Since 2010, I've been teaching pregnant people how to push out their babies. I have a different approach to the pushing phase of childbirth- I teach the PHYSIOLOGY of pushing...and it really works! Parents, doctors, midwives and doulas report to us over and over: 'People are pushing out their babies in 20 minutes with this technique---without tearing!'

As the co-owner of Oh Baby! Fitness, I've taught over 10,000 pregnant and new parents how exercise can help them have comfortable pregnancies and healthy (both physically and mentally) postpartum periods. When I tell people what I do, they picture me wearing a sweatband and cordless mic as I count out squat reps, but really, what my work looks like is a lot of education: education about the physiological changes of the perinatal period (and how exercise can help people to have an easier pregnancy and faster recovery) and increasingly education about the core box, specifically the transverse/inner abs and pelvic floor.

Oh Baby! Fitness has fitness instructors all over America teaching expectant families the specific physiology of pushing, and we've had extraordinary feedback from participants, doulas, L&D nurses, midwives and OBs. We firmly believe pregnant people can and should be taught HOW to push out their babies long BEFORE the big birthing day. They need to be taught what to do to avoid the reflex of freezing, tensing EVERYTHING (not helpful!) or panicking. Teaching people about this part of labor gives them agency and empowerment for the most exciting part of labor. Let's dive in!

1- Get excited that you can teach this part!

I'm not going to lie, I think this first step might be the hardest for some childbirth educators! There is a history of NOT educating pregnant people about pushing, instead trusting that their bodies will 'get the baby out' as it should. I 100% agree that a baby is going to come out of a birthing person, however, many people spend a not-insignificant part of labor being coached by a L&D nurse, doctor or midwife on what pushing is and how to do it. Is there any reason this needs to happen DURING labor? I'd argue no, and I've observed that teaching people the physiology of pushing while they are still pregnant results in shorter pushing stages, as well as fewer tears and cesarean sections. It also empowers people during what can be the scariest part of labor- giving them power by providing education about the coordination of muscles to most efficiently push out their babies. We trust pregnant people's bodies to get their babies out, let's also trust their brains to understand the physiology and give them a chance to practice before it's game time.

2- Understand the physiology of pushing efficiently.

Once you get excited about teaching pushing, it's time to dive into physiology. The most efficient way for a person to push out their baby is to ENGAGE their rectus and transverse abdominals and to RELAX their pelvic floor. This is easier said than done- these muscles almost always fire together, and to get the abs strong with a relaxed pelvic floor is kind of like patting your head while rubbing your tummy- which is why it's so helpful to give people a chance to practice! Often when birthing people come to push out their babies they engage ALL of their muscles, which LIFTS their pelvic floor, making it harder for the baby to come out. It's complicated stuff! But below you'll learn how to teach people to train those muscles individually and then how to put it all together in what we call 'Coordinated Pushing'

3- Teach the role of abs in pregnancy and pushing.

The first piece of education for clients is the basics of abdominal muscles. At Oh Baby! Fitness, we believe the core muscles (the pelvic floor and abs) are the key to a healthy pregnancy and easy, faster delivery.

The abdominals are made up of four kinds of muscles:

1. Rectus Abs: Most people think rectus abdominals are the only abs you have. These are at the front of the torso and are commonly referred to as the 'six-pack' and are the muscle group targeted in sit-ups. When a person is pushing and their spine is curved forward, their rectus abs are ENGAGED.
2. Internal and External Obliques: these muscles are found along the sides of the torso and aid in twisting and turning- these are not used for pushing.
3. Transverse Abs: these are the interior layer of abdominals (the inner abs) and the most important in pregnancy- both for posture during pregnancy and for pushing. These are the muscles that are engaged when you suck in your belly. It can be helpful to have your students or clients visualize their transverse abdominals as the muscular sling that carries the baby. They can be found right where the seat belt goes across your tummy.

Having your clients find their transverse abs is going to help them push out their baby- getting this muscle strong and engaged is how they will push out their baby. Have them try this to find that muscle.

Standing, so that the class can see, demonstrate a transverse ab hold/pulling your bellybutton to your spine. Tell them to think of 'hugging' the baby with their ab muscles. Let them know that hugging the baby won't hurt the baby at all. Have them stand up and try. If they have a support person with them, let that person see the difference in relaxed abs with bad posture and engaged abs with good posture. Encourage the support person to hold their abs in too- it's good for everyone to strengthen their transverse abs! Pregnant people should be encouraged to engage their transverse abs regularly throughout the day. A good cue is to ask them to pull their baby up and away from their seatbelt whenever they are driving. THIS is good posture and engaging the inner abs strengthens them and will help ease labor and pushing.

4- Teach kegel w/ relaxation or 'dropped' feeling

Now that your students and clients understand how to engage their transverse abs, we want to help them 'find' their pelvic floor. The coordination of strong, engaged transverse abdominals with a RELAXED or dropped pelvic floor is the most efficient way to push out a baby. Teaching people how to drop their pelvic floor sounds tricky but is actually pretty straightforward:

Have your students or clients get into a sitting position (cross-legged is generally good) and have them imagine their pelvic floor (sometimes it can be helpful to describe the muscle as a trampoline that supports the weight of the baby. The baby is head down on the trampoline.).

1. To help them locate their pelvic floor, educate them that the muscle connects their pubic bone to tailbone and hipbone to hipbone - it's a big muscle...the size of a piece of 8 x 11 paper! Have them imagine lifting all four corners of the muscle like a wonton wrapper. It can be helpful to have them place their pointer and middle finger right inside their hip bones, some people can feel the lift of the muscle.
2. See if they can find different degrees of tightening the pelvic floor. If they imagine an elevator, ask them to lift the pelvic floor to the first floor, second floor, third floor, and then reverse back down.. Second floor, first floor and then the basement. A full release. It's that basement feeling people who will give birth need to get acquainted with. This is where their pelvic floor needs to be to easily push out their baby. Sometimes a straw image is helpful; they want to 'suck up' the pelvic floor, and then slowly release.
3. Note: the release of the pelvic floor is just as important as engaging the pelvic floor. If your students and clients have a vaginal birth, they will need to relax their pelvic floor during the pushing stage, so it is vital to teach this release section of the Kegel.
4. While doing Kegel exercises, remind them to try not to move the leg, buttock, or abdominal muscles.Have them try doing Kegels in a side-lying position or on hands and knees. People in their third trimester may find these positions more comfortable as the weight of the baby is not on the pelvic floor.
5. Helpful cues for finding a dropped or relaxed pelvic floor are that it feels like 'peeing very quickly- like when you are in a movie and have to go to the bathroom and don't want to miss a minute'--- or the image of weight in the crotch.

5- Teach coordinated pushing

Now that your students and clients have found their engaged inner abs and dropped pelvic floor, you can help them put it all together into Coordinated Pushing! We begin with belly breathing to get people to breathe DOWN to their baby and to help them find their transverse abdominals. Educate people that they do NOT need to breathe this way to push as many will find their own breath pattern'the MUSCLE coordination is the technique.

How to Teach Belly Breathing for Labor:

1. Before you begin, remind students and clients that belly breathing is important even if they are having a planned cesarean section. Let people know that the Belly Breathing is also the first abdominal exercise they will do after they have their baby, so this is important for everyone to learn. Drawing the bellybutton to spine while exhaling is the first safe abdominal work for postpartum women.
2. Have clients place their hands on their bellies, with their middle fingers touching right above their bellybuttons.
3. Have them inhale and imagine the breath going all the way down to the baby. Their middle fingers should separate as their belly expands with the breath.
4. As they exhale, have them 'hug the baby' with their abdominals, bringing their middle fingers back together. Other cues are: 'A tiny crunch on the exhale,' 'pull the baby up and in on the exhale,' and 'exhale and engage your abdominals'.

