This is number 5 in a series on the Lamaze Healthy Birth Practices, why they are important in birth, and how they are less commonly "allowed" in women of size. The previous entries have been:
- Let Labor Begin On Its Own
- Walk, Move Around, and Change Positions During Birth
- Bring a Loved One, Friend, or Doula for Continuous Support
- Avoid Unnecessary Interventions
5. Get upright and follow urges to push
You can find a care practice paper summarizing this Healthy Birth Practice, complete with research citations, here. You can find a handout summarizing the information, here. You can find a handout illustrating various labor positions here.
[Only one more Healthy Birth Care Practice to go!]
Alert: Be aware that this post has some graphic birth pictures in it, pictures in which ladybits are clearly visible. If that bothers you, don't look at the last section of this post. Also keep in mind that the photos are copyrighted and may NOT be reproduced elsewhere without permission.
Our Pervasive Cultural Image of Birth
Are these really the best positions for birth? Do they have the best outcomes? Why is every woman shown in these positions for birth? Women are so different; isn't there any variety in how they choose to give birth? Left to their own devices, are these the positions most women would give birth in, or are these positions an artifact of outdated medical and cultural norms?
The Healthy Birth Care Practice Paper #5 describes the results of a recent national survey, Listening to Mothers II. They found that 57% of women surveyed gave birth lying on their backs, and 35% more gave birth in a semisitting position. They reported, "Only 21% of women in the survey followed their own urge to push. The rest of the women reported that nurses or other health-care providers told them to push a certain way."
Although this type of birth is obviously a very common scenario, the answer is no, women absolutely do not need to push this way in order to get the baby out. And in fact, most outcomes tend to be just as good or better for women who don't follow the current media norms about what birth "should" look like or how support personnel "should" coach women during pushing.
Types of Pushing Positions
It's not that women should not give birth in the semi-sitting (or even the lying down) position, if that's the position their bodies tell them to be in. It's that women should not be forced into this position whether they want it or not, and that care providers should be actively offering the use of other positions because outcomes are improved for baby and mother.
So Why Aren't Alternative Positions Used More Often?
Question: So why is lying down or semi-sitting used almost exclusively in most hospitals? If outcomes improve, why aren't more women encouraged to squat, use all-fours, kneel, use asymmetric positions, or be side-lying for pushing?
Answer: Because it's not part of routine hospital culture, because doctors are more comfortable attending birth in the traditional position, because doctors are not trained to catch babies any other way, and because other birth positions are not part of most birthing women's cultural expectations.
Hospitals historically promoted lying down for birth because for many years, women were heavily drugged during labor and couldn't be trusted to move around safely. Even today women are confined to bed because of the heavy use of epidurals or narcotics in most births; it's still seen as "safer" regardless of whether or not the mother is actually drugged.
In addition, lying down gave the doctor easy access to the mother's perineum to do the episiotomy that was mandatory in hospital birth for many years, and he could sit down in comfort for the birth and the perineal repair afterwards. Furthermore, this position promoted the hierarchy typical of hospitals.....the patient as dependent and subordinate, the hospital staff as in control and making the decisions. Basically, traditional positions are more comfortable for the staff, both physically and emotionally, and sadly, the staff's comfort is a higher priority than the mother's comfort.
Over time, this position became the "culture" of the hospital as the "right" way to give birth, and other positions were seen as bizarre or unscientific.
Doctors are trained in catching babies from the lying-down or semi-sitting position, and often have difficulty understanding how to catch babies in other positions. When a woman is in the all-fours position, up is down and down is up to the doctor; the orientation for fixing any problems is upside down and many doctors are not comfortable with that re-orientation.
Many doctors simply don't know how to attend women in any other position because they most likely have not seen women in any other position than semi-sitting or lying-down during their training, and many resist any changes from the way things were done during their training.
When prodded, some doctors will tell women that they can push in any position they want, "upside down if you want to".....but that when the baby is actually coming out, the mother has to be in bed with her knees pulled back or in stirrups. Unfortunately, this is the time when the most room in the pelvic outlet is actually needed and when the alternative position is most important. Letting a woman have freedom of mobility during the pushing phase for everything but the last bit is not the same as true freedom of mobility.
Women's cultural expectations also play a role in the positions they assume for birth. If the only images you ever see of birth are of women in the stranded beetle position, you have a cultural template for expecting to be in that position during labor, even when offered alternatives.
