18. Labor Positions, Pushing Tips, and How to Avoid Perineal Tearing During Birth

Of course you want labor to go as smoothly as possible... So let's dive into my top recommended positions for labor and delivery, how to effectively push despite what your nurse may recommend, and tips to reduce perineal tearing!

• Labor positions matter! Discover how certain positions can help manage contractions, encourage baby's descent, and make pushing a breeze. From side-lying to squatting, I've got you covered! 
•  Trust your instincts! Don't just push because someone tells you to. I'll show you how to listen to your body and find your rhythm during labor and pushing. You've got this! 
•  Take a breather! Pushing takes patience and rest. Learn why taking breaks between contractions can make a huge difference in your birthing journey.
•  Say goodbye to tearing worries! I've got strategies to help you prevent perineal tearing during childbirth. 

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👋 WHO AM I?

Welcome, friends! I am Beth, a certified nurse midwife, doula, and childbirth educator. My philosophy is rooted in autonomy, informed decision making, and positive mindset to help expecting parents plan for a beautiful, stress-free birth. I am here to provide value to YOU through tips and practical advice, either to guide you through pregnancy or to help you prepare for childbirth, postpartum and beyond. There’s no fluff here - only info that adds to your positive experience and saves you stress and uncertainty.

Transcript

Welcome back to episode 18 of Your Birth Bestie podcast! Today we are going to be talking about labor positions, pushing tips, and how to avoid perineal tearing during birth. And let me tell you, this is way better than just a list of tips because I want you to be completely ready for this part of  your labor. I know I wasn’t and looking back it caused so much of my negative feelings towards my first birth. And I’ll talk about my own experiences too and what I’ve found to be the most helpful for the moms I’ve cared for over the years.

But before we get into all of it, let's talk about the power of a natural-minded approach to birth. I know many of you are here because you want minimal medical interventions, and I love that! Birth is a beautiful, natural process, and there are plenty of ways to support it without unnecessary interference. From natural pain management to breathing techniques, we'll explore the benefits of relying on your body's innate abilities and using those to your advantage as we talk about labor, pushing, and avoiding perineal tearing.

And it doesn’t matter if you’re planning a hospital birth or exploring other options, the positions you choose during labor can definitely make such a difference. So, I wanted to talk about some of my favorite positions for each stage of labor, from early contractions to active pushing. Remember, it's all about finding what works best for you and your baby.

As your labor progresses, certain positions can help you manage the intensity of contractions, encourage the baby to descend further in your pelvis, and make pushing more effective. Which are all amazing things for sure! I want to start with my top three favorite pushing positions. And none of them include lying on your back, even though that’s a very common position in the hospital, and that’s intentional! Unless, of course, lying on your back is instinctually what is working for you to cope through labor. I would definitely avoid it otherwise, because there are many other things to try. So, follow your body’s cues first, but explore other options if you’re open to it!

The first position is side-lying.

Lying on either side is great for many women and is probably the most common position I have delivered babies in at the hospital. It’s comfortable for mom because it’s a resting position in the bed after maybe a long labor and she’s tired… but it also gives asymmetry in the pelvis. And it’s really a great position for all stages of labor, but really helps open the outlet of the pelvis with that asymmetry of the femur.

So to do this, lie on either side with your bottom leg straight and a peanut ball supporting your top leg, with your knee comfortably bent up to your chest. Kind of like a lunge but lying on your side and your top leg is being supported by that peanut ball. That’s a really great place to rest in labor even before the pushing stage, making sure to change positions at least every 30 minutes. Even going from one side to the other if that is working for you is great during labor. 

And then for pushing in this position, you can take out the peanut ball, grab your top knee and bring it into your chest–or have your support person help you as well. Not only is this great for opening up the pelvic outlet, but gives you leverage and control to help you push. I’ve found it to be so much more effective than pushing on your back in the bed. 

And I forgot to mention too that it’s great if you choose an epidural. There is no reason you have to labor or push on your back at any time and it could actually be more painful lying on your back and surely take longer to push your baby out, so yeah side-lying is a great option.

My next favorite position is all fours or hands-and-knees.

