Quick Points
Women should choose from a variety of positions in which to push and give birth, but supine and lithotomy positions should not be used.
Delayed pushing for women with epidural analgesia especially when the fetal station is high or fetal position is not anterior increases the chance of having a spontaneous vaginal birth.
Directing women when and how to push should be considered an intervention to be used only when indicated because spontaneous pushing is usually safer for the mother and fetus.
Incidence and severity of perineal trauma may be reduced by the use of warm perineal compresses, gentle massage, and slow crowning of the fetal head either by asking the woman not to push or by use of provider's hands to slow the extension and birth of the fetal head.
It is unclear whether time limits to duration of second stage of labor improve outcomes, but it is reasonable to consider operative birth when birth is not imminent after a nulliparous woman has been pushing longer than2hoursor has complete 4 or after a multiparous woman has been pushing longer than one hour or has complete dilatation for more than 2 hours.