Introduction

People cannot choose an option they do not know exists. This is often true of pushing during childbirth in the United States and many other parts of the world. Birthers are commonly encouraged to hold their breath and bear down for ten seconds, repeating this at least three times with each contraction. Current evidence; however, suggests that breathing while pushing may better protect the pelvic floor. Childbirth educators can support pregnant families by explaining the benefits of breathing during pushing, including:

• Less pain
• Reduced risk of pelvic floor muscle tears
• Less fatigue after birth
• Lower risk of urinary incontinence after birth

Childbirth educators can also teach advocacy skills for breathing during pushing and encourage class participants to choose a healthcare provider who supports physiological birth.

Lamaze Healthy Birth Practice #5: Avoid Giving Birth on Your Back and Follow Your Body’s Urge to Push encourages birthers to listen to their body when it comes to pushing, breathing during pushing, intuitively during the pushing stage (also known as the second stage of labor). This article presents three breathing techniques to avoid pelvic floor trauma during the second stage of labor

Technique 1: Push with an open glottis

The glottis contains the vocal cords and the space between them in the throat. 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” as the persons face may get purple during pushing), where the vocal cords come together to stop airflow and no sound is made.

One research study compared birthing people who were randomly assigned either to hold their breath during pushing or to avoid holding their breath. Researchers found that those who did not hold their breath had less pelvic floor trauma and were more likely to have an intact perineum without tearing. A systematic review found the same results. A narrative review of the evidence also found that birthing people were consistently encouraged to exhale while bearing down, which helped protect the perineum from trauma and supported vaginal opening as the baby was born.

How long should someone push while breathing out? Recent studies indicate that pushing efforts of five seconds result in less pelvic floor injury than traditional pushing recommendations (which typically uses a closed glottis technique, pushing for ten seconds, repeated three times per contraction). 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 postpartum hemorrhage in the birther.

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

When a birther is having trouble remembering to breathe during labor or pushing, that person might have better success with the instruction to make sounds. Vocalizing keeps air flowing through the glottis. There isn’t a lot of research on exactly which sounds to make; however, commonplace sounds for pushing include:

• Grrr
• Growling or groaning
• Sustained A, O, and U sounds

One study stated that the best sounds to make were “low and slow” to assist with birthing, while high pitch and fast sounds impede birthing.

In one small study in Brazil, making sounds decreased the risk of a perineal tear longer than two centimeters by 68%. Likewise, another study found that saying positive affirmations helped to decrease stress, pain perception and increase a connection with the baby being born.

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

During crowning, “blowing out” breaths refer to puffing breaths or soft “ahhh” sounds as the baby’s head emerges, rather than continuing to bear down. A birth attendant typically introduces this technique after observing crowning and encourages the birthing person to “puff” or “blow” instead of push. This can help the birthing person resist the urge to push forcefully, reducing pressure that could injure the pelvic floor.

In a study, open glottis pushing combined with blowing during crowning resulted in no perineal tearing for 41% of birthing people, compared with 19% in the closed glottis (Valsalva) pushing group without blowing. Tears that did occur were also less severe than those in the closed glottis group.

Are there times when closed glottis pushing should be performed?

If there are medical complications that warrant a speedy delivery, closed glottis pushing might be suggested to shorten the time to birth. However, when looking at the evidence, studies show mixed results with some showing shorter times for open glottis pushing and others for closed glottis pushing. In 2024, a systematic review and meta-analysis showed that when the data was pooled between studies, the result was that there was no significant difference between time of second stage labor between the two methods of breathing.

Several studies suggest that holding the breath during pushing can have harmful effects. It may alter acid-base balance and contribute to fetal distress, while also increasing postpartum fatigue for the birthing person. Encouraging breathing during pushing has been associated with positive fetal and neonatal outcomes, including comparable Apgar scores.

Conclusion

Pregnant people benefit from clear, evidence-based guidance on pushing and breathing during the second stage of labor. Techniques such as keeping the glottis open, vocalizing, and easing the baby’s emergence during crowning may help reduce pelvic floor injury and support long-term quality of life. Childbirth educators can ensure their instruction reflects current evidence, while perinatal professionals can help families understand the value of physiological, parent-led pushing and choose a care team that supports this.

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. https://doi.org/10.1097/aog.0000000000003074

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), 62-66. https://doi.org/10.4103/1735-9066.202071

Heim, M. A., & Makuch, M. Y. (2023). Breathing techniques during labor: A multinational narrative review of efficacy. The Journal of Perinatal Education, 32(1), 23-34. https://doi.org/10.1891/jpe-2021-0029

Kownaklia, J., Phanwichatkul, T., Chaichan, A., & Lee, A. (2024). Effectiveness of spontaneous pushing versus Valsalva pushing in the second stage of labor on maternal and neonatal outcomes: A systematic review and meta-analysis. Pacific Rim International Journal of Nursing Research, 28(2), 407-420. https://doi.org/10.60099/prijnr.2024.264145

Le Ray, C., Rozenberg, P., Kayem, G., Harvey, T., Sibiude, J., Doret, M., et al. (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, 227(4), P639. E36-E15. https://doi.org/10.1016/j.ajog.2022.07.025

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. https://doi.org/10.1016/j.ejogrb.2022.06.007

Roosevelt, L., Danford, K., & Zielinski, R. (2025). Impolite birth: Provider perspectives on vocalization during childbirth. Birth, 52, 627-633. https://doi.org/10.1111/birt.12907

Shamekh Taman, A. H., & Elaziz Hassen, H. A. E. A., & Mahmoud Shoukhba, N. S. (2024). Effect of breathing technique of blowing versus perineal warm compresses during second stage of labor on birth outcomes among primipara. Egyptian Journal of Health Care, 15(3), 249-262. https://doi.org/10.21608/ejhc.2024.372632

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), 1435-1449. https://doi.org/10.1007/s00192-021-05058-5

Talasz, H., Kremser, C., Talasz, H. J., Kofler, M., & Rudisch, A. (2022). Breathing, (s)training and the pelvic floor: A basic concept. Healthcare, 10, 1035. https://doi.org/10.3390/healthcare10061035

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. https://doi.org/10.1016/j.ajog.2022.01.023

Published: July 06, 2026

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