How to Teach Coordinated Pushing:

1. Begin by teaching belly breathing. They will continue to breathe this way for coordinated pushing.
2. Remind the pregnant people that coordinated pushing can be quite difficult. It's like patting their head and rubbing their belly at the same time. They should feel free to PRACTICE and bring any questions to later classes.
3. On the exhale stage of belly breathing, have students and clients engage their abdominals, and actively drop or relax their pelvic floor. They should have relaxed glutes and lower abdominals and tight, contracted transverse abdominals. This combination of relaxed pelvic floor and tight abs is the most effective way to push a baby out.
4. Have the clients practice a few times in class. Use the phrase 'drop,' 'lower,' or 'relax' the pelvic floor, rather than 'push'. Another helpful phrase is 'push with your gut, not with your butt'. Remind clients to relax their jaw. A relaxed jaw will translate to relaxed glutes.
5. Students and clients should practice on their own. It is a difficult sequence to master. Have them start with belly breathing and advance to coordinated pushing.

Interested in learning more? Download the How to Push Out Your Baby app on iTunes for a specific step by step video explanation of coordinated pushing. Oh Baby! Fitness also offers an online pre/postnatal fitness certification that will train you to teach the Oh Baby! Fitness 'How To Push Out Your Baby' workshop and also offers a live version of the Pre/postnatal fitness training in cities around America. Visit ohbabyfitness.com or email training@ohbabyftiness.com to learn more.

References

Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804 (2020). Obstetrics & Gynecology, 135(4), e178-e188. https://doi.org/10.1097/AOG.0000000000003772

About Kathleen Donahoe, ACE, AFAA, MBA

Kathleen has personally trained over 10,000 pregnant and postpartum families. As a co-author of the Oh Baby! Fitness Prenatal and Postpartum Instructor Training, as well as a presenter of live perinatal fitness trainings, Kathleen teaches fitness instructors and personal trainers the art and science of perinatal fitness. Kathleen began her career as a personal trainer in Syracuse, NY. While there, she found she loved working with women who had gained significant weight (80 lbs or more) during pregnancy, and that helping them lose weight, recover from pregnancy and take control of their bodies was an exciting and satisfying job. After moving to Atlanta in 2005 for a job in non-profit management, Kathleen missed fitness and interviewed with Oh Baby! Fitness in its first months as a company. From there, she began teaching a Pregnancy Water Aerobics class for Oh Baby!. She quickly realized she had found her passion, and within a year was teaching 15 classes a week for the company. She pursued further certifications in perinatal Pilates and pelvic floor recovery and was named the Senior Instructor for Oh Baby in 2010. She graduated with her MBA in May of 2012 and was brought on full time as COO and co-owner. After nearly 10 years of training perinatal women, Kathleen joined their ranks when she gave birth to her son Peter in December of 2013 and her daughter Beatrice in 2015. She continues to teach for the company, while focusing on training and national expansion, from her home in Seattle.

Originally published 11/14/2017
Reviewed and republished 07/28/2026

Walker: Can you describe some of the general cultural and religious guidelines surrounding labour and the birth of a baby in the Muslim culture?

Hajara: In the context of Islam, the birth of child (girl or boy) is a very joyous event; all children are seen as gifts from God.

In the Qur'an (Muslim Holy Book), childbirth and labour are recognized as extremely painful and taxing experiences. In the Qur'anic rendering of the story of the Mary mother of Jesus (a respected Prophet of God according to Islam), it quotes Mary as saying while in the throes of labour, "Ah! Would that I had died before this! Would that I had been a thing forgotten!"

The physical and emotional pain a mother endures during pregnancy, labour, delivery and postpartum is but one reason why Islam accords such an elevated status to mothers. In this regard, the Qur'an reminds people to, "Respect the womb that bore you." Additionally, some of the traditions and sayings of the Prophet in this regard include: that one owes to their mothers three times more love and obedience than that owed to one's father, and that "Paradise lies at the feet (serving the needs) of one's mother."

There are really no guidelines around labour, but as per the example set in the story of Mary, it is seen as a time to turn to God for comfort and assistance.

When it comes to the actual birth, there are a few important practices that need to be kept in mind. Upon the child actually entering the world, one of the first requirements is for the father to recite the adhaan (call to prayer) in the ear of the newborn. This is so that among the first sounds the baby hears are words declaring the Oneness of God. Another practice that is highly recommended (but not required) is to mash a dried date between one's fingers and let the baby have a taste or lick. This particular tradition hearkens back to the Prophet Muhammad who did this for his grandsons and other newborns brought to him after their birth. It is in acknowledgment of the newborn's need for nourishment and the fact that dates have the highest natural sugar content. Lastly, if the baby is a boy, arrangements need to be made for him to be circumcised.

Walker: In discussing childbirth education, what are the sources of childbirth education for Muslim women in your area of Toronto?

Hajara: The sources of childbirth education among Muslim women are the same as those for other women: prenatal classes, doctors & of course, friends. Typically, hospitals where women deliver often offer prenatal classes, but there are also a host of private childbirth educators as well.

Walker: Is it appropriate for a woman's husband to attend class with her?

Hajara: From an Islamic point of view there is nothing wrong with husbands attending childbirth education classes with their wives.

Walker: If a childbirth educator has a Muslim couple in class, what are specific things she needs to be mindful of?

Hajara: I can see two issues that childbirth educators may need to be mindful about if they have Muslim couples:

1. Muslim couples may not wish to watch videos or see pictures of actual births. This is because certain parts of the body (private parts) are considered an individual's private space and are not to be seen by others, be they of the same or opposite gender, the only exception to this being between spouses or for medical reasons.
2. Muslim couples may not wish to practice some of the breathing exercises, which may require the mom-to-be to assume actual birthing positions, in front of others.

Walker: Along those same lines, what accommodations should a childbirth educator make regarding information given: videos, handouts, exercises, etc.?

Hajara: Culturally competent ways of giving information may include letting couples know they don't have to watch the birthing videos if they are not comfortable with viewing it, so in other words, not making it a mandatory component of childbirth education classes.
With regard to the breathing exercises, childbirth educators can let couples know up front that private sessions are available (if they are) and/or let couples know that they are free to do the parts of the breathing exercise they feel comfortable doing and leave out the components they are not comfortable practicing in front of others. If this means a couple ends up practicing the deep breathing without being on their back, so be it!

Walker: Can you speak to the meaning of dress in Islam for women and how that would translate in child birth and after, and during breast feeding?

Hajara: Generally speaking, Islam has dress guidelines for both men and women, and they are in place for the purposes of maintaining one's modesty. For women, this includes covering everything except the face and hands in the presence of males that are not part of one's immediate family. That being said, this dress requirement is entirely waived when medically necessary, for example during childbirth, physicals, surgery, etc.
It's also important to note that the dress requirement for women in front of other women is significantly more lax and is why breastfeeding in front of other women is not an issue.

Walker: Would you think that a birth plan is an appropriate tool for a Muslim woman to use to state her needs and requirements?

Hajara: It's my understanding that birth plans are used to communicate one's needs, wishes and expectations for the labor and birth. If this is the case, birth plans may be the ideal tool to help communicate one's wishes, including one's faith based birth needs and requirements.

Walker: Are doulas commonly used?

Hajara: From an Islamic point of view, there is nothing that mandates or restricts the use of labour support, so that would be a decision left entirely up to the individual/couple. Though in my experience, a lot of Muslim women I know have traditionally tended to rely on labour support in the form of their own mom, sister or friend.

Walker: What are the general preferences between birthing in a hospital vs. home births?

Hajara: Again this is something that Islam doesn't really provide a guideline about, so I would say that the preferences among Muslim women would be the same as what one would see among women in general.

Walker: You were kind enough to review the Lamaze Six Practices for a healthy birth for this interview, what did you find?

Hajara: In terms of Lamaze's 6 practices of healthy birth, none of them appear to be in conflict with the Islamic approach to giving birth!

[Stay tuned for Part II of Walker Karraa's interview with Hajara Kutty...]

Hajara Kutty is an educator and postpartum mental health advocate. She is also the Greater Toronto Area Coordinator for Postpartum Support International (PSI) www.postpartum.net.com. Her articles on the topic of postpartum mental illness have appeared in media outlets across Canada. She lives in Toronto (Canada) with her husband, daughter and cat.

