Healthy Birth Practices: Get Upright and Follow Urges to Push

Unfortunately, in our society we think of birthing as something done while lying down--Michel Odent

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:

1. Let Labor Begin On Its Own
2. Walk, Move Around, and Change Positions During Birth
3. Bring a Loved One, Friend, or Doula for Continuous Support
4. Avoid Unnecessary Interventions

The new featured Healthy Birth Practice is:

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

Turn on any TV birth show like "A Baby Story" etc. and you will see women primarily delivering while on their backs or lying a bit propped in bed. Their legs are either in stirrups, or their knees are being pulled back and held in place by others. They are usually encouraged to curve their chests into a "C" position, chin to chest, while rounding their backs forward.

Some birth shows have women who are propped up into a semi-sitting position in bed, with their knees pulled back.  This gets them a little more upright but again they are sitting back on their behinds in bed, pushing the tailbone into the space where the baby has to come out.

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to their own devices, are these the positions most women would give birth in, or are these positions an artifact of outdated medical and cultural norms?

And do we really need to have everyone yelling at the mother to hold her breath and puuuuusssh while they count to ten, then to take a quick breath and do it again? Is it really necessary to "purple push" in order to get a baby out?

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

There are other positions women can use to push out their babies. 

For example, many women find they like kneeling positions for both laboring and pushing.  In this type of position, a woman might kneel on the bed, facing backwards and leaning on the raised head of the bed.  Or she might kneel while leaning on a birth ball, chair, or support person.  Leaning over keeps her hips mobile, tends to be less painful than laboring while on the back, and lets her support people apply counter-pressure if needed. It also utilizes gravity to help bring the baby down with less force from the mother.

Many women like to give birth on all-fours (another kind of kneeling position) because it gets the weight of the baby off their backs and tends to lessen pain. It also creates more room by allowing the sacrum and tailbone to move freely up and out of the pelvic outlet (the space between the pelvic bones where the baby comes out). Counter-presure is also easily applied in this position, which many women find helpful.

Some women prefer a squatting or semi-squatting position for giving birth.  Because this can be a tiring position, it's helpful to use it intermittently and have a resting position you can return to as needed.

In a hospital, women can use a squat bar to help them with squatting.  Most hospital birthing beds break down into various positions for pushing, and although it's not used that often, most include a squat bar that can be set up and utilized. 

Another option for squatting is for a woman to labor in water so that supporting a semi-squatting position is easier and can be maintained longer.

Another alternative is for a partner or support person to support women from behind while they dangle in a squat, as in this picture.  Although this position looks very tiring for the partner, if done right it is actually very practical.  Dr. Michel Odent (author of Birth Reborn and many other books) often used this position to support birthing women in his clinic in France.  It can elongate the trunk of the body and create more space for the baby to move as needed.

Birth stools often promote a kind of modified squat.  It may look like a semi-sitting position, but the angle of the mother's legs and pelvis is often closer to a squat, the mother has more freedom of movement (she can get up and go forward to deepen the squat and then sit back down to rest), and she is much more upright than most women in hospital positions get.

You can find many illustrations of birth stools in history in the Western artwork, from the Middle Ages on.  Since it was so commonly used, it obviously was a position that worked well for many birthing women.

This scene from a pioneer-era birth shows a human birth stool.  The mother sits on or between the father's spread legs (with her own legs also open).  Assistants help her by holding on to her arms/hands and giving her something to "pull" against during a pushing contraction, while the midwife catches the baby below. 

Many women like to tug against something to help them bear down during pushing.  In many traditional societies, women squat while holding on to a rope or a bar, or play "tug of war" with labor assistants (via hands or a rope or sheet).  Pulling with the hands while pushing with the lower body can be incredibly helpful because it gives you more leverage and force for pushing.

Sidelying is a great position for when the mother has limited mobility, has a strong epidural, or is very tired and needs a rest.  It gets the weight of the baby off the mother's back, opens up her pelvis, and can be maintained for long periods if the mother has help supporting her upper leg. 

A vastly underused set of positions for pushing are the asymmetric positions.  An example of this might be one knee up and the other knee down, one knee on a chair while you stand straight on the other leg, or leaning into an exaggerated lunge.  These are all great because they create more space in the pelvis, especially to one side, which often helps facilitate rotation of malpositioned babies. 

You can also adapt an asymmetric position when semi-sitting, as in this illustration.  This could easily be done on the side of a bed, on a couch, or a couple of chairs.  They key is to try a number of asymmetric positions; your body will tell you which one will be best for your particular needs.

Illustrations of all these pushing positions can be found in this great handout, which shows how these positions can be done in the hospital as well as at home.  Sometimes people think that these positions are something you can do only out-of-hospital, but with a little creativity (and flexibility from the staff), these positions are usually do-able in the hospital as well. 

Disadvantages of the Semi-Sitting or Lying Down Positions

There is a fair amount of research that shows that the traditional semi-sitting or almost lying-down positions usually used in the hospital actually have significant disadvantages.

