When it comes to birth anxiety, how to push during labor can be high on the list of things you may be anxious or really nervous about! In this blog, we will be discussing common fears associated with pushing (you’re not alone) and our top tips to guide you through how to push!
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In this blog, we will discussing:
- Top two fears of pushing: tearing and pooping, plus ways to mitigate your fears (and reduce the risk of tearing)
- Our personal fears going into our first births (and subsequent ones)
- Our top tips to enhancing your pushing experience, to include:
- Choosing the BEST pushing position for you
- Breathing techniques
- What you can expect in a hospital setting
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The second stage of labor is pushing or expulsion. This is when you’re going to push your baby out of your body. And pushing can last from a few pushes to three to 4 hours depending on if it’s your first baby, if it’s your second baby, if you’re unmedicated, or if you have an epidural.
There are a lot of factors that can kind of play into how long you push, such as how high is baby in your pelvis when you start pushing. But we do get a lot of questions about pushing and I think it’s because it’s one of those things that you just don’t know what it’s going to be like until you’re in it.
First Fear of Pushing: Pooping
Roxanne, were you nervous about pushing for your first birth as a labor and delivery nurse?
Roxanne: No. I think I was just more so fearful that I was going to have to push for forever. When I had my baby, I was going to be that person that pushed for 3 hours trying all these positions and my baby was going to have the craziest cone head.
I wasn’t afraid that I was going to poop everywhere because I was aware that everyone kind of does that during labor. (Gina was afraid of pooping.) That is a common fear that they’re afraid of pooping during labor.
But I think my biggest fear associated with pushing was tearing. That I didn’t want to tear because I didn’t want that repair. I didn’t want to have to be repaired because my initial goal was to go unmedicated. So not having an epidural where I considered just getting an epidural so that I wouldn’t have to feel the repair, which was a silly thing, but that was my fear, was tearing like pushing for 3 hours and then having an insane tear from it, that was my fear associated with pushing.
Gina, what was your fear other than pooping?
Gina: That was my number one fear, it was pooping. And then my husband announced it to the room that I was pooping. Fear unlocked. While I was pushing, butt naked, everyone was watching me as I just pooped.
“Gina’s, pooping.” “Thank you. Thank you, honey. Thank you.”
I had a pretty strong epidural so I didn’t know and I could have gone the rest of my life.
Roxanne: Me and the nurse were just like, “we’re not going to talk about it. We don’t see anything.” She’s just wiping it away. And then Barron goes, “oh, you’re pooping.”
Gina: Thank you. Thanks.
Roxanne: We both stared at him like, “what the hell, man?”
Gina: That’s probably the best thing about having to wear a mask at hospitals right now is whenever one of my doula clients poops while she’s pushing, I will deny it to the end of my day. And she’ll be like, “what does that smell?” And we’ll all be like, “what are you talking about? We smell nothing.” And she’s like, “you guys, I’m pooping.” And we’re like, “we know nothing.” We will deny it. I will deny it till the end of my days. I will never say I will never tell anybody that they are pooping when they’re pushing.
Roxanne: But no, that’s so like I wish I had a statistic that was like evidence-based, but I feel like 90% of people poop either right before you start pushing or during it.
So if you have any sort of poop in your bowels and especially the lower part of your bowels, as your baby is coming through, they are pushing whatever is in there out as well. Their head is pushing it out as well as your pelvic floor is pushing it out. Because if you’re using all of the right muscles, you probably will poop. So that’s a good sign. Like, if you start to poop, you’re probably pushing correctly and that means your baby is probably moving down because sometimes if you have a lot of poop in there, that’s what’s keeping the baby in. So you want it to come out to make room for the baby.
Gina: I had one birth where the midwife was like, “Once this big stool comes out, your baby will fly out.” I wouldn’t put it that way. I would never tell. She wasn’t like whispering it either. It was really loud. I know the person who is listening will know who they are once they listen to this episode but just know inside I was dying when she said that once this big stool comes out, your baby will just fly right out. And it was true. Once the big stool came out, the baby came flying out right after that. But yeah, pooping was definitely my biggest fear.
I hadn’t even considered tearing or any of that until you brought it up with your pregnancy that you were afraid of tearing and being unmedicated. And so for my subsequent birth, I was very anxious about tearing and having to get repaired unmedicated.
Second Fear of Pushing: Tearing
Gina: With Eoghan, I only had one stitch, and I was super anxious about that. And Sophie didn’t tear at all because I started pant breathing when she was like 1 CM out when I was not crowning, but I was just like, I don’t care that you’re telling me to slow down, because I will not tear. And I didn’t. I don’t know if it’s because it was my third baby or because I was pant breathing for ten pushes.
Roxanne: So those two and then I think my other one, my other fear, because it happened to a couple of people, like some of my college friends, is that they pushed for a really long time, that they popped blood vessels in their eyes. I was like, oh, my gosh. That’s a thing. I had never seen that in any of my labor and delivery patients. I had never seen them push so hard that they blew blood vessels in their eyes or in their face.
But if you are pushing where most of your force is kind of going upwards and you’re, like, holding a lot of pressure in your face, it’s not the most effective way of pushing, which we will go over in this podcast. But if you are doing, like, purple face pushing where a lot of pressure is in your face, that the blood vessels in your face and your eyes can pop.
So she had bloodshot some of the people that were posting there had bloodshot eyes because the blood vessels in their eyes had burst from pushing. And I was like, that’s a new fear. New fear unlocked. That’s a new fear for me. I think I was pregnant, too, at the time, and I was like, oh, God, that’s a thing that can actually happen. Like, I had been a labor and delivery nurse for, like, five years at this point. What do you mean that that’s a thing that happens to people? I’ve never seen this.
So let's address these fears.
