Sunday, October 11, 2009

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 high-risk 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... NEXT PLEASE 


  1. Great article, with excellent scientific basis, but would have been improved significantly if you had included your references.

  2. Great article! Shared on my business page on Facebook (I'm a birth doula).