Sunday, October 25, 2009

Healthy Birth Practices: Walk, Move, and Change Position

We're talking about the Six Lamaze Healthy Birth Practices, taking each one in order, discussing why it's helpful and important, and then discussing why these practices are often discouraged with women of size and how that impacts their birthing and cesarean rates.

The second Healthy Birth Practice is:

2. Walk, move, and change position

Walking around, moving, and changing positions make labor and birth easier and more comfortable.

But far too often, women are stuck in bed during labor and birth with a fetal monitor and tubes all over the place and are no longer really able to move.

This needs to change---and nowhere moreso than for women of size.

Why It's Important To Stay Mobile in Labor


Watch a typical birth on TV reality shows and you'll see that most women who labor and birth in the hospital are stuck in bed. Although hospitals now allow more movement in early labor than they used to, by the time labor has progressed very far, most women are still flat on their back, semi-sitting on their behinds, or propped a little to one side. Very few are up and moving about. And even fewer push the baby out in any position other than semi-sitting with the knees pulled back or their feet in stirrups.

This reflects our modern medical culture's expectation that women should labor and birth reclining in bed, and this positioning is strongly encouraged by doctors because it is more convenient and comfortable for them to attend.

However, if you look at labor behavior in non-Western cultures, women tend to move around in labor a lot. They may labor standing, sitting, walking, dancing, leaning over, in water, or on all fours.

Some choose to give birth lying down in bed, it's true, but more often they birth upright in a standing, squatting or in a "supported squat" position (someone holding them in a semi-squat from above and behind).

Some women give birth leaning on a table or bed, or sitting on a special "birth stool" that keeps them semi-upright. Many homebirth midwives today have special birth stools that women can choose to use. Others create a birth stool-like position by having the dad sit on a chair, knees apart, and having the mother hook her legs over his knees.


Some women have a strong instinct to pull or push against something during labor, especially when pushing out the baby. They may give birth hanging onto a bar or dangling from a rope or a person's hands. This is not unlike the "supported squat" position mentioned above, only now the woman is supporting her own weight.


Some women find themselves pulled towards laboring or giving birth in asymmetric positions, such as walking up stairs, or standing/kneeling with one foot up and one foot down. Others "do the hula" and circle their hips a lot.

This lifts up one side of the pelvis and creates extra space for poorly-positioned babies to reposition and rotate more easily. If the baby has trouble negotiating its shoulders past the mother's pubic bone, some midwives think a kneeling lunge or the all-fours position is particularly helpful for resolving things.


Because it too helps create more space in the pelvis, many women are pulled towards laboring and birthing on all fours.

This is often helps lessen back labor, and may help turn a "sunnyside up" (posterior) baby to an easier position for birth. If the baby is large or its shoulders are a tight fit, this position may help them slip out more easily.

All of these positions are much more commonly seen in non-Western cultures, and also in non-technological approaches to birth here in the West.

Why do women birth in all these different positions? Cultural expectations play a part of course---but research shows that when Western women are given access to a room in which the bed is not the central feature and are encouraged to labor and birth as they feel most comfortable, most do not choose to birth lying down in bed either.

The reason that most women prefer to move around a lot in labor and birth is because it's physiologically sensible and logical. It helps them give birth more easily and more comfortably.

Their bodies intuitively tell them they need to move and so they do it. Even in high-tech medical model births where women are stuck in bed, many still try to move as much as they can, shifting in bed, rocking their bodies, turning to their sides, trying to arch their backs. In fact, women with an epidural may have better results pushing in a side-lying position than in stirrups because there is more mobility of the pelvis in this position. Yet it is often not even tried.

This is not to say that women should never give birth lying down or in the semi-sitting position. Actually there are times when lying down can help a baby get past the mother's pubic symphysis more easily, and of course, many women in the hospital do manage to give birth vaginally in the semi-sitting position despite its challenges.

It can be done--but most women, when given true freedom of movement, do not choose these positions for birth, and there are times when other positions probably facilitate birth much better than these. The point is that women should have the choice.

What Research Says and Why

Research shows that being more upright in labor shortens the first stage of labor (dilation of the cervix) and lessens the need for epidurals. Alternative positions may also help increase the pelvic space available for the baby

Gravity helps move the baby further down into the pelvis, putting more pressure directly on the cervix, which helps it dilate more quickly and evenly. Mobility also helps change the internal dimensions of the pelvis, creating a little extra room for a baby when needed. (This is a little like how, if your boot or your jeans are a bit tight, you wiggle back and forth to get into it anyhow.)

