I recently stumbled upon a gem of an article which examines pushing positions for the second stage of labor. It was published in 1987 by the American Journal of Public Health. The author, Lauren Dundes, MHS, maintains our traditional Western lithotomy position (person on their back with feet up in stirrups) was never based on any sort of evidence. What it was based on were things like:
As a doula, it is not unusual for me to see laboring folks who start to feel like pushing when they are in an upright position, such as in the shower or on the toilet. The pressure remains between contractions, building; the person wants to push, and they are told to stop and wait for their provider. When the provider arrives the laboring patient is told to get into lithotomy position and resume pushing. Suddenly the urge seems gone! Whereas the person was just being told, "baby's right here, pant and blow, your doctor is just parking the car..." now it seems to have fizzled out.
The person may have lost the pressure to push, but the pressure to not waste the provider's time has just begun.
It's a tricky thing, gauging when to call the provider, hoping they won't need to be there too long -- especially if they are trying to keep appointments at their office. So we get the patient into the stirrups, we tell them to "curl around their baby, like a cat," grab their legs behind their knees, and "pushpushpushpushPUUUUUUSHHHHH!!!!" It's no surprise after some ineffective pushing and a baby low in the pelvis, the vacuum comes out and helps birth the baby.
But back to this lovely article. Did you know an "accoucheur" was a male birth attendant? There's your one to grow on so you capture the meaning of this quote:
"The British practitioner almost invariably directs the patient to be placed upon her side . . . while the Continental accoucheur has her placed on her back...the woman should be placed so as to give the least possible hinderance to the operations of the accoucheur-this is agreed upon by all; but there exist a diversity of opinion, what that position is. Some recommended the side; others the knees, and others the back. I coincide with the latter.... Therefore, when practicable, I would recommend she should be placed upon her back, both for convenience and safety" (bold mine).
In the 1830s, in America, there was a man named William Pott Dewees. He was the Chairman of Obstetrics at University of Pennslyvania. Let me break here to ask: am I the only one surprised that there was not only a university, but also one with an obstetrics department, in the early 1800s? I mean, weren't Paul Revere and tea tariffs just a backwards' glance? But a university there was, and Mr. Dewees published the former quote.
What stands out to me is the directive to adapt to the person catching the baby! Oh, I'm sorry, accoucheur, that you have to stand in that awkward position while you attend to a person who has gone through hours of an arduous, physical, stripping activity and they are about to split and spit another human being out, pardon my French. But by all means, let us make you more comfortable!
Speaking of French, there was another quote that shows where cultural beliefs came into birthing positions: "...it is reported that women in the United States lie flat on their backs, French women lie back on an inclined plane, English women lie on their left side, and German women use the birthing chair."
This was paraphrased from an obstetrics book published in 1884 by a man named Cazeaux. Interestingly enough, you can allegedly download this tome from Amazon for free? I didn't fall into that rabbit hole, but perhaps you may?
Dundes sums up her piece by stating lithotomy position was "implemented without verifying its appropriateness." She goes on to implore more research into this position. She writes that more families are "exercising their rights to actively participate in the birth experience...to make it a more personal and more physiologically and psychologically advantageous experience." Remember this was published in 1987! I imagine Dundes was hopeful change would come and birthing people would finally get off their backs.
Back to the future, huh? In 2019, the birth world I see pretty much matches up with Dundes' descriptions of the 80s. It doesn't seem to matter that we have more current evidence about positions for second stage, what I see over 95% of the time is a person put into lithotomy positon when it's time to push. When I see folks birthing in other positions it's usually one of three things:
If you live in an area where providers are resistant to more physiological birth positions, does that mean you're doomed to birth in the position of a dead cockroach? How can you advocate for yourself?
I recall one birth where the parent had a history of painful back issues. She labored on her hands and knees, and when the provider walked in they looked at her and said: "I can't deliver a baby in that position." This parent was able to communicate to the provider what she needed and had her baby in a way that worked the best for her body -- and this was a provider she had never met before.
I remember another birth where we tried a number of positions to help the parent bring the baby down. Ultimately what worked was lithotomy. The midwife turned to me and said, "we try to stay away from this one, but sometimes it's just what a person needs." The key to this second-stage tangle is right there: just what a person needs. We can get just what we need during labor and birth, and part of that is selecting a pushing position we are satisfied with.
Recently I was watching The Labyrinth, that incredible movie of my early teenhood. I watched that VHS tape so much it started to warp. I know just about every line, I sing every song, and I am ALWAYS ready for it to have a different ending, even though I know that never really happens.
