How to push during labour: when it starts, how your midwife guides you, and breathing tips

You push during the second stage of labour, once your cervix is fully open at 10 cm and you feel a strong urge to bear down, which many women compare to needing to poo. At SGH, the team often lets your baby move down on its own for the first hour or two, then tells you when to start pushing: hold your breath, count to ten, and push with your tummy muscles during each contraction. KKH's midwives, who deliver uncomplicated births in its subsidised wards, advise long, steady pushes and not screaming, which wastes energy. HealthHub says pushing lasts up to an hour or an hour and a half for a first baby, and sometimes only minutes after that. Near the end, your midwife will ask you to stop pushing and breathe out in short pants so your baby's head comes out slowly.

When pushing starts

The second stage of labour begins when your cervix is fully dilated and ends with your baby's birth. Contractions get more intense and you usually feel an urge to push. If you've had an epidural, the NHS says you may not feel that urge at all, and your midwife will tell you when to start.

SGH splits the second stage into two phases:

UK guidance from NICE expects most first babies to be born within three hours of active pushing starting, and later babies within two. In Singapore, SGH and HealthHub say doctors consider an assisted birth if you've pushed for more than an hour, are too tired to push effectively, or have been advised not to push. Our guide to the stages of labour covers what comes before and after.

How to push

Your midwife or doctor coaches you through each contraction, so you don't have to work it out alone. The advice from Singapore's hospitals:

• Wait for a contraction to build, then take a breath, hold it briefly and push down into your bottom with your tummy muscles. SGH describes holding your breath and counting to ten, and HealthHub says your diaphragm helps as you hold your breath for a moment, so the push comes from deep in your body rather than your face.
• Make each push long and steady, because KKH's obstetricians say long pushes help the baby through the birth canal; otherwise, they say, your baby may keep slipping back and take longer to come out.
• Keep your voice for later, since KKH says screaming wastes energy you could put into the push.
• Rest completely between contractions. Sip water if you're allowed, and let your partner sponge your face.
• Push where you feel the pressure, as if you're having a bowel movement. If a little stool comes out, the midwife deals with it quietly.

Directed or spontaneous pushing

There are two styles. In directed pushing, your midwife tells you when and how long to push. In spontaneous pushing, you push when your body tells you to and breathe however feels natural. NICE says that without an epidural, spontaneous pushing may make the second stage shorter, and that for women who've given birth before, a directed push done as you breathe out may shorten the second stage. SGH's description of its active phase is directed pushing. Tell your midwife what's working for you; the aim is a push that moves your baby down.

Pushing with an epidural

An epidural can numb the urge to push. NICE says that if you have one and your baby's head isn't yet visible, pushing can wait up to two hours for a first baby, or one hour if you've given birth before, unless you feel the urge sooner. That waiting time is like SGH's passive phase: your contractions do the work while you rest. For first-time mothers with an epidural, NICE says directed pushing may lower the chance of an unplanned caesarean. Our guide to the epidural and other pain relief in Singapore explains how an epidural is set up.

Positions for pushing

KKH's obstetricians say midwives will help you find a good position as your baby comes down. NICE's guidance:

• Avoid lying flat on your back, which can lower your blood pressure and reduce blood flow to the placenta.
• Without an epidural, upright positions and moving around may help, and may reduce problems with your baby's heart rate and the need for an episiotomy.
• With an epidural, a side position may make a birth without forceps or vacuum more likely.

The NHS suggests you try to sit, lie on your side, stand, kneel or squat; our labour positions guide shows which work with a drip, monitoring or an epidural. If pushing isn't moving your baby, NICE's first suggestions are simple: change position, empty your bladder, and get plenty of encouragement.

Breathing and protecting your perineum

As your baby's head crowns, your midwife will ask you to stop pushing and take short breaths out through your mouth. The NHS explains that this lets the head come out slowly and gives the skin and muscles of your perineum time to stretch. NICE recommends offering a warm wet compress on the perineum once the head starts to stretch it, or massage with a water-based lubricant.

HealthHub says the perineum usually stretches well but may tear. In Singapore, SGH and KKH say an episiotomy, a small cut, may be done to reduce the risk of a serious tear; NICE advises against doing one routinely in a normal birth, so ask your doctor about their approach at an antenatal visit. Our episiotomy guide covers healing and stitch care. The NHS says massaging your perineum in the last few weeks of pregnancy can reduce the chance of needing an episiotomy.

When you might need help

SGH and HealthHub list the usual reasons for an assisted birth with forceps or vacuum: you've pushed for more than an hour, you're too tired to push effectively, or you've been advised not to push. KKH notes that an assisted birth carries a higher chance of a third or fourth-degree tear, which your doctor will check for and repair. After the birth, tell your nurse or doctor if you have heavy bleeding, trouble passing urine or a lot of pain, SGH says.

An antenatal class lets you practise breathing and positions with your partner, and our guides to preparing for labour and the hospital bag checklist cover the rest.

Frequently asked questions

When do you start pushing in labour?

Once your cervix is fully open at 10 cm and you feel the urge to bear down. At SGH the team may let your baby descend for an hour or two first.

How long do you push for?

HealthHub says up to an hour or an hour and a half for a first baby, and sometimes only minutes for later babies. Doctors consider forceps or vacuum if you've pushed for more than an hour and progress has stalled.

How do I breathe while pushing?

During a contraction, take a breath, hold it briefly and push long and steady, as SGH describes. As your baby's head crowns, stop pushing and pant short breaths out through your mouth, the NHS says.

Can I push with an epidural?

Yes. You may not feel the urge, so your midwife guides each push. NICE says pushing can wait up to two hours for a first baby while contractions move your baby down.

What's the best position to push in?

Whatever helps your baby move down, other than lying flat on your back, which NICE advises against. Upright positions can help without an epidural, and lying on your side can help with one.