Today, Ken McGee, PT,  DPT, (they/them) a physical therapist specializing in pelvic floor health for the childbearing year, writes about how people can utilize breathing techniques to minimize harm to their pelvic floor during pushing.  From time to time on Connecting the Dots, they share information and resources that will be valuable to educators and the families they work with in a series called The Body in Birth.  If you have pelvic health questions, please let me know and I will work with Ken to get your questions answered. You can find all the posts in this series here. - Sharon Muza,  Community Manager, Connecting the Dots

Introduction

As the saying goes, if you don’t know your options then you don’t have options. This is certainly true when it comes to pushing during childbirth in the United States and many other places across the globe. Birthing people are often encouraged to hold their breath and sustain a pushing effort for ten seconds, repeated three times per contraction. However, recent evidence points to the alternative option of breathing during pushing efforts as being better protective of the pelvic floor. Childbirth educators can support pregnant families by informing them of the benefits of breathing during pushing, including: 

• Less pain (Yuksel et al., 2017)
• Lower chance of tearing pelvic floor muscles (Ahmadi et al., 2017)
• Lower chance of developing urinary incontinence after birth (Shinozaki et al., 2022)

Furthermore, childbirth educators can teach advocacy skills for breathing during pushing, as well as encourage pregnant people to partner with healthcare providers who are supportive of physiological birth. Lamaze Healthy Birth Practice 5: Avoid Giving Birth on Your Back and Follow Your Body’s Urge to Push encourages birthing people to listen to their body and push–and breath during pushing–in a way that feels intuitive and appropriate at the time.

This article presents three breathing techniques to promote pelvic floor integrity during the pushing stage of labor (also known as the second stage of labor). 

Technique 1: Push with an open glottis  

First of all, what is the glottis? The glottis is the part of the throat that contains the vocal cords and the space between them. When the glottis is open during pushing, that means air is still flowing past the vocal cords. Accordingly, the birthing person can be heard making a sustained exhale or hum. Compare this to closed glottis pushing (also sometimes called Valsalva or “purple pushing”), where the vocal cords come together to stop airflow and no sound is made. 

One study looked at simply telling people giving birth not to hold their breaths. In the absence of formal breathing instruction, simply not breath holding resulted in less pelvic floor injury, as indicated by less mobility of the urethra following birth (Koyucu & Demirci, 2017). 

How long should someone push while breathing out? Recent studies involving computer modeling as well as direct observation of people during birth suggest that pushing efforts of five seconds result in less pelvic floor injury than traditional Western pushing recommendations (which typically entails closed glottis pushing for ten seconds, repeated three times per contraction) (Vila Pouca et al., 2022; Ahmadi et al., 2017). Furthermore, another study involving 1710 people giving birth to their first child and using an epidural found that the direction to push two times per contraction versus three times per contraction resulted in lower rates of episiotomies, with no increased impact on neonatal morbidity or parental hemorrhage (Le Rey et al., 2022). 

In 2019–and reaffirmed in 2021–the American College of Obstetricians and Gynecologists (ACOG), in cooperation with the American College of Nurse Midwives (ACNM), stated in Approaches to Limit Labor Interventions:

 “When not coached to breathe in a specific way, [birthing people] push with an open glottis. In consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each [birthing person] should be encouraged to use [their] preferred and most effective technique.” (ACOG, 2019)

Technique 2: Make some noise  

If someone is struggling to follow the cue to breathe during labor, that person might have better success with the instruction to make sounds. Vocalizations automatically get air flowing through the glottis. There is little research on exactly which sounds to make although some common sounds for pushing include 

• Grrr
• Growling 
• Sustained A, O, and U sounds (Neta et al., 2022) 

In one small study in Brazil, making sounds decreased the risk of a perineal tear bigger than two centimeters by 68% (Neta et al., 2022)!

Sometimes people giving birth feel self-conscious about the sounds they are making. If that’s the case, the birthing person may feel more at ease if their support people also make the same sounds as them during pushing. 

Technique 3: Blow out during crowning

The blowing technique refers to puffing breaths or “ahhh’s” during crowning (when a baby’s head is exiting the vagina), as opposed to continuing forceful bearing down (Begley et al., 2019). The technique is typically implemented by a birth attendant observing crowning and encouraging the person giving birth to “puff” or “blow” rather than push. Doing so helps the birthing person to better resist the urge to exert strong effort, and in turn reduces forces that could damage the pelvic floor. 