This was my go to for both my labors. And as a little side story, in my first labor experience, my team of doctors and nurses said I had to push on my back in the bed and I listened for four hours until a vacuum device was needed… and I actually naturally just wanted to be on hands and knees, but I was encouraged to lie on my back… but after four hours, obviously she wasn’t easily coming out their way, and I have no idea why I wasn’t given options or repositioned at all every few contractions. But I had no idea what to do or that there were other options, so I just went with it. It was awful, please don’t do this. Speak up for yourself and hopefully with the ideas from this episode you can do exactly that.

But all fours or being in hands and knees is a great position to relieve back pain and encourage your baby to rotate into the best position for birth. So to do this, you would get on your hands and knees, making sure your wrists are in line with your shoulders and your knees are in line with your hips. You can rock your hips back and forth during contractions to help the baby's head press against the cervix. Also, having your birth partner apply counter-pressure to your lower back if needed can be very helpful.. I can tell you it’s not for everyone though… I am not one that likes to be touched in labor, so I remember being very direct with my nurse when she tried a hip squeeze. I let her do it for one contraction and was like nope don’t do that again please. Ice packs or heat packs are often used in this position too on the lower back if you have back pain and it feels good for you.

The squatting position is also a powerful and ancient birthing position.

It widens the pelvic outlet, giving your baby more space to descend. This is really good too in pregnancy to practice deep squats that will help with your flexibility and can actually help speed up your labor progress when it’s time. To do this in the hospital for example, your nurse can attach a birthing bar to the foot of your bed that can help you support yourself sitting up and squatting with it, using the bar as leverage. Your partner can help support you into a squatting position, from behind, while you’re on the floor as well.

And squatting is great to relax your pelvic floor between contractions to prevent straining and increase the blood flow to the area. Also, by just being in that position and not lying down, you’re using gravity to your advantage and letting your body weight assist in pushing.

And if you’re wondering how the heck you’re supposed to get into a squat or all fours if you have an epidural. While you probably won’t, but you might be able to with the support of your birth team, and actually if baby isn’t tolerating labor well at any point and mom has an epidural, a team of nurses is always there to help reposition mom, which is often into that hands-and-knees position and it works really well.

And as we’re considering positions if you have an epidural, I want to briefly mention another option too…. And that is the semi-sitting position.

The semi-sitting position is great during the pushing phase because it allows gravity to work in your favor. Picture yourself comfortably propped up in kind of like a reclined position, with your back and head supported by pillows. Your knees are bent, and you're holding the back of your thighs as you push. Or you could also try resting your feet in the stirrups on the bed and bringing your knees together while your feet stay outwards. Instead of the normal feet in stirrups and relaxing legs out to the side. This will actually make it easier to push your baby out! Overall the semi-sitting position is great to ease the pressure on your perineum, promote better blood flow to the baby, and use gravity to your advantage, especially when you want to get of your back and are confined to your bed with an epidural.

So, next I wanted to talk about pushing tips during labor. 

So you’re finally found to be 10cm dilated, that’s if you have a cervical check to confirm that (which isn’t required)… or if you’re feeling the urge to push without a cervical exam. Either way is great and I strongly recommend that no matter if you agree to a cervical exam or not, as long as you and baby are doing well, do not push until you feel the urge!

That’s my first tip for sure. Push when you naturally feel the need to. NOT only when you are found to be 10cm dilated and instructed by your doctor to begin pushing at that time. And I know this is the moment you are waiting for, but nobody is in charge of your choice to begin pushing besides you. You’re the only one capable of pushing your baby out, so you have to find it within you to make that happen and it’s so much harder if you’re not ready and don’t feel like you need to push yet.

And this is standard practice in the hospital, to push at 10cm dilated and staff would coach you and tell you when to push and for how long. But I don’t recommend that way. I’d much rather you take that control. Listen to your body: Trust your instincts and follow your body's cues during the pushing stage. Your body knows what to do.

The next super important one that I don’t feel like is ever talked about is having patience and allow yourself to rest! You may push one time, I’ve seen moms literally laugh their babies out involuntarily or vomit and the same things happen, but for the majority of moms pushing will last between 30 minutes and 2 hours. Sometimes several hours longer too as well. So remembering that labor is a marathon, not a sprint is important. You have to allow yourself moments of rest between contractions to regain energy for the next push. So if you have to skip a contraction or two and cannot push, take a break. I’d rather you push really effectively less times, than be really exhausted the entire time and show less effort making you even more tired and pushing lasting even longer. So remember it’s about the effectiveness of the push for sure! Not how many pushes you can get in during the 60 second contraction and not holding your breath for a required 10 second count each time. That can be exhausting and usually ineffective, but some moms do actually prefer this, so you’ll figure out what’s right for you.

