Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery study.

BACKGROUND: The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women. OBJECTIVE: This study aimed to assess the association between open- or closed-glottis pushing and mode of delivery after an attempted singleton vaginal birth at or near term. STUDY DESIGN: This was an ancillary planned cohort study of the TRAAP (TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial, conducted in 15 French maternity units from 2015 to 2016 that enrolled women with an attempted singleton vaginal delivery after 35 weeks' gestation. After randomization, characteristics of labor and delivery were prospectively collected, with special attention to active second-stage pushing and a specific planned questionnaire completed immediately after birth by the attending care provider. The exposure was the mode of pushing, classified into 2 groups: closed- or open-glottis. The main endpoint was operative vaginal delivery. Secondary endpoints were items of maternal morbidity, including severe perineal laceration, episiotomy, postpartum hemorrhage, duration of the second stage of labor, and a composite severe neonatal morbidity outcome. We also assessed immediate maternal satisfaction, experience of delivery, and psychological status 2 months after delivery. The associations between mode of pushing and outcome were analyzed by multivariate logistic regression to control for confounding bias, with multilevel mixed-effects analysis, and a random intercept for center. RESULTS: Among 3041 women included in our main analysis, 2463 (81.0%) used closed-glottis pushing and 578 (19.0%) open-glottis pushing; their respective operative vaginal delivery rates were 19.1% (n=471; 95% confidence interval, 17.6-20.7) and 12.5% (n=72; 95% confidence interval, 9.9-15.4; P<.001). In an analysis stratified according to parity and after controlling for available confounders, the rate of operative vaginal delivery did not differ between the groups among nulliparous women: 28.7% (n=399) for the closed-glottis and 27.5% (n=64) for the open-glottis group (adjusted odds ratio, 0.93; 95% confidence interval, 0.65-1.33; P=.7). The operative vaginal delivery rate was significantly lower for women using open- compared with closed-glottis pushing in the parous population: 2.3% (n=8) for the open- and 6.7% (n=72) for the closed-glottis groups (adjusted odds ratio, 0.43; 95% confidence interval, 0.19-0.90; P=.03). Other maternal and neonatal outcomes did not differ between the 2 modes of pushing among either the nulliparous or parous groups. CONCLUSION: Among nulliparous women with singleton pregnancies at term, the risk of operative vaginal birth did not differ according to mode of pushing. These results will inform shared decision-making about the mode of pushing during the second stage of labor.

Just go with your body? A conversation analytic study of the transition from first to second stage of labor in UK midwife-led care.

BACKGROUND: The transition from first to second stage of labor is poorly understood. While the onset of second stage is defined by cervical measurement, dilation cannot be directly sensed or externally observed. Thus, uncertainty exists when women report pushing urges before dilation is confirmed. This study aimed to explore how sensations of pushing and uncertainty over progress are interactionally managed. METHODS: We audio/video recorded the labors of 37 women in two midwife-led units in England. Our analysis focused on a subset of 28 recordings that featured discussion of transition from first to second stage of labor. The interactions between midwives, laboring women and their birth partners were transcribed and analyzed using conversation analysis. RESULTS: We identified a 'pushing until proven otherwise' rule granting temporary, contingent authority to bodily urges to push while tracking progress over time. Specifically, midwives supported reported pushing sensations without insisting on examinations. Caution was occasionally expressed in distinguishing between irresistible and forced pushing. Across multiple contractions, midwives watched and waited for alignment of sensations with signs of descent. Where signs of progress were absent over time, examinations were treated as clinically indicated. DISCUSSION: Thus, a complex interplay of women's sensations and midwifery expertise produced care. Compared to past research, our analysis demonstrates increased validation of embodied experience in contemporary midwife-led practice. However, uncertainty still requires navigation through collaborative work. We evidence how this navigation is accomplished in real-time interactions.

Cephalometric changes of pushing splints 3 compared to rapid maxillary expansion and facemask therapy on the airway space in class III growing patients: A randomized clinical trial.

