Pushing Techniques

man lying on the hospital bed

Laboring down, pushing effectively and the best positions to use during the pushing stage.

It’s almost inevitable that mothers finally reach the pushing stage after many hours in the first stage of labor only to find out that they are completely exhausted. Now what? One thing we have learned is what we have done wrong in the last few years.

One of the biggest problems is rushing the second stage of labor so that the mother feels she has to push quickly. In fact, mothers often hear a chorus of “Push, push, push” as they try hard to focus on what they are doing and feel pressured that there is somehow a deadline to have their baby as quickly as possible!

Let’s take a good look at how we can increase your chances of pushing more effectively to make the experience in the second stage of labor easier for both you and your baby. Many of these suggestions can be included easily in a birth plan.

1. The Benefit of Laboring Down

This term “Laboring Down” basically refers to the mother’s body pressing the baby down into her birth canal without her voluntary effort of pushing. She may be breathing or grunting slightly during contractions but she is simply allowing her body to do the pushing without physically bearing down.

Research has shown that women can benefit from laboring the baby down in the second stage, especially when the baby’s head is still high or not aligned well to the mother’s pelvis. And in fact, laboring down makes good sense based on what we know about the mother’s body.

The urge to push comes when the baby has reached the place in the mother’s vagina where she feels a spontaneous bearing down reflex. This may occur at approximately +2 station, which is about 1/2 way down the birth canal. If the mother waits to push, her body does some of the early work of bringing the baby down lower while she conserves energy.

Mothers can labor down for an hour or even longer, as long as there are no complications. You can use laboring down whether you have natural childbirth or an epidural. Be sure to ask your midwife or obstetrician if you are interested in the option of laboring down.

2. Position Changes are Critical

If you have taken your childbirth classes, likely your childbirth educator has shown you how the baby’s head must rotate as it passes through your pelvis. Negotiating through those passages requires some “wiggle room.” Changing positions during pushing helps to change the angle of your pelvis, so that your baby can wiggle its way through your pelvis and birth canal.

Position changes can also help to relieve discomfort such as back pain during labor, as well as decrease the likelihood of tearing. Changing your positions help stretch your perineum in various places as you push.

Let’s take a look at some of the most effective pushing positions and when to apply them:

  1. Side-lying – This is a great position to conserve energy as well as rotate a baby whose head is either posterior (OP) or transverse (OT). It can also help reduce tearing.
  2. Hands & Knees or All fours – One of the hands-down (no pun intended) best positions to slow a fast second stage, rotate a baby, relieve back pain or reduce tearing.
  3. Squatting – This has long been a favorite position in other cultures to open the pelvis and increase the urge to push. This is not a good position if the baby is OP or OT since you should encourage your baby to rotate first. It also is not ideal if the labor is going fast since it can increase tearing. In addition, squatting is not a position most women in the US are comfortable in for too long so it can be exhausting.
  4. Pushing while on the toilet – This is one of the best positions if mom is having trouble in the second stage with pushing since it is a natural place to “let go.” It is not a good position if you are having a fast labor or a strong urge to push as soon as you are 10 cm dilated.

Bear in mind that if you get an epidural, you will be limited in the positions you can use in the second stage. Most women who have an epidural in place do not have enough sensation to support their weight in positions such as hands & knees or squatting.

3. Keeping your energy level up

One of the best things you can do to conserve energy and prevent fatigue is to labor down as well as continuing to hydrate. Sometimes mothers get sick to their stomach when they push. If this happens, try drinking only tiny sips of fluid, stick to ice chips or change positions.

Most women do not feel like eating during the pushing stage. However, if you are hungry, nibbling something in between contractions is a good way to keep your energy up in the second stage.

Pacing yourself is vital. If you don’t have a strong urge to push, don’t push hard. Your urge to push will typically get stronger as the baby descends. Sometimes you will get a lighter contraction with almost no urge to push. Simply breathe then during the contraction and do not feel forced into pushing. You will only exhaust yourself unnecessarily

Do not push and hold your breath for 10 seconds! This is called “purple pushing” or directed pushing and it is not only exhausting for you but it reduces oxygen to the baby. In fact, one study showed that babies had more difficulty if the second stage was longer and the mother used directed pushing. It is much better for you to push as you feel your body’s urges and for as long as you would like to. Some mothers also find that making some noise as they push feels great. If you do feel like you want to hold your breath, do it for no longer than 6 seconds at a time.

Also make sure that if you are holding your breath for just a few seconds that you also keep your eyes open. This will help you not to scrunch up your face when you are pushing. Also part your lips as you bear down so that you are stopping your air flow in your throat or glottis, and not holding your air in with your mouth closed tightly. Both of these strategies will help you not to “push with your face.”

4. Comfort is key

Use any methods that you wish to stay more relaxed and comfortable including many of the pain relief techniques you may have used for the first stage of labor such as massage, relaxation in between contractions, music, aromatherapy, etc.. Many women enjoy music with a deeper or more lively rhythm for the second stage of labor. I have even seen women do some early pushing on the birth ball which is likely much more comfy than sitting up on the hospital bed.

It is very common for mothers to feel a stretching and burning sensation as the baby’s head crowns. This is commonly referred to as a “ring of fire.”

5. Encouragement from Birth Team

Moms can easily become discouraged when they have been pushing for several hours. It is important to realize that the average length of pushing is about 2 hours with your first baby! This means that some moms will need to push for close to 3 hours or longer in order to give birth.

Birth partners should be ready to offer suggestions for comfort, provide encouragement and feedback after every contraction. One simple way to show mom that she is actually pushing well is to get a mirror out and have her watch during a few contractions. This is especially helpful when the baby’s head starts to peak out a bit with each contraction.

6. Push only with an Urge and after 10cm

So if the mother labors down and waits to begin pushing, when will she know it’s time to push? Rather than pushing as soon as you are fully dilated, you can benefit from actually beginning your pushing when your body literally cannot stop from pushing.

This was referred to above as the “spontaneous bearing down reflex“. It could occur ten minutes after you are fully dilated or even an hour later.

7. Know when NOT to Push

As we talked about, not pushing and laboring down in the early part of second stage labor is a great way to conserve energy and reduce your pushing time. Other times when you should not push is later in labor if you have a strong urge to bear down and you are not fully dilated. If you get a strong urge to push before you are 10cm, you should breath, pant or blow during contractions so that your cervix will not become swollen or tear. Your care provider can examine you to let you know when you are completely dilated.

Another time when pushing should be slowed or stopped altogether is at the very end of second stage during crowning as the baby’s head emerges. This is a time when a very slow birthing of the head and stretching of the tissues is much desired over a fast birth of the baby. The faster the baby comes out, the more likely you will tear. If you have discussed the issue of avoiding an episiotomy with your provider, a very slow birth of the head will be crucial.

8. Following Your Body’s Instincts

A good overall strategy is to take your time and do not feel pressured or rushed in the pushing stage. Pushing is hard work and in the middle of it during active pushing, you will undoubtedly be pushing harder than you expected. However, ask for more time if you need it. Do not feel that you have to hold your breath and push for 10 seconds. Or that you can’t move during second stage.

It takes awhile to get the hang of pushing effectively. There is nothing wrong with starting to push and realizing that your urge is not strong enough. Go ahead and wait for your body to tell you when it’s time to push. Your body has a reason for taking longer, if need be. It is always a good idea to follow those instincts. They are there for a very good reason.

9. Practice Prenatal Perineal Massage

Research shows that first time mothers can improve their chances of having no tears or what is called an intact perineum, by doing perineal massage starting in their 34th week.

Do you have any techniques that worked for you? Share it.