# Umbrella review and meta-analysis of the effect of delayed and immediate pushing in the second stage of labor on neonatal outcomes

## TL;DR

This study compares the effects of immediate and delayed pushing during labor on newborn outcomes and finds no significant differences.

## Contribution

The study provides an umbrella review and meta-analysis on neonatal outcomes of delayed versus immediate pushing under epidural analgesia.

## Key findings

- No significant differences in Apgar scores at 5 minutes or neonatal ICU admissions between the two pushing methods.
- Mixed results for Apgar scores at 1 minute, with some evidence suggesting delayed pushing may improve them.
- No statistically significant differences in umbilical artery cord pH between the groups.

## Abstract

To compare neonatal outcomes for immediate pushing and delayed pushing in the second stage of labor in women receiving epidural analgesia.

Systematic searches in PubMed, EMBASE, Scopus, and CINAHL without restrictions by language, date of publication, or methodological quality.

The inclusion criteria were based on methodological and clinical factors such as population (pregnant women with epidural analgesia), intervention and control (delayed versus immediate pushing), neonatal outcomes, and study design (systematic reviews).

The outcome measures were Apgar scores at 1 and 5 min, neonatal intensive care unit admission, prevalence of low umbilical artery cord pH, and umbilical artery cord pH. The methodological quality was analyzed using the Assessing the Methodological Study Tool for Systematic Reviews (AMSTAR) and Risk Of Bias In Systematic Reviews (ROBIS) scales, and the strength of evidence was established according to the Guidelines Advisory Committee grading criteria. For the umbilical artery cord pH variable, standardized mean differences and 95% confidence intervals were calculated and pooled in a meta-analysis using the random-effects model.

Seven systematic reviews with meta-analysis were included. The results suggest no difference between groups for Apgar test scores at 5 min, nor in the rate of neonatal intensive care unit admissions. Mixed results were found for delayed pushing leading to improvements in Apgar test scores at 1 min. No statistically significant between-group differences in the umbilical artery cord pH were found. The total duration of the second stage in the delayed pushing group was not significantly correlated with the umbilical artery cord pH.

Delayed pushing produces at least the same neonatal outcomes as immediate pushing in healthy pregnant women receiving epidural analgesia with a single fetus in vertex presentation with a limited quality of evidence.

Review registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42023397616).

The online version contains supplementary material available at 10.1007/s00404-025-08118-z.