Pushing Positions
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by Connie Banack, CLD, CCCE, CPD

When we think of labour and birth, what comes to mind in terms of the position a mother is in as she pushes? For most, a woman in a semi-sitting position, holding her legs back, and holding her breath as she strains while forcing her baby out of her body. For others, lying flat on her back with her legs in stirrups, and possibly even a forceps or vacuum extractor in place as the doctor pulls the baby from her. Is this how we have always given birth? Is this the best way to bring forth a child? Letís look at how we give birth today in most hospitals around the world.

The lithotomy position, with a mother flat on her back and her feet in stirrups, was once the standard position in hospitals for women to give birth and in some hospitals it still is. Current obstetrical practices during second stage were developed with the attendant, rather than the birthing mother, in mind. Lithotomy was believed to be the ideal position for doctors to deliver the baby while sitting or standing in attendance. The doctor had easy access to watch, to help with delivery if needed, and to intervene when he or she felt it necessary.

Who it wasnít ideal for was the mother who has to push her baby uphill against the force of gravity when lying on her back. The common lack of progress despite the motherís strong efforts often led to a forceps delivery of the baby. The positioning of the stirrups also stretches the motherís perineum, which causes tearing to be a much more common occurrence. Doctors started to believe that episiotomies were needed to "protect" the motherís perineum because of the large number of tears they observed in this position and the difficulty women had in pushing their babies out while lying supine. Episiotomies became the norm and were easy to do for the doctor because of the access to her perineum. Today episiotomy rates are plummeting as this research confirms that the side effects of unnecessarily cutting the perineum are long lasting and avoidable in most circumstances and birthing positions have been modified.

Women revolted against the lithotomy position, and other routine obstetrical practices, in the late 1960ís, and the semi-sitting posture is now seen in almost all hospital birthing rooms. Now the most common pushing position, the recumbent or semi-sitting position in the standard birthing beds seen today, has virtually replaced the lithotomy position. Women are upright which allows gravity to assist babyís descent and her involvement in her babyís birth has greatly increased. But is this position any better for mother and baby? For insight, letís take a look at birthing practices prior to hospitalized birth.

Throughout history women laboured and pushed in the position she felt most comfortable. For most, that was a squat or in a kneeling, standing, or forward leaning position. Native American women traditionally kneeled, leaned forward and grasped a tipi pole or tree. In southern Africa, the woman may kneel, legs wide apart, with her heels supporting her perineum. In central Africa and Columbia women grasp the branch of a tree that is laid horizontally between two other trees [or stakes set in the ground], bending her knees into a squatting position as she pushes. An alternative is a vertical stake driven firmly into the earth.

In many cultures a woman sits on anotherís lap or squats between her husbandís or another womanís thighs. Birth stools and chairs evolved from lap-sitting and squatting positions. Birth stools are low and simply constructed with a cutout for the motherís bottom (similar to an open-front toilet seat) which enabled a woman to squat with support. As time went on, in Europe stools became more elaborate, with low backs on them. This immediately reduced pelvic mobility as womenís ability to move on the stool were impaired by the added backrest. These chairs became increasingly elaborate, especially as doctors took over childbirth, and became more and more complicated while at the same time making it harder and harder for a woman to move.

The next development was to tip the woman onto her back on a narrow table with her legs raised. The mother was even strapped to the bed with knotted bandages, metal restrainers, cuffs and straps. This was seen as a "protective measure" for the mother due to the use of hallucinogenic "Twilight Sleep" (scopalamine), which was routinely given to all labouring mothers. The newest innovation is the birthing beds that can assume many positions and come apart during the pushing stage to support an upright sitting position with various handles and foot rests for the motherís use.

Virtually all women today who birth in a hospital setting use these modern birthing beds. Although they allow a more physiologically superior position to lithotomy in terms of the motherís participation and comfort level, they still are inferior to traditional positions assumed by mothers in response to their bodyís signals.

