Evidence-based labor management: second stage of labor (part 4).

Several interventions during the second stage of labor have been identified and investigated. Prophylactic intrapartum betamimetics should be avoided, as their usage is associated with an increase in operative vaginal deliveries. Women without epidural anesthesia are recommended to give birth in any upright or lateral position. The best position for giving birth in women with epidural anesthesia is insufficiently studied, and neither recumbent nor upright positions can therefore be recommended. The routine use of maternal stirrups in the second stage of labor is not recommended. Consider avoiding water immersion during the second stage of labor, as the risks have not been adequately assessed. In nulliparous women at term with epidural analgesia, delayed pushing is not recommended. Pushing via a woman's own urge to push (open glottis) or pushing using the Valsalva maneuver (closed glottis) can both be considered. Both traditional coaching during pushing and ultrasound-assisted coaching may be considered. The use of a dental support device can be considered. All forms of fundal pressure are not recommended in the second stage of labor. Perineal massage and stretching of the perineum with a water-soluble lubricant in the second stage of labor is recommended. Perineal hyaluronidase injection as a method to reduce perineal trauma is not recommended. The use of perineal gel in the second stage of labor is not recommended. The use of perineal warm packs and heating pads are recommended. A perineal protection device can be considered. In fetuses with persistent occiput posterior position, manual rotation can be considered. Routine use of the Ritgen's maneuver does not seem to be associated with any benefits and is not recommended. The "Hands-poised" position is recommended over the "hands-on" method for delivery of the fetus. Routine episiotomy is not recommended. The routine use of ultrasound in the second stage of labor is not recommended. Waiting 1 additional hour (4 hours) for nulliparous women with epidural anesthesia before the diagnosis of a prolonged second stage of labor is recommended. A mandatory second opinion before cesarean delivery in the second stage of labor is recommended.