BACKGROUND: Early orthopaedic treatment with rapid maxillary expansion (RME) associated with facemask (FM) has been shown to be effective in correcting Class III malocclusions in children. Treatment with pushing splints 3 (PS3) has shown to correct skeletal discrepancies in Class III growing patients. However, the effects of orthopaedic treatment on the upper airways in children with Class III malocclusion is controversial. OBJECTIVES: The aim of this study was to evaluate the cephalometric changes in the airways of PS3 compared to the RME/FM protocol. MATERIALS AND METHODS: In this study, 48 patients with Class III malocclusion (age range 5.5-8.5 years old) were selected for this study, and 24 were treated with PS3 appliance and 24 with RME/FM therapy. Lateral cephalograms before (T0) and at the end of the treatment (T1) were analysed to compare pharyngeal spaces. Paired and unpaired t tests were used for data analysis (P < .05). RESULTS: A total of 41 patients (21 patients for the PS3 group, 11 males and 10 females, mean age 7.0 ± 1.2 years; 20 patients for the RME/FM group, 10 males and 10 females, mean age 7.2 ± 1.3 years) were included. The results showed a statistically significant (P < .05) increase in the nasopharyngeal space after both therapies. However, the effects were similar considering that there were no differences between groups for the assessed variables at T0-T1. CONCLUSIONS: Early treatment of Class III malocclusion with PS3 does not induce a statistically significant increase in the sagittal airway space compared to RME/FM. The absence of untreated group could not define the role of growth in the increase of space.

First and Second Stage Risk Factors Associated with Perineal Lacerations.

OBJECTIVE: To determine intrapartum factors associated with perineal laceration at delivery. METHODS: This was a planned secondary analysis of a multicenter randomized clinical trial of delayed versus immediate pushing among term nulliparous women in labor with neuraxial analgesia conducted in the United States. Intrapartum characteristics were extracted from the medical charts. The primary outcome was perineal laceration, defined as second degree or above, characterized at delivery in women participating in longer term pelvic floor assessments post-delivery. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, birth weight, and maternal age. RESULTS: Among the 941 women participating in the pelvic floor follow-up, 40.6% experienced a perineal laceration. No first stage labor characteristics were associated with perineal laceration, including type of labor or length of first stage. Receiving an amnioinfusion appeared protective of perineal laceration (adjusted odds ratio, 0.48; 95% confidence interval 0.26-0.91; P = 0.01). Second stage labor characteristics associated with injury were length of stage (2.01 h vs. 1.50 h; adjusted odds ratio, 1.36; 95% confidence interval 1.18-1.57; P < 0.01) and a prolonged second stage (adjusted odds ratio, 1.64; 95% confidence interval 1.06-2.56; P < 0.01). Operative vaginal delivery was strongly associated with perineal laceration (adjusted odds ratio, 3.57; 95% confidence interval 1.85-6.90; P < 0.01). CONCLUSION: Operative vaginal delivery is a modifiable risk factor associated with an increased risk of perineal laceration. Amnioinfusion appeared protective against injury, which could reflect a spurious finding, but may also represent true risk reduction similar to the mechanism of warm perineal compress.

Anaphase B: Long-standing models meet new concepts.

Mitotic cell divisions ensure stable transmission of genetic information from a mother to daughter cells in a series of generations. To ensure this crucial task is accomplished, the cell forms a bipolar structure called the mitotic spindle that divides sister chromatids to the opposite sides of the dividing mother cell. After successful establishment of stable attachments of microtubules to chromosomes and inspection of connections between them, at the heart of mitosis, the cell starts the process of segregation. This spectacular moment in the life of a cell is termed anaphase, and it involves two distinct processes: depolymerization of microtubules bound to chromosomes, which is also known as anaphase A, and elongation of the spindle or anaphase B. Both processes ensure physical separation of disjointed sister chromatids. In this chapter, we review the mechanisms of anaphase B spindle elongation primarily in mammalian systems, combining different pioneering ideas and concepts with more recent findings that shed new light on the force generation and regulation of biochemical modules operating during spindle elongation. Finally, we present a comprehensive model of spindle elongation that includes structural, biophysical, and molecular aspects of anaphase B.

Video Instruction for Pushing in the Second Stage: a randomized controlled trial.