During a very long labour in the 1880ís, Dr. Campbell in Georgia decided to use forceps, "but just then in one of the violent pains, she raised herself up in bed and assumed a squatting position when the most magic effect was produced. It seemed to aid in completing delivery in the most remarkable manner, as the head advanced rapidly, and she soon expelled the child by what appeared to be one prolonged attack of pain. In subsequent parturition, labor appeared extremely painful and retarded in the same manner; I allowed her to take the same position, as I had remembered her former labor, and she was delivered at once, squatting."

How is this possible? To understand, we need to understand the mechanics of the pelvis and how it moves during birth. The pelvis is made up of four independently movable bones, the left and right ilia separated in the front of the pelvis by the pubis symphysis, the sacrum attached to the ilia at the sacro-iliac joints, and the coccyx or tailbone located at the base of the sacrum. They are connected by cartilage and ligaments that are softened during pregnancy by a hormone called relaxin. This softening allows increased movement between the bones, allowing optimal passage of the baby through the pelvis.

When a mother is in an upright or forward leaning position, the angles and internal dimensions can change dramatically to allow the baby to maneuver through the pelvis. "The relationship of the pelvic brim to the lumbar spine changes, allowing the foetal head to enter the pelvis. The ischial spines [the narrowest part of the pelvis] are no longer [horizontal], allowing the foetal head to pass through them with ease. The ligaments connecting the sacrum to the ilia are more flexible [due to the effects of relaxin] which allows them to lift up about 1-2 cm straightening the posterior pelvic wall." When a woman is in a forward-leaning or upright position, the sacrum can be seen clearly as the baby moves through the pelvis, lifting the sacrum and coccyx out of the way. "If a woman is in a well supported squat, 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 Ďthrowí her pelvis out at this stage." Dr. Michel Odent calls this the ĎFoetal Ejection Reflexí.

When a woman is in a lithotomy or semi-sitting position the Foetal Ejection Reflex is impaired and the increased pain caused by the sacrumís inability to move as the baby descends can be intolerable. For anyone who has seen women giving birth, the inability of the mother to "keep her bottom down" on the bed is common as the baby moves past the sacrum. If she does continue to sit or lay in this position, her babyís head is unable to move past, or descent is markedly slowed, by the now smaller pelvic outlet due to her impacted sacrum and her tailbone being forced inwards. According to Dr. Todd Gastaldo DC, the impacted sacrum decreases the pelvic outlet by 30%. This is often compounded by epidural anaesthesia, which impairs the motherís ability to feel her babyís descent and thus does not move to accommodate her babyís descent through her pelvis.

The coccyx is designed to move out of the way as the babyís head descends. Sitting on the coccyx during birth restricts the pelvic outlet and can lead to dislocation of the coccyx. It may also cause an increased length of labour, make delivery more difficult and slow or arrest descent. These can then develop into oxygen deprivation for the baby, causing distress or worse. If it isnít resolved forceps/vacuum assisted delivery is turned to as a solution. The uses of these instruments typically incur damage to the babyís fragile head and neck muscles and nerves. The alternative is caesarean delivery, a major abdominal surgical procedure to extract the baby, which brings itís own risks into play for the mother.

Semi-sitting and lithotomy pushing positions can also result in another serious problem called shoulder dystocia. Dr. Jason Gardosi MD FRCS MRCOG from the Queen's Medical Centre in Nottingham, UK explains, "The anterio-posterior [outlet] diameter is reduced in recumbent and lithotomy positions where the weight is taken on the sacrum. The sacrum is capable of rotational movement through an axis at the upper part of the sacro-iliac joint." He goes on to add, "Many so called 'shoulder dystocias' are just difficult deliveries caused by a recumbent position. Apart from the sacrum being pushed upward, reducing the AP diameter, it is difficult to allow lateral flexion when the presenting shoulder abuts on the mattress." Dr. Todd Gastaldo adds, "And when the shoulders get REALLY stuck, MDs pull REALLY hardÖ Could this bizarre MD behavior account for at least SOME of the unexplained cerebral palsy, brachial plexus palsy, low APGAR scores, etc.? How about some of the unexplained DEATHS?" [Emphasis the doctorís]. Good questions which need to be addressed with maneuverís beyond the McRoberts Position, placing the mother flat on her back with her knees pulled up and back, simulating an upside-down squatting position. This is the standard position women are placed in when shoulder dystocia is suspected. If women were allowed to birth in positions they assumed naturally, the Gaskin Maneuver, moving to a hands and knees position, would easily be done and thus far has proven to be the most successful position for resolving shoulder dystocia.

