Bearing down with the diaphragm and abdominal muscles while lengthening the pelvic floor, timed to each contraction after full cervical dilation, defines the act of pushing during labor. You can treat pushing as a learnable coordination skill rather than a test of strength. Effective pushing shortens the second stage, protects your pelvic floor, and lowers the odds of vacuum, forceps, or cesarean delivery.
Here’s a clear breakdown of evidence-based pushing techniques, including breathing patterns, body positions, and ways to protect your perineum,whether or not you’re using an epidural.
The Second Stage of Labor and Why Pushing Matters
Full cervical dilation at 10 centimeters marks the start of the second stage of labor, which concludes with the birth of your baby. It opens with a brief latent phase often called the “rest and be thankful” window, when contractions may space out and your baby’s head descends passively through the birth canal. Many people feel a lull, even doubt, right before the urge to push arrives.
Once the fetal ejection reflex kicks in, you feel an involuntary, almost uncontrollable bearing-down sensation that is distinct from a coached urge to push. The reflex is driven by pressure on the pelvic floor and stretch receptors in the vagina, and it usually arrives as 3 to 5 strong spontaneous urges during each contraction. Effective pushing shortens the second stage, protects your baby by avoiding prolonged heart rate decelerations, and reduces your need for operative delivery.
That aligns with guidance from the American College of Obstetricians and Gynecologists (ACOG) and Lamaze International, who both emphasize patience in early second stage plus responsive pushing over rushing to bear down the moment dilation hits 10 cm.
- Latent second stage: 10 cm dilated, little urge, baby descending passively, often the “rest and be thankful” pause.
- Active pushing phase: Strong urge present, 3 to 5 short pushes per contraction, baby rotating and descending.
- Crowning: Head visible at the vaginal opening, stretching the perineum, the so-called ring of fire.
- Birth: Head and shoulders deliver, often with one final push between contractions.
Spontaneous Pushing Versus Directed Pushing
Three to five short pushes per contraction, each lasting roughly five to seven seconds and separated by breaths without sustained breath-holding, characterize spontaneous or physiologic pushing. Directed (Valsalva) pushing uses a coached, sustained breath-hold of roughly 10 seconds repeated across 3 pushes per contraction, sometimes called “purple pushing” because of the facial color it produces.
Current ACOG guidance leans toward spontaneous pushing for unmedicated births because it tends to preserve fetal oxygenation and reduce pelvic floor trauma. Reviews published through the World Health Organization (WHO) and Lamaze-aligned sources suggest directed pushing with prolonged breath-holding can shorten your second stage by a few minutes, but it may reduce fetal oxygenation and increase your risk of perineal tearing.
Most hospital teams reserve directed pushing for situations like a long second stage, maternal exhaustion, or concerning decelerations on continuous fetal monitoring. Out-of-hospital midwives and birth centers almost always default to spontaneous pushing.
| Feature | Spontaneous (physiologic) pushing | Directed (Valsalva) pushing |
|---|---|---|
| Breathing pattern | Open glottis, exhale during push | Sustained breath-hold for ~10 seconds |
| Push length | 5 to 7 seconds, body-led | 10 seconds, coach-led |
| Pushes per contraction | 3 to 5 | Typically 3 |
| Fetal oxygenation | Better preserved | Reduced with prolonged breath-holds |
| Pelvic floor impact | Less strain on perineum | Higher perineal tearing risk |
| Common setting | Birth centers, unmedicated hospital births | Hospitals with epidurals or concerning fetal tracings |
Breathing Patterns and Body Mechanics That Make a Push Count
The Anatomy of an Effective Push
A strong push uses your diaphragm and deep abdominal muscles while your pelvic floor lengthens and your perineum relaxes between contractions. Inhale slowly through the nose, then exhale through pursed lips as you bear down, like blowing up a heavy balloon. This open-glottis approach keeps oxygen flowing to your baby and prevents the Valsalva spike in blood pressure that breath-holding causes.
Coordinate one inhale, one sustained bear-down of about 5 to 7 seconds, then a slow controlled exhale to release the pelvic floor. Rest between pushes matters because clenching the perineum through the entire contraction wastes energy and tightens the very muscles that need to open.
Practice Drills Before Delivery Day
- Diaphragmatic breath-holds: Inhale for 4 counts, hold for 6, exhale for 8, repeat 10 times daily.