BACKGROUND: The second stage of labor requires active patient engagement. Previous studies suggest that coaching can influence the second stage of labor duration. However, a standardized education tool has not been established, and patients face many barriers to accessing childbirth education before delivery. OBJECTIVE: This study aimed to investigate the effect of an intrapartum video pushing education tool on the second stage of labor duration. STUDY DESIGN: This was a randomized controlled trial of nulliparous patients with singleton pregnancies ≥37 weeks of gestation admitted for induction of labor or spontaneous labor with neuraxial anesthesia. Patients were consented on admission and block randomized in active labor to 1 of 2 arms in a 1:1 ratio. The study arm viewed a 4-minute video before the second stage of labor on what to anticipate in the second stage of labor and pushing techniques. The control arm received the standard of care: bedside coaching at 10 cm dilation from a nurse or physician. The primary outcome was second stage of labor duration. The secondary outcomes were birth satisfaction (using the Modified Mackey Childbirth Satisfaction Rating Scale), mode of delivery, postpartum hemorrhage, clinical chorioamnionitis, neonatal intensive care unit admission, and umbilical artery gases. Of note, 156 patients were needed to detect a 20% decrease in the second stage of labor duration with 80% power, 2-sided alpha level of .05, and 10% loss after randomization. Funding was provided by the Lucy Anarcha Betsy award from the division of clinical research at Washington University. RESULTS: Of 161 patients, 81 were randomized to standard of care, and 80 were randomized to intrapartum video education. Among these patients, 149 progressed to the second stage of labor and were included in the intention-to-treat analysis: 69 in the video group and 78 in the control group. Maternal demographics and labor characteristics were similar between groups. The second stage of labor duration was statistically similar between the video arm (61 minutes [interquartile range, 20-140]) and the control arm (49 minutes [interquartile range, 27-131]) (P=.77). There was no difference in mode of delivery, postpartum hemorrhage, clinical chorioamnionitis, neonatal intensive care unit admission, or umbilical artery gases between groups. Although the overall birth satisfaction score on the Modified Mackey Childbirth Satisfaction Rating Scale was similar between groups, patients in the video group rated their "level of comfort during birth" and "attitude of the doctors in birth" significantly higher or more positively than patients in the control group (P<.05 for both). CONCLUSION: Intrapartum video education was not associated with a shorter second stage of labor duration. However, patients who received video education reported a higher level of comfort and a more favorable perception of their physician, suggesting that video education may be a helpful tool to improve the birth experience.

Does the type of pushing at delivery influence pelvic floor function at 2 months postpartum? A pragmatic randomized trial-The EOLE study.

INTRODUCTION: Maternal pushing techniques during the second stage of labor may affect women's pelvic floor function. Our main objective was to assess the impact of the type of pushing used at delivery on the mother's medium-term pelvic floor function. MATERIAL AND METHODS: This is a secondary analysis of a randomized clinical trial (clinicaltrials.gov: NCT02474745) that took place in four French hospitals from 2015 through 2017 (n = 250). Women in labor with a singleton fetus in cephalic presentation at term who had undergone standardized training in both of these types of pushing were randomized after cervical dilation ≥7 cm. The exclusion criteria were a previous cesarean, a cesarean delivery in this pregnancy or a fetal heart rate anomaly. In the intervention group, open-glottis (OG) pushing was defined as a prolonged exhalation contracting the abdominal muscles to help move the fetus down the birth canal. Closed-glottis (CG) pushing was defined as Valsalva pushing. The principal outcome was the stage of pelvic organ prolapse (POP) assessed by the Pelvic Organ Prolapse-Quantification 2 months after delivery. A secondary outcome was incidence of urinary incontinence (UI). The results of our multivariable, modified intention-to-treat analysis are reported as crude relative risks (RRs) with their 95% confidence intervals. RESULTS: Our analysis included 207 women. Mode of birth was similar in both groups. The two groups did not differ for stage II POP: 10 of 104 (9.4%) in the OG group compared with 7 of 98 (7.1%) in the CG group, for a RR 1.32, 95% confidence interval [CI] 0.52-3.33, and an adjusted RR of 1.22, 95% CI 0.42-3.6. Similarly, the incidence of UI did not differ: 26.7% in the OG group and 28.6% in the CG group (aRR 0.81, 95% CI 0.42-1.53). Subgroup analysis suggests that for secundiparous and multiparous women, OG pushing could have a protective effect on the occurrence of UI (RR 0.33, 95% CI 0.13-0.80). CONCLUSIONS: The type of directed pushing used at delivery did not impact the occurrence of pelvic organ prolapse 2 months after delivery. OG pushing may have a protective effect against UI among secundiparous and multiparous women.

Metabolic engineering of the oleaginous alga Nannochloropsis for enriching eicosapentaenoic acid in triacylglycerol by combined pulling and pushing strategies.