Posted by: Walker Karraa, MFA, MA, CD(DONA)

Originally published: 04/28/2011
Reviewed and republished: 07/23/2026

Hajara: From a purely religious standpoint, postpartum women are exempt from performing the five daily prayers and are not to engage in conjugal relations for forty to sixty days after birth - that in itself is a huge relief! There are however, no specific Islamic guidelines on how a woman should be cared for postpartum by the family.

And so again, where there is no religious guideline on a given matter, people are free to and often will follow the protocol of the culture they most identify with. And so this is why you'll find Muslim women of East Indian origin moving in with their moms' for the first couple of weeks up until a month.

In terms of if postpartum doulas are ever used, though I don't personally know of any Muslim couples that have opted for a postpartum doula, there is nothing really preventing Muslim couples from employing one.

Walker: Can you tell us what, if any, differences there are regarding choice or preference to breastfeed?

Hajara: There are actually a few Islamic guidelines on the issue of breastfeeding. Firstly, breast milk in Islam is considered the newborn's birth right, something he/she is entitled to. And secondly, moms are allowed to nurse their baby up until the age of 2, at which point they should wean their baby.

All that being said, it needs to be noted that if a mom is not able to breastfeed for reasons like insufficient milk production, physical issues, mental health concerns or because she has to return to work, she is Islamically exempt from breastfeeding duty. In such cases, a woman can opt to provide: a milk-nurse for her baby (think of Salma Hayek's trip to Sierra Leone in 2009), a healthy alternative like formula* or opt for a combo of some sort like pumping and supplementing (if the issue is due to return to work).

Walker: Regarding emotional health in the postpartum period, what is your experience of supporting Muslim women who have a perinatal mood disorder?

Hajara: My experience supporting Muslim women with a perinatal mood disorder has been somewhat (no pun intended) depressing.

To better explain what I mean, it's important to understand how Islam views mental illness in general. If you actually look at Islamic history, you'll see that many of Islam's greatest scholars and physicians were among the first to view mental illness as actual medical conditions. And this was at a time when most of the world opted to view mental illness as evidence of demonic possession.

In fact, two Muslim giants made some of the greatest contributions to the field of psychiatry at the time: with Avicenna (considered the father of modern medicine) including mental illnesses in his Canon of Medicine and Rhazes being the first to open a psychiatric ward.

Muslims were also among the first to treat those with mental illness compassionately as dictated by the Qur'an, use baths, drug treatments and even use music therapy to help treat mental illness!

Now the depressing part: practically no one, no Muslim I've ever met, including Muslim women with perinatal mood disorders and their families that I have had to support, knows what Islam's view on this topic is.

Not only do they not know how supportive their faith is about this topic, a good majority of Muslims tend to believe quite the opposite: that the Islamic perspective on mental illness is that it is due to a lack of faith, punishment, or my all-time favorite, demon possession!

Because of this, in my experience, a lot of Muslim women don't want to admit to any of the symptoms of a perinatal mood or anxiety disorder, thinking it means they are not committed enough to God, etc.

I have also come across families that have simply watched their loved one spiral into postpartum psychosis and done nothing believing their loved one is possessed!

And so, my experience in supporting Muslim women with perinatal mood disorders has been fraught with an additional layer of stigma and ignorance that has to be chipped away at.

Though it is truly unfortunate, I can't blame people for not knowing about the Islamic viewpoint on mental illness. Having done my studies in Psychology, never once was I even exposed to what anyone outside of Europe believed about mental illness. And this was at a University known for being left-leaning!

Closing thoughts...
Increasing our knowledge of the cultural context of maternity care is essential to addressing the full spectrum of reproductive health on the global scale. My gratitude to Hajara for her participation, knowledge, and steadfast commitment to the perinatal mental health advocacy movement.

Hajara Kutty is an educator and postpartum mental health advocate. She is also the Greater Toronto Area Coordinator for Postpartum Support International. Her articles on the topic of postpartum mental illness have appeared in media outlets across Canada. She lives in Toronto with her husband, daughter and cat.

Originally published: 04/28/2011
Reviewed and republished: 07/23/2026

When couples in my classes are learning techniques for coping in labor, such as the Sacral Rub (sacrum counterpressure), Double Hip Squeeze and Bladder32 accupressure points, I always talk about the great position the partner is in for spotting the red, purple or dark line (depending on skin color) that creeps up between the laboring woman's buttocks and how - by 'reading' that line - he or she may be able to assess more accurately the woman's cervical progress than the health care providers! This empowering thought is often met with smiles and laughter especially when I translate 'natal cleft' into more recognizable words like 'butt cleavage'. Strangely, I've never had anyone in class mention having heard of this 'thermometer' for accessing cervical dilation by sight and I find this interesting considering the number of medical professionals that come through my classes.

Photo CC
http://www.flickr.com/photos/alexyra/214829536/

I first came across this body of research as an Antenatal Student Teacher with the National Childbirth Trust in London. The article I was reading was in the Practising Midwife (Wickham S. Assessing cervical dilatation without VEs: watching the purple line. Pract Midwife. 2007 Jan;10(1):26-7. PMID: 17285929.) was a 'look back' at the original article (Hobbs, 1998) published in the same magazine. The original Practising Midwife article was based on a letter referencing a small study by Byrne DL & Edmonds DK published in The Lancet in 1990.

In the 1990 letter to The Lancet, Byrne and Edmonds outlined and graphed 102 observations from eighteen midwifes on 48 laboring women. It states 'The red line was seen on 91 (89%) occasions, and was completely absent in five (10.4%) women and initially absent in three (6.25%).' The report then goes on to talk about the 'significant correlation between the station of the fetal head and the red line length.' Later the authors write: 'To our knowledge, this is the first report of this red line. We believe that it represents a clinical sign which is easy to recognize and which may offer valuable information in obstetric management.' A more

So how does this line work? And why does this it appear? Practising Midwife Magazine presented a graphic which I have attempted to recreate above. Basically as the baby descends, a red/purplish (or perhaps brown depending on skin color) line creeps up from the anus to the top of the natal cleft in between the bottom cheeks. When the line reaches the top of the natal cleft, 2nd stage is probably a matter of minutes away. A line sitting an inch below the natal cleft is probably in transition. A line just above the anus probably signifies early labor.

Byrne DL & Edmonds DK, the authors of the original study, surmise that the cause of the line is 'vasocongestion at the base of the sacrum.' Furthermore, the authors reason that 'this congestion possibly occurs because of increasing intrapelvic pressure as the fetal head descends, which would account for the correlation between station of the fetal head and red line length.' Fascinating and logical!

Interestingly, I came across a 2nd Scottish study from 2010 published by BMC Pregnancy & Childbirth: (Shepherd A, Cheyne H, Kennedy S, McIntosh C, Styles M & Niven C) which aimed to assess the percentage of women in which a line appeared (76%. ) The study cited only 48-56% accuracy of vaginal examinations to determine cervix diameter and fetal station. So why aren't clinicians using this less invasive visual measure - especially considering how much some women may dread vaginal exams in labor?? Wouldn't the thought of using a methodology to lower infection rate after rupture of membranes has occurred motivate Health Care Providers instead of using higher risk techniques? Or how about using the accuracy of the line at the natal cleft to know when a women using epidural should really be coached to push?

My educated guess is that this information has not yet reached Medical Textbooks and non-standard practices can take years to become mainstream (for example. delayed cord clamping) - and then only if or when women request them or media sensation activates them. In addition, since laboring women are only intermittently attended by Labor & Delivery staff during early and active labor and often encouraged to 'stay in bed,' Health Care Providers aren't necessarily faced with a woman's buttocks in labor. Also vaginal examinations are considered 'accurate' so staff has no need to peek between a woman's natal cleft. However both these studies, paired with the roughly 50% accuracy rate of manual vaginal exams, show that there is potentially a more accurate and less invasive way ahead.