Lying on the back or in a semi-sitting position means that the tailbone basically gets pushed into the pelvic outlet, making the space available for the baby a little smaller. Because the woman is sitting on the bed, the bed prevents the tailbone from moving out of the way as the baby is coming out, and it compresses the pelvic outlet. When women give birth in more upright positions or on all fours, they often arch their back at the last moment, moving that tailbone out of the way and creating more space at the pelvic outlet instead of less.

Another concern with lying flat on your back or in a semi-sitting position is that it can compress the blood flow to the uterus, compromising baby's oxygen supply. In fact, doctors often warn women during pregnancy not to sleep or lie on their backs for too long---yet once the mother is in labor, suddenly this advice is no longer followed and women are left for hours in this position. Moving around freely keeps the weight of the baby and the uterus off of the blood supply to the uterus, and helps ensure a better continuous oxygen supply to the baby.

Movement is also the body's natural response to discomfort. Think about how people respond to pain in daily life. Animals in pain are often restless and move around a room. If you stub your toe, you hop about for a while until the throbbing subsides a bit. If you are too sick to move around a lot, you may rock back and forth to deal with the discomfort you are feeling, or shift position frequently.

Many women handle labor pain in the same way. Some relax deeply and become more motionless to handle labor pain, but many respond to labor pain by moving. They may shift position frequently, walk around the room, rotate their hips, push actively against the doorframe or wall, dangle from a squat bar or pull against someone's hands, or rock back and forth as they deal with the surges of labor contractions.

Being stuck in bed on your back makes it more difficult for your body to move in response to the pain and makes you more likely to need drugs for pain relief. Pain meds are not "bad" (and we can be glad they are an option when needed), but they do come with risks to the baby and the mother. It's much simpler and safer to reduce the need for pain medications by allowing the mother to move freely in response to her pain and her body's instincts, reserving the meds for when they are truly needed.

Furthermore, many women find that their bodies intuitively tell them how they "need" to move during labor and birth in order to best facilitate the descent and rotation of the baby through the pelvis. Many women feel the need to get up and move about, to go onto hands and knees, to lift one leg, or to arch their backs during labor. Often, well-meaning nurses discourage this kind of movement near the end of labor, seeing it as counter-productive to getting the baby out, when in fact it may be exactly what is needed to get the baby out. We simply need to respect women's instincts more.

This is not to say that mobility is absolutely forbidden in hospitals these days. There is progress from the past when many hospitals required women to lie flat for labor, using drugs and physical restraints in order to keep them immobilized. Many hospitals today recognize that movement in labor is beneficial and "allow" the mother to change positions, walk, use a birth ball, or even labor in water.

Many doctors will tell women that they can labor in whatever position they'd like---and the nurses will absolutely support that---BUT when it comes time to actually catch the baby, most doctors insist the woman be back in bed, semi-sitting, with her knees pulled back and her body curved into a "C" position.

Alas, this is only the best position for birth if you are the attending doctor. It allows the doctor to sit on a stool and catch the baby without discomfort. But it makes the mom essentially push the baby out "uphill," makes pushing both more painful and harder to deal with, and diminishes the pelvic space. How sad that the priority in hospitals today is on the comfort and convenience of the doctor, not the comfort, convenience, and health of the mother and baby.

The research on mobility during labor is summarized in the Healthy Birth Practice Paper: Walk, Move Around, and Change Positions Throughout Labor and its accompanying video:

When you walk or move around in labor, your uterus, a muscle, works more efficiently. Changing position frequently moves the bones of the pelvis to help the baby find the best fit, while upright positions use gravity to help bring the baby down the birth canal. The diameter of the pelvic inlet and outlet can increase as a woman moves around in labor....

Researchers who examined all of the published studies on movement in labor found that, when compared with policies restricting movement, policies that encourage women to walk, move around, or change position in labor may result in the following outcomes:
  • less severe pain,
  • less need for pain medications such as epidurals and narcotics,
  • shorter labors,
  • less continuous monitoring, and
  • fewer cesarean surgeries
In fact, no woman who participated in any of the research studies said that she was more comfortable on her back than in other positions. No study has ever shown that walking in labor is harmful in healthy women with normal labors....

