Pushing a baby out is a coordinated effort between your body’s own contractions and the force you create with your abdominal muscles. Your uterus does a significant portion of the work on its own, and your pushing adds the extra pressure needed to move your baby through the birth canal. For first-time mothers, the pushing stage typically takes up to 3 hours. For those who have given birth before, it’s usually under 2 hours.
What Your Body Does Automatically
Before you ever start actively pushing, your baby is already making a series of movements through your pelvis. The baby’s head enters the pelvis sideways, tucks its chin to present the smallest possible diameter, then gradually rotates to face your spine. As the head clears the pubic bone, it tips backward (extending), and then the shoulders rotate to follow. These movements happen in response to the shape of your pelvis and the pressure of contractions. You don’t need to think about any of them.
When your cervix is fully dilated, the pressure of your baby’s head against your pelvic floor triggers a powerful reflex called the Ferguson reflex. This creates a surge of oxytocin that intensifies your contractions and produces an involuntary, overwhelming urge to bear down. Many women describe it as feeling like they need to have a bowel movement. That sensation is your signal that pushing can begin.
Spontaneous vs. Directed Pushing
There are two main approaches to pushing: following your body’s instincts (spontaneous pushing) or being coached through each contraction by a provider (directed pushing). If you don’t have an epidural, spontaneous pushing is generally recommended. A meta-analysis of ten studies involving over 1,500 women found that spontaneous pushing reduced the rate of cesarean sections by more than half and cut the rate of episiotomy (a surgical cut to widen the vaginal opening) compared to directed pushing, with no difference in how long the pushing stage lasted or in newborn outcomes.
With spontaneous pushing, you bear down when your body tells you to, for as long as feels right, and rest between urges. Some contractions you might push once, others two or three times. Directed pushing, by contrast, typically involves a provider counting to ten while you hold your breath and push as hard as you can, repeating this several times per contraction. This coached approach can be useful if you can’t feel contractions well due to an epidural, but it isn’t necessarily better for outcomes.
How to Breathe While Pushing
The biggest practical choice you’ll make during pushing is how you breathe. The traditional approach, called the Valsalva maneuver, involves taking a deep breath, holding it, and bearing down with maximum effort for about ten seconds. While common, this technique has real downsides. Holding your breath raises the pressure in your abdomen above the level of blood flow to the uterus, which can reduce oxygen delivery to your baby. Studies have found increased stress markers in both mothers and babies when this method is used for prolonged periods.
The alternative is pushing with an open glottis, meaning you exhale slowly (or vocalize) while bearing down. Think of it as breathing out through the effort rather than locking everything up. When you push this way, blood flow to the placenta is better maintained, and oxygen levels in the umbilical cord are measurably higher. One study found that women who used a slow exhale while pushing, rather than breath-holding, reduced the length of the pushing stage by up to 50 minutes. This technique also puts less strain on the pelvic floor and perineum.
A practical approach: take a deep breath as the contraction builds, then exhale steadily through pursed lips or with a low moan as you direct your effort downward. Aim for 4 to 5 seconds of sustained pushing force per exhale, then take another breath and push again while the contraction is still strong.
Positions That Help
The position you push in changes the physical space your baby has to move through. Squatting increases the diameter of your pelvic outlet by roughly 20%. Hands-and-knees (all fours) creates the widest pelvic opening of any position. Both are significantly more effective at opening the pelvis than lying flat on your back, which is the most common hospital position but one of the least helpful from a mechanical standpoint.
Upright positions also recruit gravity. When you’re squatting, kneeling, or standing, the weight of your baby adds to the downward force of each push. Side-lying is another good option, especially if you’re tired or have an epidural that limits your mobility. It keeps pressure off your tailbone and allows the pelvis to open more freely than lying on your back does. Many people find that switching positions during the pushing stage helps when progress stalls.
Pushing With an Epidural
If you have an epidural, you may not feel the Ferguson reflex clearly, which makes it harder to know when and how to push. One strategy is “laboring down,” where you wait after full dilation and let contractions move the baby deeper into the pelvis before you start actively pushing. The World Health Organization recommends this approach for women with epidurals when time and monitoring allow it.
However, a large randomized trial of over 2,400 first-time mothers with epidurals found no difference in vaginal delivery rates between immediate pushing and waiting 60 minutes. The immediate group had a shorter overall second stage (about 102 minutes versus 134 minutes) and a lower rate of postpartum hemorrhage. The delayed group spent less time actively pushing (75 versus 84 minutes) but had a longer total process. Neither approach was clearly superior for the baby. If you have an epidural, the decision to wait or push right away can reasonably come down to your preference and how you’re feeling.
What Happens at Crowning
Crowning is the moment when the widest part of your baby’s head stays visible at the vaginal opening between contractions, no longer slipping back. It produces an intense stretching and burning sensation often called the “ring of fire.” This is the point where slowing down matters most. Pushing too forcefully through crowning increases the risk of tearing.
When you feel that burning stretch, try to stop pushing hard and instead use small, gentle breaths, almost panting. Let the contraction ease the baby’s head out rather than forcing it. Your provider may ask you to blow out short breaths or make a “horse lips” sound to keep you from bearing down. This controlled delivery of the head gives your tissue time to stretch gradually.
Protecting Your Perineum
Warm compresses applied to the perineum (the tissue between the vagina and rectum) during pushing significantly reduce tearing. A meta-analysis of studies involving first-time mothers found that warm compresses reduced second-degree tears by 60% and third- or fourth-degree tears by 66%. They also reduced the likelihood of needing an episiotomy by about 31%. The compresses are typically warm cloths held against the perineum at around 38 to 44°C (100 to 111°F), applied during contractions or continuously through the pushing stage.
You can ask your birth team in advance to use warm compresses once you begin pushing. Some providers apply them routinely, while others need to be asked. Prenatal perineal massage in the weeks before birth is another technique that may help prepare the tissue for stretching, though the strongest evidence for reducing serious tears during delivery itself comes from warm compresses applied in the moment.
Where to Direct Your Effort
The most common mistake during pushing is directing force upward into the chest or face rather than downward into the pelvis. If you’re turning red in the face, clenching your jaw, or feeling pressure in your head, the effort is going to the wrong place. Think about pushing as though you’re having a bowel movement. Relax your face, jaw, and shoulders. Focus the pressure low and deep, into your bottom.
Curling forward slightly, tucking your chin toward your chest, and pulling your knees back (if you’re on your back or semi-reclined) helps angle the force in the right direction. In upright or hands-and-knees positions, the alignment happens more naturally. Between contractions, let your whole body go limp. Rest completely. Conserving energy between pushes is just as important as the pushes themselves, especially in a long second stage.