When to Start Pushing During Childbirth

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Pushing Childbirth

The right time to start pushing during childbirth has long been a topic of debate.

Women usually, but not always, feel a strong urge to push during the second stage of labor, when the cervix is fully dilated and the baby is ready to be born.

Midwives have long championed spontaneous pushing, also known as maternal pushing, which is to push when you feel the urge, to push as intensely and as often as your body suggests, but  coached—or directed—pushing has been standard practice in U.S. hospitals for a while. In coached pushing, a labor or delivery nurse tells the laboring woman how and when to push, often telling a woman to wait if her cervix is not fully dilated. The  woman is asked to take a deep breath, hold the breath and push downward when contractions start, bearing down like this a few times during each contraction.

The rationale behind telling women to wait was that the longer the second stage of labor lasted, the riskier it was thought to be for the baby, and the more likely labor was thought to result in a C-section or the use of other interventions, such as forceps.

However, the urge to push is triggered by the pressure of the baby’s head on the pelvic floor nerves as the baby descends into the birth canal. The reflexive urge does not depend  on what the cervix is doing, but rather on what the baby’s head is doing. If the baby applies pressure on the pelvic floor before the cervix finishes dilating, the woman may feel like pushing before she is fully dilated.

Conversely, the cervix may be fully dilated, but if the baby has not yet descended far enough into the birth canal, the urge to push may not be triggered or it may be delayed. Coached pushing may offer an advantage when a woman does not feel the urge to push, such as when an epidural numbs the pelvic floor nerves or for a woman who feels tense or does not like the sensation of pushing.

Research over the last few decades has shown that as long as the baby is tolerating labor well, the length of this second stage does not necessarily affect the baby’s health and that eliminates some of the rationale for coached pushing. Recently, a study published in JAMA, the Journal of the American Medical Association, found that it’s as safe for women—and their babies—to push as soon as they feel the urge as it is to wait. According to the study results, women who pushed early were less likely to have significant bleeding or develop infections. Also, pushing early did not increase the need for medical interventions.

While the American College of Obstetrics and Gynecology (ACOG)sees some benefit to both spontaneous and coached pushing, a  2017 ACOG report advised medical professionals to encourage a laboring woman to use the pushing technique that she prefers and is most effective for her.

The study found that a labor in which the woman pushed earlier, when she first felt the urge to push, was 32 minutes shorter on average, even though the time spent actually pushing was slightly longer. Delayed pushing was not shown to increase the odds of a vaginal delivery or prevent problems, as previously supposed. The conclusion was that it may be preferable for women to start pushing when they feel the urge, even if not fully dilated. Minimal intervention should always be the goal in a low-risk birth.

How long is too long to push? The pushing part of the second stage of labor can take anywhere from minutes to hours.  For first time moms or those who had an epidural, three hours or more is perfectly normal. Before deciding if pushing has gone on too long, doctors will take a few things into consideration, such as the mother’s fatigue levels, whether the baby is showing signs of distress, or if the baby is taking too long to get into the desired birthing position.

As the baby’s head crowns, many women experience a burning sensation, but that’s a sign that labor will soon be over and you will soon get to hold the baby in your arms.

Joan MacDonald
Joan Vos MacDonald has written about health and fitness for newspapers, magazines and websites. She is a member of the National Association of Science Writers and the author of two books on health-related topics, "Tobacco and Nicotine Dangers," for young adults, and "High Fit Home," a design book about fitness and architecture. She lives in upstate New York near her children and grandchildren.

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