REVIEW

CURRENT
OPINION Methods of pushing during vaginal delivery and
pelvic floor and perineal outcomes: a review

Renaud de Tayrac and Vincent Letouzey

Purpose of review
Over the past 20 years, several randomized studies have compared Valsalva and spontaneous
pushing techniques during vaginal delivery. This review summarizes current medical knowledge
concerning their maternal and fetal consequences, focusing on pelvic and perineal outcomes.
Recent findings
We selected nine randomized controlled trials comparing Valsalva and spontaneous pushing, and a
secondary analysis of a randomized controlled trial comparing different methods of perineal protection. Two
trials showed that spontaneous pushing reduces the risk of perineal tears, but no firm conclusions can be
drawn given the heterogeneity and inconsistent results of these studies. Conflicting results have been reported
regarding the duration of the second stage of labor. Pushing technique does not seem to affect episiotomy,
instrumental delivery or cesarean rates. Maternal satisfaction seems to be better after spontaneous pushing.
Spontaneous pushing appears to have no adverse effects on neonatal well being, and one study showed a
significant improvement in prenatal fetal parameters during the expulsive phase.
Summary
Valsalva and spontaneous pushing techniques currently appear comparable in terms of duration, pelvic
floor, perineal, and neonatal outcomes. In the absence of strong evidence in favor of either technique,
the decision should be guided by patient preference and the clinical situation. Additional, well-designed
randomized controlled trials are required.
Keywords
pelvic floor and perineal outcomes, spontaneous pushing, vaginal delivery, Valsalva pushing

INTRODUCTION during which the woman controls the release of exhaled

A bearing-down reflex has been described during the last
stage of vaginal delivery, characterized by an irrepressible
urge to push. Together with uterine contractions, this
pushing mobilizes the respiratory, abdominal, and perineal
muscles to help expel the fetus. This expulsive reflex is
triggered by pressure exerted on the bladder and rectum by
the descend-ing fetus [1]. Closed-glottis pushing, also
called the Valsalva maneuver, is the technique most
commonly used by midwives and obstetricians to direct
expulsive efforts, despite a lack of evidence. The laboring
woman takes a deep breath at the start of the contraction
and is then instructed to push, with the glottis closed, as
hard as she can for as long as possible, two or three times
during each contrac-tion. This pushing technique is
illogical because, theoretically, it can adversely affect fetal
acid–base balance and fetal brain oxygenation. The
increased intra-abdominal pressure it induces may also
increase the risk of severe perineal tearing. In con-trast,
open-glottis pushing or exhaled pushing,
air, is closer to the physiological situation and to
involuntary or spontaneous pushing, that is the bearing-
down reflex [2,3], but this technique is little used.
Although pregnancy itself causes some perineal
changes, pushing probably has at least a partial role in the
impact of vaginal delivery on the pelvic floor and
perineum, by damaging the muscles, ligaments, and nerves
of the posterior perineum in particular, which can result in
incontinence and pelvic organ prolapse [4–7].
Department of Obstetrics and Gynecology, Care´meau University
Hos-pital, Nimes, France
Correspondence to Dr Renaud de Tayrac, MD, PhD, Department of
Obstetrics and Gynecology, Care´meau University Hospital, Place
du Prof Debre´, 30900 Nimes, France. Tel: +33 466683799;
e-mail: renaud.detayrac@chu-nimes.fr
Curr Opin Obstet Gynecol 2016, 28:470–476
DOI:10.1097/GCO.0000000000000325