The marine alga Nannochloropsis oceanica has been considered as a promising photosynthetic cell factory for synthesizing eicosapentaenoic acid (EPA), yet the accumulation of EPA in triacylglycerol (TAG) is restricted to an extreme low level. Poor channeling of EPA to TAG was observed in N. oceanica under TAG induction conditions, likely due to the weak activity of endogenous diacylglycerol acyltransferases (DGATs) on EPA-CoA. Screening over thirty algal DGATs revealed potent enzymes acting on EPA-CoA. Whilst overexpressing endogenous DGATs had no or slight effect on EPA abundance in TAG, introducing selected DGATs with strong activity on EPA-CoA, particularly the Chlamydomonas-derived CrDGTT1, which resided at the outermost membrane of the chloroplast and provided a strong pulling power to divert EPA to TAG for storage and protection, led to drastic increases in EPA abundance in TAG and TAG-derived EPA level in N. oceanica. They were further promoted by additional overexpression of an elongase gene involved in EPA biosynthesis, reaching 5.9- and 12.3-fold greater than the control strain, respectively. Our results together demonstrate the concept of applying combined pulling and pushing strategies to enrich EPA in algal TAG and provide clues for the enrichment of other desired fatty acids in TAG as well.

Pelvic floor muscle injury during a difficult labor. Can tissue fatigue damage play a role?

Pubovisceral muscle (PVM) injury during a difficult vaginal delivery leads to pelvic organ prolapse later in life. If one could address how and why the muscle injury originates, one might be able to better prevent these injuries in the future. In a recent review we concluded that many atraumatic injuries of the muscle-tendon unit are consistent with it being weakened by an accumulation of passive tissue damage during repetitive loading. While the PVM can tear due to a single overstretch at the end of the second stage of labor we hypothesize that it can also be weakened by an accumulation of microdamage and then tear after a series of submaximal loading cycles. We conclude that there is strong indirect evidence that low cycle fatigue of PVM passive tissue is a possible mechanism of its proximal failure. This has implications for finding new ways to better prevent PVM injury in the future.

Postpartum urinary incontinence and birth outcomes as a result of the pushing technique: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Directed pushing while using the Valsalva maneuver is shown to lead to bladder neck descent, especially in women with urinary incontinence (UI). There is insufficient evidence about the benefits or adverse effects between the pushing technique during the second stage of labor and urinary incontinence postpartum. The objective of this study was to evaluate the effects of the pushing technique for women during labor on postpartum UI and birth outcomes. METHODS: Scientific databases were searched for studies relating to postpartum urinary incontinence and birth outcomes when the pushing technique was used from 1986 until 2020. RCTs that assessed healthy primiparas who used the pushing technique in the second stage of labor were included. In accordance with Cochrane Handbook guidelines, risk of bias was assessed and meta-analyzed. Certainty of evidence was assessed using the GRADE approach. RESULTS: Seventeen RCTs (4606 primiparas) were included. The change in UI scores from baseline to postpartum was significantly lower as a result of spontaneous pushing (two studies; 867 primiparas; standardized mean difference: SMD -0.18, 95% CI -0.31 to -0.04). Although women were in the recumbent position during the second stage, directed pushing group showed a significantly shorter labor by 21.39 min compared with the spontaneous pushing group: there was no significant difference in the duration of the second stage of labor between groups. CONCLUSIONS: Primiparas who were in the upright position and who experienced spontaneous pushing during the second stage of labor could reduce their UI score from baseline to postpartum.

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.

A Hybrid Deep Learning and Visualization Framework for Pushing Behavior Detection in Pedestrian Dynamics.

Crowded event entrances could threaten the comfort and safety of pedestrians, especially when some pedestrians push others or use gaps in crowds to gain faster access to an event. Studying and understanding pushing dynamics leads to designing and building more comfortable and safe entrances. Researchers-to understand pushing dynamics-observe and analyze recorded videos to manually identify when and where pushing behavior occurs. Despite the accuracy of the manual method, it can still be time-consuming, tedious, and hard to identify pushing behavior in some scenarios. In this article, we propose a hybrid deep learning and visualization framework that aims to assist researchers in automatically identifying pushing behavior in videos. The proposed framework comprises two main components: (i) Deep optical flow and wheel visualization; to generate motion information maps. (ii) A combination of an EfficientNet-B0-based classifier and a false reduction algorithm for detecting pushing behavior at the video patch level. In addition to the framework, we present a new patch-based approach to enlarge the data and alleviate the class imbalance problem in small-scale pushing behavior datasets. Experimental results (using real-world ground truth of pushing behavior videos) demonstrate that the proposed framework achieves an 86% accuracy rate. Moreover, the EfficientNet-B0-based classifier outperforms baseline CNN-based classifiers in terms of accuracy.

