A Menu of Change

Physiological Pushing in Labor

Click to link to Toolbox ResourcesTraditionally the onset of the second stage of labor has been defined as the time of complete cervical dilation, regardless of how the woman feels. Ideally, however, this onset is dependent upon the woman's anatomic, physiologic, and emotional readiness to give birth1 and is signaled by her urge to bear down. Once a woman is completely dilated, she may experience a latent phase, during which she has no immediate desire to push. The subsequent onset of active pushing then signals that the conditions are ready for fetal descent with the woman's spontaneous bearing down efforts. Women may spontaneously push 3-5 times per contraction with an open glottis while making noise; frequency and strength of pushing may vary during the course of the each contraction and during the duration of second stage labor. Researchers have shown that progress readily occurs with spontaneous open glottis bearing down.1 In contrast, the use of directed Valsalva pushing and placement of the woman in the lithotomy position are associated with negative hemodynamic consequences for the woman and fetus.1 Valsalva bearing down may shorten the duration of the second stage of labor2 but leads to alterations in fetal acid-base balance. For women in labor, these efforts result in fatigue, increased perineal damage, and long-term negative urologic consequences.2-4

Investigators have explored maternal and newborn health outcomes associated with type of pushing used during second stage labor. Overall, spontaneous pushing compared to directed or Valsalva pushing has been associated with decreased risk of negative health consequences, in particular reduced risk of incontinence.2-7 However some researchers found no difference in second stage outcomes or duration when comparing type of pushing.1

Benefits of Spontaneous Pushing

  • Less maternal fatigue than with directed pushing

  • Potential for longer second stage but less time in active pushing time, which is associated with increased maternal morbidity8

  • Less variation in maternal and fetal acid-base balance (higher cord pH) and fetal heart rate patterns

  • Reduced risk of negative urologic changes postpartum2-4

  • Directed bearing down (instructing the woman to “breathe the baby out”) as the fetal head crowns may minimize perineal damage9

Translating Evidence into Practice

Whether a woman pushes spontaneously or as directed during second stage labor is largely determined by the professionals providing her maternity care, but adoption of the evidence-based strategy of spontaneous pushing by maternity care providers has proven to be challenging.10 The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) issued clinical guidelines calling for improved management of second stage labor and advocating for spontaneous pushing.11 The American College of Nurse Midwives (ACNM) endorsed use of spontaneous pushing as best practice consistent with physiological birth practices and evidence that suggests improved outcomes.12 Circumstances such as prolonged second stage or the use of epidural analgesia may influence the approach used by maternity care professionals.9

Duration of Second Stage Labor

The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine recommended the following guidelines for duration of second stage labor:

  • Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following:
  • At least 2 hours of pushing in multiparous women

  • At least 3 hours of pushing in nulliparous women

  • Longer durations may be appropriate on an individualized basis (e.g., with the use of epidural analgesia or with fetal malposition) as long as progress is being documented.13

Maternal Positions for Birth

Women can give birth in a variety of positions, and a number of factors influence the choice of position for second stage of labor.14,15

Movement and upright positions

  • Result in less pain and facilitate bearing down,

  • Shorten the duration of second stage,

  • Result in optimal acid-base balance and fetal heart tones, and

  • Are preferred by women to supine positions.1,16

Perineal Management

During second stage labor management the perineum should be monitored, and a variety of factors can affect perineal outcomes.17 Restricted use of episiotomy is recommended as a best practice. Common indications for episiotomy are suspected fetal macrosomia and compromise and unyielding perineal tissues, but these indications require further study. The routine use of episiotomy for second stage management is not an evidence-based practice. is associated with increased perineal damage and is therefore not recommended as a best practice.18 The support of spontaneous maternal pushing appears to be an important factor in preserving perineal outcomes.14


Click to view additional resources available in the Promoting Physiological Pushing During Labor Resource Toolbox, or search our resource library by clicking here.


  1. Roberts J, Hanson L. Best practices in second stage labor care: maternal bearing down and positioning. J Midwifery Womens Health. 2007;52(3):238-245.

  2. Prins M, Boxem J, Lucas C, Hutton E.Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. BJOG. 2011;118(6):662-670.doi:10.1111/j.1471-0528.2011.02910.x.

  3. Bloom SL, Casey BM, Schaffer JI, McIntire DD, Leveno KJ. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol. 2006;194(1):10-13.

  4. Schaffer JI, Bloom SL, Casey BM, McIntire DD, Nihira MA, Leveno KJ. A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. Am J Obstet Gynecol. 2005;192(5):1692-1696.

  5. Buhimschi CS, Buhimschi IA, Malinow AM, Kopelman JN, Weiner CP. Pushing in labor: performance and not endurance. Am J Obstet Gynecol. 2002;186(6):1339-1344.

  6. Roberts J. The “push” for evidence: management of the second stage. J Midwifery Womens Health. 2002;47(1):2-15.

  7. Bosomworth A, Bettany-saltikov J.A. Just take a deep breath.. A review to compare the effects of spontaneous versus directed valsalva pushing in the second stage of labour on maternal and faetol well-being. MIDIRS Midwifery digest. 2006; 16:2.

  8. Low, L., Zielinski, R, Tao, Y, Galecki, A, Brandon, C, Miller, J. Predicting Birth-Related Levator Ani Tear Severity in Primiparous Women: Evaluating Maternal Recovery from Labor and Delivery (EMRLD Study) Open J Obstet Gynecol. 2014; 4(6) 10.4236/ojog.2014.46043

  9. Osborne K, Hanson L. Directive versus supportive approaches used by midwives when providing care during second stage labor. J Midwifery Womens Health. 2012;57(1):3-11.

  10. Simpson, K., Knox, E., Martin, M., George, C., Watson, S. Michigan health and hospital association Keystone Obstetrics: A statewide collaborative for perinatal safety in Michigan. The Joint Commission Journal of Quality and Patient Safety. 2011; 37 (12).

  11. Association of Women's Health, Obstetric and Neonatal Nurses. Nursing Care and Management of the Second Stage of Labor: Evidence-Based Clinical Practice Guideline. 2nd ed. Washington, DC: Association of Women's Health, Obstetric and Neonatal Nurses; 2008.

  12. American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: a consensus statement by ACNM, MANA, and NACPM.http://mana.org/pdfs/Physiological-Birth-Consensus-Statement.pdf. Published May 14, 2012. Accessed March 2, 2014.

  13. American College of Obstetricians and Gynecologists and Society for Maternal Fetal Medicine. Safe prevention of the primary cesarean delivery. Obstetric care consensus no. 1. http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery. Published March 2014. Accessed May 9, 2014.

  14. Hanson L. Second stage positioning in nurse-midwifery practice. Part 1: position used and preferences. J Nurse-Midwifery. 1998;43(5):320-325.

  15. Hanson L. Second stage positioning in nurse-midwifery practice. Part 2: factors affecting use. J Nurse-Midwifery. 1998;43(5):326-330.

  16. Gupta J, Hoffmeyer G. (2004). Positions for women during the second stage of labour. Cochrane Database Syst Rev. 2004;(1):CD002006.

  17. Alber LL, Sedler KD, Bedrick EJ, Teaf D, Perakta P. (2006). Factors related to genital tract trauma in normal spontaneous birth. Birth. 2006;33(2):94-100.

  18. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009;(1):CD000081.


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