Open vs. Closed Glottis Pushing: What to Know Before Birth

If you've started preparing for delivery and you're intending to have a vaginal birth, you've probably been thinking about pushing. When patients come into our clinic for a push prep visit, they typically report feeling a little confused about what that really means. They raise questions like: How will I know if I'm pushing effectively? What if I don't really understand what that means? How will this impact my pelvic floor?

While pushing is natural, I like to describe it the way my friend and lactation consultant Sunayana Weber, IBCLC describes breastfeeding - it’s natural like walking, not breathing. While some people just get it, a lot of us require practice, repetition, and feedback to feel confident.

There's no single right way to push during birth. What matters is knowing your options, feeling confident when you use them, understanding the tradeoffs, and having more than one tool in your toolbox when it's go time.

In this post, we're breaking down the two main pushing techniques, closed glottis and open glottis pushing, the benefits and drawbacks of each, a few strategies to try if pushing stalls, what to expect if you do or don't have an epidural, and how to start practicing before your due date.

What Does "Glottis" Even Mean?

‍Your glottis is the space between your vocal cords. When it's closed, air is trapped in your lungs and chest, which you can use to create downward pressure. When it's open, air flows out as you push. That one difference is what separates these two pushing techniques and it changes how your body generates force, how much energy you use, and how much pressure lands on your pelvic floor.

‍Closed Glottis Pushing (aka "Purple Pushing")

‍This is the technique most people picture when they think about pushing during birth: take a big breath in, hold it, close your glottis, and bear down hard, often coached in a count of 10 seconds, three times per contraction. You can think about directing the pressure as pushing a tampon out.

With this technique, you’re not allowing any air to escape through the glottis which means all of your force generation goes downwards. As with all things in life, there are benefits and drawbacks to this technique.

‍Benefits:

• Generates strong, forceful pressure

• Can be effective for a faster second stage of labor

Drawbacks:

• Energy-depleting, especially over a longer pushing phase

• Places sustained, high pressure on your pelvic floor

If your pushing phase is short, closed glottis pushing may not pose much of an issue. But if you're pushing for an extended period, all that sustained breath-holding and pressure can tire you out and aggravate postpartum symptoms, particularly for folks with pelvic floor laxity.

Open Glottis Pushing

‍With open glottis pushing, you take a breath in and then push while slowly exhaling. In this case, we typically recommend using a low vocalization or a steady breath out through pursed lips rather than holding your breath like in the closed glottis push. The benefits and drawbacks of this technique are flipped compared to those of the closed glottis.

‍ Benefits:

• Less energy-depleting over a long pushing phase

• Less sustained strain on your pelvic floor

‍Drawbacks:

• ‍ Generally considered a less forceful push in the moment

• May take slightly longer to move baby down the birth canal

• May not be an effective technique for someone giving birth vaginally for the first time

One 2022 study found that open glottis pushing may have a protective effect against urinary incontinence in women who are giving birth for the second or more times. Clinically, we also see this technique being beneficial for folks who have struggled with past prolapse symptoms.

‍Neither Technique Is "Better"… They Just Serve Different Purposes

Scroll through birth content on social media and you'll probably see closed glottis (purple) pushing painted as the outdated and even harmful option. It’s often depicted as something to avoid at all costs in favor of "gentler," more "natural" open glottis pushing. But just like all things that are true in health and wellness, it’s not that black and white. Both of these pushing techniques, including the closed glottis push, are tools with a specific job. For a lot of people, particularly those pushing for the first time, both are necessary.

Choosing a pushing technique is less a case of one being better than the other and more a case of each technique does a different job well. Closed glottis pushing can generate the higher force needed to move things along, particularly for primiparous (first-time) birthers who may need that extra push to get baby past the pelvic floor and out. Open glottis pushing conserves energy and can feel more sustainable over a long pushing phase or for people who've already been through birth before. Using both and freely switching between the two based on your needs and the feedback of your birth team, tends to serve people better than committing to just one or the other.

Tips to Improve Pushing Efficacy

If labor is progressing well and baby is descending steadily, there's really no need to change anything you're doing. These tips are for the moments when things stall out, progress slows, or pushing isn’t getting you the outcome you’re looking for. If that's where you find yourself, here are some strategies worth trying:

• Relax your jaw. Your jaw and your pelvic floor tend to mirror each other's muscle tone. A clenched jaw can mean a clenched pelvic floor, which works against you when you're trying to open up and let baby move down.

• Try low vocalizations. Low, open-throated sounds (think low groans or humming) tend to correlate with a more relaxed, open pelvic floor than high-pitched sounds do.

• Use a mirror for biofeedback. This can be especially helpful if you have an epidural and have limited sensation. Being able to see your pelvic floor respond as you push gives you real time feedback you can't rely on feeling for.

• Push with knees in and ankles out. This position can help open the pelvic outlet more effectively than a wide-knee position, giving baby a better path down and out. This can be done in any position - on your side, on your back, or on all fours.

• Place a pillow under your sacrum if you’re on your back. This allows your tailbone and sacrum more room to move out of the way as baby descends, rather than being pinned against a flat surface.

• Try the "tug of war" push. This can be done by holding onto a rebozo, sheet, or your partner's hands and pulling against resistance while you push. This can help you generate more effective downward force. Your midwife, doula or labor and delivery nurse are likely familiar with this technique and can assist you!

• Change positions. Whether or not you have an epidural, shifting positions based on the positions available to you can change the shape of your pelvis and give baby more room to navigate through it.

None of these are a guarantee, but they're low risk strategies to try if you and your birth team feel like pushing needs a little more oomph.

What to Expect: Pushing With vs. Without an Epidural

How pushing feels and how you're coached through it can look pretty different depending on whether you have an epidural, but practicing pushing beforehand can make a huge difference in the moment in either case.

Pushing with an epidural: With an epidural, sensation in your pelvic floor and lower body is reduced or sometimes entirely absent depending on the density of the epidural. This means you likely won't feel the same intense urge to push that often comes with an unmedicated birth. Because of this, pushing tends to be more directed. Your labor and delivery nurse or provider will typically coach you on when to push and for how long, often using a count. This is also where tools like a mirror for visual biofeedback can be especially useful, since you're relying more on what you see and what you're told than what you feel. Practicing pushing ahead of time can also give you the confidence that you know what you’re doing, even in absence of the feeling.

Pushing without an epidural: Without an epidural, most people feel a strong, involuntary urge to push as baby descends. This urge is called the fetal ejection reflex. In this case, pushing is often more spontaneous, your body cues you on when and how hard to push, rather than being coached on a count.

In both scenarios, understanding both techniques ahead of time and practicing them gives you more ability to confidently switch between the two. If you have an epidural, you and your provider can intentionally choose between open and closed glottis pushing based on how labor is progressing. If you're unmedicated, having practiced both means your body has a broader range of tools to draw from, too

Want to Learn More About Push Prep?

‍Watch our free 10-minute guide to push prep here.

‍ And if pushing still feels like a challenge after watching that video, it might be worth working with a pelvic floor physical therapist prenatally. Training your body for birth and setting yourself up for a smoother postpartum recovery is exactly what we specialize in. For some people push coordination comes easy. For others, coordinating your pelvic floor can be a real learning curve. If that’s you - we’re here!

‍Pelvic floor muscle tension, abdominal weakness, and paradoxical breathing patterns can all get in the way of an effective, coordinated push. A pelvic floor PT can help you address these underlying issues during pregnancy so you're optimizing both your birth and your recovery.

Send us a message to learn more about working with our pelvic floor physical therapists in Austin, today!