Delayed versus early pushing during the second stage of labour in primigravidas under epidural anaesthesia with occipitoposterior malposition: a randomised controlled study.

This randomised controlled trial aimed to compare the effect of early and delayed pushing during the second stage of labour in women with occipitoposterior (OP) malposition. It included 184 nulliparous women with OP position randomised to early pushing in which women were allowed to push within one hour after full cervical dilatation or delayed pushing in which women were asked not to push for maximum of three hours or start pushing when the vertex was visible. The primary outcome was successful vaginal delivery. The rate of spontaneous vaginal delivery was significantly higher in the early pushing group (80.4 vs. 60.9%, p=.004) while the rate of instrumental vaginal delivery (30.4 vs. 15.4%) and CS (8.7 vs. 4.3%) was significantly higher in the delayed pushing group. Women in the delayed pushing group showed a significantly longer duration of the second stage (129.4 ± 7.5 vs. 61.6 ± 15.3 minutes, p<.001) and shorter duration of pushing (219.8 ± 74.8 vs. 693.9 ± 145.2 seconds, p<.001) .The rate of 2nd and 3rd degree perineal lacerations (19.6 and 13% vs. 5.4 and 8.7% respectively, p=.013) and vaginal tears (41.3 vs. 8.7%, p<.001) was significantly higher in the early pushing group. We concluded that early pushing during the second stage of labour is associated with higher rates of spontaneous vaginal delivery and vaginal and perineal lacerations.Clinical trial registration NCT03121274.Impact StatementWhat is already known on this subject? Occipitoposterior malposition is common during delivery especially in primigravida and is associated with higher rates of instrumental delivery and caesarean section. It can be managed through early or delayed pushing.What the results of this study add? Early pushing is associated with higher rates of spontaneous vaginal delivery, perineal and vaginal tears, shorter duration of second stage of labour, shorter duration of pushing, lower rates of both instrumental vaginal delivery and caesarean section.What the implications are of these findings for clinical practice and/or further research? Early pushing during the second stage of labour is associated with higher rates of spontaneous vaginal delivery and vaginal and perineal lacerations in women with OP malposition and should be tried and not delaying the pushing.

Efficacy of spontaneous pushing with pursed lips breathing compared with directed pushing in maternal and neonatal outcomes.

This is a quasi-randomised clinical trial, with 62 low-risk pregnant women in the second stage of labour. They were randomly allocated in control (CG) (n = 31) and intervention (IG) (n = 31) groups. The IG performed spontaneous pushing with pursed lips breathing while the CG was oriented to perform directed pushing associated with Valsalva Manoeuvre (VM). There was no difference between the groups regarding the occurrence of episiotomy (RR 1,1; 95%IC 1,0 to 1,2). However, there was a decrease in the duration of the maternal pushing by 3.2 min (MD 3,2; 95%CI 1,4 to 5,1) and a difference in maternal anxiety (Md (IQR) IG 46 (35-52), CG 51 (44-56) p:0,049), both favouring the IG. Spontaneous pushing was effective in reducing the duration of the pushing and showed a difference in maternal anxiety but did not decrease the maternal and neonatal outcomes. Brazilian Clinical Trials Registry (ReBEC) under the identifier: RBR-556d22IMPACT STATEMENTWhat is already known on the subject? Spontaneous pushing reduces the duration of pushing time when compared to directed pushing with VM but has no effect on other maternal and neonatal outcomes, based on a low quality of evidence.What do the results of this study add? No subject has been published on the subject. Our results suggest that the use spontaneous pushing with pursed lips breathing reduces the duration of the pushing by 3.2 min, also showing a difference in maternal anxiety. This result may indicate its use for emotional control when compared to the directed pushing.What are the implications of these findings for clinical practice and/or further research? These findings may signal an attitude in decision-making about guiding the breathing pattern in the expulsive stage.

Application of exposure enhancement technique combined with femoral condyle pushing technique in repairing the posterior horn of the medial meniscus under knee arthroscopy.