Another unconscious expectation some women have is that birth will take place in the "missionary" position, much like sex may often have been for them, and like gynecological exams always are done. And to some, birthing in other positions may not seem ladylike or "right." Cultural expectations and experiences assimilate women into a certain view of how birth is done, and this can be difficult to break out of.
A hospital's physical layout also has an influence. Having a bed in the middle of the birthing room as its dominating feature means that most women head there at some point in labor, because their cultural expectations tell them that's where they should be. But if you give a woman a birthing room with the bed de-emphasized, more women will utilize alternate positions and avoid the semi-sitting position so common in Western culture.
Women in other parts of the world who give birth outside the hospital usually give birth in "alternative" positions. When women in Western culture are given access to non-traditional birthing suites that de-emphasize the bed and have other equipment (like water tubs, ropes, birthing balls, squat bars, etc.) available, they give birth less often in the bed and more often in the "alternative" positions.
Women can overcome a lifetime of cultural conditioning and be willing to try other birthing positions if they have supportive staff who are flexible and open, but it takes active education during pregnancy and proactive reminder of position choices during labor for many women to overcome that cultural norm. If the attending staff is not on board, it most likely won't happen. And that's how these harmful practices get passed on.
Pushing and Women of Size
"Obese" women in the hospital are "allowed" to push in truly upright positions or according to their own urges even less often than women of average size. Many report they are required to indulge in purple pushing while curled into a "C" and straining to bear down. This stresses the baby, makes the mother more likely to tear, and makes it harder for the baby to get out safely.
Some providers automatically assume that all fat women are "poor pushers" because they "must" be out of shape and will therefore have less efficient pushing strength. Therefore these providers may be quicker to augment labor contractions or to move to a cesarean without an adequate trial of labor first. However, research shows that "obese" women push with just as much force as average-sized women, yet interventions based on anticipation of "poor pushing" is another reason why the cesarean rate in fat women is so high.
Some providers keep "obese" women in bed and in the traditional semi-sitting position out of the mistaken belief that fat women are too unsteady, too weak, or too unfit to push in alternative positions. Others keep fat women immobilized out of the belief that they are all about to stroke out, or because they are worried about injuries to nurses trying to support fat women in alternative positions.
And of course, the movement to mandate placement of epidurals early in labor in fat women "just in case" means that most of these women are then relatively immobilized for the pushing phase. This is yet another way that the rules and beliefs around attending "obese" women inhibit freedom of movement for them.
Sometimes the lack of willingness to try new positions comes from the mother. Inhibition about size and weight may keep some fat women from trying out some of these alternate birthing positions, even when they are "allowed" to try them. They may be too self-conscious about their weight or what's considered "feminine" to try some of these positions in front of others, especially those who may be judgmental about their fatness.
[I understand this because I felt it too. Personally, the thought of getting on all fours and waving my big naked behind in other people's faces was a little off-putting, and I've heard other fat women express similar thoughts. And yet the all-fours position is one of the best positions for women of size.]
Ideally, birth attendants who attend women of size will encourage them to be extremely mobile in labor. The mother will have a good sense of what kind of positions she is physically able to assume, and her body will instinctively tell her how she needs to move in order to get the baby out.
Waterbirth is particularly ideal for women of size, because the buoyancy of the water makes it easier to shift position, especially if the woman has any physical limitations (like knee problems) or difficulty moving around. Yet many women of size are denied access to water for labor and birth.
The issue of mobility in labor is a crucial one for "obese" women. While important for all women, full mobility during pushing may be especially important for women of size for a number of different reasons.
First, fat women tend to have larger babies as a group, and thus may need the maximum amount of space in the pelvis to get the baby out efficiently. Making fat women birth on their backs or behinds means that the available space is being compressed instead of maximized, exactly the opposite of what may be needed.
Second, some research suggests that fat women have more malpositioned babies, and this can result in longer, harder labors and more cesareans. Being immobilized during pushing makes it very difficult for a malpositioned baby to correct its position, while being able to move more freely might help create more room for the baby to move.
Third, some providers believe in the idea of "soft tissue dystocia"....the idea that extra fat pads the pelvic outlet and may prevent the baby from being able to fit through easily. Some fat women have actually been told that their "fat vaginas" (actual phrase) caused their cesareans. However, very little research exists to support the idea of soft tissue dystocia. Mostly, it's a concept that gets taught in medical school as if it is a reality and no one questions whether or not it is true. [More on that in a future post.]
