Positions and Breathing Techniques for Pushing
Pushing is part of the second stage of labor and possibly the most strenuous part of the laboring process. It may also feel like the part of labor where you are most active and involved. When it comes time to push, you may feel relief, fear, doubt, excitement, or any other number of emotions. Just like with the other stages of labor, you have options when it comes to your positioning and breathing techniques during this phase, and oftentimes utilizing different techniques can increase your comfort, make pushing more effective, and decrease the risk for severe perineal tearing. Understanding your options for the pushing phase can help you anticipate this moment with confidence.
Pushing Positions
You have most likely seen - either in real life or depicted in media - a woman lying on her back to give birth. This position, technically known as the lithotomy position, is common especially in a hospital birth setting. However, just because it’s common doesn’t mean it’s “best” or “right” for everyone, and in fact, research shows lithotomy position may in fact be harmful for some, and evidence exists in favor of upright positions for labor and birth. Some upright positions you might try during pushing are standing, squatting, lunging, kneeling, or sitting on the toilet or a birth stool.
If you’re feeling tired and don’t want to be upright, or cannot stand due to having an epidural, other positions you can try are hands-and-knees or side-lying. These allow flexibility in your sacrum when you do not have full range of motion (due to epidural) OR if you’re just simply feeling like you need or want to lie down. If you do have an epidural, ideally you should still have some control of movement, so you should be able to move into different positions (including squatting) within the hospital bed, with the help of your care staff and support team.
The best pushing position is the one that feels right to you in the moment. What’s most important is that your care provider and support team respects your wishes, supports your decision-making and does not try to force you into doing something you don’t want to do. You also may start out squatting and end up on hands-and-knees, or start out standing and end lying down. Knowing your options, advocating for yourself and having a support team and doula there to help facilitate the experience you want, will help you feel confident in your choice.
It’s always a good idea to discuss your birth preferences with your care provider and hear their feedback on the things that are important to you. These discussions may encourage you, or alert you to any red flags that may indicate your provider may pushback against some of your wishes. If you’d like to discuss pushing with your care provider beforehand to understand their preferences and procedures, here are some questions you can ask:
I would like to push and deliver my baby in a different position other than on my back - how can or will you accommodate for this?
Is there a position you will not support for pushing or delivery? If so, what position and why?
What tools are available to me at the hospital that could aid in positioning (such as a birth stool or a squat bar)?
Breathing Techniques
In the same context as the woman lying on her back, you might have also seen her her holding her breath, squeezing her eyes closed, or perhaps letting out an exasperated scream while those around her are shouting “PUSH!”. As mentioned above, just as there is more than one position to give birth, there is more than one way to breathe during pushing and delivery of your baby.
Holding your breath for a period of time while pushing is just one technique, sometimes referred to as “purple pushing” or “closed glottis pushing”. When you use this technique, you take a deep breath and hold it while bearing down and pushing. If you are being coached through this process, which is common in a hospital setting, you may be encouraged to hold a breath for a 10 second count, take a deep breath, and hold again. You may do this up to three times during a contraction. Closed glottis pushing can be tiring and strenuous, but you may find that you push more powerfully or more effectively with this type of breathing technique.
Open glottis pushing is the opposite of closed glottis: in this technique, instead of holding your breath, you take a deep breath and exhale as you bear down and push. This technique is less strenuous and typically easier when you can feel your contractions and your body’s natural urge to push. Open glottis pushing is a more gentle option for pushing that you may find more effective than other techniques.
One note about epidurals: in a hospital setting, your nurse or care provider will typically default to coaching you through the closed glottis pushing method if you have an epidural. Although you may still feel rectal pressure with contractions, you may not feel the urge to push or the sensation in your pelvic floor as you are bearing down, making it hard for open glottis pushing to be effective. However, whether you plan on getting an epidural or not, if you plan on utilizing open glottis pushing, it’s best to practice beforehand when you are having a bowel movement. People often say “push like it’s the biggest poop of your life” - but next time you’re in the bathroom, take note of how you actually poop, and the sensation of breathing out while also bearing down. That is the same sensation and muscle coordination that will help open glottis pushing be effective for you.
If you’d like to discuss breathing techniques while pushing with your healthcare provider beforehand, here are some questions you can ask:
I would like to try different breathing techniques during pushing, how will you help coach or guide me through the technique of my choice?
At what point do you deem pushing “ineffective”? What circumstances would indicate that my chosen technique isn’t working and we need to switch to something else for the health and safety of myself and/or my baby?
As with positioning, the best breathing technique for you is the one you choose in the moment. You may find that you wanted to do open glottis pushing but find that closed glottis is more effective for you - or vice versa. You may find that you do both types at different times during your pushing phase. It is important that you communicate your wishes ahead of time to your providers and support team so they can best assist you choose a technique, or encourage you in whichever technique you wish to use. Having the support and encouragement from your entire care and support team during the pushing phase and all its complexity can help facilitate a positive experience, and one where you feel heard, respected and confident in your decision-making.