Physiological Versus Directed Pushing During the Second Stage of Labor: A Non-Randomized Quasi-Experimental Study of Maternal Recovery and Clinical Outcomes

Background: Pushing technique may influence maternal effort, labor progression, and birth outcomes, yet evidence comparing physiological and directed pushing remains inconsistent, particularly for early maternal recovery. This study compared the two approaches in relation to postpartum fatigue and perceived energy, second-stage duration, and selected maternal and neonatal outcomes. Methods: This non-randomized quasi-experimental comparative study included 120 women assigned during two sequential labor-unit implementation periods to physiological pushing (n = 60) or directed pushing (n = 60). No individual random allocation sequence was used. The physiological-pushing intervention was provider-guided open-glottis, short-duration pushing with urge-led initiation, whereas directed pushing used coached closed-glottis Valsalva efforts. The primary outcome was fatigue at 24 h postpartum. Covariate-adjusted regression was used for 24 h fatigue and perceived energy, mixed-effects models for repeated scores, proportional-odds regression for categorized second-stage duration, and exact methods for binary outcomes. Propensity-score overlap weighting evaluated the robustness of the primary result. Results: At 24 h postpartum, no between-group difference in fatigue was detected after adjustment for baseline fatigue, age, body mass index, education, gravidity, gestational age, first-stage duration, and oxytocin use (physiological-minus-directed difference, 0.20 points; 95% CI, −2.05 to 2.45; p = 0.860). Adjusted perceived energy was also similar (difference, −0.79 points; 95% CI, −2.18 to 0.59; p = 0.260). Across both groups, fatigue decreased and perceived energy increased over time (both time effects p < 0.001), with no group × time interaction. The overlap-weighted analysis supported the primary finding (difference, 0.25 points; 95% CI, −1.79 to 2.29; p = 0.809). Physiological pushing was associated with lower odds of occupying a longer second-stage-duration category in the adjusted proportional-odds model (adjusted OR, 0.20; 95% CI, 0.09 to 0.45; p < 0.001; Holm-adjusted p = 0.0007). None of the six binary maternal or neonatal outcomes differed after Holm correction. Conclusions: Compared with directed pushing, physiological pushing was not associated with lower fatigue or higher perceived energy at 24 h postpartum. Directed pushing likewise showed no consistent advantage over physiological pushing across the evaluated maternal and neonatal outcomes. The observed association between physiological pushing and lower odds of a longer second-stage duration represents an exploratory secondary finding and should be interpreted cautiously in view of the non-randomized design and the possibility of residual confounding.