In The Practising Midwife (Jan 2007, Vol 10 no 1, pg 27), Lesley Hobbs writes 'Accurate reading would seem to the key to this practice. I sometimes notice in myself a wish to see the line progressing more quickly than it actually does; when I do this - and check with a vaginal exam - only to find the line is right, I get annoyed with myself and wish I'd trusted my observations.' Later she goes on to say 'I can now envisage a time when I shall feel confident enough to use this as my formal measurement mechanism and abandon intrusive and superfluous vaginal exams.'

Licensed Midwife Karen Baker from Yucaipa, CA commented 'The purple line is a curious thing. It's definitely not present on everybody but is more prominent on some than others - especially right before pushing. It tells us when she's in full swing if we are in a good position to spot it!'

I often urge couples to send me a picture of the so called 'purple line' which I promise I will use only for educational purposes but so far a picture is as elusive as the Loch Ness Monster. So, as I say in class, 'show me your purple line'!

Are you a midwife, doctor, nurse or doula who has observed this in a client or patient? Partners, have you seen this when your partner was in labor? Has anyone heard of it or witnessed it? If you are a childbirth educator, do you feel this is something that you might mention in your classes? Do you think that the families in your classes might be likely to ask for this type of assessment if they knew about it? Please comment and share your experiences.

References

Byrne DL, Edmonds DK. 1990, Clinical method for evaluating progress in first stage labour.Lancet. 1990 Jan 13;335(8681):122.

Downe S, Gyte GML, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.

Hobbs 1998. Assessing cervical dilatation without Vaginal Exams. Watching the purple line. The Practising Midwife 1(11):34-5.

About Mindy Cockeram

Mindy Cockeram is a Lamaze Certified Childbirth Educator teaching for a large network of hospitals in Southern California. She has a BA in Communications from Villanova University and qualified as an Antenatal Teacher through the United Kingdom's National Childbirth Trust (NCT) in 2006. A native of the Philadelphia area, she spent 20 years in London before relocating to Redlands, CA in 2010.

Originally published 07/02/2014
Revised 07/23/2026

Regular contributor, Penny Simkin developed the roadmap of labor as a teaching tool. Today, Penny shares how she uses the roadmap of labor to help families in her childbirth classes to understand normal labor from a physiological standpoint. She hopes that her students will take away an understanding of comfort and coping mechanisms along with recognizing the emotions a mother might be experiencing and how a partner can help with both the physical and emotional aspects. Penny is one of the Plenary Speakers at the upcoming Lamaze International/DONA International Confluence scheduled for later this month in Kansas City, MO. Read how Penny, a master childbirth educator, with this handy tool, helps parents understand what to expect during labor and birth. - Sharon Muza, Community Manager, Science & Sensibility

Introduction

Childbirth educators strive to provide timely, accurate, woman-centered information. We adapt our content and teaching methods to the time allowed, and the variety of learning styles, educational levels and cultural backgrounds of our students. We hope to build trust in the normal birth process, and instill the confidence and competence necessary for parents to meet the challenges of childbirth, and also to communicate effectively with their maternity caregivers.

In this paper I describe a teaching aid, the roadmap of labor, and some ideas to help guide parents through normal childbirth, from early labor to active labor, transition, and the resting, descent and crowning-to-birth phases of the second stage. The discussion of each stage and phase includes what occurs, women's and partners' common emotional reactions, and advice on comfort measures and ways to work together to accomplish a safe and satisfying birth.

I do not describe how I teach about routine or indicated interventions, complications, pain medications, or surgical birth. Aside from space limitations, the real reason lies in my firm belief that when expectant parents appreciate the pure unaltered (and elegant!) physiological process of labor, they have more confidence that birth usually goes well, and they may feel reluctant to bypass it (with induction or cesarean) or alter it unnecessarily. Normal labor becomes the clear standard against which to assess the benefits and risks of specific interventions and the circumstances that increase or decrease their desirability.

If I combined the discussion of straightforward labor with complications and common procedures (along with their risks, benefits, and alternatives), parents would have a fragmented and confused perception of childbirth and an almost impossible burden of separating normal from abnormal, and elective from indicated procedures. All these topics must be covered, however, if parents are to participate in their care, whether labor is straightforward or not. Therefore I teach these topics in subsequent classes, using normal birth as the reference point. I also follow this approach in some other writings.1,2

Initiation of labor, the six ways to progress and signs of labor

There are some key concepts that childbirth educators can use to raise parents' awareness and appreciation of events of late pregnancy and normal birth and how they can help the process flow smoothly. Parents need to understand these concepts well, so they can use the roadmap of labor to best advantage, and play a more confident and active role in labor.

For example, before introducing the roadmap, the teacher should inform parents about the hormonally- orchestrated processes in late pregnancy that prepare for birth, breastfeeding, and mutual mother-infant attachment. This is important because teachers face two common challenges: first, parents' impatience to end the pregnancy due to discomfort, fatigue and eagerness to hold their baby; and second, the possibility of a long, discouraging pre-labor phase.

These challenges make parents more accepting of induction or vulnerable to the belief that there is something wrong. Parents need to understand that labor normally begins only when all of the following occur:

• The fetus is ready to thrive outside the uterus (breathing, suckling, maintaining body temperature, and more).
• The placenta has reached the point where it can no longer sustain the pregnancy.
• The uterus is ready to contract, open and expel the baby.
• The mother is ready to nourish and nurture her baby.

If parents understand that fetal maturity is essential in initiating the chain of events leading to labor, they may be more patient with the discomforts of late pregnancy, and less willing or anxious to induce labor without a medical reason.

The six ways to progress to a vaginal birth

Progress before and during labor and birth occurs in many ways, not simply cervical dilation and descent, which is what most people focus on. Labor unfolds gradually and includes six steps, four of which begin weeks before labor and involve the cervix. The cervix moves forward, ripens, effaces and then dilates. When parents understand that a long pre- or early labor is accomplishing necessary progress - preparing the cervix to dilate - they are less likely to become anxious or discouraged that nothing seems to be happening. The two other steps involve the fetus: the fetal head repositions during labor by flexing, rotating, and moulding to fit into the pelvis; and lastly, the fetus descends and is born.

Three categories of signs of labor

By placing these in the context of the six ways to progress, parents may be better able to recognize the differences between pre-labor (often called 'false labor') and labor.

Possible signs of labor

These include: nesting urge; soft bowel movements; abdominal cramping; and backache that causes restlessness. These may or may not continue to the clearer signs of labor and may be associated with early cervical changes.

Pre-labor signs

The most important of these is the first one:

Continuing 'nonprogressing' contractions (that is, over time,the pattern remains the same; they do not become longer, stronger orcloser together)
Possible leaking of fluid from the vagina
Possible 'show' - bloody mucus discharge from the vagina
With these signs, the cervix is probably not dilating significantly, but is likely to be ripening and effacing (steps two and three of the six ways to progress).

Positive signs of labor

The most important of these is the first one:

Continuing, progressing contractions, i.e. contractions that become longer, stronger, and closer together (or at least two of those signs). These progressing contractions cause cervical dilation (steps four and five of the six ways to progress), which is the clinical definition of labor.
Spontaneous rupture of the membranes (SRM), especially with a gush of fluid. This happens before or at the onset of labor in about 8% of women at term.3 It most often happens late in labor. SRM is only a positive sign of labor in conjunction with continuing progressing contractions.

The roadmap of labor

I have created a visual guide to labor progress using the metaphor of a road map. It shows key labor landmarks, and appropriate activities and measures for comfort as labor progresses (see Figure 1).4 Parents can use it during labor as a reminder of where they are in the process and what to do. Teachers can use it as a tool for organized discussion of normal labor progress, and as a backdrop for discussing laboring women's emotional reactions, and how partners or doulas may assist. Health professionals can use it to help parents identify where they are in labor, adjust their expectations and try appropriate comfort measures.

