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Reply to delayed versus immediate pushing in the second stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials
Daniele Di Mascio, MD, Gabriele Saccone, MD, Vincenzo Berghella, MD
PII: S0002-9378(20)31073-5
DOI: https://doi.org/10.1016/j.ajog.2020.09.018 Reference: YMOB 13495
To appear in: American Journal of Obstetrics and Gynecology Received Date: 3 September 2020
Accepted Date: 14 September 2020
Please cite this article as: Di Mascio D, Saccone G, Berghella V, Reply to delayed versus immediate pushing in the second stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials, American Journal of Obstetrics and Gynecology (2020), doi: https://doi.org/10.1016/j.ajog.2020.09.018.
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Reply to delayed versus immediate pushing in the second stage of labor in women with 1
neuraxial analgesia: a systematic review and meta-analysis of randomized controlled trials 2
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Daniele Di Mascio MD,1 Gabriele Saccone MD,2 Vincenzo Berghella MD3
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Departement of Maternal and Child Health and Urological Sciences, Sapienza University of Rome,
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Italy
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2
Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine,
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University of Naples Federico II, Naples, Italy
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3
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel
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Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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Correspondence: Vincenzo Berghella, MD, Department of Obstetrics and Gynecology, Division of 13
Maternal-Fetal Medicine, Thomas Jefferson University, 833 Chestnut, Philadelphia, PA 19107,
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USA. E-mail: vincenzo.berghella@jefferson.edu
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Disclosure: The authors report no conflict of interest 17
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Financial Support: No financial support was received for this study 19 20 21 22 23 24 25 26
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We thank Dr Cusimano and her colleagues for their interest and their thoughtful comments on our
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study.1 Improving the health of women going through labor and their babies is the main goal of
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every obstetrician and obstetric provider. We agree with Dr Cusimano et al. that labor and delivery
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management should be guided by evidence-based, high-quality data, mostly coming from
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randomized controlled trials (RCTs), systematic review and meta-analyses of RCTs. Systematic
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reviews and meta-analyses have increasingly spread in all fields of medicine, as they provide the
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best guidance for our daily clinical practice, and therefore it is mandatory to follow a thorough and
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rigorous protocol, due to their impact on health care. The conclusions of a meta-analysis depend
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strongly on the quality of the studies identified to estimate the pooled effect, as well as on the
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quality of the meta-analysis its self.
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When performing meta-analyses of RCTs, Cochrane Collaboration guidelines, defining a priori
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methods for collecting, extracting and analyzing data should be followed,2 as we did in our review.1
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It is also important that the review should be systematic. A review is defined as systematic when
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two electronic databases are searched at minimum. In our meta-analysis, the search was conducted
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using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane
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Library as electronic databases. We agree with Dr Cusimano et al that when searching the entire
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combination of words together (i.e. : “immediate pushing” OR “delayed pushing” AND “second
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stage” OR “labor” AND “delivery”), the results of the research are much higher, even when
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filtering results by publication type, such as “randomized controlled trial” (i.e. 2,321 results on
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PubMed), but when searching for the same words without AND/OR the number of items found is
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significantly lower (i.e. 9 results on PubMed), and this justifies the small number of records - n=12
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- identified through database searching that we reported in the Results of our meta-analysis (after
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complete literature search, checking references, etc) , although we acknowledge that this might
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make the search strategy generally too narrow. Moreover, we do urge all future meta-analyses to
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publish the complete detailed search, including MeSH terms etc, with a specific date, so it can also
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be replicated. Nonetheless, to our knowledge, our meta-analysis of delayed pushing in the second
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stage of labor included all RCTs published so far on the topic and no prior meta-analysis on the
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timing of pushing in the second stage of labor is as up-to-date or comprehensive.
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In conclusion, we agree with Dr Cusimano et al. that meta-analyses should be conducted with a
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rigorous, evidence focused literature review. Every suggestion to improve systematic reviews in the
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field of maternal fetal medicine is more than welcome and will always find our complete interest
58 and enthusiasm. 59 60 REFERENCES 61
1. Di Mascio D, Saccone G, Bellussi F, Al-Kouatly HB, Brunelli R, Benedetti Panici P,
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Liberati M, D'Antonio F, Berghella V. Delayed versus immediate pushing in the second
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stage of labor in women with neuraxial analgesia: a systematic review and meta-analysis of
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randomized controlled trials. Am J Obstet Gynecol. 2020; 223:189-203.
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2. Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions,
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version 5.1.0 (update March 2011). The Cochrane Collaboration, 2011. Available at:
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https://handbook-5-1.cochrane.org/ (Accessed on August 22, 2020) 68
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