• M Prins, J Boxem, C Lucas, and E Hutton.
• Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands. marianne.prins@inholland.nl
• BJOG. 2011 May 1;118(6):662-70.

ObjectivesTo critically evaluate any benefit or harm for the mother and her baby of Valsalva pushing versus spontaneous pushing in the second stage of labour.Search StrategyElectronic databases from MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were systematically searched (last search May 2010). The reference lists of retrieved studies were searched by hand and an internet hand search of master theses and dissertations was performed. No date or language restriction was used.Selection CriteriaRandomised controlled trials that compared instructed pushing with spontaneous pushing in the second stage of labour were considered. Studies were evaluated independently for methodological quality and appropriateness for inclusion by two authors (MP and JB).Data Collection And AnalysisThe primary outcome was instrumental/operative delivery. Other outcomes were length of labour, any perineal repair, bladder function, maternal satisfaction. Infant outcomes included low Apgar score < 7 after 5 minutes, umbilical arterial pH <7.2, admission to neonatal intensive care unit and serious neonatal morbidity or perinatal death.Main ResultsThree randomised controlled studies covering 425 primiparous women met the inclusion criteria. Women who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 women; relative risk 0.70; 95% CI 0.34-1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in women who used the Valsalva pushing technique (three studies; 425 women; mean difference 18.59 minutes; 95% CI 0.46-36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 women; mean difference respectively 41.50 ml, 95% CI 8.40-74.60, and 54.60 ml, 95% CI 13.31-95.89).Authors' ConclusionThe evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed. Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.

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