www.co-obgyn.com Volume 28 Number 6 December 2016

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Methods of pushing during vaginal delivery de Tayrac and Letouzey
KEY POINTS
The expulsive phase of delivery could be managed
either by the technique of closed-glottis pushing,
also called the Valsalva maneuver, which is quite
well standardized, or by open-glottis pushing, or
exhaled pushing, often called spontaneous pushing
in the literature. Unfortunately, this second
technique is currently not standardized.
Although several studies have pointed out a potential
reduced rate of perineal tears with open-glottis
pushing techniques, no definitive conclusions could
be drawn for clinical practice.
Before more evidence is obtained, patient preference
and clinical situations should guide decisions
regarding the choice of pushing technique at the time
of vaginal delivery.
Because improved techniques and technologies have
led to a decline in both maternal and neonatal mortalities,
more attention can now be paid to preventing pelvic floor
and perineal injuries associated with childbirth that, in the
long term, can be truly disabling for women [8]. Directed
push-ing is potentially one of the modifiable risk factors
for subsequent pelvic floor and perineal dysfunction
[9]. No clinical practice guidelines have yet been
published on pushing techniques during childbirth, yet
thousands of vaginal deliveries occur every day.
The aim of this review is to evaluate the pelvic floor
and perineal outcomes, as well as other possible maternal
and fetal outcomes, associated with differ-ent methods of
pushing during vaginal delivery.
We searched PubMed, The Cochrane Library, and
EM-Premium (in French and English) for articles
published between 1984 and 2016 using the follow-ing
keywords: pushing methods, bearing-down methods, type
of pushing, spontaneous pushing, Valsalva pushing,
directed pushing, second stage of labor, expulsive phase of
labor, maternal and fetal outcomes, vaginal delivery,
postpartum uri-nary incontinence, pelvic floor disorders,
perineal trauma, and fetal well being.
Of the 29 articles analyzed, we selected all nine
randomized studies that compared Valsalva pushing with
open-glottis pushing, three of which were combined in a
meta-analysis. Spontaneous open-glottis pushing was used
in some of these studies, while others used a coached open-
glottis pushing technique. A 10th study was analyzed,
which was actually a secondary analysis of a randomized
trial to compare different perineal protection techniques
(warm compresses, massage, and manual protec-tion). The
10 studies analyzed are summarized in
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Table 1, including a description of the type of open-glottis
pushing used in each.
MATERNAL CONSEQUENCES OF THE
DIFFERENT PUSHING TECHNIQUES
Duration of the second stage of labor
The second stage of labor is defined as the period from full
dilation to birth. In three studies [10–12], the second stage
of labor was significantly shorter with open-glottis
expulsion. In the study by Jahdi et al. [10], which included
191 women, the open-glottis method shortened the second
stage of pri-miparas by 10 min and of multiparas by 8 min.
The study by Yildirim and Beji [11] in 100 women also
showed a 10-min reduction in the duration of the second
stage of labor, and a 6-min reduction in the duration of the
expulsion phase. For the 350 women studied by Parnell et
al. [12], the second stage was shorter in women who
exclusively used open-glottis pushing, but not in those who
alternated between both methods. In contrast, in the meta-
analysis performed by Prins et al. [9] of three randomized
trials, including a total of 425 women, open-glottis pushing
prolonged the second stage of labor signifi-cantly, by
nearly 19 min. In the two other trials that analyzed this
parameter [13,14], there was no significant difference
between the two groups. In summary, there is conflicting
evidence on the effect of pushing technique on the duration
of the second stage of labor.
Delivery technique
None of the studies found an influence of pushing
technique on delivery technique, that is the incidence of
instrumental and cesarean delivery [9–11,14].
Oxytocin use and risk of postpartum
hemorrhage
No significant association was reported between pushing
technique and oxytocin use during labor or the incidence of
postpartum hemorrhage [11].
Pelvic floor and perineal outcomes
Several studies found no association between push-ing
method and the incidence of perineal tears (all grades
combined) during fetal expulsion [9,11,12]. However, in
their secondary analysis of a random-ized trial in 1176
women, Albers et al. [15] observed a significant reduction
in the risk of perineal tears (all grades combined) in
primiparas who used the
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Women’s health
Table 1. Methodology and results of the selected studies comparing spontaneous and Valsalva pushing

Significant results Nonsignificant results

Author, year of Definition of spontaneous (spontaneous vs. (spontaneous vs.
publication Type of study n pushing subgroup details Valsalva pushing) Valsalva pushing)
com.obgyn-co.www

Low (2013) Randomized 249 women Randomized to four groups: Postnatal UI: mean worsening of the UI
included 12- first, standard closed-glottis score 0.35 2 vs. 0.84 1.9
Copyright .reservedrightsAll.IncHealth,KluwerWolters2016

