Table 2.

Physiologic-Based, Second-Stage Labor Practices

• For women with epidural anesthesia who do not feel the urge to push when they are completely dilated, delay pushing until the urge to push is felt (up to 2 hours for nulliparous women and up to 1 hour for multiparous women).

• Use upright positioning with the woman's feet flat on the bed. Change to a lateral position or other positions of comfort as necessary.

• Avoid forcing the woman's legs back against her abdomen.

• Discourage prolonged breath-holding. Instead, instruct the woman to bear down and allow her to choose whether or not to hold her breath while pushing.

• Discourage more than three to four pushing efforts with each contraction and more than 6 to 8 seconds of each pushing effort (avoid counting to 10 with each pushing effort).

• Take steps to maintain a reassuring fetal heart rate (FHR) pattern while pushing. Push with every other or every third contraction if necessary to avoid recurrent FHR decelerations. Reposition as necessary to treat FHR decelerations. Use the fetal response to pushing as a guide for second-stage care.

• Avoid uterine hyperstimulation during the second stage of labor. Make sure that contractions are no closer than every 2 to 3 minutes while pushing. Titrate oxytocin accordingly, use an intravenous fluid bolus of lactated Ringer's solution, and reposition to decrease contraction frequency.

• Allow the woman's perineum to stretch naturally rather than using manual massage or stretching.