Thursday, March 13, 2008

Get off your back: references

This is a collection of references about maternal positioning during labor and birth. It's from the endnotes of Jock Doubleday's book Spontaneous Creation. Bold text is the original body text, and the plain text are his references.


"Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery." (Dr. Roberto Caldeyro-Barcia, The Family Practice News, 1975:11) in Laura Kaplan Shanley, Unassisted Childbirth, 15)

Being hanged by the feet may in fact present considerable advantages over lying on one's back. No studies have been performed. But a number of trials do suggest that upright positions give greater advantages in childbirth than do backlying positions. See, for instance, Allahbadia, G.N., and P.R. Vaidya, "Why deliver in the supine position?" Aust NZ J Obstet Gynaecol 32(2) (1992):104-106; Bhardwaj, N., J.A. Kukade, S. Patil, and S. Bhardwaj, "Randomised controlled trial on modified squatting position of delivery," Indian J Maternal and Child Health 6(2) (1995):33-39; Chen, S.Z., K. Aisaka, H. Mori, and T. Kigawa, "Effects of sitting position on uterine activity during labor," Obstet Gynecol 79 (1987):67-73; Liddell, H.S. and P.R. Fisher, "The birthing chair in the second stage of labour," Aus NZ J Obstet Gynaecol 25 (1985):65-68; Gardosi, J., S. Sylvester, and C.B. Lynch, "Alternative positions in the second stage of labour: a randomized controlled trial," Br J Obstet Gynaecol 96 (1989a):1290-1296; Gardosi, J., N. Hutson, and C.B. Lynch, "Randomised, controlled trial of squatting in the second stage of labour," Lancet 2 (1989b):74-77. See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78.

Pam England and Rob Horowitz write: "When a mother having back labor lies on her back, the pain becomes unbearable as the [back of the] baby's head pushes hard against her sacrum during contractions. Lying flat on her back will not only slow (or stop) cervical dilation, but may also prevent the rotation of the baby's head to a face-down position. This is one cause of "posterior arrest," which doctors may try to correct with pitocin, epidurals, forceps or a Cesarean birth. . . . Avoid the lithotomy position. This unnatural position is advantageous only to the doctor. . . . Stirrups also may cause painful cramping, numbness, or blood clots in the legs. In addition, some women experience this position as degrading, vulnerable and powerless." (Birthing from Within, 143, 145)

Janet Isaacs Ashford writes: "According to the controlled clinical trials surveyed by Enkin, Keirse, and Chalmers, lying down on the back and sitting during labor are associated with reduced blood flow to the uterus, resulting in contractions that are less effective and more frequent. Lying on the side or standing up improves blood flow and the efficiency of contractions. In addition, women who are upright or lying on their sides have shorter labors and use less narcotic analgesia, epidural anesthesia, and oxytocin augmentation than those who are supine (Roberts, 1989). Many hospitals now allow women to walk and assume comfortable positions during labor, though the use of continuous electronic fetal monitoring can restrict the mother's mobility. . . . Enkin, Keirse, and Chalmers also found that use of an upright posture when the mother is pushing shortens the length of second-stage labor. . . . Babies born to women in upright postures have fewer abnormal hear rate patterns and less chance of low Apgar scores (Sleep, Roberts, and Chalmers, 1989). Women prefer the upright posture for birth and report less pain and backache than in the supine posture. . . . The use of a squatting posture for birth has been shown to increase intra-abdominal pressure and also increase the sagittal diameter of the pelvic outlet (Davies and Renning, 1964; Borell and Fernstrom, 1967; Russell, 1982). Both factors can contribute to a shorter, more effective labor. However, researchers note that Western women are not accustomed to assuming a squatting posture (for defecation or resting, for example) and many find it difficult to assume this position for birth. Conventional maternity wards are often equipped with labor beds and delivery tables that encourage or enforce the supine posture." ("Posture for Labor and Birth," The Encyclopedia of Childbearing, Barbara K. Rothman, ed., 314). See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78.

For information on the squatting position for birth, see Russell, J.G., "The rationale of primitive delivery positions," Br J Obstet Gynaecol 89 (September 1982):712-715; McKay, S., "Squatting: an alternate position for the second stage of labor," The American Journal of Maternal/Child Nursing 9 (May/June 1984):181-183. See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78. See also Robbie E. Davis-Floyd, Birth as an American Rite of Passage, 86-87.