However, if soft tissue dystocia were real, then how much more important would it be for women of size to be using positions that maximize pelvic space most efficiently and use gravity to help the baby be born.
Care providers who attend "obese" women often worry about the fit of the baby into the mother's pelvis because of the generally bigger fetal sizes, possible malpositions, and soft tissue worries. But if they are truly concerned, they should be using more alternative positions with women of size, not less.
Nancy Wainer, a midwife from Massachussetts, often gives the demonstration of putting on a too-small shoe as a metaphor for getting a hard-to-fit baby through the pelvis. When Nancy rams her foot straight-on into the shoe, she cannot get her foot to fit (the baby would not be able to fit through the pelvis). But when Nancy starts wiggling her foot all around, turning sideways and wiggling this way and that, the foot begins to squeeeeeeze into the shoe. Given enough time and wiggling, she shows that she is able to get her foot into the shoe (the baby can fit through the pelvis). She acknolwedges that this is not always true for every baby and pelvis, but if there is any doubt about the fit of the baby, she stresses the importance of free, unlimited movement during pushing in order to give that baby the best chance of getting out naturally.
And yet, it is women of size that are most often prevented from having access to full, free mobility during labor and pushing.
My Pushing Stories
I have had four births, and I have pushed in all different positions for them, with varying results. Only in the last one did I truly have unlimited mobility and freedom to use any pushing position I wanted.
In my first birth (induced at 40 weeks, epidural for the pain), I pushed mostly in the semi-sitting position common to hospitals. My legs were in stirrups and my chin was to my chest. My epidural was not working very well and I had enough feeling in my legs to try the squat bar at one point, but we didn't try for very long. Because the baby was positioned poorly, pushing in any position was incredibly painful and after 2 hours I consented to a cesarean.
In my second birth (membranes stripped at 39+ weeks, water broke shortly after, natural labor), I labored mostly in the all-fours position in the tub at the hospital; that was the only tolerable position for me and the midwives were very supportive of me laboring there. However, when I was ready to push, I was required to go back to the bed in my room. I tried several pushing positions on the hospital bed, but spent most of my time in the side-lying position. Alas, baby was big and posterior and nothing budged him; we ended with a cesarean after 5 hours of pushing. I wish I had been allowed to stay on all-fours in the water, or been encouraged to get up and move around and try some of the asymmetric positions, but despite supportive nurse-midwives, none of these options were tried.
In my third birth, I finally had an anterior baby after seeing a chiropractor near the end of pregnancy. What a difference!! However, baby still had an arm up by his head. This birth was induced (to get a smaller baby--augh!) and the combo of his arm by his head and the induction made labor very painful. I opted for an epidural eventually and was scooting my butt across the bed when my "cheek crawling" helped him get his arm out of the way and suddenly I was pushing. I pushed him out in 12 minutes, sans epidural.
I would have pushed him out even faster except that the nurses made me push in the "curled forward C" position. In this position, he just kept hitting my pubic bone and couldn't get out. I kept trying to lift my butt off the bed to arch my back---what my body was screaming for me to do----but they kept telling me I was doing it wrong and had to curl my chin to chest. Finally the midwife with me lowered the bed to flat so I could lie back; I lifted my butt and arched my back over my fists, and baby was born lickety-split after that. This is a good illustration of the fact that sometimes a lying-down position can be useful, especially when the mom wants to arch her back. The arching created enough extra room for the baby to get out, and I had my first VBAC.
In my fourth birth, I gave birth at home in the water. I loved that because I was able to shift positions as desired. I labored in all kinds of positions, especially all-fours, asymmetric positions on the stairs, and leaning back on the birth ball. I pushed mostly in a semi-squatting or forward-leaning kneeling position in the water, then leaned back and arched my back in the water at the end. Again the baby's arm gave us some problems, but after the midwife fixed her arm position, she shot out quickly. I pushed for a total of 24 minutes with that VBAC.
For me, I think I may have a narrow-ish pubic arch that makes pushing in the traditional "rounded C" position in the hospital a big mistake. I think my pelvis has plenty of room, but has the most room further back, which gets closed off in the semi-sitting position. Arching my back creates more room where it's needed, and being off my back makes sure there is optimal room all around.
For me, birthing vaginally is a combo of making sure my babies are well-positioned (chiropractic care was tremendously valuable for that) and making sure I had full freedom of mobility during labor ---especially being able to arch my back.
Pushing Photos of Women of Size in Non-Traditional Positions