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.
I finished another project I am so excited about! I wanted to put to pictures these 20 ACOG statements that came out in March with the goal to avoid a woman's first cesarean. Now some asked why the images didn't exactly match the recommendations. All I could reply back with was, some of these things, you wouldn't want to see in pictures, either because they would be boring, or because they would be graphic. But more to the truth is, I wanted the pictures to represent patience...we need to be more patient with labor. We need to give moms and babies more time to perform this task.
I am so grateful to all the families, doulas, and photographers who shared pictures with me -- the response was overwhelming. Because the focus is on preventing the initial cesarean birth, I am pleased that some of these moms are shown laboring toward what ended up being successful VBACs!
Patience is the key. Many of these are based on evidence that shows with more time, a woman can birth vaginally. And speaking of time -- research shows it can take 10-17 years before new evidence is implemented into practice. If we familiarize ourselves with these new recommendations, we can be the driving force behind ensuring the care we receive is current when our caregiver might still be doing things out of habit, comfort, or custom. Let's spread the word!
Pin these! Help raise awareness and get this information out there into the hands of the families that need it. The goal is to educate families, so they can enter into their providers' offices knowing what ACOG now recommends.
Stay tuned for August's adventures in celebrating World Breastfeeding Week and Breastfeeding Awareness Month. Like my Facebook page for resources that can be used by educators, doulas, and of course, breastfeeding mothers!
Some years back, I attended a conference where Diane Wiessinger was one of the keynote speakers. She shared information about breastfeeding and birth. In the course of one of her presentations, she showed a picture of a beautiful house by the water where her family spends vacations. Everything in the picture reflected calm, peace, and escape from the world. What she shared, though, was revealing: "Whenever I am here, at this home away from home, it takes me a few days before I have a bowel movement." (Yes, I know I just put poop in your pretty picture -- hold that for a minute.) Her point? If this is how a body responds and readjusts to a different (beautiful, serene) environment as displayed by bowel habits, how does that translate to pushing out your baby in a hospital room, surrounded by many strangers (and loved ones)?
I love this scene from "Open Season." I think it is a humorous, disarming way to illustrate the point. Enjoy! And my apologies to Diane if I got things wrong -- it's all open to interpretation!
This is long! Be warned!
I think when a person in is a position to serve a woman while she is in labor, that person should have required training every few years, like a recertification, on what it feels like to have a baby. I am not certain how this certification could be obtained, virtual reality plus some sort of pregnancy suit? Actually having a baby? I haven’t figured out the logistics, but I have recently had a recertification of my own, and that is called, my fourth child.
This fourth pregnancy was a surprise. Technically, I got pregnant at a time when no one would be able to get pregnant – only I guess more like I got pregnant at a time I felt I was highly, highly unlikely to get pregnant. My last menstrual period was June 10th. I did not get pregnant until July 13th at the earliest (a time when I was waiting for my period to start), to July 20-ish at the latest; looking at the date he was born now (April 6th), July 13th seems closer to the target date…we were on vacation.
I had lots of irritable contractions combined with irritable baby movements (probably more of the latter versus the former) that would happen around 10 pm to 1 am. The week before labor began I pretty much experienced these every night and I hated them. During these times, I would have waves of panic and anxiety about the reality of actually having to go through the birth process again, and I was always grateful when they were over and I could finally climb into bed.
Friday the 5th of April was pretty normal except I had two very serious bouts of grumpiness that made me feel deeply in touch with someone who was (hopefully!) going to start labor soon -- it was like total,
irrational, not-triggered-by-much anger that switched on so fast, I knew it was something else with some other root than just me being moody.
We had pizza for dinner, and like I had for the last week, I restrained myself from eating too much (“If labor starts tonight I don’t want to be too full,” was my rationale). I had two pieces and then cut myself
off. I took a little nap in bed, which I hoped would actually be “going to bed,” but I woke up at about midnight when I couldn’t ignore the antics of Wild Baby any longer. I watched TV a little and sat on the ball to try and bounce my guy into a calmer state. At 1 am I decided to watch the last episode of Mad Men on Netflix so I would be ready for the new season, with the intention of going to bed after that.
At 2 am, just when I was settling into sleep, I realized I was contracting, and these contractions felt different. They came 5-6 minutes apart, were totally manageable, and lasted about 40 seconds. I tried to sleep, but I was also mindful of needing to recognize true labor so I could get my sister and my mom on the road from two and a half hours away if this really were it.
