Does gentle assisted pushing or giving birth in the upright position reduce the duration of the second stage of labour? A three-arm, open-label, randomised controlled trial in South Africa

Abstract

IntroductionGentle assisted pushing (GAP) is an innovative method of applying gentle, steady pressure to a woman’s uterine fundus during second stage of labour. This randomised trial evaluated GAP in an upright position, compared with upright position alone or routine practice (recumbent posture).MethodsAn open-label, hospital-based, randomised trial was conducted in Eastern Cape, South Africa. Randomisation occurred following at least 15 min in second stage of labour. Participants were randomly assigned (1:1:1) using computer-generated block randomisation of variable size using opaque, sealed, numbered envelopes. Primary analysis was intention to treat. Participants were healthy, nulliparous, consenting women with a singleton pregnancy in cephalic presentation where vaginal birth was anticipated. The primary outcome was mean time from randomisation to birth.Results1158 participants were randomly allocated to GAP (n=388), upright position (n=386) and routine practice (n=384), with no loss to follow-up. Baseline characteristics were largely similar. In the experimental arm, GAP was applied a median of two times (IQR 1.0–3.0). Women in upright position alone spent a median of 6 min (IQR 3.0–10.0) upright. Mean duration from randomisation to birth was not different across groups (mean (SD) duration: 24.1 (34.9) min in GAP group, 24.6 (30.5) min in upright group, 25.0 (39.3) min in routine practice group). There were no differences in secondary outcomes, except that at two sites maternal discomfort was greater for both GAP and upright position compared with routine practice; at the other sites there were no differences.ConclusionNo benefit was identified from GAP in the second stage; some women found the position uncomfortable. The use of fundal pressure should be limited to further research to determine techniques or settings in which it can safely assist vaginal birth. Women should be encouraged to assume the position they find most comfortable.Trial registration numberPACTR201502001034448.

“Just a little help”: A qualitative inquiry into the persistent use of uterine fundal pressure in the second stage of labor in Spain

“…Until recently, no trial had attempted to standardize the level of force applied during the Kristeller. In a randomized trial, Hofmeyr et al used a standardized protocol around the application of fundal pressure. They found that gentle fundal pressure applied in an upright labor position did not expedite delivery compared to upright or recumbent and supine positions without fundal pressure.…”

The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis

“…Not every occurrence of fundal pressure use is harmful; potential harms are possibly relative to the force and duration of pressure applied [ 12 , 21 ]. Forceful downward pressure on the uterine fundus may be uneven, and can cause rapid changes in intrauterine pressure [ 12 ]. If significant downward pressure is exerted toward the maternal spine, vena caval compression and consequent maternal hypotension can occur [ 21 ].…”

“…The World Health Organization (WHO) and several other national obstetric societies specifically recommend against the use of fundal pressure [20][21][22][23]. Despite these recommendations, there are reports of routine fundal pressure use during vaginal birth [11,12], however the prevalence of its use internationally has not been determined. The aim of this study was to determine the prevalence of uterine fundal pressure during the second stage of labour for women giving birth vaginally in health facilities.…”

“…This ranges from gentle pressure to the full force of an attendant's body weight [ 7 , 11 ]. Excessive force can subject the woman’s uterine fundus to uneven, high-intensity pressure [ 12 ]. Targeted devices, such as inflatable abdominal pressure belts, have been used in research settings to apply fundal pressure in a more controlled manner [ 7 ].…”

“…The review authors concluded that there was insufficient evidence on the benefits and harms of this procedure. More recently, a trial of 1158 nulliparous women in South Africa used gentle assisted manual pushing during second stage of labour, finding no evidence of benefit but more women reporting discomfort [ 12 ].…”