In our culture, the images we see of birth are so full of fear and disempowerment. The predominant imagery is a woman lying on her back, screaming for help, screaming in pain, and a traumatic rushed emergency. We see this all the time. There are no images of upright labor and birthing positions.
Can you think of any popular culture images or stories that involve a birth portrayed differently? A pregnant person’s water breaks. Suddenly and violently in a grocery store and they rush to the hospital in emergency mode. Every birth in a tv show ends in some kind of emergency situation.
Our Culture Lacks Dominant Imagery of Upright Labor and Birthing Positions
There are no views of birth available that portray birth as a normal, healthy, and positive life experience. These images are out there. But you have to really intentionally search for them.
Our culture really gets high on reality-tv and high-drama stories. And our medical culture perpetuates these stereotypes. Medical students report never seeing a single upright birth in their OB rotation. This is incredibly problematic for normalizing birth and creating a culture of evidence-based practices.
In this blog post, I’m going to take a deep dive into positions for labor and birthing. I’m going to hang out for a while and talk about the evidence for upright birthing positions, how to support physiology even if you have an epidural, and we’ll also talk about your rights in birth. You can also learn about this in this week’s podcast episode.
Choosing Labor and Birthing Positions
The topic of birthing positions comes up a lot in childbirth courses. One of the most common misconceptions I hear is the assumption that if you choose to have an epidural, you have to give birth lying flat on your back. Birthing on your back is also called the supine position.
Nearly every professional organization such as ACOG, ACNM, Royal College of Nurse Midwives, and the WHO recognizes that upright positions are beneficial for labor. They state that birthing people should not be constrained to birthing on their back because it presents many risks.
However, in the United States, 68% of people give birth lying on their back, 23% in a semi-sitting or reclined position (head of bed raised), 3% side-lying, 4% squatting or sitting, and 1% on their hands and knees.
Why are so many people still birthing on their back?
These numbers are pretty shocking, considering the fact that obstetric textbooks state that it is beneficial for a parent to birth in an upright position (Evidence Based Birth).
So why are so many people still birthing on their back, when we know that it goes against guidance by every professional birth organization and obstetric textbooks themselves?
When a patient births on their back, it’s easier for the provider to manage the birth. It makes it easier to continuously monitor a baby through electronic fetal monitoring. This has not been shown to reduce the rate of cerebral palsy or infant death when compared to intermittent monitoring.
Some hospitals have wireless monitors that are very helpful in promoting movement and water immersion. However, I often see this leading to a parent being told to get back into the bed for traditional monitoring . I also see patients subjected to continual fiddling with the monitors to get them to work properly. I see care providers discouraging movement itself because it makes the monitors fall off. They’re great when they work well.
Most medical students have never seen an upright birth in their OB rotation.
Evidence based birth states that most medical students have never seen an upright birth in their OB rotation. They may not feel confident that they can handle an emergency in a different position when their training is entirely focused on supine positions.
Instead of birthing on your back, there are other upright positions that can be used in labor and birth. If you CHOOSE to birth on your back because that intuitively feels right to you (and I do think that this happens) then I definitely encourage you to follow your own compass in birth. There’s probably a really good reason that it feels right to you, so go with your gut.
What are upright labor and birthing positions?
So, what do we mean when we say upright birthing positions? Let’s define that. Upright labor and birthing positions include standing, sitting (on the bed, a ball, a chair, a stool, etc), hands and knees position, or squatting (can be supported by a partner, using a squat bar, or kneeling).
There’s also another position called a side lying position that offers unique benefits in birth, but does not offer the help of gravity like the upright positions.
What happens when you birth on your back?
When you lay on your back in the supine position, the pressure of your heavy uterus compresses your blood vessels and reduces blood flow to your placenta, as well as your baby. This can lead to an increased risk of abnormal fetal heart tones in your baby.
Your pelvis has a flat bone at the back called the sacrum. The sacrum connects to the rest of your pelvis and is movable. It is designed to move out of the way as your baby passes through your pelvis.
Your body produces a hormone called relaxin throughout pregnancy to support your sacrum’s ability to move and helps the pelvis take shape for your baby to pass through.
Do you feel like your hips are falling apart in pregnancy? Blame relaxin.
When you lay flat on your back in birth, your sacrum can’t move out of the way. This can make it more difficult for your baby to move through your pelvis. It creates more resistance, and resistance creates pain in birth.
When you’re on your back, you’re not able to use gravity to help your baby descend through the pelvis. Lying on your back to give birth can lead to a longer second stage of labor (the pushing stage), which can increase risks to you and your baby. It is also associated with an increase in the number of severe tears that result in incontinence. One study very clearly states, “Convincing evidence has been found associating lithotomy and supine positions with perineal trauma.” (see links)
BUT sometimes birthing on your back can be helpful.
So, we know that birthing while laying flat on your back can create its own set of risks for the birthing person and their baby. Birthing on your back can actually be really helpful in a few special scenarios. This is especially true if the baby is positioned in a certain way, if you need assistance while pushing, or to help move a very stuck baby.
My point is that you don’t HAVE to if you don’t want to. I birthed my first baby on my back, and she was a very very stuck baby and I honestly don’t know how else I would have gotten her out. I’m very lucky to have had an exceptionally patient and experienced midwife.
What are the benefits of upright labor and birthing positions?