One, everyone will deny if you poop. And nurses are like ninjas where they just swoop in with wipes and they clean that off, you don’t even notice it. You will probably not notice it. Also, you will probably not care.
In the moment with Sophie’s birth, I had taken castor oil, and then 3 hours later, I started pushing, and all of my poop came out of my body at the same time. I did not care. Poor Roxanne was chasing me, wiping my liquid poop off me. Good nurse, and in that moment could not care less at all. So, addressing that fear, no one will care to include yourself. And if your husband mentions it, just immediate divorce.
Second fear getting repaired while unmedicated. In general, I personally do not remember it being bad, but it’s also like you’re holding this brand new baby, and it’s like this really exciting moment that they kind of can distract from that pain. The worst part is the lidocaine.
The fear of tearing is common, even if you are planning on getting an epidural. Like, no one wants to tear. But there are ways that we can prevent or decrease the risks of tearing that we’ll go over.
Top Tips to Prevent Tearing: Slow Down
If you feel the ring of fire or this big stretching sensation, even if you have an epidural, you should still feel lots of pressure when you feel that or hopefully someone else is kind of queuing you like your provider, a nurse, or your partner. When they’re starting to see a lot more of baby’s head, you really want to slow down and let those tissues stretch.
And so one way that I find to be super helpful is to pretend like you’re blowing a candle out on the other side of the room. It’s still a strong puff out, but it’s really short and so it’s like half a second long. You’ll just kind of repeat that over and over and over until the push is done. And so you’ll do like five to ten of these really little pushes to kind of ease baby out.
And most likely during that easing out, baby’s head will be born. Or you’ll just do it again for the next one, which is like what Roxanne did for her first was like ten pushes of just crowning.
My first tip is just slow down because the more you kind of let those tissues slowly stretch, the less likely it is for them to just tear.
Prevent Tearing: Relax the Legs
The next thing that I found to be really successful, I see this happen a lot with some midwives at one of the local hospitals by us, which I was like, oh my God, that makes so much sense, is relax your legs.
And so, we don’t want to have super wide legs and we also don’t want to be super torqued with internal rotation either. We just want to relax the legs because this is going to help release the tension in the perineum.
Tissues only have so much tensile strength before it tears. If we’re already at max tension within that perineum because our legs are super wide and we’re putting all of this stretch across that tissue and then you add a baby head, it’s probably going to tear. And so, what I would recommend is when baby is crowning is to just relax your legs as much as possible.
So slow down your pushing with trying to like you’re blowing out a candle and then relax your legs are two things that I found to be really successful with preventing tearing.
Now I do also find that your provider plays a big role in whether or not you’re going to tear. So if your provider believes that everyone tears, you’re probably going to tear because they’re probably not going to do a lot to try to mitigate it or to decrease the severity of it, because they just believe that everyone tears. And so they’re not going to try to have you slow down while you’re pushing or relax your legs. They’re probably going to tell you to push as hard as you can to hurry up and get the baby out. It’s a little bit of anxiety of like, we want to hurry up and get the baby out because there are potential emergencies that could happen in that very short period of time. It’s like the one time that you’re probably seeing your doctor or your midwife for a prolonged period of time during your birth is when your baby is about to crown.
If your provider believes that everyone tears, they’re not going to do a whole lot to try to mitigate that. Now if your provider believes that, hey, not everyone has to tear, they may do a lot to help you not tear. So they may encourage you to slow down while you’re crowning. Relax your legs. They may do warm compresses to kind of warm up the tissues to make them easier to stretch. Like if you’re at home or a birth center or you’re in a hospital that allows water birth, that could help decrease your risk of tearing as well because of the warm water. I think your provider plays a big role in whether or not you tear.
But ultimately, if you do tear, it’s okay. It’s not the end of the world. A lot of us put a lot of fear in this, but tearing is not that bad. Our providers do a really good job of repairing our tears. We can see pelvic floor physical therapy to support healing from that tear. And so, there’s a lot that we can do to support healing so that we can return to normal function. Again, if you do tear, it’s not your fault. You didn’t do all the wrong things, you didn’t choose the wrong provider. We can repair the tear and return to normal function.
What are the different types of tears?
There are four different types of perineal tears, four different degrees.
First degree is just a tearing into the superficial skin of the perineum. So the perineum is what’s between the vaginal opening and the rectum. So that little piece of skin that’s there, there’s also muscle layers and that’s what most commonly people will tear at. So the first degree, again, just into the superficial skin, so usually takes like maybe a couple of days to heal.
A second degree is through the superficial skin into the muscle. So the perineal muscle or pelvic floor muscle.
The first and second degree are the most common tears that people will have, 95% of people who tear will have a first or second degree. And again, the first degree takes a couple of days, whereas the second degree can take like a week to heal. But usually, there are no long-term complications associated with first- and second-degree lacerations.
The third and fourth-degree lacerations are considered the more severe tears. The third degree is through the superficial skin, all the way through the perineal muscle, into the anal sphincter, and then a fourth-degree tear is through it all, so through the superficial skin, through the muscle, and all the way through the sphincter. So the two holes have now become one.
Those two are a little bit more involved with the repair and then the recovery. Also because there is an increased risk of pelvic floor dysfunction associated with the third and fourth-degree tear, having pelvic floor physical therapy is really beneficial afterward, and I would say required afterward, just so that you can ensure that there is optimal function of that pelvic floor muscles and including like anal sphincter.
Those two tears can be like the risk of having a third- and fourth-degree tear can be reduced by:
- Not having an episiotomy, because episiotomies are more likely to extend into a third- and fourth-degree tear based off of studies.
- Also if there is no operative vaginal delivery. So vacuum or forceps have a higher risk of having a third and fourth degree tear.
- If you push for a super long period of time, this also increases your third and fourth-degree tear risk. And so, choosing your provider as well as learning proper pushing mechanisms could potentially help decrease the risk of that third and fourth-degree tear.