Damage to Perineal Tissues

Pushing in the semi-sitting position, especially when pulling the knees back sharply, places a great deal of stretch and pressure on the perineum, the tissues "down there" around the vagina. It often is associated with a greater rate of vaginal tearing and damage, especially when accompanied by an episiotomy (deliberate cutting of the perineum to "widen" the vagina). 

One study found that women had significantly less tearing and swelling "down there" when in non-supine positions (sitting, squatting, or kneeling/hands-and-knees). A larger study found that the semi-sitting position was associated with a greater need for perineal suturing, whereas the all-fours position was associated with a reduced need for it. Another study found a lower rate of episiotomies, perineal repair, and instrumental delivery (forceps, vacuum) in women who used a side-lying position instead of a sitting position for birth.

Shoulder Dystocia

Although research is limited, semi-sitting positions may be implicated in some cases of shoulder dystocia -- what some midwives call "bed" dystocia.  Being in a semi-sitting position for pushing means that the woman's weight is pushing her tailbone into the pelvic outlet, making the space the baby needs to get through smaller and causing a tighter fit.  In addition, the baby must negotiate a sharp curve under the pubic arch and back up again, which is more difficult to negotiate.  In essence, you are pushing "uphill" in these types of positions.

Some research suggests that non semi-sitting positions may help prevent some cases of shoulder dystocia.  One study of macrosomic (big) babies attended by nurse-midwives in the hospital found a trend towards less shoulder dystocia if the mother was side-lying for pushing.  The number of women using that position was not high enough for the results to reach statistical significance but the trend was clearly there.  Yet few subsequent studies have been performed to confirm or disprove this relationship, because such a position is outside the realm of most hospital "culture" and therefore rarely researched. 

Pain Levels

Many women find that the pain of labor is less intense and easier to endure if they are able to move with their labors instead of staying in one position.  One study found that women reported less pain during labor and afterwards when they used a kneeling position instead of a sitting position for pushing.

When given full, free mobility, many women prefer to stand, lean over a chair, sway, get on all fours, or push with one foot up and one foot down.  Some do choose to lie on their back but often will arch their back instead of round it forward. 

If allowed to move their bodies in response to their pain cues, most women find they are able to tolerate the pain of spontaneous labor without drugs.  Having labor-strengthening drugs and being stuck on your back in bed with a fetal monitor that doesn't allow you to move means that most women "need" some kind of drugs or epidural to get through the pain of labor, which present their own risks to mother and baby.

Having more access to warm water and full mobility during labor and pushing could probably significantly lessen the number of women who need pain relief drugs, and therefore the associated complications that go with them.

Malpositions

If a mother is laboring in the usual hospital position with a baby that is in a poorer position for birth (for example, back of the head against mother's back, or occiput posterior), it is very difficult for that baby to turn and get into an easier position for birth. Getting up and moving freely can often open up the pelvic dimensions and help the baby turn. 

Studies on the use of alternative positions to help a posterior baby turn are generally small, underpowered, and contradictory, but some research does show that being on all fours during labor with a posterior baby may result in a higher rate of babies turn into the easier anterior position for birth, although the trend in that study did not quite reach statistical significance.  It did significantly lessen back pain for the mothers involved, however, which is very useful in and of itself.

Being on all fours may or may not help before labor, but may be more effective if done during labor in women with a suspected posterior baby, and especially if done for longer periods of time and more consistently than currently studied.

Even side-lying positions, properly done, may result in a higher rate of posterior babies turning to anterior during labor and possibly a lower cesarean rate. 

More (and better-designed) research is needed to determine just how effective maternal positioning really is, but anecdotally, many midwives find that if a baby is still posterior during the pushing phase, turning the mother and getting her more mobile can actually help turn the baby, at which point the baby is often more quickly and easily born. An old midwives' credo is "If you can't turn the baby, turn the mother."  At the very least, it may help lessen the mother's pain and help her labor longer without drugs or other risky interventions.

Positioning with Epidurals

What about women who get an epidural during labor? Do they have to give birth in stirrups or with their knees pulled back to their ears because of less control of their legs from the epidural?

Most women who have epidurals are not given a choice, but side-lying is still a position compatible with an epidural.  One small study found that women with epidurals had less chance of getting an episiotomy and a better chance of a spontaneous vaginal birth if they were in a side-lying position for birth rather than a sitting position. The small size of this study was a limitation, but another larger study also found that women with an epidural needed less perineal suturing if they assumed a side-lying position for pushing.

Is Semi-Sitting Really So Bad?

This is not to say that women shouldn't ever be in the semi-sitting position.  Some women want to be in this position because it's the position that feels best to them---and if so, it's perfectly fine to use it!  It's a good position for resting between contractions, and certainly, many women have successfully given birth just fine in this position over the years. 

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

Here are some photos of real women of size birthing their babies in positions other than the traditional lithotomy or semi-sitting/knees-pulled-back-in-a-hospital-bed you see on TV.  

Mind, I don't have a lot of these photos, because while women are willing to share their pregnancy and labor photos with me, most don't want to share the really intimate shots for all the internet to see.  And who can blame them for that?