Objectives: To investigate the clinical efficacy of exposure enhancement technique and femoral condyle pushing technique applying in the posterior horn of the medial meniscus of the knee. Methods: From January 2016 to June 2019, 52 patients with injury in the medial meniscus treated in our department were selected. The horizontal tear of the posterior horn of the medial meniscus was repaired by exposure enhancement technique and femoral condyle pushing technique using the meniscus suture system. Postoperatively, the efficacy was evaluated using the Lysholm scoring system. Results: These 52 patients were all followed up for 3~18 months, with an average of 12.5 ± 7.3 months. The pain and activity of all patients were significantly improved compared with those before surgery. Conclusion: Exposure enhancement technique and femoral condyle pushing technique in the repair of the posterior horn of the medial meniscus presents satisfactory efficacy. It can improve the pain and activity of the knee, and enhance the stability of residual meniscus. Therefore, it is worth promoting.

[Development and Application of Medical Device Recall Event Tracking System].

A medical device recall event tracking system was designed, which can enable the users to obtain the recall, early warning and other information related to medical devices in time. The tracking system can timely obtain and release the recall information of medical devices, effectively improve the quality control of hospital medical devices, reduce the use risk of medical devices, and ensure the life safety of patients.

Comparison of maternal and fetal outcomes between delayed and immediate pushing in the second stage of vaginal delivery: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The second stage of labor begins with complete dilatation of the cervix until delivery of the fetus. After the cervix has fully dilated, the caregiver/nurse will provide guidance to the mother regarding the push technique for delivering the fetus (immediate pushing, IP). Because some women receive analgesic medications during labor, they might not be able to push correctly. Therefore, some obstetricians choose to postpone guiding the patient to push until the cervix is fully dilated and the fetal head has begun to descend. At this point, there is an involuntary exertion sensation (delayed pushing, DP) that saves energy and, at the same time, decreases tiredness and fatigue. The best timing for pushing during the second stage of labor is still controversial. The aim of this study was to investigate the different maternal and neonatal outcomes with IP and DP in the second stage of labor. METHODS: The Cochrane Library, EMBASE, PubMed, and Airiti Library (a Chinese database) were searched up to July 2019. Search keywords included: "labor stage, second", "delayed pushing", and "immediate pushing". Gray literature and bibliographies of articles were checked. No language restrictions were applied. Only randomized controlled trials were included. Two independent reviewers identified relevant studies and extracted data. The quality of the studies was assessed using the Cochrane's Risk of Bias tool. A random-effects meta-analysis was used to pool results. Mean differences and risk ratios were calculated with 95% confidence intervals (CIs) using Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark, 2014). The risk of heterogeneity was reported as I2, and publication bias was visually assessed by funnel plots. RESULTS: In total, 15 studies (n = 6121 participants) were identified. Pooled results demonstrated the following. (1) As to maternal outcomes, in comparison, IP shortened the length of the second stage of labor by 40.9 (95% CI 23.6-58.2) min; however, DP decreased the total length of pushing by 25.4 (95% CI 13.9-37.0) min. The incidence of instrument-assisted vaginal delivery was significantly lower in the DP group in western countries (RR 0.85, 95% CI 0.74-0.97). In addition, the maternal postpartum fatigue score was 0.67 points lower in the DP group (95% CI - 1.09 to - 0.26). There was no statistical significance of the cesarean section rate or blood loss. (2) As to neonatal outcomes (Apgar score at 1 min), the DP group showed a higher score (by 0.19; 95% CI 0.10-0.27 points) than the IP group. CONCLUSIONS: Delayed pushing can decrease the total pushing time and decrease the fatigue score after delivery without significant adverse events compared to the early pushing group. Therefore, we recommend that caregivers instruct the pushing time at the optimal moment, which allows women to have more resting time and save energy during labor.

Linking the Spinal Function Sort and Functional Capacity Evaluation Tests to the International Classification of Functioning, Disability and Health Core Set of Vocational Rehabilitation.