Normal labor pathway

The roadmap portrays three pathways. The main brick road represents normal labor and shows helpful actions, positions, and comforting techniques to use as labor progresses. The twists and turns in the brick road indicate that normal labor does not progress in a straight line; the large turns between three and five-to-six centimeters and between eight and ten centimeters indicate large emotional adjustments for the laboring woman, and present an opportunity to discuss emotional support and comfort measures for the partner or doula to use. After ten centimeters, the woman's renewed energy and confidence are represented by the second wind sign. Along with discussion of emotional support and comfort measures, the teacher can offer perspective and practical advice for partners and doulas, to use both when the woman is coping well and when she feels challenged or distressed.

The roadmap provides a clear and effective way to teach about normal labor. It keeps the discussion focused purely on the physiological and psychological processes, without inserting discussions of pros and cons of interventions, complications, or usual policies and hospital practices that alter labor.

Once parents have a solid understanding of normal labor, the teacher can explain usual care practices and possible options for monitoring maternal and fetal well being during labor. She can also discuss labor variations or complications and treatments with medical (including pain medications), surgical or technological procedures. With this approach, parents are better equipped to discuss risks, benefits and alternatives, because they can distinguish situations and conditions that are more likely to benefit from the intervention from those in which the intervention is optional, unnecessary, or harmful.

Planned and spontaneous rituals

The normal labor road suggests measures to use for distraction, comfort, and progress. Distraction is desirable for as long as it helps. The Relax, Breathe, Focus sign reminds parents to use this pre-planned ritual for dealing with intensifying contractions when distraction is no longer possible. Parents need to rehearse these rituals in childbirth class (i.e. slow breathing, tension release, and constructive mental focus) and use them in early labor. They set the stage for the spontaneous rituals that emerge later in labor (as women enter active labor), when they realise they cannot control the contractions or continue their planned ritual, and give up their attempts to do so, though sometimes after a stressful struggle. Spontaneous rituals replace the planned ones. They are not planned in advance - they are almost instinctual - and almost always involve rhythmic activity through the contractions - breathing, moaning, swaying, stroking, rocking, or even letting rhythmic thoughts or phrases repeat like a mantra.

The three Rs

The spontaneous rituals usually involve the three Rs: relaxation (at least between contractions), rhythm, which is the most important, and ritual, the repetition of the same rhythmic activity for many contractions. In order to give herself over to spontaneous instinctual behavior, the woman needs to feel emotionally safe, uninhibited, accepted unconditionally by partner and staff, and to be mobile in order to find comfort.

The motto 'Rhythm is everything' means that if a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult. The rhythmic ritual keeps her from feeling totally overwhelmed. The goal is to keep her rhythm during contractions in the first stage. Once in second stage, however, rhythm is no longer the key. The woman becomes alert and her spirits are lifted. An involuntary urge to push usually takes over and guides her behavior.

The role of the partner in labor

The partner helps throughout labor, comforting the mother with food and drink, distraction, massage and pressure, assistance with positioning, and constant companionship. Sometimes a doula also accompanies them, providing continuing guidance, perspective, encouragement, and expertise with hands-on comfort measures, positions, and other techniques gained from her training and experience.2

The role of an effective birth partner includes being in the woman's rhythm- focusing on her and matching the rhythm of her vocalizations, breathing or movements - by swaying, stroking, moving hand or head, murmuring softly in her same rhythm. Then, if she has difficulty keeping her rhythm, and tenses, cries out or struggles - as frequently occurs in active labor or transition - her partner helps her get her rhythm back, by asking her to focus her eyes on their face or hand and follow their rhythmic movements. This is the take-charge routine, and is only used if the woman has lost her rhythm, is fearful, or feels she cannot go on. Partners who know about this are less likely to feel helpless, useless or frightened. Simple directions, given firmly, confidently, and kindly ('look at me,' or 'look at my hand'), rhythmic hand or head movements, and 'rhythm talk' with each breath (murmuring, 'Keep your rhythm, stay with me, that's the way...') are immensely effective in helping the woman carry on through demanding contractions. During the second stage, rhythm is no longer important; now the partner encourages her bearing-down efforts and release of her pelvic floor, and also assists her with positions.

The motto 'Rhythm is everything' means that if a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult.

The detour for back pain

A second pathway, a rocky, rough road, represents the more difficult 'back labor', which may be more painful, longer, ormore complicated than the normal labor pathway. Fetal malposition is one possible cause. The measures shown for back labor are twofold: reduce the back pain and alter the effects of gravity and pelvic shape to encourage the fetus's movement into and through the pelvis. It helps a woman endure a prolonged or painful back labor if she and her partner use appropriate comfort measures, and if they know that dilation may be delayed while the baby's head molds or rotates to fit through, or that changing gravity and pelvic shape may give the extra room that the baby needs to move into an optimal position.

The epidural highway

This third pathway represents a dramatically different road - smooth, angular, man- made, more comfortable - but it comes with extensive precautions and numerous procedures, monitors, and medications, which are necessary to keep the epidural safe. The woman adopts a passive role while the staff manage labor progress, and monitors the mother's and fetus's well being closely. The excellent pain relief and chance to sleep are the usual rewards. Discussion of how to work with an epidural in order to optimize the outcome is beyond the scope of the paper, but the basic principle is: treat the woman with an epidural as much as possible like a woman who does not have one! This essentially means, 'Keep her cool. Keep her moving. Keep her involved in the work of pushing her baby out. And don't assume that if she has no pain, she has no distress! Do not leave her alone.'

Conclusion

The roadmap of labor provides a useful framework for teachers to explain the psychological and physiological processes of labor, and a variety of activities for comfort and labor progress for women and their partners to use. By focusing on the normal unaltered process, parents learn to separate the norm from the numerous interventions that alter the process, sometimes for the better, sometimes for the worse. The intention is to give them confidence that they can handle normal labor and to participate meaningfully in decision-making when interventions are suggested.

Do you use the roadmap of labor as a teaching tool in your childbirth classes or with your clients? How do you use it? I would love to hear the innovative ways that you have found to incorporate this valuable tool in your classes. Please share with Penny and all of us in the comments section. - SM

References

1. Simkin P. Moving beyond the debate: a holistic approach to understanding and treating effects of neuraxial analgesia. Birth 2012;39(4):327-32.
2. Simkin P. The birth partner: a complete guideto childbirth for dads, doulas, and all other labor companions. 4th edition Harvard Common Press; 2013.
3. Marowitz A, Jordan R. Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health 2007;52(3):199-206.
4. Simkin P. Road map of labor. Childbirth Graphics; 2003. Available from: www.childbirthgraphics. com/index.php/penny-simkin-s-road-map-of- labor-interactive-display.html

About Penny Simkin

Penny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 11,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2008), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

Copyright © NCT 2014. This article first appeared in NCT's Perspective journal, edition March 2014. http://www.nct.org.uk/professional/research

Originally published 09/01/2014
Reviewed and republished .7/22.2026

There are some fantastic facts about pregnancy, childbirth and their new baby, that when shared, always gets a lot of "oohs" and "ahs" from everyone. Here are my top ten amazing facts about the childbearing year.

1. The placenta is the body's only disposable organ

The placenta is made from the same cells that make the baby - sperm and egg. Some cells differentiate into the baby and others go on to form the placenta. The placenta does its job supporting and nourishing the baby and when it is no longer needed, it is expelled, making it the body's only disposable organ.

2. The Montgomery glands in the areola produce a lubricant that smells like amniotic fluid

Those tiny bumps that people see on their areolas are called Montgomery glands and their purpose is to produce a natural lubricant that protects the nipple and areola. That specialized lubricant smells just like amniotic fluid, which is what the baby has been smelling/tasting for the entire pregnancy. The baby is attracted to the smell of "home" and this helps the baby to navigate to the breast for nourishment after birth.

3. The baby recognizes voices while in utero

The baby becomes acquainted with the voice of the pregnant parent as well as other voices that it is frequently exposed to. If the partner sings to the baby on a regular basis, the baby will soon recognize that distinct voice and song. After birth, the partner can repeat the song they have been singing to the baby in utero and this familiar refrain will be recognized by the baby and help calm and soothe the baby, as well as lower the baby's stress levels.

