Mise au point sur les modalités de gestion des efforts expulsifs lors de l’accouchement

Abstract

The second stage of labour includes both the passive and active stages, involving expulsive efforts. The management of this phase of labour aims to minimise the maternal and neonatal complications that could be associated with a prolonged active2nd stage, but also to limit medical interventions. On the maternal side, prolonged duration of expulsive effort appears to be correlated with increased postpartum haemorrhage, perineal injury and, in the long term, urinary and anal incontinence. From a neonatal viewpoint, expulsive efforts carry risks of neonatal acidosis, asphyxia, admission to the neonatal intensive care unit and trauma. Optimal management of expulsive efforts involves several strategies. Various aspects need to be addressed in order to optimise this management, including the timing of the start of expulsive efforts, comparing immediate pushing with delayed pushing, and the duration of expulsive efforts. In addition, it is important to examine the different pushing modalities, whether intense or moderate, using open or closed-glottis pushing, as well as the maternal position during pushing. According to the current literature, no specific technique or predefined duration appears to reduce the risk of neonatal or maternal complications. It therefore seems essential to adopt an individualised approach for each woman, placing her at the centre of the care and decision-making process, in order to take account of her preferences during childbirth.