Walking, moving around, and changing positions make labor easier and safer...Lamaze International encourages you to plan to be active throughout labor, to practice labor and birth positions during pregnancy, and to choose a care provider and birth setting that provide many different options for using movement.
Ah, and that is the key.

You must choose a birth setting and a care provider that not only "allows" but believes in the importance of mobility in labor and will do everything possible to help promote that.

Yes, "even" in women of size.

And therein lies the problem.

Mobility Restrictions Affect Women of Size Disproportionately

Even in hospitals that pay lip service to mobility in labor for other women, oftentimes "obese" women are not allowed the same freedoms.

In many hospitals, fat women are restricted to their beds--or if not outright restricted, strongly discouraged from moving about during labor. This is because of several erroneous beliefs or concerns about "obesity" and pregnancy.

Fear of Stroking Out

First, some care providers have the erroneous belief that all fat people have high blood pressure and are about to stroke out or have a heart attack at any moment. Even when a fat person's blood pressure is perfectly normal, care providers often believe that their high BP has simply yet to be unmasked and may well spike during the work of labor.

Because women with high blood pressure are typically kept relatively immobile in bed during labor, many doctors and nurses assume that fat women should be kept immobile in bed too, "just in case." But if the woman's blood pressure has been normal throughout pregnancy and is normal in early labor, chances are it will remain so, and keeping a woman of size immobile "just in case" is unnecessary and overkill.

Fetal Monitoring Issues

Another reason fat women tend to be kept immobilized is fetal monitoring issues. The baby of an "obese" woman is viewed as being at ultra-high risk for problems, so continuous electronic fetal monitoring (EFM) is often seen as obligatory in them, even in spontaneous labor with no drugs or pain meds (when EFM is usually not mandatory). This fear of problems for the baby is largely exaggerated, as the vast majority of babies of fat women do just fine--but in this litigious society, doctors tend to err on the side of interventions, even though continuous fetal monitoring has not been shown to improve outcomes.

Although theoretically, EFM should permit the woman to move around somewhat during labor, in practice it often means that the woman must lie still in bed in order to get an uninterrupted reading. Because women of size have extra adipose tissue that makes getting reliable EFM more difficult, they often have to keep extra still to get a reading.

Although telemetry (wireless) monitoring is available, it is usually not offered to women of size. Furthermore, because external EFM can be more difficult in women of size, an internal fetal monitor is often encouraged or even made mandatory for "obese" women in many hospitals. An internal monitor requires that the mother's waters be broken and a small electrode screwed into the baby's scalp. These wires go up into the mother's vagina, further restricting her ability to move around, and many women are told that once their water is broken, they are no longer allowed out of bed.

So external and internal fetal monitoring often are a big part of why women of size tend to have less access to full mobility during labor.

Fears of Falls and Worker's Comp Claims

Other reasons for restricting movement in women of size are fears about them falling, the strain on healthcare workers who might have to move them or help support their weight, and the financial burden of workers comp claims that might be filed as a result.

Although falls like this are quite uncommon in labor, the concern that a healthcare worker might injure themselves having to help a fat person is a common concern and has often been used to justify denying a woman of size access to waterbirth, to birth centers, and to movement during labor.

Barbara Harper, director of Waterbirth International, addresses the issue of denying fat women access to waterbirth based soley on BMI and fears of worker's comp claims. She says:

When I teach the professional Waterbirth Credentialing workshop, I do address waterbirth BMI restriction policies and insist that hospitals treat each woman individually...I implore them to look at pre-pregnancy activity levels.

I have been successful in having the BMI policies removed from some hospital protocols, but not in others.

There is no available scientific evidence one way or the other, with the exception that we did a search in both the US and the UK to find workers compensation cases for back injuries in labor and delivery settings. There were some, but none related to water.

Holding the leg of a 300 pound woman while she is pushing is much harder than helping her in and out of the bath.

Stereotypes about Strength and Mobility Levels

Many birth attendants also don't believe that fat women are strong enough or flexible enough to be mobile in labor. They don't encourage mobility because they've been programmed to believe that all fat people are unfit, weak, and sedentary, so why bother trying?

Unfortunately, these unconscious stereotypes about fatness also discourage medical staff from suggesting mobility and change of position options to their fat patients, most of whom could handle them just fine. Many fat women are far more flexible and fit than is commonly believed.

Summary

All of these factors combine to keep fat women in bed, on their back or semi-sitting, and strongly discouraged from moving around at all. Yet this may be the group that can most benefit from mobility in labor in many ways.