4. The baby starts labor

Even today, it is still not known exactly how a pregnant person's body starts labor or when it will happen, but recent research has revealed that there are two proteins in the fetus' lungs that are produced when the lungs are mature. These proteins seem to produce an inflammatory response in the uterus that begins the labor process.

5. The full term pregnant uterus is the strongest muscle in the human body

A non-pregnant uterus is the size and shape of a pear. But at full term, that uterus has grown to the size and shape of a watermelon in order to accommodate the mature fetus. At this point, it is the strongest muscle in the human body. It takes a lot of work to dilate the cervix and get that baby out through the pelvis. During the pushing stage of labor, the uterus does about 80% of the work, with the laboring person adding that extra "umph." If a person was unconcious, and in labor, their uterus would still be able to push that baby out without any additional pushing effort from the pregnant person.

6. Amniotic fluid and breastmilk change in taste based on what the pregnant person is eating.

The baby is tasting and swallowing amniotic fluid in utero, and of course drinking breastmilk for nourishment after they are born. The parent's diet influences the "flavor" and taste of both of these liquids. A varied and interesting diet during pregnancy means the amniotic fluid has a variety of different tastes, and the same goes for breastmilk after birth. Eat "around the world" using a variety of foods and seasonings and your baby enjoys the results too.

7. A parent's chest can heat up or cool down depending on the needs of the baby

After birth, when the newborn is placed on the parent's chest skin to skin, the parent's chest area has the ability to flush and heat up or even cool down based on feedback from the newborn's skin and body temperature. This allows the newborn to adapt to maintaining their body temperature with extra help from the parent at the start. Another great reason to have that uninterrupted skin to skin immediately after birth.

8. A 35 week baby's brain weighs just two-thirds of what it does at 39 weeks

The last weeks of pregnancy put the finishing touches on the baby and let it enter the world ready for life on the outside. There is an amazing amount of brain growth that occurs in the last few weeks. The maturing fetus adds another one-third of it's brain weight in those last few weeks, which is why is one of many reasons why it is so important to prevent preterm birth.

9. Squatting opens the pregnant person's pelvic outlet 28%

Changing positions during labor angnd pushing is very important. Doing so allows the baby to move down through the pelvis. When a laboring person squats, they are able to increase the diameter of their pelvic outlet by 28%, which is approximately one to two centimeters.

10. The capacity of a newborn's belly is the size of marble

When babies are born they are usually ready to eat within a very short while. Colostrum, baby's first food, is at the ready and provides everything that the baby needs for nourishment and hydration. Newborns need to eat frequently because their bellies are very tiny. A just born baby's stomach capacity is about five ml, (one teaspoon) which is approximately the size of a marble.

These amazing facts help families to have newfound respect for the magical process of pregnancy, birth and their newborn. Are there amazing facts that you like to share with your classes that I have not included here? Let us know in the comments section below.

Originally published 09/01/2016
Reviewed 07/23/2026

Do you talk about perineal massage with your students, clients and patients and state that perineal massage during pregnancy will/will not reduce tearing during birth? today, Rebecca Dekker, of Evidence Based Birth takes a look at the research on perineal massage during pregnancy and provides information on the outcomes for women who practiced this and those who didn't. Does the research support what you have been saying? - Sharon Muza, Community Manager

Tearing during childbirth is a common occurrence among women who have a vaginal birth. In studies where the use of episiotomies was restricted, the rate of spontaneous tearing was recorded to be anywhere from 44-79% (Soong and Barnes 2005; Dahlen, Homer et al. 2007). Studies have consistently shown that women are more likely to experience tearing during a first vaginal birth and with forceps and vacuum assistance (Aasheim, Nilsen et al. 2011).

Spontaneous tears can be classified as first, second, third, or fourth degree tears. First degree tears involve only the perineal skin, while second degree tears involve both the skin and the perineal muscle. Third degree tears involve the anal sphincter, while fourth degree tears involve the anal sphincter and tissues. Third and fourth degree tears happen at 0.25% to 2.5% of spontaneous vaginal births (Byrd, Hobbiss et al. 2005; Groutz, Hasson et al. 2011).

Women are more likely to have a third or fourth degree tear if they are giving birth vaginally for the first time, if a baby is in the posterior position or has a heavier birth weight, and if forceps, vacuum, or episiotomy are used (Christianson, Bovbjerg et al. 2003; Groutz, Hasson et al. 2011; Hirayama, Koyanagi et al. 2012).

What is perineal massage?

It is thought that massaging the perineum during pregnancy can increase muscle and tissue elasticity and make it easier for a mother to avoid tearing during a vaginal birth. Typically, women are taught to spend about 10 minutes per day doing perineal massage, starting at about 34-35 weeks of pregnancy. Women are taught to insert 1-2 lubricated fingers about 2 inches into the vagina and apply pressure, first downward for 2 minutes, and then sideways for 2 minutes. The massage can be done by the woman or her partner, and sweet almond oil is sometimes used for lubrication (Labrecque, Eason et al. 1999).

What is the evidence for perineal massage?

In 2006, Beckmann and Garrett combined the results from four randomized, controlled trials that enrolled 2,497 pregnant women. Three of these studies involved only women without a previous vaginal birth (mostly first-time moms). One study enrolled women with and without a previous vaginal birth. All four of the studies were of very good quality.

Beckmann and Garrett found that women who were randomly assigned to do perineal massage had a 10% decrease in the risk of tears that required stitches (aka 'perineal trauma'), and a 16% decrease in the risk of episiotomy - but these findings were only true for first-time moms.

It is important for you to understand that this is a 10% reduction in relative risk, and relative risk is different than absolute risk. Let me give you an example. Say you are a first-time mom, and let's pretend your absolute risk of perineal trauma is 50%. A 10% decrease in relative risk means that your absolute risk decreases by 5% (because .5 X .1 = .05). So for you, doing perineal massage reduces your absolute risk of perineal trauma from 50% to 45%.

*As a side note, all of the numbers I am reporting below are changes in relative risk.

Importantly, for second-time moms who had already had a vaginal birth, prenatal perineal massage did not reduce the risk of perineal trauma (any tearing requiring stitches). However, second-time moms who massaged did report a 32% decrease in the risk of ongoing perineal pain at 3 months post-partum.

Surprisingly, Beckmann and Garrett found that the more frequently women used perineal massage, the less likely they were to see any benefits. Women who massaged an average of 1.5 times per week had a 17% reduced risk of perineal trauma and a 17% reduced risk of episiotomy. Women who massaged between 1.5-3.4 times per week had an 8% reduced risk of perineal trauma.

Interestingly, women who massaged > 3.5 times per week experienced NO benefits and had a longer pushing phase of labor by an average of 10 minutes. So basically the finding was: the less frequent the massage, the better off the outcomes. However, this finding was unexpected, and the researchers had a hard time explaining it. I think we should interpret this result with caution, because in the largest clinical trial on perineal massage (included in Beckmann and Garrett's review), Labrecque et al. (1999) found that the more often women did the massage, the more likely they were to avoid any tears.

Other results:

There were no differences between women who did prenatal perineal massage and those who did not with regard to:

• First degree tears
• Second degree tears
• Third or fourth degree trauma
• Use of forceps or vacuum during delivery
• Sexual satisfaction 3 months post-partum
• Pain with sexual intercourse 3 months post-partum
• Uncontrolled loss of urine or bowel movements 3 months postpartum

Wait, I'm confused. You say that there was a significant decrease in perineal trauma requiring suturing. But there was no difference in 1st, 2nd, 3rd, or 4th degree tears. How can this be?

It's important for you to understand that perineal trauma is an 'umbrella' category that means all types of trauma requiring stitches, including episiotomies. Perineal massage during pregnancy decreased the overall risk of perineal trauma (the umbrella outcome), but the effect was too weak to see any difference with each of the individual outcomes (first degree, second degree, etc.). Also, the researchers think that the overall decrease in perineal trauma may have been due to the decreased episiotomy rate in the perineal massage group.

Why would perineal massage during pregnancy reduce the rate of episiotomies, but not tears?

