July 1, 2008

Birthing Positions: Don’t Just Take it Lying Down!

I attended Andrea’s birth almost 5 years ago. I think this was the third birth in which I took the role of a doula – I was just a doula in training. Andrea had given birth naturally to her first child (almost 10 pounds if I remember correctly) and was well on her way to repeating the experience.

She was doing remarkably well, positioning her body in ways that felt productive and comfortable (well, as comfortable as one could be while moving through transition). When she reached full dilation and had the spontaneous urge to push, she was positioned on her hands and knees. For her, this seemed like the easiest, most natural way to push her baby out. To my horror, the doctor would not allow her to deliver her baby in this position. The doctor wanted her on her back. Andrea pleaded with the doctor not to make her turn around and get on her back. The doctor wouldn’t budge. So Andrea ended up flipping over onto her back – and pushing her 10 pound baby out in 7 minutes! She tore horribly. To this day, I believe Andrea pushed her baby out so quickly just to spite her doctor.

The moral of this story is that there are many positions in which to birth a baby. And research has shown that birthing on the back, although most common – is NOT the ideal way to facilitate a baby fitting through the pelvis and birth canal. In all fairness, the doctor (who was the resident on call, not Andrea’s intended doctor) probably insisted on that position because she didn’t know how to “catch” a baby in any other position. The supine position is the most convenient for the doctor and is these days the one student doctors are primarily taught. However in my experience, when a woman has been given total freedom to take a birthing position of her choice, she has NEVER chosen to go on her back. The mothers I have seen have chosen to be on all-fours, side-lying, in a partial squat, kneeling, sitting on a birth stool or upright in a seated position.
Art from many cultures throughout history shows that women have used both upright and gravity-neutral positions (such as side-lying or hands-and-knees) to give birth to their babies. Until doctors began using forceps in the 17th century, women were rarely shown giving birth in supine positions (lying on the back). The ideal position for a woman would allow for optimal opening of the pelvic outlet, use the advantage of gravity and offer a smooth path for the baby’s descent through the birth canal. When a mother births in the lithotomy (flat-on-back) or “C” position (resting on tailbone with body curled in the shape of a C), she reduces the space in the outlet of her pelvis, making it a tighter fit for the baby. The sacrum gets pushed into the birth canal, thus diminishing the space for baby to move through, and preventing the rectal space from stretching. This will, in effect, lengthen her second stage of labor (pushing). Also, the baby has to work against gravity as it heads upwards over the tailbone and under the pubic bone.

When a woman is on her hands and knees or standing, the Rhombus of Michaelis can be seen clearly because the pressure from the fetal head (which is, in fact, the chin and face as it de-flexes or extends) lifts the sacrum and coccyx out of the way. If a woman is in a well supported squat [this means with knees apart and the bottom not less than 45cm off the ground, as this allows the back to arch in the correct way] standing and leaning forwards or kneeling and leaning forwards with her arms clutching onto something higher than her waist, she will instinctively arch her back and ‘throw’ her pelvis out at this stage. Sheila Kitzinger describes in her book ‘The Experience of Childbirth’ how Jamaican peasant women believe that their backs have to ‘open up’ before their babies can be born. This is the same phenomenon. Dr. Michel Odent calls it the ‘fetal ejection reflex’.

It is not uncommon for a woman to hear that her pelvis is too small for the baby to fit through. This is called cephalo-pelvic disproportion (CPD). It does happen – but rarely. It may be that due to the baby’s size a woman needs to take a number of positions in order to push the baby out. Pioneer doula Penny Simkins explains in The Labor Progress Handbook, “Many suspected cases of CPD actually involve fetuses who are subtly malpositioned (asynclitic, deflexed, occiput transverse or posterior), who will fit well through the pelvis once the malposition has been resolved. The shape of the woman’s pelvis is also a consideration. The woman may need to try pushing in a variety of positions to find the ones that optimize descent. Resolving problems of position or fit often requires extra time. Many large fetal heads will mold and fit safely through the pelvis, but molding takes time.” It is important to allow a mother to experiment with different positions to see what is the most effective for her and her baby, especially if her baby is suspected to be large.

I highly recommend having a discussion with your doctor about how he or she feels comfortable “catching” the baby. Also, find out ahead of time if your hospital has squatting bars and birth stools. Each baby, mother and birth is different and requires individual consideration, so why are we all expected to birth in the same way?



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