Wednesday, April 15, 2015

Induction's Relationship to Cesareans in High BMI Women

Many providers are so affected by the over-hyping of risk around pregnancy in women of size that they routinely induce labor in "obese" women for basically no other real reason than the woman's BMI.

But a recently-published Canadian study shows there is yet another reason to be cautious about routinely inducing labor in obese women─ an increased risk of cesarean.

Yet the authors completely missed the obvious take-home message from their study ─ reduce the number of inductions done in obese women ─ and instead call for more weight-loss intervention efforts in order to prevent cesareans. Doh!

As part of Cesarean Awareness Month, let's take yet another look at the relationship between induction of labor and high cesarean rates in obese women.

Caregivers interested in lowering cesarean rates in higher-weight women would likely get the most effective results by changing management of this group rather than focusing on weight loss efforts.

When will caregivers finally clue in to the fact that they need other tools in the cesarean prevention toolbox besides weight loss? Changing their own management behaviors is the key to lowering cesarean rates in obese women, not getting women all to "normalize" their pre-pregnancy weight.

Let's be clear. It's reasonable to encourage healthy eating and regular exercise in women before they conceive, but that doesn't usually result in significant weight loss. Research shows that only a small percentage of people lose a substantial amount of weight and keep it off. It's unrealistic to insist that women all reach a certain BMI before pregnancy. And it's incredibly foolish to hang all your hopes for lowering cesarean rates on that goal.

There are other, more powerful tools in the toolbox for that. First and foremost among them is changing behaviors around induction of labor in this group.

Background

Induction is a very common intervention used in women of size, as I have pointed out many times before. And there is quite a bit of research suggesting that induction is tied to a higher cesarean rate, especially in first-time mothers or in women with an unripe cervix.

Of course, it's only fair to point out that sometimes induction really is needed in women of size. High-BMI women have a higher rate of pre-eclampsia (blood pressure issues), for example, as this study also found. This often necessitates early induction of labor because pre-eclampsia is very serious and can harm both mother and baby.

But high-BMI women are often induced at far higher rates than their complications justify.

Often these inductions are done for "soft" reasons that are highly questionable medically.

For example, many providers induce labor in obese women because they are afraid of big babies, even though research shows that inducing labor does not improve outcomes at all and often worsens them. The combination of obese first-time mother, a suspected big baby, and induction of labor is particularly potent, doubling the risk for cesarean even in a usually low-intervention midwifery practice.

Often providers induce labor because they believe that pregnancy in a fat woman is a disaster waiting to happen, and that labor should be brought on as soon as possible before an emergency occurs. Sadly, all too often, such perceptions often become self-fulfilling prophecies because of the huge amount of interventions employed, which also carry significant risk.

Some providers induce labor because they mistakenly believe that fat women are unlikely to go into labor on their own. Research shows that higher-weight women do have many inductions for "post-dates" pregnancies and that these inductions are more likely to result in cesareans, but rarely do care providers adjust a high-BMI mother's due date to reflect the fact that many have longer menstrual cycles.

Some induce labor in the belief that fat women are too out of shape to endure a natural labor and birth. Others induce labor because they mistakenly believe inducing labor is the only way that higher weight women will have any chance at having a vaginal birth because of ""fat pads" in the pelvis" or a "fat" vagina. These assumptions are all wrong, mind, but subtle bias like this influences how higher-weight women are managed.

For these and many other reasons, providers tend to over-use inductions in women of size. Although most in the medical field never question the high utilization of inductions in obese women, there are finally now a few researchers who have begun to question this practice.

New Study Findings

A new Canadian study highlights just how many obese women have their labor induced.

Less than a third of average-weight women in the study had their labor induced, but almost HALF of higher weight women had their labor induced. No doubt some of those inductions in the high-BMI group were medically justified, but chances are that many more were not.

Most notably, this study shows that induction in obese women often leads to cesareans.

I've been saying for years that over-use of induction in obese women is one of the main reasons for a high cesarean rate in this group, yet few researchers have bothered to look at this connection or to call for fewer inductions in this group. Many ignore their own findings that inductions are tightly tied to cesarean rates in this group. Finally, now, some researchers are beginning to pay attention.

Of particular note, this Canadian study found that when covariates were controlled for, Body Mass Index (BMI) was not a significant risk factor for cesareans in women with spontaneous labor. 

This is in contrast to the false belief among many providers that obesity often prevents vaginal birth due to "soft tissue dystocia." But in this study, higher weight alone did NOT raise the risk for cesarean ─ when labor was spontaneous.