In one study cited by Evidence Based Birth, people without epidurals who were assigned to an upright birthing position while pushing were 25% less likely to have a forceps or vacuum assisted birth. They were 25% less likely to have an episiotomy. Also, they were 54% less likely to have abnormal fetal heart rate patterns. There was a very small increase in the rate of tearing (risk of 15.3% vs 12.7% in the control group).
Labor and Birthing Positions and Blood Loss
In this study, it was noted that people who used upright birthing positions were 48% more likely to have EBL greater than 500mL (but the absolute risk was 6.5% vs 4.4% in the control group). This is from a 2017 Cochrane review and meta-analysis of 32 randomized controlled studies.
Epidurals and Labor and Birthing Positions
In people with an epidural (over 60% of birthing people), being upright during the pushing stage made no difference in the rate of cesareans, assisted delivery, or the length of the pushing stage. There was also no difference in the rate of tearing, abnormal fetal heart rate patterns, or NICU admissions.
However, in one study of people with an epidural in Spain, people who delayed pushing until the urge to push was felt or baby descended and gave birth in a side-lying position (specifically with the upper foot raised above the knee), experienced fewer assisted deliveries, and a higher rate of an intact perineum (40% versus 12%). This is compared to people who pushed immediately at full dilation and birthed in the lithotomy position.
It appears that the most impactful thing one can do when receiving an epidural is to delay pushing upon full dilation and change positions frequently while waiting for the urge to push or waiting for the baby to descend.
Using a Birth Stool for Labor and Birthing Positions
Have you ever heard of a birth stool? A birth stool or a birthing seat is a short u-shaped seat that you can sit on in birth. There are wooden or metal stools people use. This is typically used by midwives in home birth or birth center settings. There are also inflatable birth stools (like the cub – which I have for clients and I love it!). You can use these in any environment.
There is a study that was done called the Swedish birth seat trial (2006 – 2009). This study found that using a birth seat shortened the second stage of labor, reduced the use of Pitocin to speed up labor, and it noted an increase in the amount of postpartum blood loss (But, this blood loss had no effect on hemoglobin levels at 2-3 months postpartum. It should be noted that this increase in blood loss of >500mL did not increase the need for blood transfusions or negative outcomes, and did not increase the rate of blood loss greater than 1000mL. This amount of blood loss may just be physiological and should be well tolerated by healthy birthing people).
Other studies have looked at hands and knees and squatting positions and found no increase in blood loss.
Squatting in Birth
There is a Turkish study out there that looks at the use of a squat bar in birth. The squat bar is a small bar that can be placed at the end of a hospital bed to use for support in squatting positions. It looks like a u-shaped bar. In this study, the use of a squat bar was associated with a 34 minute decrease in the length of the second stage compared with a back-lying position.
Upright Labor and Birthing Positions Decrease Pain
Upright positions are also associated with a reported decrease in labor pain. This has been reported in many studies. Upright positions like standing, sitting, and squatting decrease resistance and allow the body to work more effectively and use gravity as a support tool. This is most likely why pain is decreased.
A hands and knees birthing position maximizes the diameter of the pelvis and can relieve back pain, providing more room for a baby to move and descend.
Using Alternative Labor and Birthing Positions
If you are birthing in a hospital, you will most likely have to strongly advocate for your right to birth in a position of your choice. My experience is that I see many providers encourage laboring in a variety of positions, but they have a very strong preference (which is often seen as a requirement) for their patients to get on their back to birth.
It may take advocacy from you and your support person for you to birth in the position of your choice.
Providers have this preference because all of their training focuses on the supine position. Doctors nearly always want patients on their back to birth, midwives in hospitals can be more supportive of alternative birthing positions.
It is your right to give birth in the position of your choice.
Forcing a birthing person into any position to give birth is obstetric violence.
No one has the right to coerce you to birth on your back. It is your human right to have freedom of movement and choice in your position for birth. No one has the right to deny you care because of your choice in birth position. This is an incredibly vulnerable space we’re operating in when pushing. Your cervix is fully dilated and you are at your energy’s open most point.
You are fully living in the cosmic consciousness of birth. Put it in your mind that you are going to birth in the position that feels right to you. No one can force you to push on your back. They may say, “I want you to get up in the bed on your back.” And you ALWAYS have the right to say no and push in the position of your choice.
You may very well choose to birth on your back because it seems right to you. And that’s okay. But if it doesn’t, you don’t have to comply. YOU are the center of the spiral. If you are truly steadfast and confident in your birth, they will be able to adapt to your choices.
Power Dynamics, the Patriarchy, and Labor and Birthing Positions
What I often see is that the doctor holds a lot of power in the birth room. They want control over the birth process and they want to control every risk and element of that process using the exact procedure in which they were trained. This has a lot to do with risk management, liability, compliance, and the illusion of choice.
They are going to hold and court power in the birth room. Sometimes, parents feel this and have a fawning response as if they have to comply with this demand to get on their back in bed. You have the right to birth in whatever position you choose. Let them adapt. After all, they are total specialists in maternity care – they really can’t handle a person birthing on their hands and knees? How is that possible?
It’s very very hard to make a choice and stand up for yourself in a way that challenges what your provider wants you to do. The way the layers of the patriarchal power structure interact make it really difficult to assert what we really want. Practice and envision yourself doing it. Talk through and role play that scenario with your support person so you feel more confident in handling this scenario.
ATTENTION EXPECTING PARENTS
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Research for this blog article: