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The Question of Birth Positions

A growing number of women, midwives, nurses, obstetricians and childbirth educators are questioning positions that characterise modern labour and birth practices, and the passive, patient-orientated role demanded of women in contemporary maternity care. The specific practice that is being criticised is the almost exclusive use of lying down (recumbent) positions for childbirth known as supine, dorsal or lithotomy positions. There is more than sufficient evidence that upright birth positions, i.e. kneeling, sitting, standing and squatting, are more advantageous to both mother and child.

Position and movement in labour is an area of fundamental importance which has been, in the past, almost completely neglected by birth attendants in the management of labour, and therefore also prenatal teachers in the preparation of women in birth. The choice of position determines the training of midwives and doctors. It also determines their approach and the kind of environment in which women labour and give birth. It can also determine the successful outcome of the birth and the quality of the experience for both mother and baby.

Modern Western Practice

Obstetric practice in the modern world is usually regarded as a medical, if not surgical, procedure. Until recently, the normal practice in most hospitals has been (and often still is) to place you, when you are in labour, in bed on your back; at best propped up by pillows into a semi-reclining position, where monitors, drips or anaesthetic can be conveniently applied. Later, just before the time of actual birth, you may be transferred to a delivery room and placed on an obstetric table where a forceps delivery, vacuum extraction, episiotomy or Caesarian section can be performed, or, at best, your baby can be most conveniently ‘delivered’ by your attendants,

In many hospitals the choice of birth positions is already predetermined by the approach to maternity care and the routine hospital practices. Usually, the training of midwives and doctors takes the recumbent position for granted in specific obstetric practices, such as:

 The continuous assessment of foetal heart tones, uterine and other vital signs during labour and the use of electronic heart monitors which were designed for use in the recumbent position. Paradoxically, these often cause the foetal distress they are meant to detect by the imposition of the supine position for their use (1).

 Midwives are usually trained to do periodic vaginal examinations with the mother lying on her back. Where birth is active there is less need for vaginal examinations, as the progress of labour can usually be assessed by the mother’s behaviour. If an internal examination is considered to be necessary, it can usually be done conveniently enough with the mother remaining upright.

 The use of sedatives, oxytocin drugs, analgesics and anaesthesia during labour and delivery. If the mother is not lying down in the first place she is less likely to need pain relief or induction.

 The use of forceps and/or episiotomy for delivery, or the need for the midwife to routinely ‘control’ the delivery or ‘guard’ the perineum. All these practices are not usually needed in an Active Birth.

When such practices are routinely used, labour and birth are seen from the outset as a potentially pathological situation in which attendants and their attendant technology are in control, rather than the woman herself, her instincts and her biological body.

No one will deny the enormous advantages of the safety net of modern obstetrics when problems occur which may threaten the life of mother or baby, or both. However, the vast majority of labours have the potential to be uncomplicated, and it is clear that common sense in the management of labour has been completely obscured by the routine application of interventive obstetrics to normal labour, resulting in a great increase in the number of forceps deliveries and Caesarean sections.

In many countries in the developed world the majority of babies born in hospital are delivered by forceps, or induced, or both, and the Caesarean rate may be as high as 30 per cent. In the USA, approximately one in four births (25 per cent) result in a Caesarean which reflects a 400 per cent increase in the last 20 years (2). In some hospitals, as many as one in three births are Caesarean, and in some large teaching hospitals the figure is closer to 60 per cent.

Amongst other reasons, the rigid insistence on making women in labour lie on their backs contributes largely to these figures. It seems that a vicious circle arises as soon as we begin to intervene in the natural process – the possibility of complication increases, the need for intervention and for pain-relieving drugs becomes more prevalent. When a labouring woman is immobilised and forced to lie on her back, the natural process is fundamentally disturbed and the likelihood of problems occurring increases.

What is wrong with obstetrically managed birth?

Giving birth can, and usually does involve hours of intense labour and a great deal of pain, effort and endurance on your part. Naturally the prospect is quite awesome and you will probably approach the birth of your child with some fear and apprehension about what is to come.

