How to push a baby out
Today on the blog we are discussing pushing strategies!
There are 2 types of pushing strategies used during the second stage of labor, Closed or Open glottis and both can either be coached or occur spontaneously.
Closed glottis pushing, also called Valsalva pushing¹, utilizes high abdominal pressure and diaphragm descent to direct pressure downward on the uterus and help mobilize the descending fetus by compression of the top of the uterus (called the fundus). This occurs through holding the breath after exhalation and pushing downward. Historically, closed glottis pushing was popularized in the 1950s to help accelerate the second stage of labor and avoid the need for forceps delivery that was popular at the time.⁵
Open glottis pushing, also called “slow exhalation through pursed lips”¹ involves a focus on the abdominal muscles contracting, specifically the transverse abdominis and obliques, by compressing the uterus on both sides to allow progressive descent of the fetus. In contrast to closed glottis, the diaphragm rises and there is no breath holding.
What are the pros and cons of each method of pushing?
Currently scientific data does not provide conclusive data on what type of pushing should be recommended during second stage labor ¹,²,⁴ as there is a lack of depth in the research comparing these two strategies and of those conducted there are smaller sized groups performing open-glottis pushing compared to closed glottis.Mothers’ satisfaction and childbirth experience were found to be similar for both modes of pushing.⁴ One study by Barasinski, Debost-Legrand & Vendittelli in 2020, found that the effectiveness of type of directed pushing, particularly in units with a high-rate epidural analgesia, did not appear to differ between open and closed glottis groups and they concluded that women should be provided and have professionals trained in both strategies so that they can adequately provide women with support during birth.2
Open Glottis Pros
It is speculated that this pushing method may help preserve adequate placental perfusion, may be less likely to impair fetal heart rate (FHR) and reduce the need for operative vaginal delivery.⁴
One large study by Froeliger et al. in 2024, comparing open versus closed glottis pushing did find that pushing with an open-glottis method was associated with lower risk of operative vaginal delivery but only among women who’d already had children (parous) and most of which had used epidural analgesia.⁴
Open Glottis Con
Could potentially cause longer mean second stage labor ³,⁵ and have less expulsive power.¹
Closed Glottis Con
Possible changes in fetomaternal circulation, impacting fetal oxygenation and could theoretically promote the onset of hypoxia and fetal acidosis.¹
Potentially harmful impact on pelvic floor function via increased abdominal pressure/pushing of organs downward and potentially promote factors causing prolapse and possible urinary incontinence.¹
There may also be the need for stronger expulsive efforts to expel the fetus in response to a myotatic reflex at the perineum that happens when the muscle contracts in response to being stretched.¹
If long second stage, this method can be exhausting and expose the fetal head to unnecessary compression as well as possible immediate and long-term pelvic floor injury.³
Closed Glottis Pro
It is hypothesized that forced Valsalva may be a valuable technique in labors where descent has slowed or ceased.3
What are our thoughts at Women in Motion …
First time moms, delivering in a hospital setting, have an average pushing stage of labor of 3 hours with an epidural and 2 hours without an epidural. If you think of any form of endurance exercise lasting 1-3 hours we can all imagine how that athlete is using different breathing styles through the event. Birth is the same! Our goal is for our patient’s and clients to understand how to properly use both pushing strategies, and if coaching or direction is needed from their birth providers that they feel confident in how to push properly.
Trusting your birth team, is essential.
At Women in Motion we have created various resources to educate you on pushing styles.
Local Parents can come in for a one-on-one push prep session where we go over pushing position modifications based on orthopedic aches or pains or preference and provide hands on feedback to ensure the pelvic floor muscles know to stay relaxed during the pushing stage of labor. Just like it might feel seem odd to poop laying down, we all have different ideas of how we imagine bringing our babies into the world. So practicing these options with your partner can be so valuable. Having options is key.
We also have our Pregnancy Prep class that focuses on
· Various labor and delivery positions both for a medicated and unmedicated birth
· Ways to reduce the risk of perineal tearing, pelvic floor muscle trauma and various other orthopedic and nerve injuries
· How to relax your pelvic floor muscles to minimize the muscular resistance (I call this your baby door)
· Both open and closed glottis pushing strategies !