The researchers guess that the women who were trained in perineal massage were highly motivated to birth with an intact perineum, so maybe they were more likely to refuse an episiotomy. Fewer episiotomies would then mean fewer incidents of trauma requiring stitches.

So what can we learn from the evidence?

During pregnancy, massage of the perineum can reduce the risk of tearing requiring stitches, but this benefit is only seen in moms giving birth vaginally for the first time. It is thought that most of the decreased risk of perineal trauma was due to a decrease in the episiotomy rate. In the largest study included in this review (Labrecque et al., 1999), there was an overall episiotomy rate of 38%. In the U.S., 25% of women have an episiotomy during a vaginal birth (Declercq, Sakala et al. 2007), and rates are even lower for some providers. It is possible that these research findings might not apply to birth settings where episiotomies are extremely rare.

Second time moms who use perineal massage will not see any decrease in their risk of tearing, but they may reduce their risk of ongoing perineal pain at 3 months postpartum.

So in summary, for first-time moms only:

Perineal massage during pregnancy

Decreased risk of episiotomy

Decreased risk of trauma requiring stitches

If women choose to use perineal massage during pregnancy, there is no consensus on the amount of massage needed to reduce the risk of tearing.

Questions for discussion: Do you recommend prenatal perineal massage to others? Have your thoughts about this intervention changed after reading this article?

References

Aasheim, V., A. B. Nilsen, et al. (2011). 'Perineal techniques during the second stage of labour for reducing perineal trauma.' Cochrane Database Syst Rev(12): CD006672.

Beckmann, M. M. and A. J. Garrett (2006). 'Antenatal perineal massage for reducing perineal trauma.' Cochrane Database Syst Rev(1): CD005123.

Byrd, L. M., J. Hobbiss, et al. (2005). 'Is it possible to predict or prevent third degree tears?'Colorectal Dis 7(4): 311-318.

Christianson, L. M., V. E. Bovbjerg, et al. (2003). 'Risk factors for perineal injury during delivery.' Am J Obstet Gynecol 189(1): 255-260.

Dahlen, H. G., C. S. Homer, et al. (2007). 'Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial.' Birth34(4): 282-290.

Declercq, E. R., C. Sakala, et al. (2007). 'Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International.' J Perinat Educ16(4): 9-14.

Groutz, A., J. Hasson, et al. (2011). 'Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium.' Am J Obstet Gynecol 204(4): 347 e341-344.

Hirayama, F., A. Koyanagi, et al. (2012). 'Prevalence and risk factors for third- and fourth-degree perineal lacerations during vaginal delivery: a multi-country study.' BJOG 119(3): 340-347.

Labrecque, M., E. Eason, et al. (1999). 'Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy.' Am J Obstet Gynecol 180(3 Pt 1): 593-600.

Soong, B. and M. Barnes (2005). 'Maternal position at midwife-attended birth and perineal trauma: is there an association?' Birth 32(3): 164-169.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca's vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

A few years ago I listened to a really useful InJoy webinar given by CRNA Amy Wehrman on Oral Intake During Labor which is still available for review as part of their ‘Classic Injoy’ series.  In the webinar, Amy recommends eating from the BRAT (bananas, rice, applesauce, toast) diet since these foods are gentle on the stomach and less likely to cause vomiting. Of course, she also points out the lack of evidence-based research for denying people food in the hospital but many educator posts, as well as the release of the Lamaze Infographic (No Food, No Drink During Labor? No Way!), have highlighted this - as well as the need for change. Besides the BRAT diet foods, I have come upon a few studies that highlight some food for thought (excuse the pun) in labor.

Baking Soda (SODIUM BICARBONATE) in Early Labor?

Athletes employ many different food theories and diets to enhance or improve their performance. One of those methods, referred to as a 'buffer', is the use of baking soda (aka sodium bicarbonate). Dissolved in water (0.3g sodium bicarb/kg body weight) and taken roughly an hour before the event allows resistance against muscle exhaustion caused by changes in acid-base balance. Sodium bicarbonate has a proven neutralizing effect on the lactic acid that forms during muscle exertion and improves performance.

In a fascinating study in 2016 out of Sweden and the UK, Wiberg-Itzel, et al, worked together to study the effect of sodium bicarbonate on laboring women whose contractions had become weaker and consequently less effective (dystocic). Two randomized groups of 200 primiparous women in active labor were studied. The first group received no sodium bicarbonate and oxytocin/Pitocin was started immediately (adhering to local clinical guidelines). The second group was each given 4.26g of sodium bicarbonate (using an over the counter aid for indigestion called Samarin which is readily available in Sweden) mixed with 200ml of water an hour before starting oxytocin if no progress in labor was identified.

The results were quite astonishing. 84% of the sodium bicarbonate group went on to have spontaneous deliveries versus 67% of the non-bicarb group. 6.7% of the sodium bicarb group was assisted by vacuum whereas 24.2% of the other group needed vacuum assistance. Newborns from the sodium bicarb group of mothers had overall better outcomes including no APGARS <7. It is quite clear that the sodium bicarb helped the uterus recover from the muscular changes associated with labor exhaustion.

The question remains whether people should consider using sodium bicarb without further studies and if so, how much. The only known downsides of sodium bicarbonate are that it can contribute to stomach upset and water retention and so some may not tolerate it well. Will people be using a sodium bicarbonate product in early labor routinely in future? Do you have any experience using it?

Yogurt, etc.

Over the last few years, the aforementioned BRAT diet has evolved into the BRATY diet with the Y standing for yogurt. One of the reasons I encourage people to eat yogurt during pregnancy is that it may help reduce Group B Strep colonization. Although the evidence is not strong, a small study (Hanson et al, 2014) by) concluded that foods that increase lactobacilli in the pregnant person's diet (i.e. yogurt that contains probiotics like lactobacillus or acidophilus) may decrease the chance of GBS infection. In addition, some of the commonly prescribed practices in pregnancy (laxatives for constipation resulting from iron pills and calcium carbonate antacids to reduce heartburn) and the general stress pregnant women experience put them at far higher risk of killing off their 'good bacteria'.

In labor, any antibiotics received by the pregnant person can deplete their good bacteria. The death of good bacteria also decreases the parent's immunity and increases the likelihood of food allergies in the baby (Love B, et al, 2016) so eating yogurt both during and after labor may help (re)build good bacteria. Yogurt is a super source of protein and calcium and is usually well tolerated, even in people who are lactose intolerant.  There also a small observational study that suggests high serum zinc levels can lower the odds of testing positive for GBS in pregnancy.  Zinc-rich foods include oysters, red meat, shell-fish and fortified cereals. 

Protein Shakes

The 2019 ACOG Committee Opinion on limiting interventions during labor and the 2024 ACOG Clinical Practice Guideline on labor management both statethat oral hydration can be encouraged to “meet hydration and caloric needs, and that routine continuous IV fluids may not be necessary for spontaneously progressing labor”.  Oral hydration includes black coffee, fruit juices without pulp, clear tea, carbonated beverages and sports drinks.

What about a protein shake in labor? After all, protein shakes are used by professional athletes to help increase endurance. In 2013, researchers at the University of Pittsburgh evaluated people who drank a 325ml protein shake (Premier Nutrition) within 15 minutes of receiving an epidural. Their hope was that the protein shake would reduce the incidence of nausea, vomiting, and gastric emptying. Sadly the results did not support their theory as the outcomes were statistically insignificant. The lead researcher Manuel Vallejo Jr, MD did, however, state 'Physicians should feel comfortable replacing ice chips or water with a high-protein liquid supplement when vaginal delivery is expected.'

What the study did highlight, however, was the overall increase in satisfaction from the people allowed the protein shake. Isn't anything that increases a person's satisfaction in labor without increasing adverse consequences worth pursuing?

