Maternal and neonatal outcomes from a comparison of spontaneous and directed pushing in second stage

Nigel Lee, Yu Gao, Lauren Lotz, Sue Kildea

Research output: Contribution to journalArticlepeer-review


Aim: To compare the effect of directed or spontaneous maternal pushing effort on duration of second stage labour, perineal injury and neonatal condition at birth.

Methods: A retrospective cross-sectional design provided data for term women with singleton, cephalic presentation experiencing a non-operative vaginal birth without regional analgesia from January 2011 to December 2017 (n = 69,066) Participants matching the inclusion criteria (n = 19,212) were grouped based upon spontaneous or directed pushing. Propensity score matching was used to select equally sized cohorts of similar characteristics (n = 10,000). The associations with outcomes of interest were estimated using odds ratios obtained by multivariate analysis.

Findings: Directed pushing was associated with a longer duration of second stage labour for nulliparous (mean 14.4 min [12.0–16.8]) and multiparous (mean 8.0 min [6.8–9.2]) women, and an increased risk of prolonged 2nd stage of labour in multiparous women. The use of episiotomy in the directed pushing group was significantly higher both prior to and following PS matching and adjustment. Directed pushing was also associated with an significantly increased risk of neonatal resuscitation and nursery admission. There was no difference in rates of Apgar <7 recorded at 5 min of age.

Conclusion: Directed pushing is associated with an increased duration of second stage labour and risk of adverse neonatal outcomes. Our study suggests that in the absence of regional analgesia women should be supported to follow their own expulsive urges.

Original languageEnglish
Pages (from-to)e433-e440
Number of pages8
JournalWomen and Birth
Issue number4
Early online date28 Oct 2018
Publication statusPublished - Aug 2019
Externally publishedYes


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