even so, delayed pushing seems to be associated with a significant increase in spontaneous vaginal birth rates. The results found no significant differences between the immediate pushing and delayed pushing groups in the caesarean section rates, perineal lacerations, postpartum haemorrhage, and episiotomy ratio, with a limited quality of evidence. Conclusions: This study shows that delayed pushing during the second stage of labour produces at least the same maternal outcomes as immediate pushing, although we note that delayed pushing produces an increase of the duration of the second stage of labour, a shorter duration of the active pushing and a tendency to increase spontaneous vaginal birth and to reduce the instrumental vaginal birth rates and fatigue scores. This should be considered clinically. This review was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42023397616). (c) 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).