Combination of early pushing with extended second stage increases the rates of spontaneous vaginal deliveries, but might be associated with adverse maternal and neonatal outcomes.

OBJECTIVE

To evaluate the effect of combining the technique of early pushing and extended second stage on the mode of delivery, as well as adverse maternal and neonatal outcomes.

STUDY

DESIGN

This retrospective data analysis included all women delivering in a single tertiary medical center through 2015-2020. In January 2017 the protocol of second-stage management was changed to a combination of extended second stage (i.e., addition of an extra-hour to the traditional Friedman cutoffs), as well as early pushing (i.e., initiation of active pushing within the first 30 min of full dilatation). We compared delivery outcomes in women reaching full dilatation during January 2015-December 2016, vs. January 2017-July 2020.

RESULTS

Of the 15,792 parturients, 10,418 (66.0%) were managed using the "new" protocol. No difference was found in terms of baseline characteristics, except for higher rates of neuraxial analgesia (72.8% vs. 70.4%, p = 0.002) and induction of labor (22.4% vs. 17.8%, p < 0.0001) during the new protocol period. In subgroup analysis by parity and neuraxial analgesia, no change was noted in the rate of cesarean deliveries. A significant increase in spontaneous vaginal deliveries (SVD) in favor of the "new" protocol was noted, except for multiparous women with no analgesia. In addition, in primiparous women with neuraxial analgesia, a decrease in vacuum deliveries was noted. In secondary outcome analysis, a significant increase in postpartum hemorrhage and a decrease in umbilical base excess values was noted in women with neuraxial analgesia, both primi- and multiparous.

DISCUSSION: Early pushing along with extension of the second stage was associated with higher rate of SVD, at the expense of increased risk for maternal postpartum hemorrhage. Thus, combination of these two techniques must be practiced with caution.