But sometimes they still just happen, like the baby kind of just shoots out, maybe there’s no stretching involved. That could lead to a third-degree tear. It could be their arm just juts out as they’re being born and that just causes the tear to become a third or fourth-degree tear. So again, it’s never anybody’s fault when a third and fourth degree tear happens.
But we do want to try to lessen the risk of those happening by again, trying to avoid routine episiotomies, not using a vacuum or forceps, if possible, if they are pushing well, and trying to prevent prolonged pushing periods of time so that we can hopefully protect those perineum.
But there are different types of lacerations other than just the perineal lacerations that are just like the downward ones that everyone mostly thinks about.
Other types of vaginal tears from pushing
But you can tear in your labia. You can tear in just like the vaginal vault. So like the path that the baby is coming through, you can have a tear down like the inside of your vagina pretty much. You can have a clitoral tear, you can have a tear by your urethra so anywhere in the vagina that is stretching and opening, you can tear. And normally the point that you’re going to tear is the part that is the most downward and most of us usually push on our backs in the hospitals.
So that is why perineal tears are most common because when you’re on your back, the lowest point is that perineal area. But if you push on your side, there’s a higher risk of having a labial tear. If your hands and knees, there’s a higher risk of clitoral or urethral tears. So it’s just whatever is like the closest to the ground, there’s just more pressure on those areas that increases those tearing risks in those locations.
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Providers may recommend a c-section after a 3rd or 4th degree tear...
So I’ve had some clients that have had third- or fourth-degree tears in previous labors. And usually at some point during their pregnancy, their provider starts recommending that they have a caesarean bruise to avoid having another third or fourth degree tear.
So there is a slight increased risk associated. Like if you have had a previous third or fourth degree tear, potentially will still have a third or fourth-degree tear in subsequent births, but it’s like only like a 1% or 2% increased risk. And it’s usually because if that tear didn’t heal optimally and there’s some scar tissue, it usually is going to tear along that scar tissue because that scar tissue is just not as strong as healthy tissue.
So if you’re doing like scar mobilization, this can decrease that risk. But some people still do choose to have a c-section because of their recovery process after the third and fourth-degree tear. So if you’ve had a lot of pelvic floor dysfunction associated with that third and fourth-grade tear, sometimes that risk that it could happen again is too great for you. And choosing that c-section is a little bit easier of an option because it doesn’t have that risk of having that third or fourth-degree tear pelvic floor dysfunction associated with the recovery.
So that is why some providers offer it, because of the long-term complications of the third or fourth-degree tear complication for people, especially if they’ve had a long recovery from it, that option for a c section was something that I guess was nice to offer and that people appreciated. But not everybody needs to have a repeat c-section just because you had a third and fourth degree tear in previous births, because that doesn’t mean that you’re going to have third or fourth degree tear in subsequent births.
I’ve had clients who have had a fourth-degree tear, and then in their next birth they had no tear. You tear less in subsequent births and so the likelihood of you having a third or fourth-degree tear in your second-plus birth is very small.
The likelihood of you having it for your first is also very small, and then it’s even smaller for your second. But if you had a third or fourth-degree tear, it’s like a little bit higher, but still a small percentage. I don’t have the percentages off the top of my head. I think it’s like the likelihood is like 7%. But if you’ve had a previous tear, it’s like 9% or something like that, but it’s still a very small percentage. And not to say that c section would be like an easy way out instead, by any means, but not having to have that pushing phase with that potential tear again is sometimes a reason why folks will take that option. But know that your likelihood of having a third or fourth retair again is much smaller, especially if you’ve been doing like perineal scar mobilization to address that tissue. You’ve been working with pelvic floor physical therapy, and then even with the Caesarean birth, it still affects our pelvic floor function.
So don’t think like, “oh, I’ll have a c section and then I’ll have no pelvic floor issues,” because your abdominal wall where your incision is will still affect how your pelvic floor can function, because we have this kinetic chain and so muscles in one part of our body affect another part of our body. But I have seen for my doula clients who have had third or fourth grade tears in previous births have this recommended to them at some point during their pregnancies to have a c-section. Instead, all of them have chosen to go for a vaginal birth, and almost all of them have had either no tears or a very insignificant type of tear, which has been a really interesting thing to observe.
Is pushing like pushing out a watermelon?
No, because a watermelon is a hard object that does not change shape as you press it. No one can, I mean, guess some people can squeeze a watermelon. But most of us cannot manipulate the shape of a watermelon with our body. Whereas a baby, the baby’s skull has not fully fused. So their suture lines on their skull are still mobile and they can kind of override and kind of move around to adjust for the space that’s available in that birth canal, which is so amazing.
And then the rest of their body, yeah, they still have bones and their torso and legs, but again, that still is movable. If you press your arm, your arm is kind of squishy and can adjust and fit through tighter spaces than you think it can. Whereas a watermelon, again, if you try to shove a watermelon through a hole that it’s not made to fit in, it’s not going to fit. Whereas a baby adjusts to the space available.
And the tissue of the perineum is also super stretchy. Like I think it stretches like 40 times its size. I might be off on the amount that it stretches, but it can stretch pretty significantly. And the pelvis also has great movement capability to create more space for your baby as it’s kind of descending and rotating through our pelvis. And so the same thing is happening when we’re pushing. We’re actually creating more space in the bottom of the pelvis to help baby kind of evacuate the premise. And then baby’s head, the bones of their skull are kind of molding and folding over one another to get smaller as they kind of squish through the vaginal canal.
Depending on how long you push, you may have this little cone-head baby which is they’re still adorable. They put a little hat on your baby pretty quickly after birth so you may or may not notice it. And then pictures like two weeks later when you’re looking at them, you’re like oh my God, that baby has a torpedo head. That’s from all like the molding of the skull. So that baby can fit through the vaginal canal when you’re pushing.
