Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study

Midwifery. 2020 Dec:91:102843. doi: 10.1016/j.midw.2020.102843. Epub 2020 Sep 22.


Objective: To compare the effectiveness of directed open-glottis and directed closed-glottis pushing.

Design: Pragmatic, randomised, controlled, non-blinded superiority study.

Settings: Four French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals).

Participants: 250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm.

Interventions: In the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing.

Measurements: The principal outcome was "effectiveness of pushing" defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR).

Findings: In our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74-1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85-1.10).

Key conclusions: In maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups.

Implications for practice: If directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.

Keywords: Closed-glottis pushing; Delivery; Directed pushing; Open-glottis pushing; Randomised controlled trial; Second stage of labour.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Breathing Exercises / methods
  • Breathing Exercises / standards*
  • Breathing Exercises / statistics & numerical data
  • Delivery, Obstetric / methods
  • Delivery, Obstetric / standards*
  • Delivery, Obstetric / statistics & numerical data
  • Female
  • France
  • Glottis / physiology*
  • Humans
  • Labor Stage, Second / physiology*
  • Pregnancy