Should You Purple Push for Birth?

You've been preparing for this moment for months. You've done the prenatal yoga, read the books, toured the hospital, and packed your bag. But when your provider says "take a big breath in, hold it, and push" — do you actually know what's happening to your body? And more importantly, do you know whether that instruction is right for you?

This is a question that doesn't get nearly enough airtime in birth prep conversations, and as a pelvic floor physical therapist in Kansas City, it's one I talk about with almost every single one of my prenatal clients. Because here's the truth: the way you push matters — and not every pushing technique works for every body.

In this post, we're going to break down:

• What "purple pushing" actually is (and why it's named that)

• The difference between a Valsalva maneuver (breath-holding) and bearing down

• What open glottis pushing is and why it's a great third option

• How your pelvic floor responds to each technique — and why that changes everything

• How to practice and feel the difference before you're in the delivery room

This isn't just theory — it's practical, evidence-based information you can actually use. Let's get into it.

What Is Purple Pushing and Where Did It Come From?

The term "purple pushing" refers to directed pushing where you hold your breath, bear down with maximum effort, and push for a count of ten (often multiple times per contraction). The "purple" comes from the literal color your face turns from the effort and lack of oxygen.

This technique became standard practice in hospital birth settings largely for logistical and historical reasons — it was easier for providers to manage and time. But in recent decades, the research has started to catch up, and what we're finding is more nuanced than "push hard, hold your breath."

The physiological mechanism behind purple pushing is called the Valsalva maneuver — a forced expiratory effort against a closed airway (meaning: you hold your breath and strain). And while this can generate significant intra-abdominal pressure, what it does to your pelvic floor is the critical piece of the puzzle.

The Valsalva Maneuver: When Holding Your Breath Works Against You

Here's where pelvic floor physical therapy education becomes absolutely essential for birth prep.

When you perform a Valsalva maneuver — holding your breath and straining — your pelvic floor can respond in one of two very different ways:

• It can lengthen and descend (what we want for pushing a baby out)

• It can brace, stiffen, or even lift upward (the opposite of what we need)

If your pelvic floor cannot lengthen with a Valsalva, you are pushing against resistance. You're essentially trying to push a baby out while your pelvic floor is holding the door shut. This can contribute to prolonged second-stage labor, increased risk of perineal tearing, and excessive strain on pelvic structures.

Research published in the International Urogynecology Journal has highlighted that directed Valsalva pushing is associated with greater decreases in pelvic floor muscle strength postpartum compared to spontaneous pushing techniques. The evidence increasingly supports an individualized approach rather than defaulting to one-size-fits-all directed pushing. (Schaffer JI et al., PubMed Central)

The takeaway: Valsalva pushing is not inherently wrong — but it is only appropriate if your pelvic floor can actually lengthen during it. And most women have never checked.

Bearing Down: When Holding Your Breath Can Actually Work

Here's an important distinction that often gets lost in the purple pushing debate: holding your breath is not automatically bad. The problem isn't the breath-holding itself — it's whether your pelvic floor is lengthening in response to it.

Bearing down — also sometimes called a "downward push" — involves a similar increase in intra-abdominal pressure to the Valsalva, but with a key difference: the pelvic floor actively lengthens and descends, opening space for the baby to move through. When this happens, breath-holding or a sustained push can actually be an effective and efficient pushing strategy.

Think of it like this: the Valsalva is pushing against a locked door. Bearing down — when your pelvic floor is cooperating — is pushing through an open one.

So how do you know if you're one of the moms who can use this technique effectively? You have to actually check. Which is exactly what we do in birth prep sessions at enCORE Therapy.

Open Glottis Pushing: A Powerful Alternative Worth Knowing

Open glottis pushing is exactly what it sounds like: pushing while keeping your airway open — breathing out, exhaling, or making a sound while you push. No breath-holding involved.

This technique has gained significant attention in the research literature as a gentler, potentially more physiologically aligned way to push. A landmark Cochrane Review found that spontaneous (open glottis) pushing was associated with fewer abnormal fetal heart rate patterns compared to directed Valsalva pushing, and some studies suggest it may reduce perineal trauma. (Lemos A et al., Cochrane Library)

Open glottis pushing tends to be more instinctive — many moms naturally grunt, moan, or exhale during contractions. It also tends to feel more sustainable over a long pushing stage, because you're not depleting your oxygen supply with every effort.

From a pelvic floor standpoint, exhaling while pushing can actually facilitate pelvic floor lengthening naturally, making it a strong option for moms who find that their pelvic floor tends to tighten or brace under pressure.

