How to push during labor

How long does it take to push a baby out?

The amount of time it takes to push a baby out varies greatly, but on average, it takes from 20 minutes to two hours. Two factors that affect that time span:

• If you're a first-time mom, pushing usually lasts longer. According to one large study of women with minimal intervention during labor and delivery, 90 percent of women having their first baby completed the second stage of labor (the pushing stage) in just over three hours, while 90 percent of women having their second (or later) baby completed the second stage in less than 45 minutes.
• If you have an epidural, it will generally take longer to push your baby out.

Healthcare providers have guidelines for how much time to allow for the second stage before considering it "prolonged." If the pushing stage becomes prolonged, a provider may recommend steps – such as having a C-section – to minimize risks and assist with the birth. The current guidelines are:

• For women having their first baby without an epidural, the second stage is considered prolonged after three hours of pushing. For those with an epidural, up to four hours might be okay. Increased time may also be allotted for a baby who is in posterior ("sunny-side up") or other unusual position, as long as the baby is doing fine and there's progress with pushing.
• For women having their second (or later) baby without an epidural, the second stage is considered prolonged after two hours of pushing. Up to three hours might be allotted for women with an epidural or a baby in an unusual position, if the baby is fine.

When to start pushing during birth

Pushing is the second stage of labor (the first is active labor when the cervix is opening up, the second is pushing and birth, and the third is delivery of the placenta). The second stage begins when your cervix is dilated completely to 10 centimeters.

Once you're fully dilated, you can start pushing right away, or you can take a break at this point and wait for the urge to push.

Many women report feeling better once the pushing stage starts. Despite the physical effort involved, you've passed transition – which is often the most challenging part of labor, at the end of active labor when your cervix fully dilates.

Pushing can be a relief for women who feel an irresistible urge to push – it's very satisfying to act on the urge and feel your baby moving down and out. Not all women feel the urge to push, though, and that's okay. Your provider and other members of your labor team can tell you when to start pushing and guide you through the process.

How to push during labor

There are a two main methods for pushing during labor, and there's ongoing research on the advantages and disadvantages of each. The American College of Obstetricians and Gynecologists (ACOG) recommends that women be encouraged to use whichever pushing technique they prefer and think is most effective for them.

Directed pushing

Directed or coached pushing means a labor support person (usually a labor and delivery nurse or midwife) will lead you through the pushing stage. Typically, they'll tell you to take a deep breath at the beginning of a contraction, hold it, then tighten your abdominal muscles and push down with as much force as possible (called "bearing down") while they count to 10.

You'll hold the air in your chest – don't blow out before pushing or keep the air in your cheeks. Keeping the air in your chest increases your power. This is also known as the Valsalva method. (Some moms say it feels like straining to have a bowel movement.)

Then you take a quick breath and push for another count of 10, aiming to get in three pushes during each contraction. You'll rest between contractions. If you're very tired, you can rest (not push) through a contraction now and then, too.

This widely practiced method is usually begun as soon as you're fully dilated to 10 centimeters, even if you don't feel an urge to bear down. Coached pushing has long been routine in most U.S. hospitals.

Spontaneous pushing

Some providers prefer spontaneous pushing, which means following your own instincts, bearing down and pushing according to your own reflexes in response to your contractions and the pressure you feel as your baby's head moves down.

This method is also known as physiological or mother-led pushing, and it only works in unmedicated labors. Midwives often favor spontaneous pushing, pointing out that it respects a woman's instinctual knowledge of when and how to push.

Once you start feeling the urge, you may push for just a few seconds during the peak of the contractions at first, and not during every contraction, or you may push with tremendous force – again, doing what your body tells you to do. Women who aren't being coached generally let a contraction build before bearing down. Also, spontaneous pushes tend to be in shorter but in more frequent bursts during contractions.

As your baby descends and puts increasing pressure on your pelvic floor (the muscles and other tissue that support your uterus, vagina, bladder, and rectum), you may begin to push harder and more often during contractions. Your body will help to guide your efforts. You may also grunt, groan, or make other noises when pushing.

Whichever method you use, to avoid tearing, your provider may tell you to stop pushing when your baby's head is crowning (is visible in the birth canal). To keep yourself from pushing, you can do breathing exercises, or lean back and try to relax the muscles of your perineal floor.