To many women the prospect of a painless, effortless, managed birth might, at first, seem to be an attractive proposition. After all, you might ask, why suffer needlessly when medication and modern technology is readily available to make the birth easier, quicker and less painful?

Regretably, it is not as simple as all that. Every interventive obstetric technique has known side effects for mother and baby, while many subtle or long-term effects may not yet be apparent. When help is genuinely needed the benefits of the intervention may well outweigh the risks. However, routine use of obstetric management tends to complicate birth unnecessarily.

Doris Haire in her booklet, The Cultural Warping of Childbirth (3), has written an excellent report on obstetrics in the USA where high-tech birth is the norm and more deeply entrenched than in most places, and now provides a model for developing countries where traditional birth practices are disappearing.

Haire points out that the infant mortality rate in the USA is amongst the highest in the world. There is also a staggering incidence of neurological impairment amongst American children which, she feels, is attributable largely to the ‘unphysiological practises which have become so much a part of American obstetric care’. She lists an abundance of scientific literature and research to substantiate her remarks (see Recommended Reading).

We have known since the 1960s that all obstetric medications given to the mother, whether they are used to quell nausea, to induce labour, to relieve pain or to anaesthetise, do cross the placenta and do alter the baby’s environment in the uterus, entering the baby’s circulatory system and hence the baby’s brain within seconds or minutes. Contrary to what many women are told, this includes regional anaesthetics such as epidurals (4).

The baby’s central nervous system forms and develops rapidly in the last part of pregnancy, during the birth itself and during infancy, and is susceptible to the effects of drugs given around the time of birth and after. We have only to recall the thalidomide tragedy to realise that the testing of the safety of these medications is often sorely inadequate. Of course, it is important also to bear in mind that babies vary in their vulnerability to the effects of these drugs and, in instances of real need, the judicious and minimal use of medication is usually successful. However, in antenatal clinics and hospitals, mothers are usually uninformed about the hazards or side effects involved in taking such medications and are deluded into assuming that there are no risks involved.

Let us take a look at some examples of the most widely used medications for labour and birth, and their more common side effects. I have deliberately omitted the more severe and rare complications but readers who are interested can look up the research references listed here.

THE PROMISE OF PAIN RELIEF
Pethidine (Demerol in the USA)

This is a narcotic-like analgesic used to ‘take the edge’ off pain. Given usually as an intramuscular injection, some women find it makes labour more tolerable and others that it causes them to lose control. There are possible side effects to the mother, such as nausea or dizziness, and it will slow down the mother’s breathing and respiration, hence reducing the baby’s oxygen supply. Often Pethidine is mixed with sedatives to reduce nausea and these too will cause sleepiness and enter the baby’s bloodstream.

It is now common knowledge that Pethidine can depress the baby’s respiratory system and jeopardise the start of breathing after birth, resulting in the need to resuscitate the baby (5).

Traces sometimes remain in the baby’s system after birth so that, in addition to adjusting to life outside the womb, the baby’s system will have the added burden of detoxification (6). They can also depress the baby’s sucking reflex and because they remain in the baby’s system for several weeks they can affect the initiation of breastfeeding and mother-infant bonding (7).

Epidurals

This is known as a regional anaesthetic which is injected locally into the epidural space between two lumbar vertebrae in the lower spine. When it works effectively the result will be a blocking of pain impulses, bringing numbness from the waist through the lower body.

While the effects of the drugs used for epidurals on the baby are not the same as Pethidine, we know that they enter the baby’s circulation and brain tissues within minutes (6). Their immediate and long-term effects on the neurological development of the baby are relatively unknown and direly under-researched, despite the widespread use of this form of pain relief, worldwide.

Side effects for the mother, such as severe headaches following the birth, can occasionally occur (these are caused by accidental scratching of the membrane surrounding the spinal cord by the injection needle), and a lowering of maternal blood pressure is common.

