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by Brittany Sharpe McCollum, CCE(BWI), CD(DONA), CLC How will I know when to push? You’ll know because you won’t be talking about it anymore; it will just be happening. This most simple of answers is true even if a bit tongue-in-cheek.  When someone is close to pushing, the rectal pressure can feel intense and people often talk a lot about it -  I feel a lot of pressure. I have to poop. I think I have to push. When the body and baby are ready, though, there is no more talk about wanting to push.  It just simply becomes a deep grunting downward movement facilitated by the strong muscular uterus and the feeling of pressure becomes secondary to that involuntary downward force. How can we follow the instincts the body provides to push babies out in a way that is protective of the pelvic floor, optimal for the baby’s oxygenation, and works with the forces at play? We can learn to breathe in a way that is functional, coordinating the lengthening of the pelvic floor muscles with inhalation and the bearing down effort of the uterus with exhalation.   We can recognize the body’s innate wisdom and recognize what spontaneous pushing looks like - short pushes of five or six seconds, knees moving inward with the bearing down, and the lower back arching, with the sacrum free to shift out of the way when the baby descends. We can adopt positions that allow for greater space at the bottom of the pelvis, giving the baby more wiggle room to make their way out, including internal rotation of the thighs, hands and knees, and side-lying. Although this way of pushing is often instinctual in births that are unmanaged, we can also mimic this for use with an epidural.  Using the contractions as a guide, the laboring person can be encouraged to follow a more intuitive way of pushing than the typical directed option of “pushing for a count of ten,” “curling around the baby,” and “holding air in” that is often presented as the only option. How does pushing spontaneously prove beneficial? Research tells us that pelvic floor well-being is directly related to the amount of time spent doing “open-glottis” pushing (exhaling while bearing down - an instinctive style of pushing).  Another way to think about this is that the more time someone spends doing directed pushing, the more likely it is for pelvic floor damage to occur (we’re talking long-term issues such as prolapse and incontinence as well as short-term issues such as perineal tearing).  Even spending just part of second stage of labor pushing with exhalation and in shorter grunts can help protect the pelvic floor both short and long term. When babies are making their way under the pubic bones, compression of their head can cause decreases in oxygenation and lying on the back for pushing decreases blood flow to the pelvic region, including the placenta. The body is wise, though, and babies are equipped to handle periods of decreased blood flow with their reserves of oxygen due to their vast number of red blood cells.  However, prolonged pressure on the baby’s head while pushing in a reclined position (such as what can be seen in ten second pushes while holding the chin to the chest) can use up the baby’s reserves, putting them at a greater risk of distress.  Shorter pushing and frequent position changing can maximize the baby’s oxygenation. The uterus is an incredible muscle that both pulls up on the cervix, thinning and opening it during the first stage of labor, and curls down around the baby, pushing the baby out of the body, in the second stage of labor.  To work with this incredible force, one can utilize gravity to assist in the forward motion of the  uterus through adopting upright or forward leaning positions (as opposed to reclined positions).  As the baby moves through the bottom or outlet of the pelvis, internally rotating the thighs (think “closing the knees”) creates MORE space for the baby to emerge, which means less pressure on the baby’s head. The body has an innate ability to birth babies. When it comes to supporting the body’s innate functions in pushing out a baby, we can better tap into the spontaneous process when we have the knowledge that allows our brains to let go and let our bodies take over.  When we have this knowledge, we are also then able to apply a modified version of it to scenarios that may require guidance, such as decreased sensation from an epidural or concerns that warrant a quick second stage.  This refocusing of the process on the instinctual needs of the laboring parent can recenter them as the focus of the birth and support a gentler and more instinctive pushing phase.  Sources Cited: Ahmadi Z, Torkzahrani S, Roosta F, Shakeri N, Mhmoodi Z. Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial. Iran J Nurs Midwifery Res. 2017 Jan-Feb;22(1):62-66. doi: 10.4103/1735-9066.202071. PMID: 28382061; PMCID: PMC5364755. American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth. Obstetrics and Gynecology. Feb 2019; 133(2):406-408. Doi:10.1097/AOG.0000000000003081 Bloom SL, Casey BM, Schaffer JI, McIntire DD, Leveno KJ. A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. Am J Obstet Gynecol. 2006 Jan;194(1):10-3. doi: 10.1016/j.ajog.2005.06.022. PMID: 16389004. Calais-Germain B, Pares NV.  Preparing for a Gentle Birth: The Pelvis in Pregnancy. Healing Arts Press: Rochester, VT; 2012. Gupta, J.K., Sood, A., Hofmeyr, G.J., et al. Position in the second stage of labour for women without epidural anesthesia. Cochrane Database Syst Rev, 2017 May,   Lemos A. et al. The Valsalva maneuver duration during labor expulsive stage: repercussions on thematernal and neonatal birth condition. ev Bras Fisioter.. Jan-Feb 2011;15(1):66-72. doi:10.1590/s1413-35552011000100012. Bio: Brittany Sharpe McCollum (she/her), CCE(BWI), CD(DONA), CLC is the owner of Blossoming Bellies Wholistic Birth Services, established 2007 and based out of the greater Philadelphia PA, area.  She provides childbirth education classes, birth doula services, and dynamic labor support and pelvic biomechanics training workshops for birth professionals and expectant parents. Brittany has had the honor of presenting at international childbirth related conferences, including the Birth Works International Conference 2016, International Chiropractic Pediatric Association Summit in 2018, the Evidence Based Birth conference in 2019, the Midwifery Forward 2020 Conference, the ICEA 2020 Virtual Conference, the Utah Doula Association Mini Conference, the ACNM Midwifery Day conference, and more.  In addition, Brittany facilitates private workshops for obstetricians, midwives, nurses, doulas, childbirth educators, and other prenatal support resources around the country, both virtually and in-person, as well as two bi-annual trainings for the larger birth community.  She is also a contributing author to the book “Baby Got VBAC: An Inspiring Collection of Wisdom for Better Births After Cesarean.” Brittany lives in South Jersey with her partner and their four children. Check out her website for upcoming webinars, classes, workshops, conference events, and more at, follow her on Instagram @blossomingbelliesbirth, and stay in touch on Facebook at Blossoming Bellies Wholistic Birth Services.