Everyone was asleep, and as long as I was okay, I felt no need to wake them. I was feeling hungry, so I ate half a lemon Chobani (again, not wanting to eat a lot) in the morning quiet. I did call my sister at 3 am to let her know it was go-time. I labored longer, in the quiet of my living room, tending to small errands and tasks between contractions. At 4 am I woke Brad up to tell him I was in labor. He came out to the living room and asked, “What can I do?” and I immediately answered, “Take the recycling out, it’s driving me crazy and I have contemplated doing it myself for the last 2 hours.” I was hoping he would just lie back down on the couch and snooze a little, but he was up and ready to go.
I thought I would wait to call my midwife until 5 am, but at 4:30 my contractions began to get stronger and longer and closer together, just as they should, and I finally had some show. I phoned Linda to let her know I was in labor. She asked me a few questions, and then said she would be over soon. She lives about 40 minutes from us.
At 6 am, Linda arrived, and things were beginning to feel real. We had our tub set up in the dining room and I was feeling a pull to climb in, but I didn’t want to stall labor if I wasn’t that far along. I asked Linda to check me and she said I was 3 centimeters (“Not quite active labor!” I thought with a little disappointment), about 90% effaced, baby maybe at -2 station? I can’t remember that part. I mentioned I wanted to get in the tub, but I should probably try the shower instead (so gravity could keep helping my labor), and Linda agreed.
I got in the shower, and I really don’t know how long I was in there. The water felt great on my belly and during contractions I would swing from side to side so the water could fan over me. In between contractions I alternated putting my foot up on the side of the shower to lunge, in case my baby was posterior like his two brothers before him. Soon I found I had to vocalize during the contractions. I was in the bathroom alone and I had a lot of time to think. The thought that kept coming back to me was, “All is as it should be,” which was part of a prayer Brad had said earlier in the week when I was feeling really overcome with fear. I rubbed my belly and talked to the baby and told him to hurry, it all felt like it was happening in slow motion.
When I got out of the shower it was about 7 am and Linda checked me again. I was 5 centimeters. I went straight for the tub at that point, dropped my towel, and climbed in.
Jacob and Jonas were awake and had been for a while. Soon Isaac woke up and came straggling out of his bedroom in his standard sleeping attire – undies and a t-shirt. Brad told him we had company and he might want to put clothes on. Before Isaac woke up I remember Brad asking Jonas if he knew why Linda was at our house so early? Jonas admitted he didn’t, and we made a joke about Linda just coming for an early-morning visit. Brad then said, “Your mom is going to have the baby today.”
I looked to the tub for the relief it had brought in the past; with both Isaac and Jonas I got into the Jacuzzi tub at 5ish centimeters and after an hour was at 9ish centimeters, and I was hoping for the same, with the addition of having the baby in the water. After 30 or 40 minutes it seemed the tub wasn’t going to work as I had planned. I had intense pain in my lower abdomen to the point of not being able to sit in a relaxing position, so the whole time I was in the water I had to be on my hands and knees, and I didn’t want to stay that way much longer. Also, Brad started making pancakes in the kitchen.
At about 7:45 my mom, sister Shiela, and her two boys arrived. I headed to my bedroom, finished with the tub. Linda had set things up around the pool in preparation of a water birth, so some rearranging was in order, moving things to my room, getting equipment ready if needed. Once in my room it was just Linda, my mom, Shiela, and I. Brad had the boys going with pancakes and if they were making any noise, I sure didn’t hear it.
I asked someone to bring the piano bench into my room as I was laboring standing up, and I wanted to continue to lunge in case I had a malpositioned baby (which I don’t think he was, but I was a little gun
I think I had Linda check me again, and I think I was 7 centimeters? I am not really clear on this part. I wasn’t ready to sit down, so I continued to labor standing up. Shiela was a super doula – she would squeeze my hips during my contractions, and it brought so much relief! One thing I know about that double-hip squeeze is, it is hard to do when you have to press your arms together at the height of a woman’s hips – you get tired fast, and the laboring woman usually doesn’t want you to stop. If the
mom can get on her hands and knees on the floor, you can squeeze her hips with your own inner knees by straddling over her back, but I didn’t even want to try or offer that as I didn’t feel good in that position.