- Perineal drops: Sit on an exercise ball, inhale, then visualize your pelvic floor descending as you exhale.
- Kegel release drills: Contract the pelvic floor for 3 seconds, then fully release for 7 seconds, focusing on letting go rather than squeezing.
- Side-lying pushes: Rehearse lying on your left side with a pillow between the knees, bearing down gently on the exhale.
Tip: Practice exhaling through the push, not holding your breath. The exhale keeps oxygen flowing to your baby and helps your pelvic floor lengthen.
Positions for Pushing With and Without an Epidural
Unmedicated Position Options
Upright positions like squatting, hands-and-knees, and kneeling use gravity to bring your baby down and widen the pelvic outlet by up to 10 percent. Side-lying is a strong resting position that still allows effective pushing and protects your perineum. Squatting with a partner or squat bar generates strong intra-abdominal pressure, but it can be exhausting in a long labor.
Evidence from Cochrane reviews and Lamaze International supports upright and side-lying positions for a shorter second stage and fewer interventions. For an OP (occiput posterior) baby, hands-and-knees or forward-leaning positions encourage rotation. When maternal exhaustion sets in, side-lying with a peanut ball between the knees lets the team continue helping the baby descend without draining your legs.
Pushing With an Epidural
A dense epidural often blunts the urge to push, leading many providers to suggest delayed pushing, sometimes called laboring down, for thirty to ninety minutes after full dilation. This lets your baby’s head descend passively while conserving your energy. Once the urge arrives, or the head is visible, the team guides pushing with hand cues and a mirror.
Troubleshooting reduced sensation starts with the provider or nurse placing a hand on the fundus (top of the uterus) so you can feel where to bear down. A mirror lets you watch the head descend with each push, and your partner can press a rolled towel against the perineum to give a pressure cue.
Positions like supported squatting on the bed, throne position with the back of the bed raised 45 degrees, and side-lying all work well with continuous fetal monitoring. The Mayo Clinic and NHS both emphasize that epidural pushing stays safe and effective when guided by provider feedback rather than a fixed count.
| Position | Best for | Epidural-friendly? |
|---|---|---|
| Upright squat | Strong gravity assist, OP rotation | With squat bar and provider support |
| Hands-and-knees | Back pain, OP babies, perineal protection | Difficult with dense block |
| Side-lying | Resting, perineal protection, slow second stage | Yes |
| Throne / semi-reclined | Provider access, continuous monitoring | Yes |
Protecting the Perineum and Handling the Ring of Fire
Slow Crowning and Warm Compresses
Crowning is the moment your baby’s head stretches the vaginal opening, often described as the “ring of fire,” a stinging, burning sensation that signals the perineum is at maximum stretch. Slowing the head’s emergence here reduces tearing dramatically. Warm compresses held against the perineum during crowning increase blood flow and relax the tissue, and ACOG-cited studies show they cut severe tearing rates by roughly 25 to 30 percent.
When your provider asks you to stop pushing, pant through the contraction instead of bearing down. This controlled crowning lets the perineum adapt and gives the team time to check for nuchal cord loops or shoulder positioning. Counter-pressure on the perineum, with a warm washcloth or the provider’s hand, supports the tissue as the head emerges.
Pelvic-Floor-Aware Pushing for Long-Term Recovery
Using a long exhale and a relaxed pelvic floor while pushing helps lower the long-term risk of prolapse and incontinence. Bearing down with a clenched pelvic floor, common in coached Valsalva pushing, repeatedly loads the pelvic floor muscles under high pressure and is linked to postpartum prolapse symptoms. A simple cue: breathe out as if fogging a mirror, then let the pelvic floor drop while you bear down.
For shoulder delivery, the provider may ask you to stop pushing entirely while they rotate the shoulders or perform a gentle perineal release. Forceps or vacuum extraction is sometimes needed when your baby’s head is low but progress stalls; both are safe, evidence-based tools in experienced hands. The decision to perform an episiotomy is now rare and reserved for situations like fetal distress with a rigid perineum.
Warning: Never push through the ring of fire without provider guidance. Slow, controlled crowning protects your perineum and gives the team time to respond.
