Mode of delivery unchanged with delayed or immediate pushing in second stage labor with epidural analgesia

Référence

Di Mascio D, Saccone G, Bellussi F, et al. Delayed versus immediate pushing in the second stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol 2020;223(2):189-203.

Sommaire

This systematic review and meta-analysis of 12 randomized controlled trials (5445 participants, 96% nulliparous) compared birth outcomes when the instruction for the second stage of labor was to start pushing immediately versus to delay pushing. Studies were selected for inclusion if the participating women were randomized to immediate versus delayed pushing in the second stage of labor, and the outcome of mode of delivery was reported. All the studies included women with uncomplicated singleton pregnancies with vertex presentation in spontaneous or induced labor at or near term (36 - 42 weeks), and the use of neuraxial analgesia. Analgesia routinely consisted of epidural administration of bupivacaine, with or without fentanyl. Delayed pushing was defined as instruction to patients to delay pushing for at least 1 hour, and up to 3 hours, on reaching full cervical dilatation unless the urge to push was irresistible, the fetal head was observed at the perineum, or pushing was medically indicated. Masking was not feasible and not used in any of the included studies. Meta-analysis showed no significant differences in the rates of mode of delivery between the delayed and immediate pushing groups (spontaneous vaginal delivery 81% vs 78%, operative vaginal delivery 13% vs 15%, cesarean delivery 7% vs 8%). The delayed pushing group had a small but statistically significant difference in rate of chorioamnionitis (2 studies: 9% vs 7%; relative risk [RR] 1.37; 95% CI 1.04 - 1.81; number needed to treat to harm [NNTH] = 41; 22 -323). There were no significant differences in the rates of other maternal complications, including intrapartum fever, endometritis, postpartum hemorrhage, episiotomy, and severe perineal lacerations. Neonates had a higher incidence of low cord blood pH, as variously defined by the original study authors, in the delayed pushing group (5 studies: 2.7% vs 1.3%; RR 2.0; 1.3 - 3.1; NNTH = 71; 44 - 168). However, there were no significant differences in Apgar scores of less than 7 at 5 minutes or in neonatal intensive care admissions. The study was limited by the fact that the quality of evidence of the included studies was low.