An epidural will certainly increase the need for obstetric intervention. Of course the mother will be immobile and reclining so contractions tend to be less efficient, and labour is often much longer and may need to be artifically stimulated with an oxytocic drip.

All these factors contribute to a lessening of the blood supply to and from the uterus, so foetal distress (lack of oxygen) is far more likely. Sometimes the pelvic muscles become limp and do not help the baby to rotate in the usual way (with the added disadvantage of being without the help of gravity).

An epidural can also inhibit the mother’s ability to push her baby out spontaneously and, one way or another, the risk of a forceps delivery or a Caesarean section is increased.

When mothers give birth actively, with the help of a midwife, the forceps rate rarely rises above 5 per cent and drugs are only used in cases of unavoidable distress or to save a life. By contrast, in countries such as the USA, the incidence of forceps deliveries can be, according to Doris Haire, as high as 65 per cent in some hospitals. An unnecessary forceps delivery can be traumatic for both mother and child and can occasionally result in injury or damage to the baby (8).

Although, at times, the total freedom from pain offered by an epidural may be indispensable, it is important, for a successful outcome, to weigh this advantage against the attendant risks, which are considerable. Occasionally the price of a few hours of comfort can be a damaged baby and may very well be a complicated birth (9-12).

So, might it not be better in the long run to learn how to use your body to release, minimise and transform the pain of labour and to have access to a pool of warm water or a shower – an effective and totally harmless way to reduce pain? If an epidural is really needed, then its use can be minimal and, in this way, the attendant risks are reduced.

STIMULATING LABOUR
Induction

An induction may be used to initiate labour or to stimulate contractions once it has begun. It is usually done by introducing an intravenous drip of Syntocinon (Pitocin in USA), a powerful synthetic hormone, into a vein in the mother’s arm.

Normally, when the uterus contracts, the blood vessels which carry blood to the placenta are temporarily constricted. In between contractions, blood is stored in the placenta to keep up a constant supply to the baby during contractions. When contractions are stimulated by Syntocinon they tend to be longer, stronger and closer together than in a normal labour. The periods of constriction are therefore longer than usual so that the overall oxygen supply to the baby is reduced and foetal distress is therefore more likely. Doris Haire writes in Drugs in Labour and Birth,‘The situation is somewhat analogous to holding an infant under water and allowing the infant to come to the surface to gasp for air but not to breathe.’

The incidence of postnatal jaundice in babies who have been induced is also thought to be higher (13-14).

In addition, strong contractions usually occur as soon as the drip begins to work so the gradual build-up in intensity of a normal labour is absent. This often means that the mother cannot cope with the pain of the stronger contractions and will need pain relief, so the baby will end up with the combined effect of painkillers and the drugs used for induction.

Of course, continuous foetal monitoring will probably be necessary with all these risks and so the snowball effect continues as one intervention necessitates another.

Studies have shown that there is no evidence of any natural advantage in routinely inducing births that are ‘overdue’ and a failed induction frequently ends up as a Caesarean section (15-18).

Would it not be better to reserve this option as a last resort and discover how to change position to stimulate contractions, or how to improve the birthing environment so that the mother can secrete her own natural hormones? Learning how to allow the normal physiology to unfold without disturbance is the most effective way to ensure that the mother will secrete her own hormones.

Birth Before Obstetrics

Historical studies show the prevalent use of vertical positions – kneeling, squatting, standing or sitting postures – with many variations and as many methods of support.

There is evidence going back thousands of years of the bodily positions taken in childbirth. The head of a silver pin from Luristan in Iran, first millenium BC, depicts a squatting mother. The remains of a clay statue of 5750 BC from a shrine at Çatal Hüyük, a Copper Age (Chalcolithic) city in Turkey, shows a goddess giving birth in the same position, as does an 8½ inch Aztec stone fertility figure from Mexico. A relic of the Mound Builders of eastern Arkansas, a pre-Columbian culture of unknown date, shows a woman squatting with her hands on her thighs. The Egyptian hieroglyph meaning ‘to give birth’ shows a mother squatting.

