💨 Pushing with Power, Not Pressure: Why “Purple Pushing” Isn’t the Only Way

If you’ve ever watched a birth scene on TV, you’ve probably seen it: a person in labor is flat on their back, legs in the air, holding their breath while someone counts loudly—“1, 2, 3, 4, 5… PUSH HARDER!”

This is what many know as “purple pushing”—a form of directed pushing where you hold your breath and bear down forcefully, often until your face turns red or purple. While it’s a common practice in many hospitals, it’s not necessarily the most supportive, gentle, or effective method for every birthing body.

Let’s unpack what purple pushing is, why it became the norm, the potential drawbacks, and how you can advocate for breath-based, intuitive pushing—whether you’re planning an unmedicated birth or have an epidural.

🌬️ What Is Purple Pushing?

Purple pushing is a Valsalva maneuver—a forceful pushing technique that involves holding your breath, curling your body, and bearing down as hard as possible during each contraction (usually for 10 seconds at a time). It’s called “purple” because many people turn red or purple from the strain.

This style of pushing is often:

• Directed by nurses or providers
  
  

• Timed by counting to 10 (sometimes several times per contraction)
  
  

• Done on the back or in lithotomy position
  
  

• Encouraged regardless of sensation or urge
  
  

🚨 Why Purple Pushing Can Be Harmful

While sometimes medically necessary (e.g., in very fast births, emergencies, or certain fetal positions), routine purple pushing has some potential downsides:

🫁 Decreased Oxygen Flow

Holding your breath and straining may reduce oxygen to you and your baby—especially when repeated many times per contraction.

🧠 Increased Risk of Perineal Trauma

Forced pushing can increase pressure on the perineum and pelvic floor, raising the risk of tearing and long-term pelvic floor issues.

⏱️ Shortened Rest Periods

You may have less time between pushes to rest and recover, increasing fatigue and stress during the second stage.

🧍‍♀️ Less Alignment with Your Body’s Cues

Directed pushing can override your body’s natural urge to push (also known as the fetal ejection reflex), which may make pushing less efficient or more painful.

🤔 Why Is It So Common in Hospitals?

Many providers are trained to use directed pushing as the default. It became widespread due to:

• Routine epidural use (which can reduce pushing sensation)
  
  

• A desire to shorten the second stage of labor
  
  

• Institutional policies around “time limits” for pushing
  
  

• Outdated labor management protocols
  
  

However, newer evidence supports a more physiological, patient-led approach when possible.

🌿 Alternative Pushing Techniques: Breath Is Your Superpower

There are multiple ways to push that work with your body, not against it. These are often referred to as instinctive pushing, exhale pushing, or breath-based pushing.

Here’s what that can look like:

1. 

Exhale (Open-Glottis) Pushing

• You take a deep breath and slowly exhale as you push, making a sound or sighing.
  
  

• You might push several times per contraction, or only once, depending on the urge.
  
  

• There’s no breath-holding or intense bearing down.
  
  

2. 

Fetal Ejection Reflex

• In undisturbed labor, the body may spontaneously begin pushing without effort.
  
  

• This reflex is powerful and often quicker, more efficient, and less painful.
  
  

3. 

Breath-and-Bearing Down Gently

• You can use your breath to “nudge” baby down with each wave, using low vocal tones (e.g., “oooooh” or “ahhhh”).
  
  

4. 

Upright or Side-Lying Positions

• These positions work with gravity and reduce pressure on the perineum.
  
  

• Being off your back can help baby rotate more easily and support a gentler descent.
  
  

💉 Can You Push Physiologically with an Epidural?

Yes! While epidurals can dull sensation, you still have options:

• Ask for “laboring down”: waiting until baby passively descends before pushing.
  
  

• Use side-lying, kneeling with support, or squatting with a bar if movement is possible.
  
  

• Ask for guidance in using breath to push instead of holding your breath and bearing down.
  
  

• If you feel an urge to push—even faintly—you can still follow your instincts and cue your breath to match.
  
  

🗣️ How to Talk to Your Provider

It’s absolutely okay to ask your provider about their approach to pushing before you go into labor. Here are some questions to consider:

• “How do you usually guide pushing in the second stage?”
  
  

• “Are you comfortable with me pushing according to my body’s cues?”
  