Breathing is something I wanted to talk about too… It’s usually not best to have coached pushing or maybe you’ve heard of “purple pushing” during birth. This is when you’re told to take a deep breath in during a contraction, hold your breath, bear down into your bottom, and push for as hard as possible for 10 seconds. Then repeat 2 more times during each contraction. I’d so much rather you first, wait for the urge to push like I mentioned and focus on your breathing. It can be slow, deep breaths to converse your energy and stay centered. Coached pushing is forced and aggressive in my experience, and I don’t like the energy it brings into the labor room. It can be done more gently for sure, but often times it turns into shouting and cheering and it’s very chaotic in my opinion and not my favorite thing. So if you do want someone to count for you, keep this in mind that it doesn’t have to be loud and chaotic. That’s just a side note and kind of a pet peeve of mine to be yelling at women even though I know it’s supposed to be encouraging…

But instead what is really great, is when it’s time to push… take a deep breath in, and as you exhale, direct that energy towards pushing. Your breath is your power for sure, but that doesn’t mean you have to hold it in! Work with this and find your rhythm. Labor can be an intense and challenging process, but don’t forget to find your rhythm and pace yourself. Pushing with steady and controlled efforts can make a significant difference in your experience.

And my last tip is that you might feel nervous or uncertain, or like you have no idea what you’re doing. That’s totally okay and normal and within a few contractions you’ll get into a rhythm! So to feel more empowered and in control during this stage of birth, focus on your breathing, don’t forget to pace yourself, and plan for several positions you would like to try in labor that will hopefully help work with gravity and encourage the baby’s decent, ease pressure on your back and perineum, and feel most comfortable for you.

Okay, so after talking about labor positions and some information on pushing during labor, let’s talk briefly about how to avoid perineal tearing. Let’s face it, nobody wants to tear and experience the short and long term effects of that… so why not talk about how to prevent it or really reduce the severity of a tear!

And this statistic will sound worse than how I want you to think about it, but perineal tearing is a common thing that happens during childbirth, affecting about 90% of moms delivering vaginally. And this includes all tears… not all are severe. In most cases, you can be reassured that many tears are minor and heal quickly with proper care, and often times don’t even need stitches. The perineum is very adaptive and is meant to stretch to birth your baby and thankfully it heals quickly too. But either way, if we can reduce the trauma to that area, we will!

So, you’ve already done the first one just by listening to this episode, which is preparing for the pushing stage. You really want to try for controlled pushing and easing your baby out slowly to allow the tissue to stretch. Sometimes though, you just can’t help it and the fetal ejection reflex kicks in and you follow your body’s cues. As long as it feels natural and you’re in control, this is probably just fine. You can also request for your provider to give you cues of when to slow down and when to kind of pant to gently ease your baby out. Having this reminder can be helpful.

Also, keeping the perineum warm with a warm washcloth during the pushing stage might help reduce tearing. Many providers will apply lubrication during crowing to help as well, so this is an option. 

Perineal massage is something you might have heard about. It can be done at the end of your third trimester by you or with the help of your partner and is done by inserting two fingers with lubricant at the opening of the vagina and moving them from side to side, with slight downward pressure. It can also be done by your provider during labor. BUT to be honest, the research is conflicting whether it helps or not with reducing tearing, but I don’t see anything negative. Unless of course it’s painful, please don’t do that! So it’s really personal preference. It may help a little, but it might not make a difference. 

And my last tip, and most important factor to reducing perineal tearing is to deliver in an upright position or at least not flat on your back. We talked about this before too, but just a reminder it is the biggest factor to reduce perineal trauma, so please consider taking labor positioning seriously! And remember it is common to have some degree of tearing, although with these tips I hope you can get away without any perineal tearing, and remembering your body is designed to handle childbirth. It is not always possible to prevent tearing completely, these tips will help lower the risk.

Thank you so much for tuning in to Your Birth Bestie podcast! If you enjoyed this content, be sure to subscribe to the show and share it with any soon-to-be parents that might love this information too! I am wishing you all the best as you prepare to meet your baby, whenever that may be. And as always, message on Instagram @bethconnors_cnm and let’s chat about how I can help you support your birth goals. See you next time!