When you endeavor to give birth on your back, your heavy uterus compresses the major maternal blood vessels (Bienarz, J., et al., "Aortocaval compression by the uterus in late human pregnancy: II. An arteriographic study," Am J Obstet Gynecol, 100 (1968):203; Goodlin, R.C., "Aortocaval compression during cesarean section: a cause of newborn depression," Obstet Gynecol 37 (1971):702; Humphrey, M., et al., "The influence of maternal posture at birth on the fetus," J Obstet Gynaecol Br Commonwealth 80 (9173):1075 in Yvonne Brackbill, et al., Birth Trap, 13)

...interfering with circulation and decreasing blood pressure (Bienarz, J., et al., "Aortocaval compression by the uterus in late human pregnancy: II. An arteriographic study," Am J Obstet Gynecol, 100 (1968):203; Goodlin, R.C., "Aortocaval compression during cesarean section: a cause of newborn depression," Obstet Gynecol 37 (1971):702; Humphrey, M., et al., "The influence of maternal posture at birth on the fetus," J Obstet Gynaecol Br Commonwealth 80 (9173):1075 in Yvonne Brackbill, et al., Birth Trap, 13; see also Flowers, C., Obstetric Analgesia and Anesthesia (New York: Hoeber, Harper & Row, 1967); James, L.S., "The effects of pain relief for labor and delivery on the fetus and newborn," Anesthesiology 21 (1960):405-430; Blankfield, A., "The optimum position for childbirth," Med J Aust 2 (1965):666-668 in Doris Haire, The Cultural Warping of Childbirth, 17)

...increases the possibility of fetal distress (Flynn, A.M. et al., "Ambulation in labour," Br Med J 26 (1978):591; Humphrey, M., et al., "The influence of maternal posture at birth on the fetus," J Obstet Gynaecol Br Commonwealth 80 (1973):1075 in Yvonne Brackbill, et al., Birth Trap, 13. See also Laura Kaplan Shanley, Unassisted Childbirth, 24. See also Lumley, J., "Antepartum fetal heart rate tests and induction of labour," in Young, D., ed., "Obstetrical intervention and technology in the 1980s," Women's Health 7 (1982):9.)

Upright birthing positions are associated with more intense and more efficient contractions (See Marjorie Tew, Safer Childbirth? A Critical History of Maternity Care, 33; Chan, D.P.C., "Positions during labour," Br Med J 1 (1963):100-102; Flynn, A.M. et al., "Ambulation in labour," Br Med J 26 (1978):591; McManus, T.J. and A.A. Calder, "Upright posture and the efficiency of labour," Lancet 1 (1978):72-74; Diaz, A.G., R. Schwarcz, R. Fescina, and R. Caldeyro-Barcia, "Vertical position during the first stage of the course of labor, and neonatal outcome," Eur J Obstet Gynecol Reprod Biol 11 (1980):1-7; Williams, R.M., M.H. Thorn, J.W.W. Studd, "A study of the benefits and acceptability of ambulation in spontaneous labour," Br J Obstet Gynaecol 87 (1980):122-126; Hemminki, E. and S. Saarikoski, "Ambulation and delayed amniotomy in the first stage of labor," Eur J Obstet Gynecol Reprod Biol 15 (1983):129-139; Melzack, R., E. Belanger, and R. Lacroix, "Labor pain, effect of maternal position on front and back pain," J Pain symptom Manegem 6 (1991):476-480 in World Health Organization, Care in Normal Birth, 1999)

Elizabeth Noble writes: "Squatting, while uncomfortable for most people without prior practice, offers one of the most functional positions for birth. According to studies in Sweden by Dr. Christian Ehrstrom, when a mother squats the pelvic outlet is at its widest, increased by one to two centimeters. The pelvis is completely tilted to align with the spine, making the most curved passage for the baby's descent. The contraction of the abdominal muscles is very efficient in squatting as they are in a shortened, middle position of their range. Not only does gravity provide additional force from above, but there is no counterforce from below. The vagina becomes shorter and wider, and less effort is required by the mother to open up and let the baby out at her own pace. During crowning of the baby's head, there is an equal stretch all around the perineum, so that this muscular membranous "cuff" is least likely to tear . . . Women who squat for birth can generally deliver their babies without any manual assistance at all. Gravity and the free space around the perineum allow the baby's rotation maneuvers to be accomplished spontaneously." (Childbirth with Insight, 78). See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78.