Purpose The International Classification of Functioning, Disability and Health (ICF) Comprehensive Core Set for Vocational Rehabilitation (CSVR) is a shortlist of functioning domains developed for use with people of working age that experience limitation in their work-related functional capacity. Functional capacity can be measured by, for example, Spinal Function Sort pictorial questionnaire and Functional Capacity Evaluation tests such as the: Complete Minnesota Dexterity Test, grip strength test, pushing, pulling, progressive iso-inertial lifting and carrying. However, these tests have not yet been linked to the CSVR. The objective of this study was to evaluate the extent to which the Spinal Function Sort and Functional Capacity Evaluation tests could be mapped to the ICF categories of the CSVR. Methods Two raters independently performed the linking of the Spinal Function Sort and the Functional Capacity Evaluation related tests to the CSVR according to established ICF linking rules. If an item could not accurately be linked to a CSVR category, the item was linked to the most fitting ICF category. Disagreements were resolved in a consensus meeting. Interrater agreement between raters was expressed in percentage agreement. Results The Spinal Function Sort and Functional Capacity Evaluation tests described a total of 39 unique ICF categories, out of which only six (15%) came from the CSVR. Interrater agreement ranged between 17 and 91%. Conclusions The study found six categories including vestibular functions, muscle power functions, writing, lifting and carrying objects, fine hand use and hand and arm use within the CSVR using the Spinal Function Sort and The Complete Minnesota Dexterity Test. With the rest of the items, the CSVR was considered too broad.

The Liberty Mutual manual materials handling (LM-MMH) equations.

We summarise more than 40 years of Liberty Mutual psychophysical research on lifting, lowering, pushing, pulling and carrying, including the 7 studies used to develop the 1991 Liberty Mutual Tables and 12 subsequent studies. Predictive equations were developed based on 612 mean maximum acceptable loads (MALs), representing 388 unique conditions from 123 female and 149 male participants, starting with a maximum reference load that is scaled based on frequency, height, distance (vertical for lift & lower, horizontal for push, pull and carry tasks) and horizontal reach (for lift & lower tasks). Representative coefficients of variation are provided to allow for the calculation of MALs for any percentile. Each equation performed well and, overall, they explained 90% of the variance in MAL values, with RMS differences of 6.7% and 4.8% of the full range for females and males, respectively. We propose that these equations replace the 1991 Liberty Mutual Tables. Practitioner summary: We propose predictive equations to replace the 14 manual materials handling tables in Snook and Ciriello (1991). These equations are based on 12 more publications, matched the empirical data well, are easier to use and allow for both a wider range and more specific inputs than the tables.

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.

OBJECTIVE: The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effect of delayed versus immediate pushing in the second stage of labor on mode of delivery and other outcomes in women with neuraxial analgesia. DATA SOURCES: The research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and the Cochrane Library as electronic databases, from the inception of each database to August 2019. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included only randomized controlled trials in pregnant women randomized to either delayed or immediate pushing during the second stage of labor. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was mode of delivery. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) value of greater than 0% was used to identify heterogeneity. RESULTS: Twelve randomized controlled trials, including 5445 women with neuraxial analgesia randomized to delayed versus immediate pushing during the second stage of labor, were included in the meta-analysis. Of the 5445 women included in the meta-analysis, 2754 were randomized to the delayed pushing group and 2691 to the immediate pushing group. No significant difference between delayed and immediate pushing was found for spontaneous vaginal delivery (80.9% versus 78.3%; relative risk, 1.05; 95% confidence interval, 1.00-1.10; 12 randomized controlled trials, 5540 women), operative vaginal delivery (12.8% versus 14.6%; relative risk, 0.89; 95% confidence interval, 0.75-1.08; 11 randomized controlled trials, 5395 women), and cesarean delivery (6.9% versus 7.9%; relative risk, 0.89; 95% confidence interval, 0.73-1.07; 11 randomized controlled trials; 5395 women). Women randomized to the delayed pushing group had a significantly shorter length of active pushing (mean difference, -27.54 minutes; 95% confidence interval, -43.04 to -12.04; 7 randomized controlled trials, 4737 women) at the expense of a significantly longer overall duration of the second stage of labor (mean difference, 46.17 minutes; 95% confidence interval, 32.63-59.71; 8 studies; 4890 women). The incidence of chorioamnionitis (9.1% versus 6.6%; relative risk, 1.37, 95% confidence interval, 1.04-1.81; 1 randomized controlled trial, 2404 women) and low umbilical cord pH (2.7% versus 1.3%; relative risk, 2.00; 95% confidence interval, 1.30-3.07; 5 randomized controlled trials, 4549 women) were significantly higher in the delayed pushing group. CONCLUSION: In women with spontaneous or induced labor at term with neuraxial analgesia, delayed pushing in the second stage does not affect the mode of delivery, although it reduces the time of active pushing at the expense of a longer second stage. This prolongation of labor was associated with a higher incidence of chorioamnionitis and low umbilical cord pH. Based on these findings, delayed pushing cannot be routinely advocated for the management of the second stage.