Substantial scientific evidence supports spontaneous maternal bearing down for its associated maternal and fetal physiologic benefits. Imposing specific directions for Valsalva pushing does not result in optimal outcomes but continues to be widely used, particularly when labor progress is less than optimal. However, there are numerous evidence-based approaches that can be used to avoid reverting to directed, prolonged Valsalva bearing down. Nursing care challenges may be encountered when using physiologic approaches; therefore, strategies are detailed to alleviate a variety of problems including ways to promote physiological descent and effectively support women's spontaneous efforts. For example, maternal postural interventions are suggested for asynclitic and occiput posterior fetal positions. When fetal heart rate abnormalities present and the fetus may be compromised, modifications to spontaneous bearing down are suggested as alternatives to longer and stronger Valsalva pushing, such as encouraging the women to use short pushes or breath through contractions until the fetus recovers. Open knee-chest maternal positioning can help to diminish a premature urge to push, while the closed knee-chest position may be more useful if cervical edema occurs. Even with clinical challenges, evidence-based care can help achieve the improved outcomes documented from women's spontaneous bearing-down efforts during the second stage.