Feel free to change positions during the pushing stage. You may become tired in one position, or you may feel that another position – something more upright, for example – is more productive.

Learn about the benefits of different positions during labor.

You can always discuss pushing techniques with your doctor or midwife during your pregnancy. Your decision about how to push may be based on a number of factors, including whether or not you'll have an epidural, whether your labor is being induced for reasons pertaining to the baby, and how previous labors and deliveries progressed (if this isn't your first baby), for example.

What does pushing during childbirth feel like?

During the pushing stage, your contractions will probably come pretty regularly, about two to five minutes apart and lasting about 60 to 90 seconds. They'll still be intense, but maybe less so than during transition.

Here's what you may feel:

• A great deal of pressure in your rectum, perineum, and low back
• An overwhelming urge to push (some women don't, however)
• "The ring of fire," a burning, stinging sensation as your baby's head crowns and your vagina stretches for your baby to emerge. The burning doesn't last long – soon there's a feeling of numbness instead as the vaginal tissue stretches thin, blocking the nerves.

You may also feel your provider take steps to help reduce tearing (such as using warm compresses or massage on your perineum). Most women don't need an episiotomy or assistance from forceps or vacuum, but if you do, it will be during this last phase.

You may be able to reach down and feel your baby's head as it begins to emerge, or use a mirror to watch your baby's head appearing.

Finally, you'll feel your baby's slippery, wet body coming through your vagina and out into the world.

How to push with an epidural

An epidural can dull – or even eliminate – the urge to push. Or you may feel the pressure but no burning or stinging sensation as your baby's head crowns.

You can rely on your labor coach, doula, nurses, midwife, or doctor to help you know when and how to push with an epidural. You might choose to delay pushing until you have a stronger sensation, too. In some cases, your provider may let the epidural start to wear off when it's almost time to push, so you can better feel what you're doing. But your labor team can help you coordinate your muscles and push your baby out, even if you can't feel everything that's going on.

What is laboring down?

Some women don't feel the urge to push right away after they're fully dilated. Laboring down means taking a pause – for as long as an hour or two. This gives time for the sensation to develop as the baby descends. Your contractions will be doing the work of moving your baby down the birth canal without your pushing.

Laboring down is also called delayed pushing or passive descent, and it can be used with either coached or spontaneous pushing methods.

Laboring down can also be used in conjunction with position changes if your baby is in the posterior position. It's harder to push your baby out when they're facing your bladder rather than your back, and often – with a little extra time and turning – your labor team can coax your baby into facing the easier direction.

If, however, you feel a natural urge to push, there's no reason to delay pushing unless you're exhausted. In fact, pushing as soon as you feel the urge may feel like a relief.

You can labor down with an epidural, but it's possible that no matter how long you wait you may not feel the urge to push. In this case, you'll need direction from your provider or labor coach.

Some benefits of laboring down:

• Delayed pushing can help you save your energy if you have a long labor.
• While delayed pushing can make the entire second stage longer, it results in less time spent actively pushing.

There may be times when delayed pushing isn't a good idea – if your baby's heart rate isn't reassuring, or there's another reason to expedite delivery, for example.

There are also some potential disadvantages of delayed pushing, and some providers will discourage it unless there's a good medical reason to use the technique (such as time needed to attempt to reposition the baby). In some studies, women who delayed pushing (rather than pushing as soon as they reached 10 cm dilation) had higher rates of:

• Chorioamnionitis, a bacterial infection in the tissues and amniotic fluid surrounding the baby
• Postpartum hemorrhage
• Babies with acidemia (excess lactic acid in the blood from reduced oxygen transmission from the placenta. In this case, acidemia may be caused by a longer labor.)
• Babies with higher rates of sepsis (again, likely due to longer labor)

If you're thinking of laboring down, talk with your provider about your reasons for wanting to wait.

Want to learn more about the process of labor and delivery? Our Childbirth Class Videos will teach you the signs and stages of labor, pain management techniques, medical procedures, and more.

Learn more:

• How to make a birth plan
• What to pack in your hospital bag
• Preparing for your baby's arrival
• What happens to your baby after delivery