The second stage of labor begins once the cervix is fully dilated to 10 centimeters and culminates in the birth of the baby. This active pushing phase requires collaboration between the birthing person’s physical effort and the guidance of the medical team. Understanding how to work with the body’s natural impulses can make the process more efficient and less taxing. Effective pushing involves strategic timing, proper technique, and optimizing body position to facilitate the baby’s passage through the birth canal.
Recognizing the Urge and Timing
The moment to begin actively pushing is guided by two main approaches: the physiological urge and medical direction. The physiological approach encourages waiting until a strong, involuntary urge to push is felt, often described as intense rectal pressure. This approach respects the body’s natural timing and is associated with a reduced risk of perineal trauma and less maternal fatigue.
When the cervix reaches full dilation, “laboring down” or passive descent may occur, especially if an epidural is in place and the spontaneous urge is absent. During this phase, the uterus continues to contract, allowing the baby to descend lower into the pelvis without active pushing effort. Delaying active pushing until the baby is visibly lower shortens the overall active pushing time and conserves energy.
Directed or coached pushing involves the medical team instructing the person to push, typically at the peak of each contraction, even if the natural urge is absent. This method is often employed when an epidural has dulled sensation or when delivery needs to be expedited for medical reasons. Directed pushing frequently uses a sustained breath-holding technique, contrasting with the shorter, instinctual pushes of the spontaneous method.
Mechanics of Effective Pushing
The physical technique centers on engaging the correct muscles and using an effective breathing pattern. The goal is to use the abdominal muscles to create downward pressure, similar to a strong bowel movement, while consciously relaxing the pelvic floor. Pushing into the face or throat should be avoided, as this increases pressure in the head and neck without efficiently directing force toward the pelvis.
There are two primary breathing techniques: open-glottis and closed-glottis pushing. Open-glottis, or physiological pushing, involves exhaling or making noise while bearing down, keeping the throat open. This gentler method reduces pressure changes associated with breath-holding, potentially leading to less maternal fatigue and better oxygenation.
Closed-glottis pushing, also known as the Valsalva maneuver, requires taking a deep breath and holding it while pushing for up to ten seconds. While this technique generates significant downward force, it may increase the risk of pelvic floor injury and reduce oxygen supply to the baby. Modern practice increasingly favors open-glottis pushing, allowing the birthing person to follow a natural rhythm of several shorter pushes per contraction.
The rhythm of pushing should align with the uterine contractions, which provide the primary expulsive force. Pushing efforts are most effective during the peak of a contraction and should be followed by rest and breathing in the interval between contractions. Resting when needed conserves strength.
Optimizing Positions for Delivery
The position chosen for pushing influences pelvic capacity and effort efficiency. The traditional semi-reclined position, while convenient for medical staff, may limit sacrum mobility and work against gravity. Upright and forward-leaning positions are often more beneficial because they utilize gravity to aid the baby’s descent.
Squatting is mechanically advantageous, as it can increase the pelvic outlet diameter by up to 10 to 15 percent, creating maximum space for the baby. Supported standing or leaning forward also uses gravity effectively and can help relieve back pain. These positions encourage the baby to navigate the curves of the birth canal more easily.
Positions that offer support and rest, such as side-lying, help conserve energy or slow a rapid descent. When side-lying, a peanut ball or pillow between the knees can open the pelvis asymmetrically, assisting in fetal rotation. The hands-and-knees position reduces pressure on the perineum, potentially lowering the risk of tearing, and is useful if the baby needs to rotate.
Changing positions frequently throughout the second stage is beneficial, as different angles help the baby navigate the pelvis effectively. Positional adjustments allow the pelvis to subtly shift, which can sometimes resolve a temporary stall in progress. The most effective position is the one that feels most comfortable and instinctual.