Pushing is not like pushing a watermelon out of your vagina because one, the tissues of the perineum and the vaginal canal can really stretch pretty significantly to accommodate a baby. And then your baby’s skull is not this immovable object. It can mold and change shape as it kind of fits through. So know that your baby can fit through your pelvis and it’ll be okay.
Is your pelvis too small for pushing??
So the next thing that you may be told when it comes to pushing is your baby is way too big or your pelvis is too small and these two are not going to work together in order for you to have a vaginal birth.
And I find that assessment to be really unfair because one, the pelvis is super dynamic, so it can change shape, the diameters can increase depending on how you are positioning your legs, how you’re moving your hips, if you’re laying flat on your back, are your legs super wide.
And so all of these different movements can change the shape of your pelvis and increase space for your baby. And so likely if you’ve had any sort of assessment that is looking at your pelvic size or whether or not you have an adequate pelvis, you’re probably in a static position with your legs super wide or the assessment is done stationary like there’s no movement happening. And so it’s not taking into account your movement capability, which is much more significant in determining how much you can open your pelvis.
And yes, some of us do have some movement restrictions just based on common postural tendencies. For many of us, we may have less movement towards the back half of our pelvis because the posterior pelvic floor and the pelvic outlet may be a little bit more restricted just due to some common prenatal compensations.
And so during pregnancy, we tend to favor more extension or like arching in our back. So think like proud chest or like pushing our chest towards the ceiling. And then we tend to favor more external rotation at the hip. So think like a duck feet, so your toes are pointed outward type of stance. This postural tendency tends to result in a tighter posture pelvic floor and a more closed pelvic outlet.
And so if you cannot move out of that position, then we could have some issues with whether or not baby can more easily navigate through the pelvic space, but that can be addressed with pelvic floor releases, with some mobility work of the hips, with different types of focuses on internal rotation during pregnancy.
And we talk a lot about movements that you can do during pregnancy to help create more space in your pelvis to prepare for birth in episode three, our prenatal fitness podcast episode.
If your pelvis was assessed in a stationary position, typically with your leg super wide and somebody tells you “your pelvis is really narrow, I just don’t think it’s going to be very easy for a baby to fit through your vaginal canal.” Or if you’ve had a C section prior and they’re like, “oh, well, your pelvis hasn’t been proven and we just don’t think your baby is going to fit,” I find that to be very unfair because again, the pelvis is very dynamic and it can create a lot of space. And if no one is assessing the amount of movement that you have within your pelvis, it’s not going to be an accurate assessment for me and for you.
Now the other thing to take into account, so even if they do this dynamic assessment where they’re having you be in a lunge and they assess and then they’re doing like a squat or a deadlift, and then they’re assessing all these different pelvic diameters, the other big piece of this puzzle, again, is your baby.
Your baby’s head shape can change as they fit through the pelvis. And so someone telling you that your baby’s too big or that your pelvis is too small when you have not been given an opportunity to try is not fair to me. And so in most situations, your pelvis is probably not too small. We just need to work on creating more space. And your baby is likely not too big. They just need to fit through your pelvis in the way that’s best for them.
Movements to Prep for Pushing
So movements that you can do during your pregnancy to help ensure that you can open the bottom half of your pelvis to support pushing, are going to be movements that help to, one, create more space in the bottom of the pelvis and then also release tension within the pelvic floor. And so in order to create more space in the bottom of the pelvis for pushing, we want to focus:
- Internal rotation of the femurs: knees in, ankles out type movements or closed hip positions
- Think knees are moving towards midline as the ankle moves outwards. And so we can incorporate exercises into our prenatal routine that favor more internal rotation.
- Hamstring Strengthening to pull the pelvis into internal rotation
- Lat strengthening to support pushing efforts and lat engagement pulls the sacrum out of the way
So really any sort of like single leg exercise, we can find that internal rotation. So if I was doing a step up, I’m placing 1ft onto the box, that leg is bent, I’m then going to take my opposite hip and push it or rotate it towards the forward knee. And so I’m bringing my belly to my thigh. When I do that, I should feel more of a stretch in my hamstring and glute. So I’m thinking is keep weight in my big toe, my knee is staying stacked over that ankle, I feel this stretch in my glute and hamstring and then I could step up to face forward.
So finding more of that external rotation and then finding internal rotation as I step down. But incorporating those more internally rotated focus exercises are going to ensure that we can open the bottom half of the pelvis. And so this can be like with step ups, lunges, staggered stance RDLs.
If we want to focus more on bilateral type movements, we can just really focus on toes being a little bit more in.
And so if you’re doing any sort of like deadlift type movements, particularly with bands or low weights, we can focus more on the toes being a little bit more pointed in to favor more of that internal rotation as you do the movement.
And so one of the movements that I really like to do would be like a straight leg deadlift with pull down or row. I’m going to have my toes be slightly pointed in, I’m going to inhale to lower down as I feel that stretch in my hamstring. And then going to reach forward with the band. And then I’m going to exhale to stand up to extend in my hip as I row or pull the band down.
What this movement is doing is it’s incorporating my lats with my hamstrings at the same time. And what I usually find with pushing is there’s a lot of pulling that’s happening. So we’re pulling our legs, we’re pulling a sheet, we’re pulling on the bed. And so having strong lats can help us have a stronger push as well by incorporating more of our body. And so focusing on lat strengthening can be the other aspect of preparing to push as well.
So we’re finding more of that internal rotation, ensuring that we have that movement capability within our pelvis with all of our single leg or staggered stance type movements, or with our deadlifts and hinge type movements, with toes a little bit more in. Again, those hamstrings are going to help pull the pelvis into internal rotation. So strong hamstrings are going to be helpful here. And then we can pair this with strengthening our lats, which are going to help us pull during labor. But we also want to be able to release the lats as well. So we want that good full range of motion within our lat muscles.
