Purple Pushing: Why Are We Still Told to Push Like This?
If you've ever watched a birth video, you've probably seen it.
The person is lying back, often with their legs supported. A contraction starts. Someone tells them to take a deep breath, hold it, and push.
“Push! Push! Push!”
Again.
And again.
Until their face is red and they're completely exhausted.
The contraction ends.
Then they do it again.
This is what people often mean when they talk about purple pushing.
It has become such a familiar part of birth that many people assume this is simply what pushing is supposed to look like.
It isn't.
In fact, there are several different pieces of this familiar hospital birth scene that are worth looking at separately: the position you're in, the way you're encouraged to push, and when you're told to start pushing in the first place.
So how did this become the norm?
For much of history, people did not routinely give birth lying flat on their backs.
Upright positions, squatting, kneeling, sitting and using birth stools have all been used across different cultures and throughout history. People often moved, changed positions and worked with their bodies as labour progressed.
The shift toward more recumbent positions happened alongside the development of modern obstetrics and the increasing use of interventions such as forceps.
There isn't one simple moment when someone decided that everyone should give birth on their backs. Instead, birth became increasingly medicalized, and moved into hospitals. The way providers were trained to manage birth influenced the positions that became standard.
A person lying back in bed is also easier for a provider to examine, monitor and assist. It provides convenient access for things like fetal monitoring, vaginal examinations and assisted birth.
Over time, what was convenient for managing birth became what many people came to think of as the normal position for giving birth.
Canadian maternity guidelines actually acknowledge this. They note that health-care providers are likely to promote recumbent positions because they provide convenient access for monitoring and examinations.
The bed also becomes the focus of the hospital room. You arrive, you're shown to the bed, monitors are attached, and lying down can quickly become the default.
That doesn't mean anyone is intentionally taking away your choices. The environment itself can influence what feels like the obvious thing to do.
What does this look like in Canada?
The Canadian Maternity Experiences Survey gives us an interesting picture.
Among women who had a vaginal birth, 47.9% reported lying flat on their backs when their baby was born.
That's almost half of vaginal births.
At the same time, Canadian maternity guidelines recommend supporting people in positions of comfort during labour and birth and encouraging movement and position changes.
So there can be a difference between what guidelines support and what happens routinely.
That difference is worth paying attention to.
Then there's the pushing itself
Lying on your back and being coached through every push are two different things.
Purple pushing generally involves taking a deep breath, holding it and bearing down for an extended period, often while someone counts.
This is also called Valsalva pushing or closed-glottis pushing.
There is another way to approach pushing: Your body is capable of pushing without someone counting to ten.
When you're not being directed through every second of a contraction, you may naturally take breaths between efforts, respond to the pressure you're feeling and push in a way that feels instinctive.
Canadian maternity guidelines specifically recommend encouraging people to follow their instinctive pushing behaviours. They describe spontaneous pushing as waiting for the contraction to build, then pushing several times during the contraction with breaths between efforts.
The same guidelines state that routine provider-directed pushing involving extended breath holding and sustained pushing throughout each contraction is not recommended because there is no proven benefit to doing it routinely and there have been reports of harm.
That doesn't mean coaching is never useful.
Sometimes you may want guidance. Sometimes you may need it.
The important distinction is between supporting someone while they push and assuming that there is only one correct way for them to do it.
What if you have an epidural?
This is where things get a little more complicated. Epidurals can change the experience of the second stage of labour. You may have less sensation and may not feel the same overwhelming urge to push that someone without an epidural might experience.
Canadian guidelines note that epidurals can prolong the second stage of labour and increase the likelihood of forceps or vacuum birth. At the same time, modern low-dose epidurals can allow more mobility than people sometimes realize. An epidural does not automatically mean you have to lie flat on your back either.
Depending on the type of epidural, your hospital's policies and your individual circumstances, you may still be able to move into different positions with assistance.
Side-lying, supported upright positions and other position changes may still be possible. So if you want an epidural, you don't need to think of that decision as automatically choosing between pain relief and movement.
The same is true of when you actually start pushing.
Once your cervix is fully dilated, you don't necessarily have to start actively pushing immediately in every situation.
You may hear terms such as labouring down, passive descent or delayed pushing.
The idea is that contractions can help the baby descend while you wait for the urge to push.
Canadian guidance recognizes delayed pushing as an option in certain circumstances, particularly when there is no urge to push and the baby has not descended sufficiently, as long as the baby's heart rate and the mother's condition remain reassuring.
That doesn't mean waiting is always better. It means there isn't a single rule that applies to every person.
Your baby's position and descent, whether you have an epidural, how you and your baby are doing, and how labour is progressing all matter.
You don't have to push on your back
One of the biggest misconceptions about pushing is that there is one correct position.
There isn't.
You might push:
on your side
on your hands and knees
kneeling
supported in a squat
standing
leaning forward over the bed
sitting upright
semi-reclined
or on your back
You may change positions more than once.