[If any of you want to share your pushing photos with me, I'd be happy to have some more!]

Other big moms have labor photos but may not have had photos taken of the actual emergence of the baby because they were too self-conscious.  If some of us can hardly bear to have our pictures taken in full clothing and normal circumstances, imagine the inhibitions some may have for taking photos at one of the most intimate times of our life. 

So I don't have as many pushing photos as I would like.....but I do have shots of a few positions, and hopefully that will be enough to inspire other women of size to experiment a little too.

My profound thanks to the women who were willing to share their stories and their photos with the world. 

You will never know how many lives you touch, now and in the future.  Bless you for being willing to share and inspire others.

You will probably notice that all of the photos here so far are of women of size giving birth in the water.  That's partly because that's just what's been sent to me, at least for the pushing phase.

But it's also because water is one of the best places for women of size to labor and give birth, because the buoyancy from the water helps us change positions and hold them more easily (like this semi-squat position). It helps us be more mobile and flexible, which is often just what we need most to get our babies out.

Many women of size who have had waterbirths swear by water for the pushing phase as well as for the laboring phase. It's truly heaven-sent.

Be aware that if you are a newbie to birth, your inital reaction to some of these positions may be to be taken aback. Our cultural conditioning around birth is so strong that our reaction to seeing a woman give birth in alternative positions (or in the water!) can be strong because it just doesn't seem right or even ladylike.

 

And sometimes those feelings may be even stronger towards a woman of size using alternative positions.

Some care providers who are perfectly fine with using alternative positions and/or water for women of average size shy away from doing them with women of size.  It's part of that cultural conditioning of fear around "obesity." 

And even sometimes the women themselves secretly believe themselves to be "too high-risk" to try anything a little out of the ordinary. 

So seeing these images may make some viewers squirm a bit.  It may make some providers squirm even a bit more. 

Yet these are some of the best positions for women of size, and the fact that so many of the vaginal birth pictures I have of women of size involve water or the hands-and-knees position speaks volumes about its efficacy and comfort for us.  Providers, take note.

But just as making love does not need to take place in the missionary flat-on-the-back-and-legs-spread position, neither does birth need to take place in that position.  Any position you can use to get the baby in is a position you can use to get the baby out. Be as creative in birthing as you are in lovemaking....maybe even more so!

In particular, close-ups of a woman giving birth on all fours may be seem strange to some readers because, let's be frank, you get a close-up shot of her behind. 

Our society prefers to ignore the fact that that part of our anatomy is quite close to where we give birth. It seems very strange to some people to see a baby's head coming out right by your behind, yet they forget that it comes out that close to "there" whether you are facing up or down. 

Either way, the proximity is the same, but when a woman is on all-fours, we are forced to emotionally recognize that same proximity, and some people are grossed out by that fact.

But look closely.  Some of these photos illustrate the very advantages we've been talking about.  When a woman is birthing on all fours, oftentimes witnesses will exclaim later about how the shape of her behind changed.  [One husband described it memorably....."Your butt got really square!"]  That strange shape is the mother's bones moving out of the way to create more space for the baby.  Ask yourself....would that have happened if the mother had been sitting on her behind instead?

Although it's an unfamiliar and even strange sight for newbie observers, the truth is that the all-fours position is an awesome position for women of size.

So challenge yourself and your perceptions. If you have a negative reaction, remember that this is because of cultural conditioning, and all you need to overcome this cultural conditioning is exposure to different images and ideas.

Consider the possibilities.....all of them. 

Conclusion

As the healthy care birth practice paper on pushing notes:

Throughout history, images depicted in art show that women have used many positions to give birth to their babies, including standing, sitting, hands-and-knees, and side-lying. Until doctors began using forceps in the 17th century, women rarely were shown giving birth lying on their back. With the support and encouragement of family members and community midwives, laboring women used objects such as posts and ropes to gain leverage during pushing. They often used birthing supports or stools to help them squat, crouch, or kneel.

Historically, women usually used a wide variety of positions for birthing.  In traditional societies, you still see many women using these positions for birth, but in medicalized birth, they are rarely used.  Instead, women in Western hospitals most often birth on their backs or propped up a bit, with knees pulled back or their feet in stirrups.

This kind of birth is a recent cultural artifact, not a medical necessity.  In fact, a reasonable amount of research suggests that outcomes are usually just as good or better with alternative positions. 

No, there's nothing wrong with birthing on your back or in a semi-sitting position if that's what feels best to you at the time.

However, there is something wrong with birthing that way because that's what most comfortable or convenient for your doctor, that's the only way he/she was trained to deliver babies, because a nurse tells you to stop moving a different way, or because you are too inhibited to follow your body's cues and get up and move.

Women should not be forced to birth in any particular position but should be able to move at will. 

The important thing is to move freely while birthing and to respect and follow your body's internal "knowing" about how best to move to get your baby out.

Alas, this kind of mobility is not promoted in many hospitals, and especially not for women of size.  That's why it's particularly important for fat women to find size-friendly providers who understand and actively promote freedom of mobility during all of labor and pushing, whatever the mother's size.