And so, if you remember, a common postural tendency during pregnancy is extension or arching in our back. And this causes the lats to get really tight. And so it’s kind of pulling us into this arched position. When we’re in more extension, it’s harder to find internal rotation.
And so it can be helpful to also do some lat releases to be able to find a little bit more of that posterior pelvic tilt or that rounding in the back. Because it makes it easier for us to find internal rotation in the pelvis. And so, understanding that the rest of our spine and how it’s positioned can influence how we can then move our pelvis is also really important. Nothing’s in isolation and more of that posterior pelvic tilt or rounded position is also going to help us release that posterior pelvic floor as well.
And so one of the movements that I really like to do to help release tension in the back half of the pelvic floor are hip-shifted movements, because this kind of forces your hips and your pelvic floor into internal rotation.
The types of exercises that I can incorporate into my routine are going to be one focusing on finding internal rotation.
- Can I move my hip through this range of motion? I’m going to be focusing on strengthening my hamstrings because my hamstrings help pull my pelvis into internal rotation.
- I’m going to focus on strengthening my lats because pushing is a lot of pulling.
- But I also want to release my lats because I want to be able to find a more rounded position because that’s going to make internal rotation easier to achieve.
- I both want the shortening and strengthening of my lats and also the releasing and lengthening. I want this full range of motion of my back muscular to support pushing.
If you want more on what type of exercises could you be doing to support preparing your pelvis for birth or just keeping a strong pregnancy, keeping a pain-free pregnancy, you can always join our prenatal fitness programs.
We offer them online. We have them in the Team Builder app, which is a list of exercises with short demo videos if you prefer to kind of work out at your own pace.
We have a full and a mini version of that depending on how long you want to work out and kind of your workout settings.
And then we also have an on demand program where you watch a video at the same time as you work out, if that’s kind of your preference with workout delivery. So if you’re like, “well, thanks for the exercises, just tell me what to do,” we can tell you what to do with our prenatal fitness programs.
So as we are preparing for birth, it can also be helpful to understand how does your birth location manage the second stage of labor or how are they going to manage pushing. And so different birth locations kind of have a different approach to supporting pushing.
Some are super hands-off, so this is going to be more of like your midwife-run facilities, your freestanding birth centers, your home birth settings are just going to kind of let you do your thing until you kind of want or ask for more support. And then typically in a hospital setting, you may be more coached to what you’re doing.
But again, it can kind of vary from provider to provider and from hospital to hospital or birth location or birth location.
And so, it can be helpful to talk to your provider ahead of time, “hey, what can I expect when it comes to pushing? Like, what do you guys typically do? “
And so, what I typically see in a hospital setting is:
- You are probably going to be on your back or in the bed in some position, most likely on your back or slightly sidelying.
- They’re going to have you grab onto your legs and spread your knees as wide as you can,
- They’re going to tell you to curl around your baby
- Take a deep breath
- Then push like you’re having the biggest bowel movement of your life.
- And then you’ll push for three to four times, you’ll rest, and then you’ll do that again.
Your knees are going to be super wide. You’re curling around your baby, and you’re pushing like you’re having a big bowel movement. This works because babies will come out.
And so this is why this is still a coaching technique that is taught. Whether or not it’s the most effective technique is a whole other conversation that we’re going to have today with you guys. And so, the first thing is going to be:
We don't necessarily want to be forced into any pushing position
You should choose the pushing position that feels best for you. If that’s on your back, awesome. Lay down on your back. If it’s on your side, go on your side. If it’s in all fours, go in all fours. But the best pushing position is the one that you choose.
And so I’m not anti-supine pushing or being on your back while you’re pushing, because for me, with two home births, so there are unmedicated births, I still ended up kind of on my back, my side, because that was the position that I felt like I could relax the most into. And for other people, the position that feels best for them is different, and that’s okay.
So the best pushing position is the one that you want to be in. And so if that’s on your back, that’s totally fine. Some folks find that they can generate more power in that position, especially if they have an epidural. Other folks find that they feel better in a sidelyingor a more upright position. The first thing is no one should be forcing you into one specific position.
What if your medical team is not allowing you to push in the position you want to push in?
Just voicing it in a non-confrontational way that you would prefer to push in a different position. Is that something that the providers can support? And also letting it be known in prenatal visits, like, hey, this is the position that I would like to try during pushing. Is this something you can support? Like, “hey, I would like to push on my side, or I would like to push in hands and knees, or I would like to push standing. Are these positions that you can support?”
Because potentially, if your provider is like, “no, everyone will push on their back no matter what. That is the position that we deliver in because of X, Y and Z.” Maybe it is time to find a different provider, but if you’re already at the pushing phase, just saying like, “hey, this is the position that I would like to stay in to push” and having your birth partner.
And if you have a doula there, advocate for that position being like this is a position that they would like to stay in. Because if they just put their hands on you and move you to a different position, unless, again, there’s, like, an emergency where they need to maneuver you quickly because of baby’s heart rate or whatever, if they just put their hands on you and force you into a position that you’re not wanting to be in, that is assault.
That’s not something that someone is going to do or should do in a hospital. But just like voicing these again in prenatal visits is the best time to start kind of getting the feel of the waters of whether or not they’re going to be open to these types of positions. If someone’s like, “hey, I would like to push in this position, is that something you can support in the time of pushing?” And your doctor is like, “Absolutely not.” What are they going to do? Not deliver your baby and just stand there while you push on your side as your baby delivers? Like, no, they’re going to still catch your baby however uncomfortable it might be for them, they’re not going to just watch you deliver your baby by themselves. I feel like that goes against some oaths we’ve got, but I don’t know.
