Aldrich CJ, D'Antona D, Spencer JA The effect of maternal pushing on fetal cerebral oxygenation and blood volume during the second stage of labour. Br J Obstet Gynaecol. 1995; 102:(6)448-53

Barnett MM, Humenick SS Infant outcome in relation to second stage pushing method. Birth. 1982; 9:(4)221-8

Bergstrom L, Seidel J, Skillman-Hull L, Roberts J “I gotta push. Please let me push!” Social interactions during the change from first to second stage labor. Birth. 1997; 24:(3)173-80

Beynon CL The normal second stage of labour; a plea for reform in its conduct. J Obstet Gynaecol Br Emp. 1957; 64:(6)815-20

Borders N, Wendland C, Haozous E, Leeman L, Rogers R Midwives' verbal support of nulliparous women in second-stage labor. J Obstet Gynecol Neonatal Nurs. 2013; 42:(3)311-20

Bosomworth A, Bettany-Saltikov J Just take a deep breath: a review to compare the effects of spontaneous versus directed Valsalva pushing in the second stage of labour on maternal and fetal wellbeing. MIDIRS Midwifery Digest. 2006; 16:(2)157-65

Caldeyro-Barcia R, Giussi G, Storch E The bearingdown efforts and their effects on fetal heart rate, oxygenation and acid base balance. J Perinat Med. 1981; 9:63-7

Cooke A When will we change practice and stop directing pushing in labour?. British Journal of Midwifery. 2010; 18:(2)76-81

Chang SC, Chou MM, Lin KC Effects of a pushing intervention on pain, fatigue and birthing experiences among Taiwanese women during the second stage of labour. Midwifery. 2011; 27:(6)825-31

Davis-Floyd RE, 2nd edn. London: University of California Press; 2004

London: The Stationery Office; 1970

Downe S The transition and the second stage of labour: physiology and the role of the midwife, 15th edn. London: Churchill Livingstone; 2009

Downe S Debates about knowledge and intrapartum care.Chichester: John Wiley and Sons; 2010

Enkin M, Kierse M, Neilson JOxford: Oxford University Press; 2000

Gupta JK, Hofmeyr GJ, Shehmar M Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012; 5

Hanson L Second-stage labor care: challenges in spontaneous bearing down. J Perinat Neonatal Nurs. 2009; 23:(1)31-9

Hollins-Martin CJ Effects of valsalva manoeuvre on maternal and fetal wellbeing. British Journal of Midwifery. 2009; 17:(5)279-85

Humphrey MD, Chang A, Wood EC, Morgan S, Hounslow D A decrease in fetal pH during the second stage of labour, when conducted in the dorsal position. J Obstet Gynaecol Br Commonw. 1974; 81:(8)600-2

Johnstone FD, Aboelmagd MS, Harouny AK Maternal posture in second stage and fetal acid base status. Br J Obstet Gynaecol. 1987; 94:(8)753-7

Jordan B Authoritative Knowledge and its' construction.London: University of California Press; 1997

Kopas ML A review of evidence-based practices for management of the second stage of labor. J Midwifery Womens Health. 2014; 59:(3)264-76

Lemos A, Amorim MM, Dornelas de Andrade A Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2015; 10

Low LK, Miller JM, Guo Y Spontaneous pushing to prevent postpartum urinary incontinence: a randomized, controlled trial. Int Urogynecol J. 2013; 24:(3)453-60

Myles M, 5th edn. Edinburgh: E&S Livingstone; 1964

National Institute for Health and Care Excellence. Intrapartum Care for healthy women and babies. 2014. (accessed 18 January 2016)

O'Connell MP, Tetsis AV, Lindow SW The management of the second stage of labor. Int J Gynaecol Obstet. 2001; 74:(1)51-6

Perez-Botella M, Downe S Stories as evidence: Why do midwives still use directed pushing?. British Journal of Midwifery. 2006; 14:(10)596-9