Over and over, a contraction would come, and I would tell Shiela, “Hips, hips, hips,” and she would start
In reality I have no idea what kind of time span this all happened in, I say over and over, but maybe it was only about 5 contractions? Or maybe it was 10?
I did finally sit on the bed for a bit. I remember taking my watch off and handing it to Shiela with the feeling that this was taking too long. I know for a fact I wasn’t looking at my watch or paying attention to how long it was taking in a linear fashion, but it was more some sort of symbolic resignation that I
would try to just flow with the timetable my body and baby presented even though I am as impatient as they come; in the last picture of me with my watch on, I see the time is 8:55 am.
I decided to visit the toilet. I spent a couple of contractions there, and Shiela was with me. She said my noises changed and she knew I was getting closer. As I sat laboring on the toilet, I opened the shower door next to me and contemplated getting back in -- I was looking for anything to comfort me at this point. Then I decided to see if I could feel anything inside of me, so with one finger about one knuckle in I was shocked to find something! “Is that a head?” I asked. But then I realized it was a bulging bag of water, with a head behind it. After all the years of hearing practitioners say, “I feel a bulging bag of water” (which I did remember Linda saying when she checked me last), I finally knew what that felt like and what it meant. I think I almost gingerly hopped off the toilet at that point, feeling remotivated.
I had one contraction standing up, with Shiela at my hips. Then I had another, and my water exploded all over the floor. There was a little meconium but Linda said it looked old and there was no reason for concern. I finally climbed into bed.
At this point I knew it would soon be time to push. I suddenly had the need for Brad to come and be with me, so I called to him and patted the side of the bed next to me, I just wanted him to sit with me and be near. Shiela was on the other side of me, and Linda was at the foot of the bed. My mom was by the door, ready with the camera, and the boys were in the living room playing Legos (again, I never heard anything from the boys, and there were 5 of them. Actually, I think after they ate pancakes they walked to the park with the dog to play for a bit. But I do know when the baby was born, they were playing Legos in the living room).
I did begin pushing at some point, and Linda said I still had a rim of cervix and she was going to try and move it, and I was totally fine with that because if anything was holding this baby up, I wanted it gone. So for a couple of contractions she worked on that and I guess it went away. I was pushing with such intensity but it felt fruitless. I truly felt nothing moving or changing and I imagined pushing forever
and not making any progress. It was at this point that I remember thinking, “I should have gone to the hospital so I could have the drugs!” (Interestingly enough, when I had my babies in the hospital, I never thought to ask for drugs, because I know if I had had the thought, I would have asked; maybe at home when it is not an option, my brain safely went there, just as a way to cope and vent.) Brad and Shiela were helping me pull my legs back during the pushing. Instead of rolling my chin to my chest, which I have helped women remember who-knows-how-many-times, I arched my head back against my pillows. I also had my body twisted in some way, crooked a little. Linda gently reminded me to get better aligned (with words and heart I could understand at that point), while giving me positive encouragement for this task I had to undertake.
Linda! What else could you want from a midwife? Really, not one thing. As a doula, I get really uncomfortable when people say, “Stacie, I couldn’t have done it without you.” Because, come on, you could have, and you would have. I don’t want anyone’s birth experience to have me entangled as an
essential ingredient; it should be all about the mom and her family, not me. But I have to concede that
when the right person is helping you with the right words and attitude and presence and spirit, it helps make the experience even more amazing, if that is possible. When you have the right midwife, the feeling is similar to being in your own home – the comforts of being in your own bed, using your own bathroom, lunging on your own piano bench – Linda was a natural extension of that. It felt right that she be here, in our home, unobtrusively watching over the birth of our baby.
The support Shiela gave me was also invaluable. Family members don’t always make the best doulas.
Shiela actually has taken a DONA-doula training, and that coupled with what she knows about me (just about everything), made her perfect for the job. She stayed by my side, she gave me verbal encouragement, she wished she could help me more. The truth of the matter is, only the mother can have the baby, but she doesn’t have to be alone while she is having her baby. I will forever treasure that my sister was there to support me during one of the most intense experiences of my life.