Usually as a doula, what I’ll do is I’ll just kind of ask out loud to my client, “what position do you want to push in?” And then I’ll look at the nurse or whoever is there to support us pushing, like, “can you help me get her in this position?” Or “can you support us in this position?” And then if someone says, “hey, I really need you to get on your back,” I’ll usually ask my client because at that point, you also might not care what position you’re in. You just want your baby out of your body. And if getting onto your back is the best way to do that, sometimes that’s the best choice for you.
And so usually at this point, I’ll look at my client, I’ll be like, “hey, are you comfortable in the position you’re in right now?” And if they say yes, I’ll say, “hey, she’s comfortable where she’s at, she’s not going to move.” And I just kind of say that without presenting an opportunity for more conversation. Because if that’s the position that you feel most comfortable in, that’s the position that you should stay in. And so ways that you kind of advocate for yourself with the pushing position that you want is, like Roxanne said, talk about it during your prenatal appointments, “hey, I would like to explore other positions. Are you supportive of that? Do you support me pushing in something besides on my back? I’m not opposed to being on my back, but I also am open to exploring other positions.”
If the first time that you’ve talked about it is when you show up at the hospital, have it in your birth plan, talk about it to your nurse, like when you’re in triage, when you make it to your room, “hey, when it comes to pushing, I would like to explore a few different positions and just kind of feel what works best for me in the moment. Can you support me in that and kind of get a good vibe for them?”
If you kind of wait until you’re actively pushing at that moment, you or your partner can say, “hey, I’m comfortable in this position right now and I would like to stay here.”
And that’s usually what I would say is like the best ways to kind of advocate for yourself while you, you are pushing. So coming back to the common position that you’re kind of put into when you’re pushing is you’re thrown on your back. Go into whatever position feels best for you. If that’s on your back, that’s fine. If you do want to be on your back, just try to create some space for your sacrum.
The hospital beds have this little cutout portion at the bottom you can kind of scoot your hips into. You can put like a pillow along one side of your back so you’re slightly tilted, maybe try to get into sidelying. We just want to try to create some space for that sacrum to be able to move.
How To Push During Labor: Knees In, Not Out (Opening the Pelvis for Pushing)!
As your baby is navigating through your pelvis, the next thing you’ll be coached to do is going to be having your knees spread super wide. And so external rotation of femurs or really wide knees opens the top of the pelvis. And so you might hear like, “oh, we need to create space for your baby.” Really what we’re doing is we’re making it easier for other people to see what’s going on.
And you can still see with internal rotation, as well. But really wide knees are opening more of the top of your pelvis. It’s creating space for your baby, but not at that point of labor. And so we want to really create more space at the bottom part of the pelvis. And this gets a little bit more complicated depending on how exactly high or low baby is within your pelvis.
If baby is at the pelvic outlet so they finish their rotation or the pubic bone, we want internal rotation on both sides. And this is typically when the baby is about to start crowning.
So you’re seeing baby’s head and baby’s head doesn’t go back in anymore when you’re pushing or in between pushes. If baby is still kind of like sucking back in between pushes or you can’t quite see baby’s head, we actually might be in lower mid pelvis area where we still want internal rotation, but it may be a little bit more one sided. And so if you’ve been pushing for a while and you’re seeing baby’s head just kind of like rocking to get underneath the pubic bone, so they’re like, kind of rotating, but then they suck back in. Trying to favor internal rotation a little bit more on one side could be more beneficial.
But just to make it simple, just focus on internal rotation with both legs. If you want to dive deeper into specific movements, join our childbirth education course where we break down pelvic mechanics, labor positions that open each pelvic level, and how to know when to move into each position.
But we want to open the lower half of the pelvis, and that is not with super wide knees, that’s with knees in, and ankles out. And you can do that in all sorts of positions. You can do it on your back side, laying all fours, standing.
Just think like, knees kind of caving in is going to create more space in your pelvic outlet. And if you don’t believe me, sit on your sitz bones. So those little bones on the bottom of your butt, put your hands on each one of them. And then I want you to bring your knees closer together and then move your ankles further apart. So you’re bringing your knees in, ankles out. So touch your knees together, and then your feet are moving apart from one another. And then feel kind of where those bones go. And then I want you to bring your feet together, but spread your knees apart now and pay attention to where those bones go.
And so when your knees are touching your ankles go out, you should feel those sitz bones move further outwards as well. So we’re creating more space laterally in the bottom of the pelvis. But when your knees are wide and your ankles are together, you should feel those bones move closer together. And so you can just feel that in your own body to know that internal rotation is going to create more space in the bottom part of our pelvis.
When you’re told to spread your knees super wide, this is not creating more space in the bottom of your pelvis. But you’re coached to do that because babies still come out. Babies will still come out with our knees super wide. Now, they might come out a little bit easier with our knees in.
Neutral Spine: Use the Diaphragm to Push
The next common coaching technique that you may be told is to curl around your baby. And the thought process behind this is if we curl around baby, we’re putting more abdominal compression, and this is going to help push the baby out.
Pushing is a pressure management activity. And what this means is we are increasing pressure within the abdominal cavity to push the baby out. And so we need to think about baby like a fluid. Fluids are going to go from places of high-pressure gradient to low-pressure gradient. We’re increasing pressure within the abdominal cavity to kind of push baby out into this lower pressure gradient, which is outside the best way that we can manage pressure within our abdominal cavity is in a neutral spine position, so the diaphragm stacked over the pelvis or rib cage stacked over the pelvis. And when we’re in this stacked position, we can better increase pressure within our abdominal cavity and make our pushes stronger than if we curled around our baby.
Think about it like when you’re pushing toothpaste from the top down, how much more effective and faster the flow is, as opposed to when you squeeze from the sides. It still comes out, but it’s not as much and it’s not as strong.