The solution? Simple. Allow the mother to assume a position she feels most comfortable in, which in almost all cases does not involve a lying down or semi-sitting position on a bed. It is extremely rare that a woman will spontaneously assume a lying or leaning back position during second stage. the very position most women are expected to assume in a hospital situation. At the same time, obstetrical practices of frequent and/or continuous monitoring with stationary fetal monitors combined with the many interventions and medications used routinely interfere with the bodyís natural response to labour. If a woman is unable to assume a naturally active position like a squat, kneeling, or other forward-leaning positions (i.e. hands and knees), then avoiding sacral and coccyx impairing positions like lithotomy and semi-sitting would be wise and only make common sense. Sidelying is an excellent alternative when the situation warrants it, such as when a mother has an epidural.

This is especially important when the baby is in a less than optimal position, such as posterior (babyís back is to the motherís back), deflexed, asynclitic (babyís head is crooked in the motherís pelvis), or a hand is also presenting with the babyís head. These are not uncommon considerations as up to 50% of babies present in one or more of these positions. Sadly, this is also why so many cesarean sections are performed, as doctors and nurses do not know the benefits of movement and after prolonged labour due to mal-presentation, a cesarean is often performed citing Failure to Progress or Cephalo-Pelvic Disproportion (baby is too big).

Often movement is all that needed during labour to turn the babyís head or allow correction of position in order for the baby to negotiate the motherís pelvis and this is not the case when a woman is not allowed to change position during pushing. "Lying down, sitting or in a semi-reclining position [during second stage] dramatically increases the Curve of Carus [sacral angle] while pulling the large glutoid muscles tight, meaning that the Rhombus of Michaelis [sacrum and tailbone combined or the posterior pelvic wall] is unable to move backwards as it should." Knowing the motherís pelvic structure and her ability to relax can also really help in determining efficient positions and movements to ease descent. Allowing a birthing mother the ability to move as she needs, providing support and suggestions for both movement and relaxation, and giving her the time she needs, without limits, to birth her baby is the answer. A simple, proven, common-sense approach that will guarantee reduction of interventions, and the risks of an assisted delivery and cesarean section for birthing women and their newborns.

References:

Kitzinger S., Rediscovering Birth, Pocket Books, 2001, p 188

Kitzinger S., op. cit., p 189

Eglemann G., Labor Among Primitive Peoples, J. H. Chambers St Louis, 1882, Reprinted AMS Press, New York, p 23

Sutton J, Scott P, Understanding and Teaching Optimal Foetal Positioning, Birth Concepts New Zealand, 1995, p 11

Sutton J, Scott P, op. cit., p 11

Balaskas J, Active Birth, Harvard Common Press Boston, 1992, p 139

Davis-Floyd R, Birth as an American Rite of Passage, University of California Press Berkley Los Angeles London, 1992, p 122

Odent M, Birth Reborn, Birth Works Press Medford, 1994, p 47

Sutton J, Scott P, op. cit., p 50

Common Knowledge Charitable Trust, What you can doÖ new preparations for your birthing body, Common Knowledge Charitable Trust New Zealand, 2001, p 3

Connie Banack is a practicing doula and a doula trainer in Alberta, Canada. She is the President of ICAN (International Cesarean Awareness Network) Inc., Executive Director of Canadian Programs for CAPPA (Childbirth And Postpartum Professional Association), and owner of Mother Care, a trainings, support, and supply company for birth professionals and expectant parents. She is married and has three sons.

Copyright Mother Care, 2002.

 

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