Best Tips for Pushing During Labor: Open Glottis + Positions
You've gone through the different phases of labor, and now it's time to meet your baby! Pushing involves a combination of breathing and changing positions. Since your uterus is really what pushes baby out, you also want to make sure you're working WITH your contractions and relaxing the pelvic floor as you push.
Pushing positions like squatting, kneeling and on all fours use gravity and pelvic opening to help move baby down. Still, 68 percent of American women push on their back during labor, even though research shows this isn't the best position for mama or baby. Here's how to breathe through contractions, listen to your body, and avoid pushing on your back.
Use breath to push with open glottis pushing
Open glottis pushing, or slow exhalation while pushing, follows your body's natural urge to bear down and push. Essentially, you slowly exhale when you feel like pushing—instead of holding your breath. While you breathe out, you may grunt or moan. Making these "deep noises" and slowly exhaling helps contract your abdominal muscles, pulling the stomach in and moving baby further down the birth canal for delivery.
Open glottis pushing is also beneficial because it:
Decreases baby's risk of heart rate changes (Open glottis pushing allows for uninterrupted blood flow to your uterus and baby)
Helps avoid fatigue that makes you too tired or unable to push
Decreases your risk of vaginal tearing as you push out baby
A downside of open glottis pushing is that it can slightly extend the second stage of labor. However, this extra time helps your tissues slowly expand as you push. Making this tissue expand too quickly puts you at risk of tearing and pelvic floor issues.
Note: Open glottis pushing can be difficult if you've had an epidural and can't feel your contractions. However, you can still do open glottis pushing with an epidural! If you plan on having an epidural, learn to watch contractions on the monitor. When you see a contraction on the monitor, you want to exhale. A good exhale requires a good inhale, so take nice deep breaths in when you’re between contractions.
How to do open glottis pushing
You feel an intense pressure to bear down and push (this can feel like you need to poop).
Push as if you are pushing a tampon out to help relax the pelvic floor (don't push like you're pooping—this uses different muscles).
As you push, exhale through your mouth like you're blowing the petals off a flower.
As you exhale, you can make deep noises like grunting, groaning, or moaning (one push typically takes about 5 seconds).
Take several breaths in and out after you push.
Continue to push for another 5 or so seconds and take resting breaths through each contraction. (You can usually get 3-5 pushes in during a contraction).
Limit or avoid closed glottis pushing (if possible)
Closed glottis pushing, or Valsalva pushing, involves holding your breath and pushing for an extended period—like counting to 10. This method delivers a strong push by creating high abdominal pressure. This breathing method can sometimes shorten the time it takes to push your baby out. Closed glottis pushing can be helpful if you need to get baby out fast or give that one final push.
But, closed glottis pushing has more downsides and risks than open glottis pushing because it puts forceful pressure on the baby, umbilical cord, and tissues. This intense pressure, especially if you do it for hours, can:
Increase baby's risk of heart rate changes (closed glottis pushing can restrict blood flow to your uterus and baby)
Use up a lot of energy and make you too tired to push
Increase your risk of vaginal tearing
Increase your chance of having urinary incontinence issues
Follow YOUR urge to push with non-directed pushing
Also called spontaneous pushing, non-directed pushing means following your self-perceived urge to push. Listening to your body and pushing when it feels right works naturally with open glottis pushing. Research shows combining non-directed and open glottis pushing helps synchronize the uterus and respiratory systems—which helps you get enough oxygen.
Closed glottis pushing is often done with directed pushing, which means your healthcare provider or support person tells you when to push. Although directed pushing is often the norm in hospitals, research does not support directed pushing. Directed pushing has been shown to cause cardiovascular stress, reduced oxygen, and fetal heart rate changes.
Avoid pushing on your back with these positions
Before the pushing stage, you want to keep changing positions to help move baby down the pelvis! Modifying your position can also help reduce pain during labor! Once you're ready to push, remember to keep your knees in, ankles out, and your trunk over the pelvis. This positioning helps relax the pelvic floor and angle your pelvis to help move baby down.
Pushing on your back often works against this optimal pelvic alignment. Instead, try these positions that help open the pelvis and work with gravity to improve your pushing.
Semi-squatted with birthing bar: Squatting helps you take advantage of gravity and increases the size of your pelvis. Adding the birthing bar helps take some of the load off your legs since this position can be tiring.
Hands and knees (quadruped): Like squatting a position, getting on all fours and angling your ankles out helps open up the pelvis. This position can also help relieve back pain during labor.
Birthing ball (quadruped): This modified hands and knees position lets you put less pressure on the wrists and rest your upper body on a birthing ball.
Sidelying with birthing ball/peanut ball: While lying on your side, elevate one leg with your ankle out using a birthing ball. You can also pull down on the bar of your hospital bed to create pressure and increase abdominal contraction. Birthing in the side-lying position may also help reduce tearing by slowing descent and allowing your tissues to stretch. If you’ve had an epidural, this is a non-back position that may work for you.
Towel roll under sacrum: If you want or need to lay on your back while pushing, keep the head of the bed more elevated and roll a towel directly underneath the right side of your sacrum (under the center line of your right butt cheek). This is a great pushing position if you’ve had an epidural. Propping up the back helps move your tailbone out of the way and relaxes the pelvic floor.
Epidural pushing positions
There's a misconception that getting a traditional (non-walking) epidural means you have to push on your back. This is NOT always true! Some women CAN push in an upright position with an epidural. You just have enough sensation to change positions safely with little assistance. What is safe for you and your baby depends on your epidural experience. However, if you can’t move easily—which is the norm—pushing with your back elevated with a towel or sidelying with a peanut ball are epidural-fiendly.
Pushing in an upright position may help women with epidurals shorten labor and pushing time. Research shows that women who have epidurals and push in an upright position may decrease their risk of fetal heart rate abnormalities and episiotomies, vacuum, and forceps-assisted deliveries.
Takeaway
When it's time to push out your baby, try to listen to your body. Pushing during labor is all about trusting your body! Still, your healthcare provider and/or support person can offer you support and encouragement as you push. Avoiding pushing on your back and open glottis breathing can make all the difference—helping your baby move down the birth canal and reducing your risk of tearing and pelvic floor issues.
If you need more help preparing for labor's mental and physical demands, check out the Expecting and Empowered Labor + Delivery Online Course. Remembering how to push during the main event can be challenging, but practicing breathing and preparing for delivery can help.
Sources
Barasinski C, et al. (2016). Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial-the EOLE study protocol.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223691/
DiFranco JT, et al. (2014). Healthy birth practice #5: Avoid giving birth on your back and follow your body's urge to push. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235063/
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Kibuka M, et al. (2017). Position in the second stage of labour for women with epidural anaesthesia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464234/
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Stremler R, et al. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. https://pubmed.ncbi.nlm.nih.gov/16336365/