Why Mobility in Labor May Be Even More Important in Women of Size

No one has ever really studied mobility in labor in an "obese" population, so it's difficult to conclusively prove that mobility is important in this group. However, if it is helpful in women of average size, there is no reason to believe it wouldn't also be helpful in women of size.

Anecdotally, "obese" women who have had access to full freedom of movement during labor and birth usually report having fewer cesareans and fewer other problems compared to their previous births in which movement was restricted. (This was certainly true for me and a number of women of size I know from ICAN.)

Now, that's only anecdata at this point, but many women of size and their birth attendants find they achieve better results when they move freely and use non-traditional birthing positions. Waterbirth in particular seems to be VERY helpful to many women of size because the water buoyancy makes it easier for them to shift positions and maintain them with less stress.

One thing that many doctors worry about in fat women is the dubious concept of "soft tissue dystocia." Basically, this means that they worry that extra adipose tissue "down there" will make it harder for a baby to fit through easily. Many (in all seriousness) blame the higher cesarean rate in "obese" women on soft tissue dystocia (or "fat vaginas" as some doctors call it).

Ironically, almost no research has been done on "soft tissue dystocia" to see if it really is a valid concern or not, but doctors everywhere have been trained to believe it with every ounce of their being. A minor detail like lack of proof makes no difference. (I seriously doubt its validity as a real factor for fat women, but that's a whole 'nuther post.)

But let's pretend for a moment that soft tissue dystocia might be real, and that a fat vagina might reduce the pelvic space available to push the baby out. IF that were true (and that's a big IF), then mobility in labor would be even more important for "obese" women because it could open up the pelvic dimensions and give their babies a little more room to get out. It might make the difference between a cesarean and a vaginal birth, or a shoulder dystocia and a normal spontaneous vaginal birth. Every centimeter counts and mobility in labor can help add a little extra room that might make a difference.

And yet, fat women are the ones least likely to be given access to full mobility in labor. Ironic how the logic is so inconsistently applied, isn't it?

Conclusion

If you are pregnant, the most critical issue is to find a care provider and a birth setting that is supportive of you moving around as needed, whatever your size, and which will encourage you to labor spontaneously as much as possible (which will help you retain the ability to move freely).

Major red flags would be facilities that require or strongly encourage"obese" women to have constant EFM (especially mandatory internal monitoring), have BMI limits on access to waterbirth or other "alternative" modalities, or who assume that you will be induced and/or "need" an epidural because of your size. These are not birth settings where you will be encouraged to be as mobile as possible, and you are likely to have a higher risk for a cesarean under these conditions.

However, some hospitals and birth centers (and even homebirth midwives) talk a good game but
it's only lip service. In the end, some don't really support full mobility or spontaneous labor for fat women either. These have to be a little more carefully vetted because they can be wolves in sheep's clothing, pretending to be something they are not.

Tour the hospital and birth center and see just how many woman in labor are out walking the halls, ask how many use the tubs to labor in water, and how many have full mobility not only in labor but to actually push the baby out too. Ask your care provider what the weirdest position is that he/she has ever caught a baby in, and how often women in his/her care give birth in any position other than semi-sitting. Ask to interview former clients and see whether they felt they were encouraged to be truly mobile in labor.

If you observe carefully and ask a few open-ended but pointed questions, you'll be able to find the providers who truly support mobility and spontaneous labor instead of the ones who just give lip service to it. That won't guarantee you a better birth, of course, but it's a good step on the journey towards it.

Graphics from Wikimedia Commons or excerpted from www.transitiontoparenthood.com/ttp/foreducators/arthome.htm. (Many thanks to Janelle Durham for making these latter illustrations and information available freely!)

5 comments:

Jen Anderson said...

This is a great, very informative post. But, like some of your other posts, it has made me afraid to get pregnant (which I'm trying to do).

I had to put a lot of effort into finding an obstetrician who is In Network for my insurance, who also has privileges at a hospital that is also In Network for me. There are no in network midwives in my area, and no geographically convenient birthing centers that are also in network.

I live in New York City, by the way, not someplace sparsely populated. Ironically, if I lived in the suburbs, I'd have many birthing centers available to me.

So I found ONE doctor who a friend recommended. If I vet that doctor, and find him or the hospital lacking, then I'll have to start over with another doctor and another and another. I can imagine spending the entire 9 months of pregnancy switching doctors constantly and never finding the right one.