Valsalva vs. Bearing Down vs. Open Glottis: They Are NOT the Same Thing

Let's make this crystal clear, because this is where even well-meaning birth educators sometimes blur the lines:

• Valsalva = breath-held, closed glottis, straining. Pelvic floor may OR may not lengthen. If it doesn't, you're working against yourself.

• Bearing down = similar pressure increase, BUT pelvic floor actively lengthens and descends. Breath may be held or partially released. This is productive pushing.

• Open glottis = exhale-based, no breath-holding, airway open. Often facilitates pelvic floor lengthening automatically. More physiologically aligned for many women.

These are three distinct neuromuscular patterns. Your body might do one of them really well and another terribly, and you won't know until you actually explore it. This is a core part of why pelvic floor physical therapy and birth prep go hand-in-hand.

How to Actually Practice These Pushing Techniques at Home

This is my favorite part, because you don't have to wait until you're in labor to start learning. Here are three practical ways to connect with your pelvic floor response before your due date:

1. Manual Touch (Feel What's Happening)

Place your fingertips on your perineum (the area between your vaginal opening and rectum). Now try a breath-held Valsalva push. Do you feel your perineum descend toward your hand, or does it stay put — or even pull away?

Now try the same thing with an exhale-based open glottis push. Does the response feel different? For many women, it absolutely does. This is real-time biofeedback from your own body, and it's incredibly useful information.

2. Use a Mirror (Watch What's Happening)

A handheld mirror can give you a visual cue to go along with the tactile one. Position yourself comfortably and use the mirror to watch your perineum as you try different pushing strategies. You should see visible descent of the perineum when you push effectively. If you see your perineum lift or show no movement, your pelvic floor is bracing.

This might feel awkward at first — and that's okay. Getting familiar with your own anatomy before birth is genuinely one of the most empowering things you can do to prepare.

3. Practice with Pooping (Seriously)

I know this sounds funny, but bear with me — bowel movements are actually the perfect low-stakes training ground for pushing mechanics. Your body uses the exact same pelvic floor patterns.

Next time you're on the toilet, notice: are you holding your breath and straining? Or can you exhale and let your pelvic floor open? Can you feel the difference between bearing down with an open floor versus bracing against yourself?

Practicing a relaxed, coordinated bearing down with a slow exhale during bowel movements is genuinely useful birth prep. It teaches your nervous system the pattern — which is exactly what you want when the real moment arrives.

Why Pelvic Floor Physical Therapy Is the Missing Piece in Birth Prep

ACOG (the American College of Obstetricians and Gynecologists) has increasingly supported individualized pushing techniques and noted that spontaneous pushing may offer advantages for fetal outcomes and perineal integrity. (ACOG Clinical Guidance, ACOG.org)

But here's the thing — no book, birth class, or even the most well-intentioned OB can tell you which technique is right for your body without actually assessing your pelvic floor. That's where pelvic floor physical therapy comes in.

In a birth prep session with a pelvic floor PT, we can:

• Assess your baseline pelvic floor tone (tight? weak? uncoordinated?)

• Test how your pelvic floor responds to different pushing strategies

• Teach you to voluntarily lengthen and relax your pelvic floor on demand

• Practice bearing down and open glottis techniques with real-time feedback

• Help you build the body awareness to advocate for yourself in the delivery room

At enCORE Therapy in Kansas City and Overland Park, birth prep is one of our specialties. We work with moms throughout pregnancy — and we especially love seeing clients in the third trimester to put this kind of preparation into practice.

So, Should You Purple Push?

The honest answer is: it depends on your pelvic floor.

If you hold your breath and push and your pelvic floor lengthens and descends — great. That technique can work for you. If your pelvic floor braces, stiffens, or lifts when you Valsalva, then directed breath-holding pushing is working against your body's mechanics, and you need a different strategy.

Open glottis pushing is a valid, evidence-supported option for almost any mom. It's worth learning and practicing regardless of your pelvic floor profile.

And the beautiful thing? You can actually find out before labor which technique works best for your body. That's not a luxury — it's smart, evidence-based birth prep.

Ready to Prep Your Pelvic Floor for Birth?

If you're pregnant and in the Kansas City or Overland Park area, we would love to work with you at enCORE Therapy. Our pelvic floor physical therapy birth prep sessions are designed to give you real knowledge about your body — not generic advice — so you can walk into your birth feeling informed, prepared, and confident.

You deserve to know your options. You deserve a provider who will assess your individual pelvic floor and help you find the pushing strategy that works for you.

Reach out to enCORE Therapy today to schedule your birth prep session. Because the best birth preparation is the kind that's personalized to you.