**3.5 Immediate versus delay pushing**

There are two common practices used in the management of the second stage of labor: (1) delayed pushing, or "laboring down" in which the patient rests and the fetal head passively descends with contractions), and (2) immediate pushing, where pushing with contractions is initiated once the cervix is complete. Delayed pushing was thought to provide several benefits, including reducing maternal fatigue, minimizing the risk of perineal trauma, and allowing time for the baby's head to mold and adjust to the birth canal [26]. However, a meta-analysis of randomized control trials, involving 5445 patients with epidural analgesia, showed delayed pushing was associated with increased morbidity. Among patients in the delayed pushing group, there was a significantly prolonged duration of labor, higher incidence of chorioamnionitis, and lower umbilical cord pH, with no difference in the mode of delivery [27]. Another large multicenter randomized clinical trial including 2414 patients found similar rates of spontaneous vaginal delivery: 85.6% in the immediate pushing group versus 86.5% in the delayed pushing group. Again, in the delayed pushing group there was a longer second stage of labor, higher rates of chorioamnionitis, increase neonatal acidemia, and also higher rates of postpartum hemorrhage [28]. The trial was stopped prematurely because of concern for excess morbidity in the delayed pushing group. Based on these findings, it is reasonable to prioritize immediate pushing over delayed pushing [28].

#### **3.6 Maternal position**

There are varying opinions regarding the optimal maternal position during the second stage when pushing. Maternal position may play a significant role in facilitating fetal descent. A Cochrane review comparing different pushing positions found that an upright position offers several benefits, including reduced fetal heart rate abnormalities, decreased rates of episiotomy, and a shorter duration of the second stage of labor by 6.6 minutes [29]. However, an upright position was associated with a higher risk of postpartum hemorrhage when compared to the supine position [29].

Both upright and lateral pushing techniques are effective in preventing perineal trauma [29]. Pushing in the lateral recumbent position can also aid in rotating a fetus in the OP position. In the epidural and position trial collaborative group study, a higher rate of vaginal delivery was observed when patients pushed in a lateral recumbent position compared to other positions [10, 32]. Nevertheless, due to the variability in findings and individual patient and provider preference, there is no position recommended over others.

ACOG recommends frequent position changes during labor to enhance comfort and promote optimal fetal positioning, as long as these positions are not contraindicated for the patient [30]. It is important for healthcare providers to consider individual circumstances, patient preferences, and safety when determining the most appropriate pushing position.

#### **3.7 Operative vaginal delivery**

Over the last 15 years, the rate of operative vaginal deliveries has declined as the rates of cesarean deliveries rise [4]. An operative vaginal delivery involves the use of either a vacuum or forceps to assist in the delivery of the baby. This procedure may be necessary in situations where there is a need to expedite delivery due to maternal or fetal factors. Some specific indications for operative vaginal delivery include a prolonged second stage of labor, non-reassuring fetal heart tones, maternal exhaustion, and maternal cardiopulmonary disorders or brain aneurysms that prevent prolonged maternal pushing [23].

Although there are risks associated with operative vaginal delivery, including maternal perineal trauma, lacerations, fetal scalp and skull injuries, and intracranial hemorrhages, large studies have demonstrated no difference in serious neonatal morbidity between operative vaginal delivery and unplanned cesarean delivery [4]. The safety of the procedure depends on the practitioner's experience and the station of the presenting part [32]. The overall success rate of operative vaginal delivery has been reported to be between 86 and 91% [33]. However, lower success rates have been found in cases where maternal BMI exceeds 30 kg/m<sup>2</sup> and ironically, maternal obesity is known to be a risk factor for operative vaginal deliveries [31, 34].

Because obese patients generate lower pressure during pushing, an operative device may be needed to supplement the force during the second stage of labor.

Overall, the decision to proceed with an operative vaginal delivery is based on individual circumstances and requires careful consideration of the potential benefits and risks for both the mother and the fetus. It is important for healthcare providers to assess each situation on a case-by-case basis to make an informed decision, but operative vaginal deliveries should be considered a safe and acceptable alternative to cesarean delivery [4].