I was struck by the opening credits -- when the words "It's only forever," play. This one day, when we birth our babies, stays with us forever. Shouldn't we do all we can to improve our experiences so the memories bring us happiness instead of disappointment? Enter, the Labyrinth...
The basic premise: Sarah is an imaginative girl who loves to dress up and pretend play. She has to baby-sit her half-brother, Toby, and she dreams her story to be that of having a wicked stepmother and she being forced to work and have no life. Her brother begins to cry from his crib. She accidentally sends Toby off to the Goblin King, Jareth. She then has to rescue him, through the maze of a huge labyrinth, or he will be lost to her forever. Ultimately she has a few choices -- live in her pretend world forever and forget about Toby, become Jareth's queen and live happily ever after with him, or fight to get Toby back -- and of course, that's what she does.
But did I mention who Jareth is?
Um, yeah -- that's why I was always Team Jareth...but I digress.
1. This is a piece of cake!
Often labor starts out so small, we work up confidence and think, like Sarah after making a good choice, "this is a piece of cake!" That's right before she falls into a hole with nothing to stop her except a bunch of "helping hands."
While early labor is often something we can handle on our own -- occupying our minds, resting, bouncing on a ball, relaxing in a tub or shower -- as things progress, our bodies will demand more from us. Instead of worrying that this is a predictor of how hard labor may be (at some point in the future -- I call this 'catastrophysing,' and in real life, I am pretty good at it), we need to enlist support from those around us. This is where partners, doulas, midwives, mothers, nurses -- whoever is there to fill that role, come in.
Labor WILL get more intense -- that's the nature of the process. With support, we can be lifted up by those caring people on our birth team, those helping hands.
2. There can be a lot of waiting!
There is an average amount of time women will labor. For first time pregnant people that is 12ish-24ish hours. Be mindful of that when you start telling people you are in labor, people forget birth is a marathon, not a sprint. It may only be an hour of time that has passed and well-meaning friends and family can start to ask if your baby has been born yet!
Some families consider sitting with this information for a while until there is something more exciting to report. Often the invitation (or expectation) that people will wait happily in the lobby can be a lot of pressure to the laboring person! I have been at more than one birth when a guest pops into the laboring person's room, unannounced, and either there was nothing going on, or the person had to be shooed out quickly because it was pushing time or naked time or toilet time -- this doesn't have to happen to you! You can decide where your loved ones will bide their time, and it doesn't have to be at the hospital.
3. It may help to lose your head
Whether it comes as a loss of control, or a needed suspension of reality, staying in our left brain where logic and reason try to make sense of things isn't always productive in labor.
As labor progresses, we need to move to our right brain and listen to what our bodies are saying. Linear flow of time, labor math, and trying to make predictions according to what we know and what has happened all need to go by the wayside. Our team should help protect this state of mind by moving with us, going at our pace, finding another place for their fears besides our ears, and knowing how to help if we are truly lost -- like getting into take-charge mode. Labor is challenging, and we are working hard enough to keep our own heads straight -- partners and others can respect this and flex to it as long as we are feeling safe and moving forward.
4. Ultimately, birth isn't fair
We learn. We read. We immerse ourselves in information and do our best to plan for our births. But in the end, there are so many things that aren't in our control. Does this mean we shouldn't even try?
What can we really plan about birth? We'd like to think we can plan a lot -- hospital, support team, safety. But we've all seen videos of women birthing unexpectedly in their cars (as a doula I had that happen once). So what's a pregnant person to do? I'll tell you: take a comprehensive childbirth class where you'll learn your options in a nonbiased way. Understand the labor process, how to cope, and what to expect. Build your dream birth on a foundation of sound evidence-based information -- this will ensure if your Plan A becomes a Plan B, you will know exactly what your new set of choices are -- because you ALWAYS have choices. Birth, like life, may not be fair, but you can adjust the scale in your favor with knowledge and options.
5. "You have no power over me."
I recently had a conversation with a pregnant woman who shared: "I know no one can make me do anything I don't want to do. I can always say no or ask for other options. That's my right."
Not sure what your rights are? According to the American College of Obstetricians and Gynecologists (ACOG), pregnant people:
This is what ACOG is laying down that many physicians aren't picking up: no one can guarantee the outcome for you and your baby -- and because of that, the choices we make during pregnancy and birth are ultimately our own. This doesn't mean you have to be contrary out of the gate, this simply means when you have researched, thought over, pondered, prayed about a decision which may differ from that of your medical provider, no one holds more power than you.
♥ four young boys and a boy dog (offspring)