Our abdominal wall and our muscles are only so strong. We are so much stronger with pressure by increasing pressure within our abdominal cavity. And so if you ever watch like powerlifters or folks that are lifting like really heavy weights, they’re not clenching their abs in to stabilize their spine.
They’re breathing out. And they’re increasing the diameter of their torso to increase the pressure within it to stabilize their spine. And then they’re adding in some muscular force. So, they’re kind of combining the two to have a really strong stack for their spine within their torso. And we could do the same thing when we’re pushing. And this can make our pushes a lot more effective.
And so when you inhale, we’re going to inhale in that neutral spine position, so diaphragm stacked over the pelvis, and then we’re going to inhale to begin the push. And so this increase in pressure is going to increase pressure within the abdominal cavity and begin to push baby down. So you should already feel the perineum kind of bulging downwards. And then when we exhale, we can add on to it to push baby out with muscular force. So either holding your breath or exhaling to breathe out. So purple pushing, which is when you’re holding your breath, versus gentle pushing, where you’re blowing out at the same time. And so you can kind of choose whichever exhalation works best for you.
But this neutral spine position is going to help us manage pressure, and it’s going to make our pushes so much more effective than curling around our baby, which is going to make it a lot harder to really increase pressure within the abdominal cavity.
When we’re pushing, we do want to maintain a more neutral spine position. And if you ever watch someone push intuitively, you’ll see that they tend to come to a little bit more of a neutral position as well.
Breathing Techniques for Pushing
And now, when it comes to how we breathe, you’re typically told to take a big breath in and then hold your breath and bear down like you’re having the biggest bowel movement of your life. Or you’re told to take a deep breath like you’re going underwater, and then hold your breath as you bear down, however, you want to breathe while you push is the best technique if you want to hold your breath as you bear down. If you want to exhale, exhale as you push.
In the hospital settings, typically they’re not familiar with coaching gentle pushing and it’s harder to kind of teach it in the moment as well. And so if you don’t just get gentle pushing, you’re typically going to be encouraged to do more of like the purple pushing or holding your breath as you bear down because that’s really easy to teach to somebody in the moment.
And so with gentle pushing, the few things that I typically see that are like the issues are:
- The exhale is not long enough. So we’re taking really quick breaths. We want a six to eight second count exhalation.
- The pushes are not strong enough. So, we’re not just blowing air out, we are forcefully blowing air out as we bear down.
And so think like you’re blowing up a balloon. And so we want a long and a strong exhalation as we push for the gentle pushes. And so those are kind of the two things that I typically see with gentle pushing. But know that it is okay if you do want to hold your breath as you push as well.
And same thing, we want like a six to eight count as we push. And you could even do like a combination of both similar to pushing positions, the best breathing technique and the best pushing position is the one that you choose to do and you should be supported in whatever it is that you were trying to explore.
Practice Pushing: Use the Toilet
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When it comes to pushing, it can be helpful to kind of practice on the toilet as well. So, you can sit on the toilet whenever you’re having a bowel movement, find your neutral spine position, can even let the knees kind of cave in a little bit more. Take your big breath in, feel that perineum bulge down, and then exhale to bear down. And you can practice your gentle pushing here. And so, the toilet is like a really great place to kind of practice pushing. But again, whatever breathing technique you want to use, whatever pushing technique or pushing position that you want to do is going to be totally fine.
Pushing like you're pooping?? Maybe not.
Now the last tip that you’re told is to push like you’re having the biggest bowel movement of your life. And Roxanne, this was a cue that you used to give people.
Roxanne: Oh yeah, everyone push like you’re pooping because it’s like the whole, I mean, in our minds it’s like, oh, that’s something that everybody can relate to. Like push like your poop in and the muscles are pretty similar. So, this just kind of hits home to some people. That makes a lot of sense. I said it until 2019. I mean, that’s like four years of labor and delivery nursing. I would say push just like your pooping. And sometimes you can give like an internal cue so you could place your fingers inside of the vagina and give pressure and then they know like oh, push into that pressure. But most of the times, push like your pooping.
Until I gave birth, I had said push like your poop in, until I was actually pushing my own baby out. I was like, that’s a terrible cue because pooping does not feel the same as what I am doing currently. It is more like if you’ve ever had a tampon and then had the pleasure of pushing said tampon out, that is more similar to what is happening when you’re pushing. And in my brain during pushing, I was like, I should be telling people to push like you’re pushing a tampon out or a baby out, but like, vagina like having a reference point of what is happening in your body. And that’s why we say push like you’re pooping. Because you will remember like, oh, I know how to poop. This is what I do. But pushing out a tampon is actually using the muscles in that part of your body. You’re mostly relaxing all of those muscles so that the tampon just falls out or you’re directing that energy.
Yeah, same exact thing when you’re pushing a baby out. And my mind just like, blew as I’m like, this baby has been crowding for 45 minutes, but story for another day.
So, yeah, it’s not push like you’re pooping or having the biggest bowel movement. It might feel like you are pooping. It probably will feel like you are pooping at the same time. But it’s really like pushing something out of your vagina, which if you put your fingers in your vagina and you try to push your fingers out and then you think about that comparison between pooping, they’re similar. It’s a similar place, but it’s slightly different.
It’s a slightly different place of focus. And so when we shift our focus from our butt to our vagina, it can really make our pushes a lot more effective as well. And so think like you’re pushing a tampon out. Think like you’re pushing a menstrual cup out. If you are like, I don’t use any period products and I have never had that luxury. Just insert your clean fingers into your vagina and try to push your fingers out and then remember how that feels differently than pooping at the same time, that final cue of push like you’re pooping, I’m always like, I kind of but not quite the same.
