• second stage;
  • management;
  • passive descent laboring;
  • downrest and descend;
  • physiologic second stage


Objective:  To determine which method of pushing—passive descent or early pushing—most benefits women with epidurals during second-stage labor.

Data sources:  MEDLINE, CINAHL, and Cochrane Database.

Study selection:  Studies limited to randomized controlled trials in English, comparing passive descent to early pushing in women with effective epidural analgesia.

Data extraction:  A hand search was performed. Data included number of instrument-assisted deliveries (forceps and vacuum); noninstrumental or spontaneous vaginal births, cesarean births, pushing time, episiotomies, lacerations; maternal fatigue; and fetal well-being.

Data synthesis:  Seven studies were eligible for a sample size of 2,827 women. Pooled data indicate that passive descent increases a woman’s chance of having a spontaneous vaginal birth (relative risk: 1.08; 95% confidence interval: 1.01-1.15; p = 0.025), decreases risk of having an instrument-assisted deliveries (relative risk: 0.77; 95% confidence interval: 0.77-0.85; p ≤ 0.0001), and decreases pushing time (mean difference: −0.19 hours; 95% confidence interval: −0.27 to −0.12; p ≤ 0.0001). No differences were found in rates of cesarean births (relative risk: 0.80; 95% confidence interval: 0.57-1.12; p = 0.19), lacerations (relative risk: 0.88; 95% confidence interval: 0.72-1.07; p = 0.20), or episiotomies (relative risk: 0.97; 95% confidence interval: 0.88-1.06; p = 0.45).

Conclusions:  Significant positive effects were found indicating that passive descent should be used during birth to safely and effectively increase spontaneous vaginal births, decrease instrument-assisted deliveries, and shorten pushing time.