"It was established in 1976 than an increase of 30 to 40 mmHg pressure is exerted by the fetal head on the cervix as a result of the effects of gravity, that is, standing instead of lying down. This means that, although the frequency of the contractions is the same, the effectiveness of the contractions is much greater, and hence the efficiency and rate of the dilatation of the cervix is improved. . . . In order to prove the superiority of the upright position in practice, the 1976 study alternated the posture of women volunteers every half-hour from the dorsal to the standing position. There was an abrupt fall in the intensity of the contractions when the women lay down, and the effectiveness of contractions in dilating the cervix was doubled when they stood up. The mothers also found the standing half-hour much less uncomfortable or painful; it was often difficult to persuade them to lie down again."
Sally Inch, Birthrights, 31; see Schwarcz, R., A.G. Diaz, R. Fescina, and R. Caldeyro-Barcia, Latin American Collaborative Study on Maternal Posture in Labor (1977); reported in Birth and the Family Journal 6(1)1979.


  1. Keep us posted- is Jodie going to contact the hospital?

  2. Great compilation!
    Notice how old most of these studies are, but given the current labor analgesia/anesthesia rates, supine birth will remain the default. It seems to me that loss of mobility is a much greater culprit in labor dystocia than the lack of pain perception itself. Please don't laugh at me, as I'm wondering if a safe way could be devised to 'prop up' women who are laboring with an epidural. Sort of like a birth stool, but with better support? Designed with the doctor's convenience in mind (now I'm being a bit sarcastic LOL)?

  3. Judit, no one is laughing! I was just corresponding with the fabulous doctorjen, and her epidural clients almost always birth hands & knees or squatting. She says they have a great anesthesiologist who is able to give the women enough sensation and mobility to be upright even with epidurals. Anyway, I'm sure we'd love to hear more about this, doctorjen!!!

  4. I had a badly stuck baby with my first birth, and although I was totally and completely numb, a FANTASTIC labor nurse devised a way to get me up and squatting. It was still hard work to get him out but I do think she's the reason I ended up with a vaginal birth rather than a c-section.

  5. After giving birth, it really seems like a special form of torture to force a woman to birth on her back. My worst contractions were the ones that happened when I was lying in bed. Agonizing.

  6. Yes, agreed Lauren! Hey, I'm wondering why the international community isn't up in arms about this long-standing method of torture. We get all in a huff about nasty things like waterboarding (and we should) and then here are millions of American women tortured on their own soil, in the name of science and progress.

    Okay, enough of my smart-alecky remarks. Except for when I was in very early labor (and still not entirely sure I was in labor) I never once laid down or even held still during a contraction. I HAD to be leaning over the counter or the table, swaying my hips back and forth. It felt so much better that way.

  7. Hey, I heard my name! Anyway, I find that with some help it is possible to get almost all epidural moms upright. Most have enough sensation to support themselves on hands and knees. We put the back of the bed up most of the way so mom can drape her upper body over the top of the bed and then help them get their knees securely under them, and it usually works. They may need assistance to get in this position, but they usually can sustain once we get them up. Also, squatting is not too hard. My labor bed go into a full chair position with the feet dropped all the way down. We then put the squat bar on the bottom of the bed. Mom can sit at the edge of the top of the bed between contractions and with help when a contraction starts and leaning on the squat bar, they can drop down into a squat to push. Some epidural moms have enough sensation to get themselves up and down and if not, they can use their arms for support and we just help them get up and down. Again, once they are in the squat they usually have enough sensation to support themselves. I have a policy of no operative vaginal delivery without trying a full squat first, and it almost always works. And very importantly, I try to let all epidural moms labor down as much as possible and not do any pushing until they have some urge and sensation. If we get to 2 hours of complete dilation with no sensation yet, we negotiate about turning it off and then most moms eventually get an urge to push.
    I find it much harder to move a mom with an epidural around, and they don't tend to be changing positions frequently like a mom laboring spontaneously without anesthesia, but it's both possible to do it and helpful. My nurses were way skeptical at first, but after seeing a few babies come sailing out quickly in a squat they are all big believers now and will be telling me to get mama up if I haven't for some reason thought of it! The hardest part is moving all the wires we have going with an epidural - external fetal monitor, external contraction monitor, urinary catheter, IV, epidural line, and blood pressure cuff. We have it down to a science now, though - we unplug everything that unplugs, pull all wires to one side, flip or move the mama, and replug everything in, passing them under the mama's belly if we've moved to hands and knees. I enforce with my labor clients and my nurses that the mama's comfort is our number one concern and the monitors are our job to keep track of. So mama moves as she needs to, and we chase the cords.

