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The second stage of labor begins when the cervix is dilated to 10 centimeters and ends with the birth of your baby. The baby is expelled by the combined forces of uterine contractions and intra-abdominal pressure.

Initially, at the time of complete dilation, you may or may not feel the urge to push. You will be instructed about when it is appropriate to begin pushing.

You will push only during contractions. While pushing with your abdominal muscles, there are three important aspects to consider: your position, your breathing, and relaxing your perineum.

Women are sometimes surprised to learn that pushing a first baby out may take up to two or more hours, depending on the circumstances. The second and subsequent births usually require shorter pushing time.

Pushing Positions
The positions in which you push are the most important part of the pushing technique, as certain positions may better facilitate or actually slow the progress of the second stage of labor. Whatever position you choose, your back should be kept rounded or in a curved-back posture as you push.

Semi-Reclining Position
This position is generally comfortable and easily assumed. Your knees are flexed and relaxed apart while your body is maintained in a C-curve position with back support. Your hands may hold the coach’s hands, side rails, or your own legs. This position is not good when you have back pain.

Squatting Position
Squat while being supported in front or back, by the back of the bed, a chair or your coach. Since squatting may be tiring, many women find it relaxing to sit, stand, or kneel between contractions. Squatting is a very favorable pushing position because the baby’s descent is assisted by the natural force of gravity, and the pelvic opening is at its widest diameter. Keep feet as flat as possible.

Kneeling Position
Kneel on the bed or a pillow while being supported in front by the back of the bed, a chair, or the coach. Many women find this position to be an easier, more comfortable position than squatting, and they still receive the benefit of the natural force of gravity and a wide pelvic opening.

Hands and Knees Position
Assume a position on your hands and knees with support as needed. Resting your head on the coach and placing a pillow under your knees may give you greater comfort. This is a particularly useful position when you have back pain.

Standing Position
Stand with front or back support. The baby’s descent is assisted by the natural force of gravity in this position.

Sitting on the Edge of the Bed or a Chair
Sit on the edge of the bed or a chair with support as needed. Gravity will assist the baby’s descent in this position.

Side-Lying Position
Lie on your side with your knees drawn up in a comfortable position. The top leg is usually supported by the coach. This is a very beneficial position as it allows for maximum blood flow to the uterus and provides greater comfort for women experiencing back labor pain. This position is also advantageous for a baby in the posterior position as it may facilitate rotation to an anterior position.

Supine Lithotomy Position
This is the traditional position assumed in the delivery room. Your legs will be supported by stirrups, and your body may be supported in the C-curve position by the coach, a bean bag or pillows. Using these back support aids will help prevent compression of the large blood vessels from the heart. You can hold on to the hand grips on the delivery table.

Breathing for Birth

Pushing Pattern

1. To begin a contraction, take one or two cleansing breaths to allow the contraction to begin to intensify.
2. Inhale a third breath, hold, and push. (See the two pushing methods in the “Pushing Methods” list.)
3. When you need air, take a quick “catch breath” (exhale quickly, inhale a new breath), hold, and push.
4. Repeat this pattern until the contraction subsides.
5. To end a contraction, take two cleansing breaths, then totally relax. Pushing is hard work!

Pushing Methods

1. Strong pushing is done by holding your breath while simultaneously bearing down with your abdominal muscles. Your glottis is closed using this method, so there is no release of air, and therefore no sounds are made.
2. Gentle pushing is done by slowly exhaling your breath under pressure while simultaneously bearing down with your abdominal muscles. Your glottis is opened or partially opened using this method, so air is released and sounds such as grunting, moaning, or groaning are often made. Exhalation of your breath also can be done through pursed lips.

The following strategies may be helpful as you push:

• Pay attention to your contraction; your pushing effort should be as long and strong as the power of the contraction dictates
• Prolonged breath-holding over an extended period of time is physiologically undesirable as it increases the chance of maternal exhaustion as well as causing alteration in your blood pressure, which may result in oxygen deprivation in your baby; therefore, it is advisable to do some gentle or exhale pushing to decrease exhaustion and minimize blood pressure changes at the beginning of Stage II if you do not experience an urge to push immediately and/or periodically during Stage II when your contractions are not as strong
• Push while the coach counts (each count is about one second); pushing to a count of around five or six is average; do not hold your breath for more than 10 seconds at a time
• The “catch breath” should be done quickly and without releasing abdominal pressure; this will prevent your baby from slipping backwards in the vagina
• Mental visualization of your baby moving down the birth canal and your vagina subsequently opening up may be helpful; when your baby is very low in the birth canal, watching as you push may increase the effectiveness of your pushing effort
• During delivery of the baby’s head, the physician or nurse midwife may ask you to stop pushing; at that time, lie back, and gently blow

Reminder: Do not push as you practice at home. Instead, practice positions, learn to hold your breath, and think through the pushing process.

Perineum (Pelvic Floor Muscles)

• It is important that your perineum remain relaxed while you are pushing.
• Practice the Kegel exercise during pregnancy so that you will be able to feel the difference between a tense and relaxed perineum.
• Please see the “Prenatal Exercises” chapter for Kegel exercises instructions.