When push comes to shove

Directed pushing is the most commonly used approach during the second stage of labor (that’s from when the cervix is 10 cm dilated till when the baby is born). Most often the mother will be directed to hold her breath to the count of 10 and push. The goal is to repeat this “hold your breath while I count to 10” three times during each contraction until the baby is born.

Spontaneous pushing is when the mother is allowed to push (or not push) in whatever manner she feels she should. Most women make some noise when they push and are not holding their breath for more than a few seconds.

For over a decade there have been studies showing that spontaneous pushing is associated with better outcomes than directed pushing, and there are more than a few researchers calling for reform in this area.

A 2011 review of randomized trials of directed pushing (“Valsalva”) verses spontaneous pushing concluded:

“The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour…  spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.” (1)

What to know about pushing:

Holding your breath for more than a few seconds at a time is not helpful, and if directed pushing is continued for long periods of time it is detrimental to the baby (decreased blood flow to fetus and lower oxygen levels, associated with abnormal heart rate patterns and lower apgar scores at birth) and it is also detrimental to the mother (postpartum bladder and urinary troubles and more severe tearing are more likely with directed pushing).

There is no correlation with length of pushing and negative outcomes (for baby or mom) as long as the baby’s heart rate is being monitored. That means it is just fine to be in the pushing phase for two or three or four or five hours…; there is no time limit as long as that baby’s heart rate looks good. A long second stage is only disadvantageous if the mother is using a directed pushing technique and holding her breath.

What to do about it:

Push when you feel like pushing (and not before). You do not need to start pushing at 10 cm. The pushing sensation (Ferguson’s reflex) is more closely associated with station than with dilation, and most people feel it when the baby’s head is at +1 station.

Don’t be afraid to be vocal. It’s better to make noise when you push (or be exhaling or blowing air out) than to hold your breath.

If you have an epidural try to have the dose adjusted so that you have enough sensation for pushing: ideally you should feel an urge to push and you should be able to move your legs and the muscles in your lower body.

If you have an epidural that is blocking all physical sensation and you have no desire to have your dose lowered so that you feel the urge to push, delayed pushing or passive fetal descent is a better approach than directed pushing. Passive fetal descent means that you take a nap or watch a movie until the baby is near crowning. You let the uterus do the job of bringing the baby down, and then only push as the head and shoulders are born (as directed by the care provider).

Why in the world would anyone tell me to hold my breath while they counted to 10?

It is surprising that directed pushing has lingered as long as it has. Perhaps some quirks of human nature come into play: we are creatures of habit, and we are not as patient as we should be.

In easier births where the pushing phase is short directing pushing does not appear to significantly impact the birth. In more difficult births the blame is placed elsewhere (fetal distress, failure to progress, or Celphalopelvic Disproportion (CPD)) and the directed pushing is assumed to have helped the effort rather than to have caused additional problems.

And lastly, there is a seemingly logical premise behind directed pushing: the attending care provider believes that the shorter the second stage is, the better the outcome will be for the baby. So push! Push harder! Till your face turns purple! Let’s get that baby out!

If you find yourself surrounded by an enthusiastic group of cheerleaders at your delivery coaching you to hold your breath for a count of 10 while you push, remember:

You can ask to do spontaneous pushing or delayed pushing (passive fetal descent) instead.

Your care provider should be familiar with the terms. These approaches are becoming more common and the evidence supports them as a better option for you and your baby. (And in my opinion, they’re much more pleasant to experience!)


1. May 2011; Prins et al.; Effect of spontaneous pushing verses Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. Volume 118, issue 6, p 662-670
And since the night is late, I’ll paste my remaining references below, in no particular order. The information in the above bullets under “what to know” and “what to do about it” did all come from research papers published in reputable scientific journals, but I don’t have time now to do detailed footnotes.


*Feb 1993; Thomson. Pushing techniques in the second stage of labour. Journal of Advanced Nursing; Volume 18, Issue 2,
*Nov 1997. Petersen et al. Pushing Techniques During Labor: Issues and Controversies. Journal of Obstetric, Gynecologic, and Neonatal Nursing. Volume 26, Issue 6, p 719-726
*May 2007. Albers et al. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. Journal of Midwifery and Women’s Health. Volume 52, Issue 3, p 246-253
*June 2005. Simpson et al. Effects of Immediate Versus Delayed Pushing During Second-Stage Labor on Fetal Well-Being: A Randomized Clinical Trial. Nursing Research. Volume 54, Issue 3, p 149-157

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