month follow-up or coached pushing (P ¼ 0.57); perineal massage had no

for 145 women (n ¼ 39); second, prenatal
perineal massage then
closed-glottis or coached
pushing (n ¼ 34); third,
spontaneous pushing
(n ¼ 32); four, prenatal
perineal massage then
spontaneous pushing
(n ¼ 40)
Prins (2011) Meta-analysis of 425 Continuous or intermittent
three randomized open-glottis pushing. None
trials (Thomson, of the women in these three
1993; Lam, studies received epidural
2006; Bloom, analgesia
2006)
Jahdi (2011) Randomized 191 Spontaneous pushing ¼ push
when the woman felt the
bearing-down reflex, no
specific instructions
Number28Volume 6
The second stage of labor was 18.6 min
longer with spontaneous pushing [95%
CI: 0.46–36.73] (P ¼ 0.04)
Duration of the second stage of labor shorter Cesarean rate 2 vs. 1.1% (P ¼ 1); Apgar
with spontaneous pushing: 47.4 36.8
vs. 57.1 33.1 min (P < 0.0001) in
primiparas and 26.1 23.4 vs.
effect: mean worsening of IU score
0.13 1.6 vs. 0 (P ¼ 0.57); duration
of the second stage of labor:
151.7 133.3 vs. 131.1 91.1 min
(P ¼ 0.47); vaginal deliveries: 24
(68.6%) vs. 31 (86.1%) (P ¼ 0.25)
Rate of instrumental or cesarean delivery:
RR ¼ 0.7 [95% CI: 0.34–1.43]
(P ¼ 0.33); rate of perineal tearing:
RR ¼ 0.95 [95% CI: 0.64–1.40]
(P ¼ 0.79) or episiotomy RR ¼ 0.79
[95% CI: 0.53–1.19] (P ¼ 0.26); 5-
min Apgar < 7: RR ¼ 0.35 [95% CI:
0.01–8.43] (P ¼ 0.51); umbilical
venous and arterial pH: RR ¼ 0.00
[95% CI: 0.22 to 0.22] (P ¼ 1.00);
risk of admission to neonatal intensive
care unit: RR ¼ 0.83 [95% CI: 0.40–
1.75] (P ¼ 0.63)
score <7: 0 vs. 2.2% (P ¼ 0.22) at
1 min, 0 vs. 1.1% (P ¼ 0.29) at 5 min

(n ¼ 100). Valsalva pushing 33.2 22.8 min (P < 0.0001) in

(n ¼ 91) multiparas
Yildirim (2008) Randomized 100 Spontaneous pushing ¼ open- Duration of the second stage of labor shorter Nonreassuring fetal status: 4 vs. 18%
glottis pushing (n ¼ 50). with spontaneous pushing: 40.8 19.1 (P ¼ 0.08); increased doses of
Valsalva pushing (n ¼ 50) vs. 50.1 26.3 min (P ¼ 0.045) and oxytocin during fetal expulsion: 6 vs.
© shorter expulsion phase: 9.6 5.5 vs. 8% (P ¼ 1); episiotomy rate: 78 vs.
14.8 7.5 min (P ¼ 0.001); higher Apgar 58% (P ¼ 0.17); umbilical pO2
scores: 7.9 0.6 vs. 7.3 0.8 19.7 5 vs. 20.2 8.8 (P ¼ 0.8) and
(P ¼ 0.001) at 1 min and 9.9 0.3 vs. pCO2 46.5 7 vs. 48.5 8.9
2016December

9.5 0.6 (P ¼ 0.001) at 5 min; (P ¼ 0.2); PPH rate: 8 vs. 12%

improvement in maternal satisfaction score (P > 0.05)
(P < 0.01)
1040-
Table 1 (Continued)
Significant results Nonsignificant results
Author, year of Definition of spontaneous (spontaneous vs. (spontaneous vs.
Wolters2016Copyright872X

publication Type of study n pushing subgroup details Valsalva pushing) Valsalva pushing)

Albers (2006) Data taken from a 1176 Spontaneous pushing or Reduced incidence of perineal tears in
randomized trial Valsalva pushing 26% of primiparas with spontaneous pushing by
comparing primiparas and 16% of multivariate analysis (RR 1.65; 95% CI
Copyright

different perineal multiparas used Valsalva 1.05–2.59)

protection pushing
techniques (warm
compresses,
massage, and
manual
rightsAll.IncHealth,Kluwer

