Clinical Question

Does maintaining an open glottis during delivery prevent perineal trauma?

Evidence-Based Answer

Open glottis pushing during the second stage of labor is a prolonged exhalation while contracting the stomach muscles. There is conflicting evidence about whether maintaining an open glottis during delivery prevents perineal trauma. (Strength of Recommendation: B, three randomized controlled trials [RCTs]) There were no differences in perineal tears or lacerations between the open glottis and closed glottis (i.e., Valsalva maneuver) delivery methods; however, in a primiparous population, a decrease in lacerations and a higher frequency of intact perineum occurred when using an open glottis delivery method. Perineal tears longer than 2 cm may be less frequent using open glottis pushing during delivery.

Evidence Summary

A 2020 RCT (n = 250) in France compared the effectiveness of directed open glottis pushing vs. closed glottis pushing.¹ Participants were women of any parity, 18 years and older, with singleton pregnancies, a cephalic presentation at 37 weeks' gestation or longer, and without a history of a cesarean delivery or fetal heart tone abnormalities. All women in the study received standardized training in both types of pushing and were randomized to open glottis (n = 125) or closed glottis (n = 125) pushing during labor. Both groups had greater than 95% epidural rates. The primary outcome was the effectiveness of pushing, which was defined as a spontaneous vaginal delivery with no episiotomy or second-, third-, or fourth-degree perineal lacerations. No differences were noted between the groups in the effectiveness of pushing (adjusted relative risk [RR] = 0.92; 95% CI, 0.74 to 1.14) or in overall risk of perineal lacerations (adjusted RR = 0.98; 95% CI, 0.83 to 1.14) or second-degree lacerations (adjusted RR = 0.82; 95% CI, 0.44 to 1.53). Moderate compliance was noted in the open glottis group with limited validity.