Mechanics For Vaginal Delivery: Is There A Right Way To Push?

I recently gave birth to my 1st child and was blown away that no one actually prepared me for the 2nd stage of labor, aka pushing phase, 10 cm dilation to birth. My husband and I went to several classes to prepare us for our newborn. During these classes they discussed the stages of labor, what tools they could use during labor, reasons for a c-section, joys and challenges of pregnancy, and how to breathe during the first stage of labor to make it through contractions. When I actually went through my 2nd stage of labor, I realized no one ever discussed how to push and breathe during this phase.

You might ask, why should I read this article? What does she know that I can’t just ask my friend who has kids? It might help if I give you a little background about myself. I am a Doctor of Physical Therapy with more than a decade of clinical experience. In 2016, I began specializing in conditions related to pelvic floor dysfunction, such as urinary incontinence, prolapse, and pregnancy related pain. So you could say I know a thing or two about pregnancy and women's health.

During a treatment session, I will evaluate the strength of the diaphragm, muscle tension, and function of the pelvic floor. Knowing diaphragm mechanics and how to move the pelvic floor correctly definitely helped me during labor to push out my son in just 28 minutes.

Knowing how to use your diaphragm and pelvic floor are really important in 2nd stage labor. However they aren't the only thing you need to know. I want to talk about the differences of breath holding, exhale pushing, and sounding during your 2nd stage of labor.  

Breath holding is the process I followed during my 2nd phase. There were multiple reasons why it was appropriate for my labor. One reason could be if you have an epidural. With an epidural, you have decreased sensation of your pelvic floor allowing it hard to notice when you are dropping. By taking a diaphragmatic breath in, your intra-abdominal pressure increases which pushes on your pelvic floor and causes your pelvic floor to drop. Imagine using a French press: this is how the diaphragm works.

Another major reason breath holding could be beneficial is if there are any complications with the mother or baby, where you need to speed up the delivery process. In my case, my son’s heart rate was dropping with every contraction, so we needed him out as fast as possible! You have a greater chance of tearing your perineum with breath holding due to a quicker stretch. According to Traub, the perineum has the ability to stretch 250% if given the opportunity.

Another way you could be coached in is exhale pushing or sounding out. This is also called the “open glottis” technique. You would still take your big diaphragmatic breath inward; but instead of holding your breath, you would breathe out, or make sounds like “aww, oooh”. This technique does allow for a slower descent of the fetal head causing less trauma to the pelvic structures (Flynn et al). If my son’s heart rate was not decreasing I would have applied the open glottis technique.  

More studies are leaning towards open glottis techniques but it just all depends on your own personal situation and the status of your baby. There are other techniques to help aide in a vaginal delivery. If you have an epidural you can use a peanut ball to lay on your side, or you can use the support of the bed and actually move into a quadruped position.  If you are laboring on your back with or without epidural you can grab hold of your thighs above your knees and let your knees fall inward keeping space between your knees. This causes your hips to go into internal rotation, opening your sit bones to allow more room for the baby.

If you do not have an epidural there are several positions you can go into allowing for your diaphragm to relax and opening more space for the baby into your pelvis. A common one is a deep squat with some support under your heels or holding onto a strap above head and falling into a half squat. Prior to delivery you want to practice these positions and see which one might work for you.

The biggest thing to do before you deliver is to have a discussion with your OBGYN and midwife to discuss your plan. Remember though, your plan could change depending on what is happening during your 2nd stage. You want to learn how to drop your pelvic floor, drop and relax your diaphragm, and know the difference between a closed and open glottis technique. Also make sure you have a good support team on your delivery day (spouse, family member, friend, doula, etc.).

Disclaimer:  The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.

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  1. Traub C.  Pushing Power (2020, January 22).  Pushing Power. Retrieved from
  2. When and How to Push:  Providing the Most Current Information About Second-Stage Labor to Women During Childbirth Education. Simpson, Kathleen. The Journal of Perinatal Education. 2006; 15(4): 6-9.
  3. Effects of immediate versus delayed pushing during second-state labor on fetal-well being:  a randomized clinical trial. Simpson, K., James, D. Nursing Research. May-June 2005; 54(3):  149-57.
  4. The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. Park, H., Han, D. J. Phys. Ther. Sci. 2015; 27: 2113-2115.
  5. How can second-stage management prevent perineal trauma? Critical review. P. Flynn, J. Franiek, P. Janssen, W.J. Hannah adn Mc.C. Klein. Can Fam Phys, 1997; 43: 73-84.
  6. Effects of pushing techniques during the second stage of labor: A randomized controlled trial. Koyucu, R., Demirci, N. Taiwanese Journal of Obstetrics & Gynecology. 2017, 56: 606-612.

Dr. Ashlea Lytle

VP Colorado Region | Physical Therapist | Doctor of Physical Therapy
Ashlea Lytle is a Doctor of Physical Therapy (DPT) who has been practicing for over a decade in the Denver area. She specializes in sports, general orthopedics, and pelvic health for adults and kids. She splits her time at Activcore in Castle Rock, CO (located inside Optimal Health Chiropractic) and at Activcore in Greenwood Village, CO (located inside Pilates Denver).
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