Review highlights evidence-based practices for safer vaginal birth

Review highlights evidence-based practices for safer vaginal birth | Image Credit: © New Africa – © New Africa – stock.adobe.com.

Recommended methods of managing vaginal birth include immediate pushing in the second stage of labor, reducing pain with neuraxial anesthesia, using a warm compress, and actively managing the third stage of labor with oxytocin, according to a recent review published in O&G Open.¹

The CDC has reported 2,486,856 US vaginal births in 2021, 68% of which were vaginal births.² Therefore, the review was conducted to summarize existing literature discussing vaginal birth, allowing clinicians to apply evidence-based practice.¹

Immediate vs delayed pushing in the second stage of labor

Immediate pushing was compared to delayed pushing by 1 hour from complete dilation. In a 2018 randomized controlled trial (RCT), the mean duration of second stage was significantly reduced in patients with immediate pushing vs delayed pushing, while vaginal, cesarean, and operative vaginal delivery rates did not significantly differ between groups.

Chorioamnionitis and postpartum hemorrhage were also lower in the immediate pushing group, while differences in neonatal morbidity outcomes were not found. Similarly, a 2020 study reported no differences in neonatal morbidity or delivery method passed on immediate vs delayed pushing.

“There is a possible increased risk of chorioamnionitis and postpartum hemorrhage with delayed pushing,” wrote investigators. “Thus, [the American College of Obstetricians and Gynecologists] recommends immediate pushing when complete cervical dilation is achieved.

Neuraxial analgesia and laceration prevention

The effects of neuraxial analgesia use during vaginal birth were also assessed. Epidural anesthesia was not linked to adverse effects or cesarean delivery rates in a narrative review, but a potential need for operative vaginal delivery was reported. However, this link was not found in an analysis of trials conducted in 2005.

An association between epidural use and increased first stage of labor duration was reported in 2 systematic reviews, with 1 review reporting an increased duration of 32.28 minutes. No differences were reported between epidural vs combined spinal-epidural in the duration of first or second stage of labor.

Laceration prevention was also discussed, as perineal trauma during delivery has been linked to severe morbidity. Intrapartum perineal massage has shown efficacy for preventing lesions, with a meta-analysis reporting a relative risk of 0.49 for lacerations in women receiving this treatment vs those who did not.

Additionally, a meta-analysis of 4 RCTs reported decreased rates of third- and fourth-degree perineal tears from continuously holding a warm compress to the perineum during and between pushes. In a separate RCT, no impact was reported from delayed pushing. Therefore, authors recommended a warm compress in labor to reduce laceration risks.

Reevaluating the use of episiotomy

According to investigators, there are no well-supported indications for an episiotomy in vaginal birth. One RCT reported a 30% reduction in severe perineal or vaginal trauma among women receiving selective episiotomy, but evidence about the use of episiotomy during operative vaginal delivery remains conflictive.

Higher odds of third- and fourth-degree lacerations were highlighted following midline episiotomy vs mediolateral episiotomy. However, mediolateral episiotomy has been linked to increased dyspareunia risk.

Both methods may also increase postpartum perineal pain and stress urinary incontinence. Therefore, investigators stated episiotomy should not be included in routine practice.

Benefits of delayed cord clamping

Traditionally, doctors have performed delayed cord clamping during labor, defined as umbilical cord clamping between 30 and 60 seconds from time of birth. Alongside a positive safety profile, data has indicated this practice improves fetal neurodevelopment and significantly decreases pre-discharge mortality among preterm infants.

Additional benefits of delayed cord clamping include increased hemoglobin levels, blood volume, and iron levels at birth in low-risk full-term and preterm infants. However, uptake remains limited, with delayed cord clamping utilized by approximately 52% of US hospitals.

Investigators highlighted endorsements from multiple health organizations such as the World Health Organization and the American Academy of Pediatrics. Based on these data and endorsements, the authors recommended delayed cord clamping be performed for both full-term and preterm neonates.

Management of the third stage of labor

Finally, management during the third stage of labor was discussed. This included delivery of the placenta. According to investigators, clinicians should wait for placental delivery without intervention during expectant management. In comparison, active management includes the use of interventions to expedite placental delivery.

Oxytocin is also recommended for use during the third stage of labor, with intravenously (IV) administration indicated as the most effective for reducing severe postpartum hemorrhage risk. While no standard dose has been established, usage in studies ranged from 5 to 10 units IV. Overall, the review highlighted the importance of managing vaginal birth with evidence-based practices.

“Integration of evidence-based care into standard practice will ultimately improve outcomes for mothers and neonates,” wrote investigators. “The authors acknowledge that this is not an exhaustive list of all aspects of care surrounding vaginal birth.”

References

1. Tannous AM, Warffuel J, Van Backle A, et al. An evidence-based approach to vaginal birth. O&G Open. 2025;1(3):24. doi:10.1097/og9.0000000000000024
2. Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP, Division of Vital Statistics. Births: Final data for 2021. National Vital Statistics Reports. 2023;72(1).