And so if that cue works for you, awesome, go for it. If it’s not quite clicking for you, think like you’re pushing a baby out of your vagina and it’s a little bit different, I promise you it’s going to feel slightly differently.
And so the common things that you may be coached to do in a hospital setting will be to lay flat on your back, spread your knees super wide, take a deep breath in, curl around your baby, and then bear down like you’re having the biggest bowel moon of your life. And that is going to work for some people, like, your baby will still come out with all of those pushing cues.
There might be better cues out there and ultimately the one that clicks best for you is the best one to do so. The best pushing position, the one that you want to be in, the best breathing technique, the one that you want to breathe in, if you want to be a little bit more effective with it, finding a more upright pushing position could be beneficial. Or the one that you relax the most in. And so for me, being supine sideline was the one that I could relax most in because the fetal ejection reflex or that spontaneous pushing was like super overwhelming for me. And then for your breathing technique, whatever feels best for you is the best one to do so.
We should talk about the fetal ejection reflex, also known as vomiting out of your vagina.
And so for some folks she always uses this analogy for the fetal ejection reflex and I laugh every time. It’s accurate though, not for everybody, but I just feel like it’s a bit graphic but I feel like it’s accurate for what fetal ejection reflexes are like for me.
Now if you’re unmedicated, there will probably be a point where your body starts to spontaneously bear down and push. If you have an epidural, you might not notice it or you might not experience it unless you’re progressing really fast and then you might still notice it. But typically this is only going to be if you’re unmedicated.
And so what the fetal ejection reflex is, is towards the end of labor, near the end of transition, so maybe you’re anywhere from like eight to 10, your body will start to spontaneously push and it’s like this deep grunting bearing down uncontrollable sensation.
For some folks it’s like super strong and for other folks it’s like very subtle. I find the ones that are a little bit more subtle, baby is still kind of adjusting their position, and then once they adjust it’s like really strong from there.
And so when you have this fetal ejection reflex, sometimes what I’ll see is the nurse or the provider will want to check you to make sure that you’re 10 CM, depending on how long you’ve been doing it. There’s a chance that you might not quite be 10 CM yet. And so they might tell you to stop pushing or else you’re swell your cervix. Then you’re sitting there thinking like, “oh my God, my body is doing all of these things wrong. Like it shouldn’t be pushing right now. I don’t know why it’s pushing, I can’t stop it.”
And so then you start tensing and fighting and it becomes really scary. And just know that the likelihood of you swelling your cervix from the fetal ejection reflex is pretty low. Most likely not going to happen. This is just a normal part of your labor and so if you feel like you need to take a break from it, like it’s too overwhelming, or you do feel concerned about swelling, doing like a slight inversion.
So putting your hips a little bit higher than your head can be really helpful to just take some pressure off of the cervix or just go with it.
So if anyone tells you to stop pushing and you are spontaneously bearing down, vomiting out of your vagina cannot stop it: Don’t add to the pushes, but just let them happen and try to relax with them as best you can. If you do want to stop it, come into a little bit of an inversion, and that might take some pressure off.
But ultimately, the likelihood of you swelling your cervix is probably pretty low, but could be a good question to bring up to your provider. And so for me, with both of my home births, when I started bearing down, my midwife did not ask me if she can check me to make sure that I was 10 CM because she trusted that my body was doing it because it was ready to push.
Now, there are some times when you may start bearing down really early, and this is sometimes due to baby’s position. And so, if you’re less than 8, and you’re bearing down, then we do want to kind of address baby’s position.
Usually, I see it more when babies are OP or the back of their head is towards your spine, also known as, posterior or sunny side up, just based on kind of the pressure that’s happening. And so if you are bearing down really early, it could be helpful to do some of those interventions like inversions, to kind of relieve some of that pressure.
But if you are bearing down spontaneously, you’re over 8 CM, just don’t add to the pushes. Let them happen. You don’t need to try to stop them and know that your body is not doing anything wrong. Like, this is normal for you and it’s okay to do so.
The second stage of labor is definitely kind of scary for some folks. For me, it’s the most intense part of labor, I was almost like, afraid of it with Sophie’s birth. It was because I knew what the intensity was, and I was like, oh, man, but you’re at the end. And so it’s also really exciting and motivating because you know that you’re going to meet your baby soon, and so you don’t have to wonder how many more contractions you have to go through. You’re like, oh, finally, like, I’m here. But do know that sometimes if it’s your first time pushing, it might be a few hours, especially if your baby is kind of high. And so it can be helpful to let your baby be a little bit low before you start actively pushing with things.
And if you have a lot of concerns or fears about pushing, it can be helpful to talk to your provider about it to understand how they manage pushing. You can take childbirth education courses like ours that dive a lot deeper into different pushing techniques. Because if we understand what to do or what is happening, it can really take a lot of the fear away.
So if you understand why we are pooping and that literally nobody cares, it might take some of that fear away. If you understand what causes tears and some ways to try to mitigate it, it could help take some of that fear away. If you understand how tears are repaired and how it doesn’t always affect long-term function, it might take some of that fear away.
And so being more educated on what to expect from your provider, with your medical team, can be very helpful. In the moment, your body may just figure out exactly what to do. And I feel like that’s what my body did during pushing, and a lot of my patients have done that during pushing. It just clicks for them, and they know exactly what to do. But if that doesn’t happen for you, choosing a birth team, like whether it is your provider and the people that are in the room with you, your doula, family, or whoever choosing a birth team that is going to support you and help guide you if needed in a way that is aligned with what you’re wanting is so helpful.
Prepare for Your Birth with MamasteFit
If you want more support throughout your pregnancy, join our prenatal fitness programs and childbirth education courses where we dive a lot more into pushing in those courses. If you need more support after birth, join our postpartum fitness programs and education courses. If you’re a professional, we offer both birth worker and fitness trainer courses that you can learn from us and earn CEUs.