Petersen L, Besuner P Pushing techniques during labor: issues and controversies. J Obstet Gynecol Neonatal Nurs. 1997; 26:(6)719-26

Prins M, Boxem J, Lucas C, Hutton E Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. BJOG. 2011; 118:(6)662-70

Reeder SR, Mastroianni L, Martin LL, 14th edn. Philadelphia: Lippincott; 1980

Roberts JE, Goldstein SA, Gruener JS, Maggio M, Mendez-Bauer C A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor. J Obstet Gynecol Neonatal Nurs. 1987; 16:(1)48-55

Roberts JE The “push” for evidence: management of the second stage. J Midwifery Womens Health. 2002; 47:(1)2-15

Rossi MA, Lindell SG Maternal positions and pushing techniques in a nonprescriptive environment. J Obstet Gynecol Neonatal Nurs. 1986; 15:(3)203-8

Rothman BKNew York: WW Norton; 1982

London: RCM; 2007

London: RCM; 2012

Sampselle CM, Miller JM, Luecha Y, Fischer K, Rosten L Provider support of spontaneous pushing during the second stage of labor. J Obstet Gynecol Neonatal Nurs. 2005; 34:(6)695-702

Schaffer JI, Bloom SL, Casey BM A randomized trial of the effects of coached vs uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. Am J Obstet Gynecol. 2005; 192:(5)1692-6

Thomson AM Pushing techniques in the second stage of labour. J Adv Nurs. 1993; 18:(2)171-7

Thomson AM Maternal behaviour during spontaneous and directed pushing in the second stage of labour. J Adv Nurs. 1995; 22:(6)1027-34

Walsh DLondon: Routledge; 2007

Way S To push or not to push?. Professional Care of Mother and Child. 1991; 1:(2)

Yeates DA, Roberts JE A comparison of two bearingdown techniques during the second stage of labor. J Nurse Midwifery. 1984; 29:(1)3-11

Yildirim G, Beji NK Effects of pushing techniques in birth on mother and fetus: a randomized study. Birth. 2008; 35:(1)25-30

Using the Valsalva technique during the second stage of labour

02 February 2016
11 min read
Volume 24 · Issue 2


The Valsalva technique for directed pushing during the second stage of labour is an intervention still used by some health care practitioners in the UK, despite evidence suggesting that this is not the best approach to intrapartum care. Current research in this area is limited, with ambiguous findings. The latest National Institute for Health and Care Excellence (NICE, 2014) guidelines recommend that until further research is forthcoming, women should be guided by their own instinctive urge to push during the second stage and directed pushing should not be used as part of routine intrapartum care. Midwives are encouraged to ensure that women are fully informed of the latest evidence, and use their professional judgement in conjunction with the woman's individual needs and preferences while undertaking care during the second stage of labour.

The Valsalva technique of directed pushing during the second stage of labour is a childbirth intervention that has long been common practice in Western culture (Petersen and Besuner, 1997; O'Connell et al, 2001; Cooke, 2010). This intervention is often highlighted as an example of how some health professionals continue to attempt to override the physiological elements of childbirth by using practices that are no longer evidence-based (Perez-Botella and Downe, 2006). More than 50 years ago, British obstetrician Beynon (1957) was critical of the Valsalva technique, questioning why doctors and midwives believed it was their role to encourage a mother to force her baby through the birth canal as rapidly as possible.

The technique of deep breath-holding and then forceful pushing against a closed glottis during the expulsive phase of labour is widely known as the Valsalva technique, after the 18th-century doctor Antonia Valsalva who first described it (Perez-Botella and Downe, 2006). Hollins-Martin (2009) further describes the technique as ‘purple pushing’, presumably because with prolonged breath-holding the small blood capillaries in the cheek and face burst, giving a purple tinge to the face. Way (1991) describes a similar technique to increase pressure in the Eustachian tube and, as a result, reduce blockage in the inner ear. Other terms describing this particular style of second stage management include directed, coached and closed glottis pushing (Kopas, 2014).

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • New content and clinical newsletter updates each month