A Partner Coaching Script and What Nurses Actually Look For
A Phrase-by-Phrase Coaching Script
Partners and doulas can repeat these cues out loud during each phase of a contraction. Print this and tuck it in your hospital bag.
- Contraction starts: “Inhale slowly through your nose. Exhale and let your belly fall. You are safe, and the team is right here with you.”
- First push: “Long breath in, now bear down gently into my hand. Exhale as you push, five, six, seven, and release.”
- Second push: “Same again, breathe in, drop your chin to your chest, follow the urge. Slow exhale, beautiful work.”
- Between pushes: “Soft jaw, soft shoulders, sip of water after this contraction ends.”
- Crowning: “Pant with me, short breaths in and out, do not push. The team has you.”
- After delivery of the head: “One more when you feel the next urge, you are almost there.”
What the L&D Nurse Is Watching For
Your labor and delivery nurse monitors the fetal heart rate tracing continuously during active pushing, looking for decelerations that signal your baby is not tolerating a push. A brief drop with each contraction is common, but a slow recovery to baseline or repetitive deep variables may prompt the provider to slow pushing, change position, or apply a vacuum.
The nurse also watches contraction strength on the tocodynamometer, checks your blood pressure every 15 minutes, and times the second stage so the team can intervene before maternal exhaustion sets in.
Force and duration of pushing should always be guided by your urge and provider feedback, never a fixed count. A common rule of thumb: if there is no progress after 2 to 3 hours of pushing for a first birth, or 1 to 2 hours for a subsequent birth, the team reassesses position, contraction strength, and whether an operative delivery is needed. ACOG uses these timeframes to flag a prolonged second stage without setting hard limits.
Support Person Checklist
- Water and lip balm: small sips between contractions prevent dry mouth.
- Counter-pressure: firm pressure on your lower back during contractions eases back labor.
- Cool cloth on the forehead or neck: regulates temperature during long pushing phases.
- Breathing cues: mirror your exhale rhythm, slow and steady.
- Affirmations: short phrases like “you are doing it” or “you are almost there” between contractions.
- Phone on silent: protect focus from constant notifications.
The Big Picture
Pushing during labor is not a strength contest; it is a coordination contest between your breathing, your pelvic floor, and your baby’s position. The most useful thing you can do before delivery is practice exhaling while bearing down, rehearse two or three positions, and choose a support person who can repeat simple cues when you are too tired to remember them. Show up with a plan, trust your body’s urge, and let the team handle the rest.
FAQ
When should you start pushing during labor?
Most providers recommend waiting until you feel a strong, involuntary urge to push, usually after full cervical dilation to 10 cm. Pushing too early against an undilated cervix can cause swelling and slow your labor. With an epidural, you may need to wait longer for the urge to build or use coached pushing once the head descends.
How long does the pushing stage of labor last?
For a first birth, active pushing averages 1 to 2 hours, sometimes up to 3 hours with an epidural. For subsequent births, it often lasts under 30 minutes. ACOG defines a prolonged second stage as over 3 hours for first births and over 2 hours for subsequent births, but exact timing depends on your wellbeing and your baby’s.
What is the difference between coached and spontaneous pushing?
Coached (directed, or Valsalva) pushing uses a sustained breath-hold for about 10 seconds across 3 pushes per contraction. Spontaneous (physiologic) pushing follows your body’s urge with shorter pushes and open-glottis breathing, usually 3 to 5 pushes per contraction. Spontaneous pushing tends to preserve fetal oxygenation better.
Does pushing cause hemorrhoids or tearing?
Prolonged breath-holding and rapid crowning raise the chance that pushing will lead to hemorrhoids or perineal tearing. Slow, controlled crowning, warm compresses, and side-lying positions all reduce your tearing risk. Most first-degree tears heal within weeks, and hemorrhoids usually resolve with conservative care.
How can you avoid tearing while pushing?
Practice perineal relaxation before delivery, use warm compresses during crowning, exhale while bearing down, and choose side-lying or hands-and-knees positions when possible. Stop pushing and pant when your provider asks during crowning so the perineum can stretch gradually.
What position is best for pushing during delivery?
Upright, side-lying, and hands-and-knees positions all have evidence supporting shorter second stages and fewer interventions. With an epidural, side-lying or a throne (semi-reclined) position works well and allows continuous fetal monitoring. Switch positions every 20 to 30 minutes if labor stalls.
