Closed Glottis pushing/Valsalva's

Maneuver a.k.a. Purple Pushing

A common and long standing practice at our hospital here in Aruba

which I would like to address is closed glottis pushing or "purple
pushing". This is when a woman, who in the second stage of labor or
the "pushing stage" has coached pushing. The nurse/OB, stands in
front or next to you and instructs you to hold your breath and push for
10 counts/seconds. This is the part where you feel : 1) you're either
going to poop out contents that have not even reached your bowels or
2) your head is going to explode and will be a huge mess to clean up
afterwards ...whichever comes first.
This practice is a common mistake that takes place at all our hospital
births. Why? It starts with the woman's lack of childbirth education
about pushing, and the nurses' lack of concern or ignorance about
such practices.
Why is holding your breath for ten seconds not good during pushing? I
mean.. soooo many women have done it inconsequently. Yeah, that's
what we're all lead to believe. Modern research is indicating otherwise.
In an article from mar 15 2003, Lisa Miller CNM spoke about this topic and strongly
advised against it. Why? Because of the following :
Purple pushing--or closed-glottis pushing--during which the patient holds her breath for
10 seconds while pushing, is safe in the approximately 80% of women with low-risk

pregnancies. But that doesn't mean it works best. Furthermore, in physiologically highrisk cases, the baby can't tolerate that kind of pushing
In one study of 10 healthy, near-term pregnancies, near-infrared spectroscopy used to
evaluate fetal effects revealed that closed glottis and coached pushing efforts led to
decreased mean cerebral 02 saturation and increased mean cerebral blood volume. All
Apgar scores were below 7 at 1 minute and below 9 at 5 minutes.
This maneuver causes a trapping of blood in veins, preventing it from entering the heart.
When the breath is released, the intrathoracic pressure drops and the trapped blood is
quickly propelled through the heart, producing an increase in the heart rate (tachycardia)
and the blood pressure. Immediately, a reflex bradycardia ensues. All of this disrupts the
blood flow to the uterus and ultimately to the baby. This disruption in blood flow
indicates a disruption in oxygen flow, which ultimately shows up on the fetal heart
monitor as fetal distress.

There is no clear evidence that closed glottis pushing (Valsalva's Maneuver)

shortens second stage, decreases fatigue or minimizes pain. It has otherwise been
suggested that bearing down for a prolonged period with a closed glottis alters the
contractile pattern of uterine smooth muscle, leading to inefficient contractions
and failure to progress. Studies suggest that encouraging women to believe in their
ability to push the baby out may be as important as the type of breathing. A variety
of studies published between 1992 and 1996 show that physiological effects of
Valsalva's Maneuver can include: impeded venous return; decreased cardiac filling
and output; increased intrathoracic pressure; affected flow velocity in middle
cerebral artery; raised intraoccular pressure; changed heart action
potential/repolarization; increased arterial pressure; increased peripheral venous
pressure; altered body fluid pH, which contributes to inefficient uterine
contractions; decreased fetal cerebral oxygenation. (Nursing Times 95:15, April
15, 1999)
Open-glottis pushing, on the other hand, allows the patient to exhale while bearing down
and leads to minimal increases in maternal blood pressure and intrathoracic pressure,
maintained blood flow, and decreased fetal hypoxia. Long Valsalva pushing can adversely
affect maternal hemodynamics, which in turn adversely affects fetal oxygenation

Another consequence of purple pushing that often happens when a

woman pushes "in her face" , is that the blood vessels around the eyes
and around the pupil burst and thus the new mom sports the new look

of blood-shut eyes. ( Yes, another thing they fail to mention to you).

This poses no real harm to the mom, but it doesn't quite make you look
so sexy or motherly in those post-delivery pictures.
Many women do not know these risks. Many women, when in the
pushing stage, forget these things and will depend on the nurse/ob for
instructions trusting that they know what's best. But as we have
learned, even the best and most educated doctors don't
always do what is in the best interest of the mother and baby.

However, there are alternatives to facilitate pushing and eases the

baby downward and out. The supine position (laying down on your
back) offers minimal comfort or ease and actually makes it harder for
the baby to make its descent. While on the other hand, a squatting
position makes use of gravity to help the baby through the birth canal
with less head-exploding pushing. It also aids in : facilitation of
alignment of the presenting part to the pelvic axis, encouragement of
the mother's efforts toward giving birth, allowing for larger pelvic
diameters, improving comfort, and promoting fetal well being. Granted,
there are certain obstetricians here in Aruba who absolutely refuse to
let a laboring woman go into the hands and knees position for example
and require them to get on their back! This is where our midwives are
so cherished and valued. Midwives will work with you and get the
position that is most comfortable for you when it comes time to push.
Another accessory unknown to most mothers is the birthing stool. This
is wonderful chair that looks like it's missing a chunk in the middle.
According to me, only one midwife here in Aruba has one, and I was set
to use it for my daughter's birth! That is...until I was unfortunately
handed over to an ob in my 41st week due to pre-eclampsia. So there
went my no tearing/minimal perineal damage experience with the
birthing stool.

Birthing stool
Pregnant Aruban moms, future pregnant Aruban mothers, Take this to heart. Educate
yourselves. Find out what your options are. Stand up for the birthing experience you want
and deserve. I mean, come on, AZV (social insurance that
practically everybody has) will pay for your prenatal appointments wherever you choose
to go. And if the ob/gyn or midwife does not share your point of view on childbirth or is
not willing to comply with the birthing experience you want..then by all means