protection)
Wolters2016

Schaffer (2005) Randomized 128 Continuous or intermittent Increased FBC after spontaneous pushing: Maximum urethral closure pressure;
open-glottis pushing. None 482 137.7 vs. 427 94.4 ml (P ¼ 0.05) maximum urinary flow; detrusor
of the women received and increased first urge to void: overactivity; urodynamic UI: 11/67
epidural analgesia. 202 104.1 vs. 160 84.9 ml (P ¼ 0.03) (16%) vs. 7/61 (12%) (P ¼ 0.42)
Urodynamic testing was
performed 3 months after
delivery
©
Women’s health
open-glottis technique, with a significant relative risk (RR)
of tearing after Valsalva pushing of 1.65 [95% confidence
interval (CI): 1.05–2.59] in multi-variate analysis. Simpson
and James [14] also found significantly fewer perineal tears
(all grades com-bined) with open-glottis pushing. Pushing
method did not, however, affect episiotomy rates [9,11,12].
Urodynamic testing of 128 patients, 3 months after
delivery, showed that Valsalva pushing adversely affected
bladder capacity and first urge to void [16]. This study
found no difference, however, in urethral closure pressure,
urinary flow, or the onset of detrusor overactivity or
urodynamic urinary incontinence. Another study found no
effect of pushing technique on postnatal urinary
incontinence [13].
Maternal satisfaction
The only study that investigated this parameter found that
open-glottis pushing was associated with a higher maternal
satisfaction score [11].
FETAL CONSEQUENCES OF THE
DIFFERENT PUSHING TECHNIQUES
Fetal heart rate abnormalities
A single study, including only 45 patients, showed that
open-glottis pushing significantly reduced fetal heart rate
(FHR) abnormalities, accompanied by a reduction in fetal
oxygen desaturation and fewer episodes of desaturation
below 30% for longer than 2 min [14]. Another study
found no effect on the incidence of nonreassuring fetal
status in 100 deliv-eries [11].
Apgar score
Pushing technique did not affect the Apgar score in three
studies [9,10,14]. However, 1-min and 5-min Apgar scores
were significantly higher after open-glottis pushing in
Yildirim and Beji’s study [11].
Other measures of neonatal well being
No difference was found between the two pushing
techniques in terms of umbilical artery pH, pO 2 and pCO2
[9–14] or rates of admission to a neonatal intensive care
unit [9].
DISCUSSION
Although a considerable number of randomized studies
have been published on this topic, often with large sample
sizes, it is still not possible to
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conclude that one technique is preferable to the other. One
reason for this is the variety of open-glottis pushing
techniques adopted. Spontaneous pushing was used in
some cases, that is women were not asked to hold their
breath while pushing but neither were they instructed to
exhale as they pushed [10,13–15]. In other studies, women
were asked to breathe out as they pushed, but could exhale
continuously or intermittently [9,11,16]. In one study, a
combination of open-glottis and closed-glottis (Valsalva)
pushing was used [12]. Finally, in some studies, pushing
began at different times in the two arms, with Valsalva
pushing initiated as soon as full dilation was diagnosed,
while open-glottis pushing was only initiated when the
woman felt the urge to push [10,14].
Most of the studies, however, took steps to avoid
potential bias from the influence of epidural anal-gesia, in
particular on the duration of the second stage of labor, by
enrolling exclusively users [14] or nonusers [9,16] of
epidural analgesia.
Another potential source of bias is that these articles
generally failed to specify whether the women had attended
antenatal classes, or whether these classes had addressed
breathing techniques. This is probably a crucial factor,
because the open-glottis technique can be learned and is
probably less effective when discovered for the first time at
the end of labor than after one or more specific training
sessions during the antenatal period. Such prep-aration is
all the more justified in light of the satis-faction expressed
by women after using this technique [11]. Nevertheless, not
all women may want or be able to use this pushing method.
The methodological issues, described above, probably
explain the conflicting results on the duration of the second
stage of labor obtained from the various studies. Yet this
parameter directly influ-ences the risk of perineal tearing
during vaginal delivery, and several studies have shown
that the risk of severe perineal tears increases significantly
when the second stage is prolonged (beyond 1 h for
multiparas without epidural, 2 h for multiparas with
epidural and primiparas without epidural, and 3 h for
primiparas with epidural) [17–21]. Prolonged expulsive
effort is also a risk factor for anal incon-tinence several
years later [22].
Two studies showed that open-glottis pushing
significantly reduces the risk of perineal tears (all grades
combined) independently of second-stage duration [14,15].
In the first study, the result was only significant among