A relief from the temple of Kom Ombo, a town on the Nile in Upper Egypt, shows a woman giving birth in the kneeling position. Birth in the same position can be seen in a marble figure from Sparta, about 500 BC. In ancient China and Japan, women customarily gave birth in the kneeling position on a straw mat. All scenes, of course, depict only the final birth, but positions used during the rest of labour can also be traced.

In the Old Testament, Exodus, chapter I, verse 16 states:

When ye do the office of a midwife to the Hebrew women, and see them upon the stools …

A Corinthian vase depicts a woman in labour seated on a birthchair. An early Greek relief and a Roman marble bas-relief both show a woman giving birth on a stool supported by two assistants. The birthstool was also recommended for uncomplicated labours by Soranus in the early part of the second century AD and by many subsequent writers. It was described as, ‘In a form like a barber’s chair but with a crescent-shaped opening in the seat through which the child may fall.’ The first birthstools may have been rocks or logs of wood, developing over time into complex, adjustable chairs with many varied devices.

There are also many examples of women giving birth without a stool using a variety of upright postures and always supported by one or more attendants while the midwife receives the baby.

From Birthchair to Bed to Delivery Table

In the Western world, the birthstool or chair remained indispensably part of the equipment of most midwives up to the middle of the eighteenth century. Each wealthy household had its own stool, whilst among the poor a stool was transported from house to house. The birthstools of royalty were carved and ornamented with jewels. Dutch, German and French sixteenth century drawings show the great use of birthstools, as do Chinese drawings of the same period. Even today, a birthchair is still used by some Egyptian women.

The first record of a woman lying down for birth describes Madame de Montespan, mistress of Louis XIV, who lay down in a recumbent position so that he could watch the birth from behind a curtain. Then in the mid seventeenth century in France, two brothers named Chamberlain invented the forceps. The best position for a forceps delivery is to have the woman lying down. This invention was jealously guarded by the Chamberlains who performed their deliveries shrouded by black drapes, but the obstetric fashion for ladies of quality to give birth in recumbent positions became firmly entrenched, and the physician took over from the midwife in the birth chamber. In the same century, François Mauriceau became the leading figure in French obstetrics. He scorned the use of the birthchair and advocated childbirth in bed, lying on the back. As forceps gained popularity, the birthchair lost favour and, by the end of the eighteenth century, little more was heard of it.

In the nineteenth century, Queen Victoria was the first woman in England to have chloroform while giving birth. Delivery under anaesthetic further established the lying down position on the back or on the side. Birth positions which lend themselves more easily to the convenience of the attendants who perform these procedures became the only choice, and the practice of confining a woman to bed for the major part of her labour and then on to an obstetric table for delivery, eventually spread throughout the West. This practice has become so widespread that the word ‘confinement’ is commonly used to describe the birth process.

The birthchair had given way to the bed and the delivery tables of the nineteenth and twentieth centuries. Women were flat on their backs, a position that made them passive and controllable, and although this offered a fine view to the attendant, it was in total defiance of the active forces of gravity and the joyous independence that comes from naturally and instinctively giving birth actively, on one’s own two feet.

Ethnological Evidence

Primitive tribes have adopted various birth positions through the customs of their tribe but, more important, by their instinct. Some forty positions have been recorded, and their relative merits have been much disputed. Women of different tribes squat, kneel, stand, incline, sit or lie on the belly; so, too, do they vary their positions in various stages of labour and in difficult labours.

Dr G. J. Englemann, in his book Labour Among Primitive Peopleswritten in 1883, was one of the first to investigate the various positions assumed in labour or childbirth by early people, and he found that the four principal positions were squatting, kneeling (including the all fours and knee-chest positions), standing and semi-recumbent.

Ethnologists entirely confirm the evidence of the historians. Whatever the race or the tribe under observation – African, American, Asian and so on, the same upright positions always predominate with a great variety of means of support. Figures reveal that, for the most part, women throughout the world today still labour and deliver in some form of upright or crouching position, usually supported.