  

• “If I have an epidural, can I still labor down and use breathing-based techniques?”
  
  

• “Can I change positions or avoid pushing on my back?”
  
  

And if you’re already in labor:

• “I’d like to try breathing with my pushes instead of holding my breath.”
  
  

• “Please don’t count to 10 for me. I’ll let you know what I need.”
  
  

• “Can we wait until I feel the urge to push?”
  

🌈 Final Thoughts: You Know How to Push

Pushing is an ancient, instinctive act. While your provider may offer helpful support and suggestions, you are the expert on your body’s sensations. You don’t have to hold your breath and turn purple to bring your baby into the world.

Whether you’re unmedicated or have an epidural, you deserve the space and respect to trust your breath, your rhythm, and your baby.

References

1. Roberts, J.E. (2002). The “push” for evidence: Management of the second stage. Journal of Midwifery & Women’s Health, 47(1), 2–15. https://doi.org/10.1016/S1526-9523(02)00204-9
   – Classic article reviewing second-stage labor management and comparing spontaneous vs. directed pushing.

2. Yildirim, G., & Beji, N.K. (2008). Effects of pushing techniques in birth on mother and fetus: A randomized study. Birth, 35(1), 25–30. https://doi.org/10.1111/j.1523-536X.2007.00207.x
   – Found that spontaneous pushing resulted in shorter pushing phases, less perineal trauma, and higher maternal satisfaction.

3. Bloom, S.L., Casey, B.M., Schaffer, J.I., et al. (2006). A randomized trial of coached vs. uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13. https://doi.org/10.1016/j.ajog.2005.06.070
   – Found no significant benefit to directed pushing in terms of delivery time, with spontaneous pushing posing fewer risks.

4. Berghella, V., & Baxter, J.K. (2009). Evidence-based labor management: Second stage of labor. Obstetrics and Gynecology Clinics, 36(2), 327–336. https://doi.org/10.1016/j.ogc.2009.03.004
   – Discusses updated guidelines around delayed pushing and use of breath control.

5. Simkin, P., & Ancheta, R. (2011). The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia. 3rd Edition. Wiley-Blackwell.
   – Offers detailed explanation of purple pushing, breath-based techniques, and fetal positioning in second stage.

6. Brancato, R.M., Church, S., & Stone, C. (2008). Pushing techniques in labor and birth: A review of the evidence. MCN: The American Journal of Maternal/Child Nursing, 33(6), 344–349. https://doi.org/10.1097/01.NMC.0000341253.70613.3d
   – Comprehensive review comparing Valsalva pushing to spontaneous methods, with a focus on pelvic floor and neonatal outcomes.

7. Katz, V.L. (2001). Contemporary management of the second stage of labor. Clinical Obstetrics and Gynecology, 44(4), 801–809.
   – Details the physiology of pushing, including implications of breath-holding and maternal positioning.

8. Hansen, S. (2016). Understanding the fetal ejection reflex. Midwifery Today, Issue 117. https://www.midwiferytoday.com
   – Explores the natural, involuntary pushing reflex that occurs in safe, undisturbed labors.

9. Lemos, A., Amorim, M.M.R., Dornelas de Andrade, A., et al. (2011). Pushing/bearing down methods for the second stage of labour. Cochrane Database of Systematic Reviews, (10):CD009124. https://doi.org/10.1002/14651858.CD009124
   – Cochrane review analyzing outcomes of spontaneous vs. directed pushing techniques.

10. American College of Nurse-Midwives (ACNM). (2012). Position Statement: Support for physiologic birth.
    https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000266/Physiologic-Birth-05-2012.pdf
    – Recommends spontaneous pushing and physiologic labor support as best practice.

11. Simkin, P., & O’Hara, M. (2002). Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186(5 Suppl Nature), S131–S159. https://doi.org/10.1067/mob.2002.123610
    – Includes discussion on pushing positions, breathing methods, and comfort in labor.

12. Walker, D.S., Lannen, B., & Spence, K. (2012). Promoting physiologic birth. Journal of Perinatal Education, 21(4), 230–237. https://doi.org/10.1891/1058-1243.21.4.230
    – Encourages strategies to reduce intervention, including breath-coordinated pushing.