Abstract：
The effect on obstetrical outcomes of closed- or open-glottis pushing is uncertain among both nulliparous and parous women.
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.
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.
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.
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.
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.
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.
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.
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.
摘要：
背景：闭门或开放声门推挤对产科结局的影响在未分娩和分娩妇女中都不确定。
目的：本研究旨在评估单胎阴道分娩或近期尝试分娩后声门张开或闭合与分娩方式之间的关系。
方法：这是一项TRAAP（TRAnexamicacidforPreventionProsponsiveDelivery)随机对照试验的辅助计划队列研究，2015年至2016年在15个法国产科单位进行，纳入妊娠35周后尝试单胎阴道分娩的妇女。随机化后,前瞻性地收集了劳动力和分娩的特征，特别注意积极的第二阶段推动，并在出生后立即由主治医生填写具体的计划问卷。暴露是推动的模式，分为两组：闭门或开放声门。主要终点为手术阴道分娩。次要终点是产妇发病率项目，包括严重的会阴裂伤,会阴切开术,产后出血,分娩第二阶段的持续时间，和复合严重新生儿发病率的结果。我们还评估了产妇的即时满意度，交付经验，分娩后2个月的心理状况。通过多变量逻辑回归分析推送模式与结果之间的关联，以控制混杂偏差，通过多层次混合效应分析，和中心的随机截距。
结果：在我们的主要分析中包括的3041名女性中，2463（81.0％）使用闭合声门推动和578（19.0％）开放声门推动；他们各自的手术阴道分娩率为19.1％（n=471；95％置信区间，17.6-20.7)和12.5%(n=72；95%置信区间，9.9-15.4；P<.001）。在根据平价分层的分析中，在控制了可用的混杂因素后，在未分娩妇女中，两组之间的手术阴道分娩率没有差异：闭合性声门组的28.7％（n=399）和开放声门组的27.5％（n=64）（调整后的比值比，0.93；95%置信区间，0.65-1.33；P=.7）。与闭合性声门推动相比，使用开放式声门推动的女性的手术阴道分娩率显着降低：开放式声门推动的女性为2.3％（n=8），闭合性声门组的6.7％（n=72）（调整后的比值比，0.43；95%置信区间，0.19-0.90；P=0.03）。在未分娩或分娩组中，两种推挤方式的其他母婴结局没有差异。
结论：在足月单胎妊娠的未产妇女中，手术阴道分娩的风险根据推挤方式没有差异.这些结果将为有关第二阶段劳动期间的推动模式的共同决策提供信息。
目的：本研究旨在评估单胎阴道分娩或近期尝试分娩后声门张开或闭合与分娩方式之间的关系。
方法：这是一项TRAAP（TRAnexamicacidforPreventionProsponsiveDelivery)随机对照试验的辅助计划队列研究，2015年至2016年在15个法国产科单位进行，纳入妊娠35周后尝试单胎阴道分娩的妇女。随机化后,前瞻性地收集了劳动力和分娩的特征，特别注意积极的第二阶段推动，并在出生后立即由主治医生填写具体的计划问卷。暴露是推动的模式，分为两组：闭门或开放声门。主要终点为手术阴道分娩。次要终点是产妇发病率项目，包括严重的会阴裂伤,会阴切开术,产后出血,分娩第二阶段的持续时间，和复合严重新生儿发病率的结果。我们还评估了产妇的即时满意度，交付经验，分娩后2个月的心理状况。通过多变量逻辑回归分析推送模式与结果之间的关联，以控制混杂偏差，通过多层次混合效应分析，和中心的随机截距。
结果：在我们的主要分析中包括的3041名女性中，2463（81.0％）使用闭合声门推动和578（19.0％）开放声门推动；他们各自的手术阴道分娩率为19.1％（n=471；95％置信区间，17.6-20.7)和12.5%(n=72；95%置信区间，9.9-15.4；P<.001）。在根据平价分层的分析中，在控制了可用的混杂因素后，在未分娩妇女中，两组之间的手术阴道分娩率没有差异：闭合性声门组的28.7％（n=399）和开放声门组的27.5％（n=64）（调整后的比值比，0.93；95%置信区间，0.65-1.33；P=.7）。与闭合性声门推动相比，使用开放式声门推动的女性的手术阴道分娩率显着降低：开放式声门推动的女性为2.3％（n=8），闭合性声门组的6.7％（n=72）（调整后的比值比，0.43；95%置信区间，0.19-0.90；P=0.03）。在未分娩或分娩组中，两种推挤方式的其他母婴结局没有差异。
结论：在足月单胎妊娠的未产妇女中，手术阴道分娩的风险根据推挤方式没有差异.这些结果将为有关第二阶段劳动期间的推动模式的共同决策提供信息。
