At some point during your pregnancy, you’ll likely start wondering about labour and how you’re going to handle the contractions.

Many women focus on making labour playlists and learning techniques for dealing with active labour.

Perhaps you’ll enroll in birth preparation classes that teach breathing and relaxation.

Your partner might learn which pressure points relieve pain and how to perform a double hip squeeze, which provides relief for many a labouring woman.

What few women think about is the pushing stage of labour, which comes after dilation is completed and the baby is ready to come out. In almost every depiction of birth we see the mother sitting or lying down, with a team of people standing around her yelling “PUSH!”.

Purple Pushing / Directed Pushing

Despite what popular shows and movies would like you to think, holding your breath and pushing until you’re purple in the face is not the most effective, comfortable or natural way to give birth. Yet we’re conditioned to accept this as part of normal labour, thanks to the ongoing medicalisation of birth.

What Happens During The Pushing Stage?

Most women will feel some urge to bear down or push as they near full dilation. As your baby’s head presses on receptors in the cervix and later in the vagina, the brain receives the signal to release more oxytocin. This oxytocin surge triggers the strong, expulsive contractions that push out your baby. Known as the Ferguson’s reflex, these contractions are involuntary and can feel powerful and intense.

Some women may not feel the urge to push and others may stop having contractions and fall asleep. Sheila Kitzinger called this ‘the rest and be thankful’ stage. It’s not a failure to progress but your body taking a break and preparing for pushing your baby out. If your baby’s heart rate is good and there are no signs of distress, there’s no hurry.

At this stage of labour (transition) women might feel overwhelmed, lost or afraid. This is largely to do with the increased levels of adrenaline occurring at this time. The adrenaline is present for a reason – to prepare the mother to be alert and ready for her baby’s birth. The adrenaline provides the ability to work with her body, as the powerful pushing contractions bring the baby down into the birth canal. In a natural, undisturbed labour, women often experience the pushing urge as a force that is primal and powerful.

If you’re giving birth in a hospital, it’s not uncommon for the midwife to ask if they can check your cervix to see if you are fully dilated. Often you will be told you can go ahead and push. This ‘giving of permission’ to push tends to cause women to think they must push, whether they feel any urge or not. If women express concern about pushing, their care provider might give them instructions such as: ‘Take a deep breath, hold to ten and push as hard as you can.’ This is known as purple or directed pushing.

What Is Purple Pushing?

Purple or directed pushing has come about thanks to the era of highly medicalised labour and birth. For most of the 1900s, women gave birth in hospitals, lying flat on their backs or with epidurals in place. This limited or inhibited the natural pushing urge.

Doctors had also decided that each stage of labour should only take a certain time, and it was believed that babies who were not born as quickly as possible after dilation would suffer brain damage or die. Unfortunately directed pushing is still a technique used in hospitals around the world, despite the evidence to show it has no benefit for women and babies experiencing normal labour.

Directed pushing requires women to take a deep breath, hold it to the count of ten and push as hard as possible. Another breath is taken, held and the pushing begins again. The woman’s face is very likely to turn a deep red-purple and her eyes may begin to bulge. In some circumstances blood vessels in the eyes may burst.

In most situations women are directed to push during each contraction. If a mother says that she can’t feel the urge to push or isn’t having any contractions (during the restful phase) she might be told to push anyway. Pushing without the urge or without contractions to help is extremely hard work and exhausting. Unless there’s an urgent need for your baby to be born, directed pushing can do more harm than good.

Why You Should Avoid Purple Pushing?

Being instructed to push against your body’s natural instinct does not improve anything for women experiencing a normal labour, with a healthy baby that is not distressed. Effects of purple pushing are:

Increased risk for tearing
Low maternal oxygen levels
Low maternal blood pressure
Exhaustion
Increased likelihood of interventions (episiotomies, assisted delivery, c-section)
Fetal distress
Potential problems with urinary continence after birth.

A review of existing studies showed there is little evidence demonstrating benefits from directed or purple pushing. The authors conclude further research is warranted but state “supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.”

The UK’s peak body The National Institute for Health and Care Excellent (NICE) recommends in their Intrapartum Care Guidelines women should be informed in second stage to be guided by their own urge to push. If women find pushing ineffective or request guidance, strategies to assist the woman can be provided, such as changing position, emptying the bladder, support and encouragement.

Spontaneous pushing during second stage is more likely to be a positive and powerful experience if your care providers support you to be guided by your body. If you and your baby are well and coping, there is no need to force your baby down before your body is ready. Labour is not the time to find out your care provider’s thoughts on the second stage so do some research before your baby’s birth. Discuss birth options, positions, time limits and the sort of support your care provider offers during labour to make an informed decision.

Remember, just because your care provider or hospital has certain policies on labour and birth, the decision is ultimately yours to make. Choosing care providers who view birth as a normal process will help you to feel supported and confident during labour.

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