Pushing was hard, it was really hard – it seemed harder than it ever had been. I know I was lost in my head, and in there, the storm was raging. Every push came with screams, I hate to say it. I have never screamed with any of my other babies. And also, I cried, which was something new for me. In hindsight I probably could have pushed more effectively keeping those screams to myself, but they just came out. I know the boys didn’t appreciate the noise (although they all later admitted they weren’t scared), I am thankful my neighbors didn’t call the police, and the screaming is not my favorite thing about the birth video – oh well!
After so much pushing (again my sense of time is really off here), finally his head emerged. I felt his head with my hand, but it really didn’t mean anything to me, I just wanted the rest of him out! I pushed for one or two more contractions, maybe three, and then his shoulders popped and he tumbled out on a
wave of fluid and tons of baby poop. Linda helped bring him to my chest, all the while rubbing him and talking to him and watching him carefully. I was so relieved and instantly went from that person experiencing the very hard work of pushing toward a goal, to that mother experiencing her baby
for the first time. I was rubbing him and toweling him off and just taking him in, my body relieved of the burden with the prize in my arms. He was born at 9:42 am.
We all watched as he turned from purple-y to pink. His apgars were 8 and 9. Very soon after birth he wanted to nurse and he seemed to know just what he was doing. The boys peeked in one by one, only appearing mildy interested (we had two 13 year olds, two 11 year olds, and one 7 year old), and then backing out of the room again.
There were lots of things in the birth kit we didn’t use. My perineum didn’t need massaging, which Linda was prepared to do. We didn’t need the bulb syringe to suction the baby’s airways. There are lots of Chux pads that didn’t get used. Everything just happened easily and well, as it so often can when left to its own devices. I am sure the level of comfort and security factored into that for me as well. I am still struck by how ordinary things were and how extraordinary they were. Within a couple hours I was back in my shower. A little while later I threw a load of laundry in. My mom bought donuts and I happily ate three. Our new (nameless) baby was being admired and touched and held by his cousins and brothers and dad and aunt and grandma, while also nursing and visually taking in all he could. In many ways it was like a normal Saturday morning at home, but then, it was also like some rare, high holy day, calm with introspection, peace and joy.
Ezra Christian was 8 pounds, 1 ounce. There was much debate about his name – the other choices were Benjamin, Ruben, and Abraham. He was born on what we in the LDS religion believe to be Christ’s birthday, and also the day the LDS religion was restored; Christian is my brother’s middle name, and we
felt it appropriate for Ezra as well.
Moving through that birth, I didn’t feel alone. I remembered so many births and situations and strong mamas moving gracefully through this work. I could name each and every one that came to mind, but hey, this one’s my story. Just know if I have been with you for the birth of your baby, you were with me during mine in spirit and endurance and admiration. This has brought me so much more appreciation and compassion for birth and women while experiencing it – that’s why I feel there should be something birth workers can do every few years to get back in touch with what it can really be like to physically grow and have a baby. It changes you, and sometimes we forget that.
In tonight's class we talked about the stages of labor. I asked the moms and dads, in movies or on TV, how do women know it's time to push? The answer was, when they are told to "Pushpushpushpushppppuuuusssshhhhh!!!!!!!" Moms push while their faces are turning into blue balloons, and the message is sent over and over again: You won't know how or when to push. You need to wait for someone to tell you.
I then shared, "I only know how things are at my house, but when someone is in the bathroom having a BM, they don't need someone else on the other side of the door telling them to 'Pushpushpushpushppppuuuusssshhhhh!!!!!!!' Why is that?"
Shaking off the visual, a dad said, "You don't need anyone to tell you -- you just know."
This often-practiced (well-mastered?), necessary bodily function and the way we know how to do it can guide us when it is time to push a baby out. Society would have us believe otherwise, that we must rely on experts to tell us when our bodies are ready to push out our babies -- you make the baby, you grow the baby, but you won't actually know how to push the baby out -- yet many women have found this is simply not true.
There is evidence that shows when women direct their own pushing, babies receive more oxygen during second stage, pushing time is reduced, and there is less damage to the pelvic-floor muscles. We have the built-in ability to feel and follow our bodies' urges to push, while also knowing the guidance and wisdom coming from within makes the way safer and more effective than any outside "Pushpushpushpushppppuuuusssshhhhh!!!!!!!"
Do you believe it? Click here to read even more about what the evidence says.
♥ four young boys and a boy dog (offspring)