Xylitol-based chewing gum

This last item is one I recommend people have in their hospital bag 'just in case'. While I hope that the people in my class don't experience a cesarean section, I'm well aware that the cesarean section rate in our local hospitals - more than half of which are unplanned mimic the national average at approximately 32%. After a cesarean section, people in our area are not generally released until they have produced a bowel movement. This can be a particularly stressful thought at a time when healing is paramount. In a 2017 study in the Journal of Maternal-Fetal Neonatal Medicine, researchers Ciardulli, et al reviewed seventeen randomized control trials (representing over 3000 people) to examine the effect of people using chewing gum after a cesarean section. They concluded that: 'Gum chewing starting right after cesarean delivery three times a day for about 30 min (until the first flatus) is associated with early recovery of bowel motility. As this is a simple, generally inexpensive intervention, providers should consider implementing cesarean postoperative care with gum chewing.'

Of course, the next question would undoubtedly be what kind of gum? A recent study from Taiwan (Lee, et al, 2016) specifically examined the effect of the natural sweetener Xylitol in gum. The study used three control groups (gum containing Xylitol, Xylitol-free gum or no gum) to determine whether Xylitol-based gum should be recommended. They concluded 'After cesarean section, chewing gum increased participants' return of bowel activity, as measured by the appearance of bowel sounds and the passage of flatus. In this context, xylitol-containing gum may be superior to xylitol-free gum.' Not only is Xylitol billed as helping to prevent tooth decay, it prompts the mouth to produce more saliva which in turn would start involuntary peristalsis.

Although the studies I read did not talk about specific guidelines for xylitol dosage, I came across a few brands (Pur, Epic Xylitol, Xlyoburst) which carried roughly one gram per serving (serving = one piece of gum) and could be ordered online or found in health food stores. Interestingly, one of the warning labels I read mentioned the possible side effects of exceeding 40-50g of xylitol: diarrhea, borborygmi (rumbling sounds of gas moving through the intestine) colic and increased bowel movements. Of course, these side effects (in moderation) are exactly the reason xylitol based gum can be useful after a cesarean section or any surgery which could impair the intestinal tract.

Food for thought?

Would you feel comfortable sharing the science behind ingesting baking soda and yogurt in labor? How about a protein shake? Would it be useful to discuss xylitol chewing gum for faster recovery of bowel motility following a cesarean section? What do you recommend that people eat in labor? Have you found any foods or fluids that worked well for you or the families you educate?

References:

Ciardulli, Saccone G, Di Mascio D, Caissutti C, Berghella. Chewing gum improves postoperative recovery of gastrointestinal function after cesarean delivery: a systematic review and meta-analysis of randomized trials. J Matern Fetal Neonatal Med. 2018; 31(14):1924-1932.

Hanson L, Vandevusse L, Duster M, Warrack S, Safdar N. Feasibility of oral prenatal probiotics against maternal group B Streptococcus vaginal and rectal colonization. J Obstet Gynecol Neonatal Nurs. 2014 May-Jun;43(3):294-304. doi: 10.1111/1552-6909.12308. Epub 2014 Apr 22. PMID: 24754328.

Jian Tao Lee, RN, PhD, Mei-Hui Hsieh, MS, Po-Jen Cheng, MD, and Jr-Rung Lin, PhD. The Role of Xylitol Gum Chewing in Restoring Postoperative Bowel Activity After Cesarean Section. Biological Research For Nursing. 2015; Vol 18, Issue 2, pp. 167 - 172

Love BL, Mann JR, Hardin JW, Lu ZK, Cox C, Amrol DJ. Antibiotic prescription and food allergy in young children. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology. 2016;12:41. doi:10.1186/s13223-016-0148-7.

Oral intake during labor. ACOG Committee Opinion No. 441. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:714.

Vallejo Jr M. American Society of Anesthesiologists (ASA) 2013 Annual Meeting. Abstract #1066. Presented October 12, 2013.

Wiberg-Itzel E, Wray S, Akerud H. A randomized controlled trial of a new treatment for labor dystocia. The Journal of Maternal-Fetal & Neonatal Medicine. DOI: 10.1080/14767058.2017.133268.

About Mindy Cockeram, LCCE, IBCLC

Mindy Cockeram is a Certified Lamaze Childbirth Educator and IBCLC working with a large hospital chain in Southern California where she's been teaching for 15 years. She trained initially through the UK's National Childbirth Trust in Wimbledon, England. She graduated from Villanova University in 1986 with a bachelor's degree in Communications and a minor in Business Studies. Mindy is the author of four books: Cut Your Labor in Half: 19 Secrets to a Faster and Easier Birth, Pregnant Again? A Childbirth & Breastfeeding Refresher, Breastfeeding Doesn't Have to Suck: Tips, Tricks and Knowledge for a Great Experience and Pump It Up! A Practical Guide to Confident & Efficient Breast Pumping, ". She resides in Redlands, California with her British husband and two children.

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
• Open glottis breathing may cause less perineum damage (Goodlatte, 2024)
• Shorter labor, lower risk of cesarean birth (Isaac, 2023)

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.

Studies have indicated the efficacy of breathing during labor when compared between a group of pregnant persons receiving breathing interventions and a group left without breathing instruction. When participants used breathing techniques, they had a 45% lower risk of ceserean birth, a shorter labor and 1.54 times more chances of vaginal delivery (Isaac, et al., 2023).

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

When to conduct the icebreaker

Using an icebreaker when the class comes together for the first time helps to calm the nerves and jitters that some people may feel when their birth class begins. Start off your class with one of the fun icebreakers below to put everyone at ease. If you are offering a series, consider starting each week with a different icebreaker, so the community continues to grow and become more relaxed during class.

How long to allow for this activity

Icebreakers should be short and sweet, so the facilitator can move on to the learning content. Plan for no longer than 10 minutes at the beginning of class to move through the icebreaker topic you have selected.

How to conduct this activity

Introduce the icebreaker topic to the class. You can have it written on the white board or a sheet of poster paper, or in your slide deck or just verbally share. Ask for a volunteer to go first. After they have answered, invite them to select another person/family to speak. If appropriate and depending on the question, each person in attendance can answer for themselves, or the family can answer as a unit.

If the icebreaker also serves the purpose of collecting resources, consider jotting down the answers to share back with the group after class. If you have a large group, and cycling through everyone will take more time than you feel you can allocate to this activity, break them into subgroups and have them share responses within their smaller circles.

Potential topic questions for your icebreakers

• How did you choose your doctor or midwife and birth location?
• What was the last question you asked your health care provider?
• What qualities do you possess that will make you a great parent?
• What qualities does your partner possess that will make them a great parent (if everyone is partnered in the class)?
• What was your favorite childhood book that you look forward to reading to your own child?
• How do you want to feel after you give birth?
• What is one word or phrase to describe the pregnancy experience so far?
• What is one thing you have done/changed so far because of being pregnant or your partner being pregnant?
• What is the last thing you read about pregnancy, birth or parenting?
• What is the best (or hardest) part of this pregnancy so far?
• Share the wackiest advice you have received on the topic of pregnancy, birth or parenting?
• After sharing with a partner (if partnered), who was the second person you told that you were pregnant?
• Invite everyone to share their name and the details they know about how/why they received that specific name.
• Ask each person (or family) to share two truths and a lie and the others in the class have to guess which is the lie.
• Share the last item purchased or acquired in preparation for the baby’s arrival.

How you can modify this activity

These questions can be asked for both in-person and virtual classes with opportunities to build community in either format. A modification to this activity might be to invite each family to “sponsor” the icebreaker each week by choosing the question for the week from a list of questions you share, providing structure to their selection.

What do families say about starting their childbirth class with an icebreaker?

Many people choose to take a childbirth class not only to receive information to help them feel prepared and confident for what’s ahead, but also to meet and connect with others who are going through shared experiences. Families have shared they appreciate the opportunity to meet and learn about others in the class, and even identify a commonality upon which to potentially build a friendship. They also appreciate something light-hearted when many of the topics discussed can feel big, important and serious.

Conclusion

Do you use icebreakers in your childbirth classes? If you do not, what would make you reconsider this? If you do, what are some of your perennial favorites? Please share in the comments section below so we can all gain some new ideas to start our classes. Also check out these other previous Brilliant Activities for Birth Educator icebreaker ideas.

• Solve the Puzzle of Virtual Teaching
• An Anatomy Icebreaker