Open glottis and Closed glottis Pushing
*Note: When necessary (direct quotations from articles or studies), the word woman has been replaced to more accurately reflect our birthing population, which includes trans men and non binary people.*
After every birth I attend, I always learn more and more and am inspired to go home and learn as much as possible to better support my clients.
Our Full Moon brought my first doula baby of 2023 (biggest of congratulations to the family!) and it has led me down a delightfully interesting rabbit hole of research regarding the differences between coached Valsalva style pushing (deep breath, hold it in, bear down like you're pooping) and open glottis pushing (sometimes called gentle pushing or "breathing baby down").
Before we get into it, I want to say that I am NOT a medical professional.
I am a secondary health care professional (RMT) and a full spectrum doula.
I have the utmost respect for our medical teams and believe firmly and kindly in a collaborative environment for our birthing families.
We all bring a special magic to the space and mine is that I KNOW my clients and we have spent weeks/months at building a relationship and learning and preparing for how they want to approach this epic transformational and sacred experience in their lives!
My goal is always, always, always to ensure that they feel empowered, educated and able to make their own decisions regarding their care.
I also recognize when I have more to learn and this birth was no exception!
I realized that I have more work to do in coaching my client's BEFORE labour begins, on the different breathing techniques and positions (I obviously already do but I think more role playing, more practice and more information in the hands of the birthing people is essential).
Let's get to it!
What's the difference between the two? What are the effects of using one or the other? How do we know which to use?
*It's important to note that most of the studies that have been done seem to have a small sample size so I think it's reasonable to call for more research and larger sample sizes. *
Open Glottis Pushing
Push when the urge to push is felt. While pushing, sound or breath may be exhaled.
Less of an impact on blood flow/oxygen to birther=less chance of heart rate changes in baby
Longer pushing time
Journal of Midwifery and Women's Health
Less perineal pain immediately post birth
Egyptian Journal of Health Care, 2022 EJHCVol. 13.No.1
Less risk of pelvic floor/urinary issues 3 months postpartum
International Journal of Obstetrics and Gynaecology
Closed Glottis Pushing
When contraction begins, take a deep breath. Hold it in and bear down. Medical Provider usually tells you when to take a deep breath and do it again. Usually, they are aiming to see 3 pushes per contraction. Often, birther is told to keep breathe in and not make any sounds.
Shorter pushing time.
Increased frequency of "abnormal urodynamics" at 3 months postpartum. Ie: issues with urinary incontinence
ACOG: Approaches to Limit Intervention during Labor and Birth.
"Prolonged pushing and breath holding can cause changes in the maternal cardiovascular system and uteroplacental perfusion."
Taiwanese Journal of Obstetrics and Gynaecology
Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial – the EOLE study
Chloé Barasinskia, AnneDebost-Legrand MD, MPH, FrançoiseVendittelli MD, PhD
The hypothesis of our study was that closed-glottis pushing might be associated with more risks to birthing person* and child, for two reasons. First, its use of high abdominal pressure might induce pressure on the perineum, which in turn would respond by bulging and contracting, due to the myotatic reflex to stretching (Shafik et al., 2003). This perineal pressure may increase the risk of perineal lacerations. Second, closed-glottis Valsalva type breathing might reduce maternal blood pressure and thereby diminish placental perfusion and fetal oxygenation (Barnett and Humenick, 1982)."
Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on birthing person* and fetus: a systematic review of randomised trials
M Prins, J Boxem, C Lucas, E Hutton
Main results Three randomised controlled studies covering 425 primiparous people* met the inclusion criteria. People* who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 people*; relative risk 0.70; 95% CI 0.34–1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in people* who used the Valsalva pushing technique (three studies; 425 people*; mean difference 18.59 minutes; 95% CI 0.46–36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 people*; mean difference respectively 41.50 ml, 95% CI 8.40–74.60, and 54.60 ml, 95% CI 13.31–95.89).
Authors’ conclusion The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed.
Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging birthing people* to choose their own method of pushing should be accepted as best clinical practice.
Obstetrician–gynecologists and other obstetric care providers in the United States often encourage people* in labor to push with a prolonged, closed glottis effort (ie, Valsalva maneuver) during each contraction. However, when not coached to breathe in a specific way, people* push with an open glottis 48. A Cochrane review of eight RCTs that compared spontaneous to Valsalva pushing in the second stage of labor found no clear differences in the duration of the second stage, spontaneous vaginal delivery episiotomy, perineal lacerations, 5-minute Apgar score less than 7, or neonatal intensive care admissions, or duration of pushing 49.
A meta-analysis that included three RCTs of low-risk nulliparous people* at 36 weeks of gestation or more without epidural analgesia found no differences in the rates of operative vaginal delivery, cesarean delivery, episiotomy, or perineal lacerations. However, the study found a somewhat shorter second stage of labor with Valsalva, although confidence intervals were wide (mean difference −18.59 minutes; 95% CI, −0.46 to −36.75) 50. One of these RCTs found an increased frequency of abnormal urodynamics 3 months after giving birth in association with Valsalva pushing 51. The long-term clinical significance of this finding is uncertain.
However, in consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each person * should be encouraged to use their* preferred and most effective technique.
After many hours of reading and listening to podcasts (I highly recommend Evidence Based Birth , especially the Protecting the Perineum series), my take away is this:
ALL birth professionals (doulas, childbirth educators, medical professionals, and more) need to be well versed in BOTH methods so we can effectively inform our clients or patients in how to do BOTH so THEY can CHOOSE which way feels better for them.
Both have their benefits and risks.
It's important to know the WHY behind why people recommend what they recommend. If you are recommending closed glottis, why? If you are recommending open glottis, why? Obviously, your recommendation is different if your goal is to shorten pushing time or if your goal is to protect the long term pelvic floor health, right?
The learning NEVER ends! There are always new studies being done and new perspectives to be exposed to.
Let's all work on more clearly communicating why it is we do what we do.
It makes it a lot easier to have a space of informed choice and autonomous birthing families!
And of course, I'm a human. I have biases. I will never pretend that I don't.
If someone asks my PERSONAL opinion, I will undoubtedly say that I believe that upright positions are better, that a birther directed pushing stage is better and that low risk birthers would often be better off in a birthing centre or at home with a midwife AND I'm also very capable of maintaining my professional ethics of providing non biased care to my clients.
My opinion doesn't matter when it comes to my support.
It's not my job to pretend that I don't have preferences. It's my job to ensure that my client knows that I will:
Provide any and all information that they desire on a variety of subjects related to their pregnancy and labour.
Support them WHOLEHEARTEDLY in whatever THEY choose.
Back them up when needed.
Be focused on evidence based information and education.
As always, my goal is to bring the magic back to our birthing spaces, to foster collaborative working relationships within my community and to improve the care of birthing families! I love you all!
Feel free to comment with which way you pushed your baby out or if you have any questions!