In the FA movement, we often talk about trying to open the eyes of our other doctors. Why not our OBs? I'd love to hear your thoughts on how to convince your doctor to allow delivery in an atypical position, and so on. I could print out some of your posts, but there's no guarantee that an OB would read them.

Well-Rounded Mama said...

Hi Jen. Thank you for your comment and for sharing your concerns.

I often struggle with trying to find the right balance on the blog. I don't want to scare people away from getting pregnant, but neither do I want to white-wash how obstetrics discriminates against fat folk. It's a difficult balance to find, honestly. But really, just because I'm showing the worst of things in an effort to educate people doesn't mean that YOU will experience that. You really CAN have a positive and supportive pregnancy experience...it just takes a little awareness and education and self-advocacy. Choosing a decent provider is the first and biggest step in many ways.

Truly, your best bet is with a midwife. Not that there aren't fat-phobic midwives out there too, but generally speaking they are more size-friendly and more normal birth-friendly than OBs. And generally they use less automatic interventions with women of size than Docs.

I have put out feelers for you about finding the names of some good size-friendly OBs *and* midwives in NYC. You can email me off-site to get those names (kmom at plus-size-pregnancy dot org) in a few days. Did you also consult Stef's Fat-Friendly Practitioners list and see if she has anyone for NYC? I have a link on my website.

I'd also encourage you to consider going out of network if necessary. That sounds SO incredibly financially daunting I know, but it's really not as insurmountable as it might sound at first. Many of us have done it. It's really worth a little extra expense to have a really respectful birth and not be pushed into all kinds of unneeded interventions.

If there IS no extra money to consider this, I understand---especially in this economy!---but we in ICAN have worked many times with folks who were SURE they couldn't afford it and yet somehow managed to work somthing out.

I'm not telling you that you HAVE to go out of network or have a home birth or a birth center birth or whatever; I'm suggesting that you consider ALL your options, regardless of insurance, and THEN make a decision. Interview a bunch of folks from different settings and see what kind of $ arrangements might be made, and THEN decide what the right course is for you.

If that's in-network and there's no other real choices, then do your best to find a doc who is open to more alternative ideas and open to being educated about HAES. One thing I've learned over the years is that there is a HUGE variety of docs and what they'll "allow" and not. You really can be a savvy consumer and save yourself a lot of grief by vetting carefully ahead of time.

So, hang in there. Don't get discouraged! You CAN do this. And you CAN find a respectful and size-friendly provider. It takes a little legwork, and it's important to be educated about birth issues...but you really can find good people out there.

Pampered Mom said...

Jen - Have you tried asking your health insurance for an exemption? I have a feeling that's not the right term (check your health insurance paperwork), but I'd give them a call. Let them know that they don't have any midwives in your area that are in network. There are instances where my midwife has had clients who were able to obtain one of these from their h/i.

Green Mountain Mama said...

Thank you for a thoughtful post, that points out lots of food for thought for nurses and doctors. I do want to mention that as a nurse, when I am responsible at a birth, I am taking care of two people. One of them I cannot see. The best way for me to know what is going on with the baby is to carefully asses his or her well-being by listening to the heartbeat - both during and after contractions. I need to do it long enough to know how the baby is reacting to labor, and then to pushing during second stage. Sometimes it is very hard to do that when there a big insulating layer! In addition, not all abundant women move well - sometimes I need to almost nag to get them out of bed. (Granted, that happens with the skinny minis too.) I'm also thinking - with both these kinds of moms - about blood sugar levels, and what equipment I need to have available if we have pushing problems or breathing problems. So....I would encourage you to find a facility that listens to women (if you're in NYC, start calling up the Connecticut River Valley....) and know that there are passionate professionals out here as well as passionate mothers and fathers. Stay healthy and here's to happy birthing days and healthy babies!

Jen Anderson said...

Well-Rounded Mama, thanks for the encouragement. I'll email you about that info. I tried the Fat Friendly Practitioners list and the only one in my network is not taking new patients right now, and only has privileges at an out of network hospital. But I guess after an out of network hospital gets paid by the insurance company, I can negotiate with them to get down my share of the bill.

Pampered Mom, thanks for the suggestion. I'll give it a try when the time comes. I already have a recommended midwife in my area. I'd just have to see if she's comfortable with my age (38), as well as fat friendly.