Getting Pushed Around in Second Stage

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: 

• Competition between midwives, barber-surgeons, and doctors (16th Century)
• Borrowing a position used for hundreds of years to remove stones from the bladder (17th Century) 
• Cultural expectations and beliefs from different areas of the world (19th Century)
• Use of forceps (16th Century) and anesthesia (19th Century) necessitating a person to be supine

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. 

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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: ​

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"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: 

1. They're birthing out of the hospital with a licensed midwife or doctor, and they have all the freedom to choose the position that is effectively working for them
2. They experience back or other pain in the lithotomy position and they cannot tolerate it, and they choose to speak up
3. The baby comes like a train and no one has time to get the person into the lithotomy position

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?

• Discuss pushing positions ahead of time with your provider. If you wait until your baby is due to have this conversation, you may be learn your doctor is not into alternatives. Using the keys of shared decision-making, communicate that you will choose pushing positions that feel good and work for you
• When it's time to start pushing, let your birth team know how things are feeling. It can take a few tries before something feels productive and comfortable.  When a position hurts or stops feeling effective, let your care-team know you need to try something else
• Remember: YOU are having a baby and deserve comfort; YOU have the right to make decisions for yourself; YOU are the consumer

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.