primiparas, which is of particular clinical interest because
primiparity is an independent risk factor for severe (grades
3 and 4) perineal tears. Spontaneous pushing was used in
both of these studies. In contrast, in the two
Volume 28 Number 6 December 2016
 Methods of pushing during vaginal delivery de Tayrac and Letouzey
studies that examined the influence of open-glottis pushing
on the perineal tear rate (all grades com-bined), including
Prins et al.’s meta-analysis, no effect was demonstrated
[9,11].
Partial evidence for the potentially adverse effect of
Valsalva pushing on postnatal perineal function was
obtained in a single study, in which urodynamic studies
performed 3 months after deliv-ery demonstrated a
significant decrease in both functional bladder capacity and
first urge to void, but no significant detrusor overactivity,
sphincter incompetence, or stress incontinence [16].
Further evidence of the relationship between open-
glottis pushing and perineal protection is pro-vided by two
studies conducted in a nonobstetric setting, on the use of a
novel method for strength-ening the abdominal and
perineal muscles (ABDO-MG) in the treatment of urinary
incontinence in women [23] and in men [24]. The ABDO-
MG device consists of a mouthpiece to restrict the
exhalation rate, coupled to an abdominal electrical nerve
stimulation unit. Both studies found improved abdominal
muscle strength (of potential value in childbirth), no pelvic
floor or perineal adverse effects, and significant
improvement in urinary incontinence in both sexes [23,24].
Finally, apart from a single study with low stat-istical
power, Valsalva pushing has not been shown to adversely
affect fetal acid–base balance or fetal brain oxygenation.
A recent Cochrane review was also published on the
type of pushing, comparing ‘Valsalva Manoeuvre’ vs. all
other pushing techniques [25 ]. Seven studies (815 women)
& adapt to the existence and type of antenatal prep-aration
comparing spontaneous pushing vs. directed pushing, with
or without epidural analgesia were analyzed. Overall, for
this comparison there was no difference in the duration of
the second stage (mean difference 11.60 min; 95% CI 4.37
to 27.57). There was no clear difference in perineal
laceration (RR 0.87; 95% CI 0.45–1.66) and episiotomy
rate (RR 1.05; 95% CI 0.60–1.85). The primary neonatal
outcomes such as 5-min Apgar score less than 7 was no
different between groups (RR 0.35; 95% CI 0.01–8.43),
and the number of admissions to neonatal intensive care
(RR 1.08; 95% CI 0.30– 3.79) also showed no difference
between spon-taneous and directed pushing and no data
were avail-able on hypoxic ischemic encephalopathy. The
duration of pushing (secondary maternal outcome) was 5
min less for the spontaneous group (95% CI 7.78 to 2.62).
The authors have concluded that in the absence of strong
evidence supporting a specific method of pushing, patient
preference and clinical situations should guide decisions.
In the same review [25 ], the timing of pushing was
&
also studied, comparing delayed pushing
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
(which begins after the urge to push is felt) vs. immediate
pushing (which begins as soon as full dilatation has been
determined). For the primary maternal outcomes, delayed
pushing was associated with an increase of 54 min in the
duration of the second stage of labor (95% CI 38.14–
70.43), and there was no difference in perineal laceration
(RR 0.94; 95% CI 0.78–1.14) and episiotomy rate (RR
0.95; 95% CI 0.87–1.04). Delayed pushing was also
associated with a 20-min decrease in the duration of
pushing (95% CI 36.19 to 4.02) and an increase in
spontaneous vaginal delivery (RR 1.07; 95% CI 1.03–
1.11). For the primary neonatal outcomes, there was no
difference between groups in admis-sion to neonatal
intensive care (RR 0.98; 95% CI 0.67–1.41) and 5-min
Apgar score less than 7 (RR
0.15; 95% CI 0.01–3.00). There were no data on hypoxic
ischemic encephalopathy. Delayed push-ing was associated
with a greater incidence of low umbilical cord blood pH
(RR 2.24; 95% CI 1.37– 3.68) and increased the cost of
intrapartum care by $68.22 (95% CI 55.37, 81.07).
CONCLUSION
Our current knowledge of these two methods of pushing
during the expulsive phase of vaginal deliv-ery suggests
that they produce similar outcomes in terms of second-
stage duration, the risk of perineal tearing, and neonatal
status at birth. The data cur-rently available already justify
the inclusion of different pushing techniques in clinical
practice, although midwives and obstetricians will need to
received by their patients. Appropriately designed studies
are still required, in order to pro-vide a sufficiently strong
evidence base for the development of clinical practice
guidelines.
Acknowledgements
None.
Financial support and sponsorship None.
Conflicts of interest
There are no conflicts of interest.
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This review is the only available analysis of the literature on this subject.
Volume 28 Number 6 December 2016