Qualitative research examining the practices of expert midwives in Ireland and New Zealand identified the instruction to “slow, blow and breathe the baby out” as possibly contributing to their higher rates of intact perineums among patients (Begley et al., 2019).

In one study, open glottis pushing combined with blowing during crowning resulted in 41% of birthing people having no perineal tearing, compared to 19% in the group with closed glottis (Valsalva) pushing and no blowing (Ahmadi et al., 2017). The severity of the tears that did occur were also lesser than those in the closed glottis group (Ahmadi et al., 2017).  

Are there times when closed glottis pushing NOT should be performed? 

If there are medical complications that warrant a speedy delivery, closed glottis pushing consistently results in a shorter pushing stage. Depending on the study, the reduction in time from open to closed glottis pushing varied from 17 to 62 minutes (Koyucu & Demirci, 2017). 

Fortunately, several studies have found that babies who were born following pushing where breathing was encouraged fared well in regards to fetal wellness and neonatal results, including comparable Apgar scores (Koyucu & Demirci, 2017).

Conclusion

It is important to share with pregnant people the best practices around pushing–and breathing–during the second stage of labor. Keeping the glottis open, vocalizating, and controlling the crowning phase may all improve outcomes in birthing people by reducing injury to the pelvic floor. Protecting pelvic floor health can have impacts on quality of life for years to come. Childbirth educators can review how they instruct breathing during the pushing stage to ensure that what they are teaching matches with current evidence. Likewise, perinatal professionals can help pregnant people understand the value of physiological pushing for pelvic floor health, and encourage them to partner with a healthcare team that supports spontaneous pushing that is parent-led. 

References 

American College of Obstetricians and Gynecologists (2019). ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth. Obstetrics and Gynecology, 133(2), e164-e173.

Ahmadi, Z., Torkzahrani, S., Roosta, F., Shakeri, N., & Mhmoodi, Z. (2017). Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial. Iranian Journal of Nursing and Midwifery Research, 22(1), 62-6.

Begley, C., Guilliland, K., Dixon, L., Reilly, M., Keegan, C., McCann, C., & Smith, V. (2019). A qualitative exploration of techniques used by expert midwives to preserve the perineum intact. Women and Birth: Journal of the Australian College of Midwives, 32(1), 87-97.

Le Ray, C., Rozenberg, P., Kayem, G., Harvey, T., Sibiude, J., Doret, M., ... & Chantry, A.A.(2022). Alternative to intensive management of the active phase of the second stage of labor: a multicenter randomized trial (Phase Active du Second STade trial) among nulliparous women with an epidural. American Journal of Obstetrics and Gynecology. doi:10.1016/j.ajog.2022.07.025

Koyucu, R.G., & Demirci, N. (2017). Effects of pushing techniques during the second stage of labor: A randomized controlled trial. Taiwanese Journal of Obstetrics & Gynecology, 56(5), 606-12.

Neta, J.N., Amorim, M.M., Guendler, J., Delgado, A., Lemos, A., & Katz, L. (2022). Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 275, 46-53.

Shinozaki, K., Suto, M., Ota, E., Eto, H., & Horiuchi, S. (2022). Postpartum urinary incontinence and birth outcomes as a result of the pushing technique: a systematic review and meta-analysis. International Urogynecology Journal, 33(6), 1435-49.

Vila Pouca, M.C.P., Ferreira, J.P.S., Parente, M.P.L., Natal Jorge, R.M., & Ashton-Miller, J.A. (2022). On the management of maternal pushing during the second stage of labor: a biomechanical study considering passive tissue fatigue damage accumulation. American Journal of Obstetrics and Gynecology, 227(2), 267.e1-267.e20.

Yuksel, H., Cayir, Y., Kosan, Z., & Tastan, K. (2017). Effectiveness of breathing exercises during the second stage of labor on labor pain and duration: a randomized controlled trial. Journal of Integrative Medicine, 15(6), 456-61.

About Ken McGee

Ken McGee, PT, DPT, (they/them) is a transgender physical therapist and birth doula based in Seattle. Their practice centers the experience of queer people during birth and gender transition. You can reach Ken through their website.

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