You might start on your side and decide you want to get onto your hands and knees.
You might find that one position feels better for back pressure while another feels better as your baby moves down.
You might end up giving birth in a position you never planned to use.
That's all okay.
Canadian guidelines encourage freedom of movement and support choosing positions that are comfortable during both labour and birth. They also note that upright positions and changing positions can have potential benefits, including helping with comfort, descent and fetal positioning.
Interestingly, Canadian data shows that this freedom of movement isn't necessarily reflected in every birth. While 71% of Canadian hospitals surveyed had a policy stating that the position a woman adopts for birth is her own choice, almost half of women with vaginal births reported giving birth flat on their backs.
Having the option is one thing.
Knowing you can actually use it is another.
What if pushing takes a while?
This is another area of birth where the clock can sometimes become the focus.
There are situations where a longer second stage is reasonable, particularly when the baby is continuing to descend and both the mother and baby are doing well.
If progress is satisfactory, the fetal heart rate is reassuring and maternal assessments are reassuring, continuing the second stage beyond an arbitrary time limit may still result in a vaginal birth without increasing adverse maternal or perinatal outcomes.
That doesn't mean time limits never matter.
It means time is one piece of information, not the whole picture.
A provider can also look at:
Is the baby continuing to descend?
Is the baby's position changing?
Is the fetal heart rate reassuring?
How is the person giving birth doing?
Is there evidence that something isn't progressing normally?
Those questions tell you much more than simply looking at the clock.
Sometimes intervention really is needed
Talking about physiological pushing doesn't mean pretending intervention is never necessary.
Sometimes a baby needs help being born.
Sometimes the baby's position makes vaginal birth more difficult.
Sometimes the baby isn't tolerating labour well.
Sometimes there is a medical reason birth needs to happen sooner.
Vacuum, forceps or caesarean birth can all be appropriate in the right circumstances.
The goal isn't to avoid intervention at all costs.
The goal is to understand why it is being recommended and what is happening in your particular situation.
Canadian data shows that assisted vaginal births have actually declined over time, from 17.4% in 1991/92 to 13.2% in 2015/16. During that period, vacuum-assisted births increased while forceps-assisted births declined.
These tools have an important place in maternity care.
Knowing that doesn't mean you have to assume every recommendation is necessary.
It means you can understand the reason for the recommendation and make decisions based on what is happening in front of you.
So why does purple pushing remain so common?
Part of the answer is simply familiarity. Providers are trained to manage births in particular ways. Hospitals are designed around particular workflows. Epidurals can change sensation. Continuous monitoring can make movement more complicated. Some positions make examinations and interventions easier.
Coached pushing can also feel reassuring to everyone in the room. The provider knows when the contraction is happening. The person giving birth has someone telling them what to do. Everyone has a job. It can feel organized.
That doesn't automatically make it wrong.
It also doesn't make it the only option.
The same is true of pushing on your back. It may be the position you choose. It may be the position you need for a particular medical situation. It may simply be the position that feels best to you.
The problem isn't the position itself.
The problem is assuming you don't have another choice.
What can you actually ask for?
You don't need to walk into your birth with a rigid list of rules about exactly how you will push.
You can't know ahead of time what position will feel best.
You may not know whether you'll have an epidural.
You can't know exactly how your baby's position will affect your labour.
Instead, it can be much more useful to understand your options.
You can ask:
“Can I change positions while I'm pushing?”
“What positions are available with my epidural?”
“Do I need to start pushing right away, or can I wait for the urge?”
“Is there a reason you want me in this position?”
“Can I push with my body's urge rather than being counted through every push?”
“Is my baby tolerating labour well right now?”
“Is there a medical reason we need to change what we're doing?”
Those questions don't mean you are refusing care.
They mean you're participating in it.
You don't have to know exactly how you'll push
You don't need to decide during pregnancy that you'll never accept coaching.
You don't need to avoid an epidural because you're worried you won't know how to push.
You don't need to choose your birth position months ahead of time.
You don't need to prove that you can give birth without help.
You just need to know that pushing isn't one single, predetermined process.
There are choices around position, technique, timing and intervention.
Sometimes you'll have plenty of room to make those choices.
Sometimes you won't.
The important part is knowing the difference.
Because “this is how we usually do it” isn't the same as “this is the only way it can be done.”
You don't need a perfect pushing plan.
You need to understand what is happening, know what options may be available, and feel comfortable asking questions when circumstances allow for them.
This is why birth prep matters.
You don't need to memorize every possible intervention or have a 10-page birth plan.
You need to understand your options well enough to recognize them when they come up.
That's a big part of what I help my doula clients prepare for.
I provide in-person birth doula support throughout Winnipeg, the Interlake and surrounding communities, helping you prepare for birth and supporting you through whatever your labour ends up looking like.
Want to learn more about working with me?
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