  8. Decided to start a new comment because that one was getting ridiculous long. Thought you might like to hear about a nice upright birth I attended an hour and a half ago. Second baby, spontaneous labor at 40 weeks 4 days, no augmentation, no IV, no AROM, just labor. Mama did a lot of laboring in bed because she was tired, but at the very end of labor, she got up. She had been grunting a bit with contractions, but not really pushing, and she thought she needed to pee. We went to the bathroom, but she wasn't able to get comfortable and wasn't able to go. She hopped up and down from the toilet several times, and then squatted on the floor holding on to the sink for a bit. Finally, she said "forget it" and we headed back into the labor room. At this point, she stopped at the end of the bed and squatted down on the floor holding on to the end of the bed. This felt good to her, so we spread some pads on the floor, and over the next few contractions she would go from kneeling to squatting, to kneeling on one knee, to hands and knees. Suddenly, her water broke with a huge gush. Then she decided to try the bathroom again and we went back in the bathroom, but again, a lot of up and down but not able to go. She decided to head back into the labor room, but then she knelt back down on the floor in the door of the bathroom suddenly and pushed all out with a contraction, and gave me that wide eyed "baby's coming" look. I asked her if she was comfortable there in the doorway, and she didn't answer but got up and headed back towards her pile of bed pads on the floor and knelt back down. Over the next 3 contractions she knelt, squatted, leaned back on her hands and feet (like a crab walk position almost!) and then back to squatting, sometimes holding the edge of the bed for support with both hands, sometimes with one hand, sometimes with her hands on the floor. Finally, she pushed out the baby's head in a squat but almost sitting over one leg, so that leg was flexed and the other one a little extended, and then for baby's big, tight-fitting shoulders, she first knelt, then leaned back on her hands and lifted her hips in the air and the little linebacker finally slid out. The dad then sat down on the floor behind the mom and we slid a dry bit of pad under her and she sat down on the floor, leaned back into her partner's lap, and snuggled her baby on her tummy. The thing that always impresses me about a spontaneous second stage in an upright mother is that it's not a matter of getting in one position and pushing the baby out, but most mamas move frequently including during contractions. In the 3 long pushing contractions she had, she probably changed position 15 times - and with that baby's kind of sticky shoulders, I'm glad she was freely mobile and able to wiggle all over and push him out! That, in my experience, is what a true upright birth looks like! Most docs, though, would be driven nuts by having the baby be such a moving target (of course he was never more than a couple inches from the floor and could have easily just slid onto the pads on the floor) and having to get on the floor themselves. Luckily, I'm young and healthy and can kneel or squat myself pretty well, and fortunately tonight I didn't have one of the 2 currently 3rd trimester pregnant nurses trying to get down there with me.
    Anyway, that's what an upright birth can look like in the hospital - even with a doctor.

  9. wow Dr. Jen! That was awesome!!!!! Thank you so much for sharing!!! where do you practice at? We could sure use a Doc down here in the south that had as much trust and patience in the birth process! Bless you! Keep up the good work!!!

  10. Great post and enjoyed reading the comments. I happened to be touching briefly on this in my blog when a commenter directed me to your blog. I linked up to the post :)

  11. Thanks for the link!

  12. LOVE Dr. Jen's story about the spontaneous upright birth. An inspiration!!

  13. Hi DoctorJen!
    I love your story. I was wondering if you know of anyone in the NYC area that has similar attitudes towards childbirth and patient advocacy like you do.
    I am a fourth year medical student, and having had seen my share of disrespect towards patients and ridiculous hospital policies, I'd really like to have my baby without any of these unnecessary things. I would have a home birth to avoid all of that, but my husband needs the safety of the hospital for his sanity. The prospect of fighting off interventionalist physicians and staff anywhere near labor gives me a lot of anxiety right now.
    I hope you can recommend someone with a philosophy like yours!
    (you can email me at martisiusj at yahoo dot com)
    Thank you!


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