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Best Practices in Second Stage Labor Care: Maternal Bearing Down and Positioning


  • Joyce Roberts CNM, PhD,

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    • Joyce Roberts, CNM, PhD, FACNM, FAAN, is Professor of Nursing and Director of the Nursing Midwifery Program at The University of Michigan and member of the faculty in the School of Medicine, Department of Obstetrics and Gynecology.

  • Lisa Hanson CNM, PhD

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    • Lisa Hanson, CNM, PhD, is an Associate Professor and member of the faculty in the Nurse-Midwifery Program at Marquette University, Milwaukee, WI, and maintains a full-scope midwifery practice position at the Aurora Midwifery and Wellness Center in Milwaukee.

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Despite evidence of adverse fetal and maternal outcomes from the use of sustained Valsalva bearing down efforts, current second-stage care practices are still characterized by uniform directions to “push” forcefully upon complete dilatation of the cervix while the woman is in a supine position. Directed pushing might slightly shorten the duration of second stage labor, but can also contribute to deoxygenation of the fetus; cause damage to urinary, pelvic, and perineal structures; and challenge a woman's confidence in her body. Research on the second stage of labor care is reviewed, with a focus on recent literature on maternal bearing down efforts, the “laboring down” approach to care, second-stage duration, and maternal position. Clinicians can apply the scientific evidence regarding the detrimental effects of sustained Valsalva bearing down efforts and supine positioning by individualizing second stage labor care and supporting women's involuntary bearing down sensations that can serve to guide her behaviors.