How to Push

Not sure what you’re doing? You are not alone.

When I ask moms what they wish they knew during labor and delivery, a common response had to do with effective pushing. If you felt like you had no idea what you were doing, you’re not alone. I had no idea what I was doing either.

I delivered my first child (vaginally) before I was a pelvic floor PT. So I’m right there with you. I pushed like a mad woman (3, maybe 4 contractions worth). I had a grade 2, almost grade 3 tear, despite Olivia only being 6 pounds 15 ounces.

I didn’t know how to push. I did what they told me to do. I held my breath, beared down, and pushed with everything I had. This is called purple pushing and increases the risk for perineal trauma/tearing. I didn’t allow my pelvic floor relax and open, because I DIDN’T KNOW.

Why it matters

How you push impacts your risk for perineal tearing/trauma, risk of needing instruments to assist delivery (forceps, vacuum), and even risk of c-section due to lack of progress. Emergency c-sections are VERY different. That has nothing to do with how you were pushing. That’s where it becomes unsafe to continue and the safety of mom and baby are #1 priority. We have plans and sometimes they don’t work out. That’s what happened with my second son (he was an emergency c-section).

Your positioning also plays a large factor in how effective your pushing is. On your back is pretty typical, but may be the LEAST effective position to push in. Your pelvic bones can’t move and you’re not utilizing gravity to your advantage.

If you were previously instructed in ineffective pushing, it is important to remember that your midwife/OB/labor and delivery team has the safety of mom and baby as their #1 priority. Not necessarily your pelvic floor. But the more educated you are on your options going into a delivery, the better. There is no one position that is the “right” position to push in.

Positions…variety is your friend

Technically, the blog is about pushing, but I’m going to include various laboring positions because it really is kind of a package deal. You spend much more time in labor than you do pushing. So….bonus content… laboring positions:

Labor positions (with epidural)

On back
- pillow under one hip (putting you slightly on your side)
- legs on peanut ball (in butterfly position)
- ball under just one knee
Laying on your side
- Pillow between knees
- Peanut ball between knee (hips in neutral)
- Peanut ball between feet (gets hips into rotation)
- Bottom leg straight with top leg draped over peanut ball
Side of the bed support by partner or ball

Labor positions (without epidural)

All of the above plus…
Birthing ball
Hands and knees
Kneeling/standing lunge
Shower
Birthing tub
sitting backward on the toilet
Walking (ask if your facility can do intermittent or portable monitoring)

Ideally, you want to change positions every 30 minutes to help progress labor. The nurses and medical team are your best friends during this process. These departments typically have all sorts of fun toys to try different positions. Experiment, ask if the nurses have any recommendations, and let them help you get into different positions.

Pushing positions

If you need to be on your back, you can place a towel roll or IV bags underneath your sit bones to allow your sacrum (bone at the base of your spine/pelvis) the space to move and fit baby through the birth canal.
Laying on your side
- Lowest rate of perineal tearing
- Partner, nurse, or you can hold your leg up
- Get your ankle higher than your knee to open the pelvic outlet (bony part of the pelvis near the exit)
Squatting
- Squat bar
- Birthing tub
- Birthing chair/throne
Quadruped/Hands and knees
- Bed flat: Hands and knees with bottom at end of bed
- Bed angled like recliner: Backward facing with trunk supported on back of bed
Tub/shower

It’s a common misconception that the only option you have for pushing is on your back if you’ve had an epidural. You can ask for your epidural to be turned down so you can move more, have partner/staff help you get into positions and then support yourself with partner/pillows/balls/etc.

Ideally the strength of contractions from your uterus and the fetal ejection reflex will push the baby out while your pelvic floor relaxes and gets out of the way. This relaxation is best to be practiced before you’re actively trying to push. **hint hint pelvic floor therapy visits**

Avoid “purple pushing”: This is where you are coached to hold your breath and push for 10 seconds. If you hold your breath and feel like your eye balls are going to pop out from pushing so hard, you are likely closing off your pelvic floor while your uterus is trying to push baby out. This tug of war can be responsible for prolonged second/pushing phase of labor and perineal tearing.

Labor down if you are able. This is where you are fully dilated, but wait 20-30 minutes before pushing to allow your uterus to help baby descend into the birth canal.

Spontaneous pushing. Push when you feel the urge. Listen to your body.

BREATHE! Not only does this help you and baby get oxygen, it also decreases the strain on your pelvic floor.

Perineal massage or warm compress on your perineum has been shown to reduce risk of tearing.

Delay when crowning/ring of fire. If you push really hard right when baby is crowning, this can lead to increased tearing. Hold for one contraction to allow baby’s head to stretch your tissue. On the next contraction push.

The unknown…

Trust the professionals. Your labor and delivery nurses, midwives, and OB’s have TONS of experience delivering babies. They know when things are progressing normally and when things are at risk for going south. We can have every plan in place, but some times things just happen. At the end of the day, everybody’s goal is to get baby out safely and to keep mom safe.

Sometimes you NEED a c-section. Sometimes they NEED to use forceps/vacuum. Sometimes you NEED forceful pushing to get baby out as fast as possible. Maternal mortality is a very really thing. The United States has the highest maternal mortality rate out of any developed country. Which is beyond ridiculous.

Also, full confession, I have never been responsible for delivering a baby. I have ZERO knowledge of what all goes into the medical side of bringing a new life into this world. This info is only being discussed so you have a little knowledge going into the main event. It is up to you to do your homework ahead of time and research different pushing positions and techniques. Look into birthing coaches or doulas. Don’t wait until the day of the big event to learn a new skill.

Labor and delivery prep

A pelvic floor therapist can help you learn how to push effectively. At Mid-Missouri Pelvic Health, we offer labor and delivery prep sessions to go over

info on how to relax your pelvic floor
labor and pushing positions
how to do perineal massage
home stretches for labor prep
education on the stages of labor
info for the early post-partum stage (pooping, body mechanics with baby, scar massage, etc.)

If you are experiencing any pregnancy aches and pain or pelvic floor issues (pooping, peeing, sex, etc.), please see a pelvic floor therapist as soon as possible.

If you would like to schedule a labor and delivery prep visit, we recommend 3 (28-30 weeks, 33-34 weeks, and 36-37 weeks). Click here to get scheduled.

How to Push