However, obesity DOUBLED the risk for cesareans during inductions. According to the study:
Obese women were twice more likely (aOR 2.2, CI 1.2-4.1) to deliver by emergency C-section if their labour was induced...The twofold increase in the risk of C-section rates in obese women after induction was independent of pregnancy complications, parity, prior caesarean deliveries, chronic maternal health conditions, treatments for infertility, or maternal age.
That's a really important distinction. A higher weight itself did not increase the risk for cesareans when labor was spontaneous, but when labor was induced, it did. And this was independent of pregnancy complications and other factors that might also increase the risk for cesarean.

This suggests that induction itself (and decision-making during induction) was more of a real factor than the obesity itself.

For example, previous studies have found a lower threshold for surgical intervention in high-BMI patients. Many obese women would probably benefit from their caregivers simply waiting longer before opting for a cesarean. Others would probably benefit more from caregivers waiting for the mother's cervix to be fully ripe before labor was induced.

But most likely, obese women would probably benefit MOST from a lower induction rate. 

Sometimes, induction truly is necessary, and women of size do have higher rates of some complications that make induction a consideration. But many women of size are being induced for dubious reasons, mostly reflecting subtle provider bias and fear rather than true medical indications. These "soft" inductions need to STOP. If inductions are used, they should ideally wait until the cervix is ripe and caregivers should employ more patience in labor before resorting to a cesarean.

Lowering the number of inductions done and changing the management of inductions when they are done should help lower the outrageously high cesarean rates in obese women.

Focus on Realistic Change

To summarize, several recent studies have observed that caregivers often use a high rate of interventions during labor with their obese patients and have questioned whether this is truly beneficial. The authors of this recent Canadian study also noted that:
Even among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery...Although obesity in pregnancy is not an independent justification for labour induction, obese women are more likely to be induced and if induced are more likely to undergo delivery by C-section.
Astoundingly, the authors of the Canadian study then completely missed the mark in evaluating their findings. Like many in the obstetrical field, their response was NOT to call for fewer inductions, but rather to call for increased weight loss interventions prior to pregnancy.

What?!?!? Once again, the researchers missed a tremendous opportunity for improving outcomes in higher-weight women because they can't see beyond their own relentless focus on weight loss.

Rather than focusing their efforts on the unlikely success of weight-loss interventions, caregivers should be focusing on lowering the induction rate in this group and changing their threshold for surgical intervention. 

THOSE are the interventions most likely to bring about fewer cesareans.

Several studies have found that inductions are tightly tied to elevated cesarean rates in high-BMI women, and when induction is controlled for, the differences in cesarean rates are much smaller or disappear entirely. Induction is the root of the problem, independent from obesity itself.

Additionally, several studies over the years have found that when induction is frequently used with obese women, it often is the starting point for other poor outcomes.

If you want to improve outcomes in obese women, start by addressing the high induction rate, especially in first-time mothers. 

A few researchers are beginning to get it. A recent American study found that first-time obese mothers induced at term had a much higher cesarean rate (40% vs. 25%) and a higher rate of neonatal admissions to the NICU than those obese women who were managed expectantly. They concluded:
Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.
A major Irish study recently recommended that inductions only be undertaken for strict indications in obese women:
Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
One recent French review concluded:
It may be possible to reduce primary and thus repeat cesarean delivery rates among obese women by preventive actions targeting labor induction in primiparous women and prelabor cesarean deliveries in multiparous women.
Bottom line, care providers need to be much more cautious about the amount of interventions they employ in the pregnancies of higher weight women.

In particular, induction of labor should be avoided when not truly medically indicated, especially in first-time mothers. If it occurs, it should usually wait until a woman's Bishop Score indicates a ripe cervix, and more patience during labor should be employed before moving to a cesarean section. 

These changes, rather than browbeating women about weight loss interventions, will be the ones that bring about the biggest improvements in outcome for women of size.


References

BMC Pregnancy Childbirth. 2014 Dec 20;14(1):422. [Epub ahead of print] Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population. Vinturache A, Moledina N, McDonald S, Slater D, Tough S. PMID: 25528667
...This study is a secondary analysis of the All Our Babies Cohort, a prospective, community-based pregnancy cohort in Calgary, Alberta...(n=1996)...Women with increased pre-pregnancy BMI were more likely to develop pregnancy complications such as preeclampsia (OR 3.5, CI 2.0-4.6 for overweight; OR 5.3, CI 3.3-8.5 for obese) and gestational diabetes (OR 3.0, CI 1.8-5.0 for overweight; OR 6.5, CI 3.7-11.2, for obese) than normal weight women. Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1). CONCLUSIONS: Even among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery....
Am J Obstet Gynecol. 2014 Jul;211(1):53.e1-5. doi: 10.1016/j.ajog.2014.01.034. Epub 2014 Jan 31. Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m(2) or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks...RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022)...The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001)...CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.
Am J Obstet Gynecol. 2015 Feb;212(2):241.e1-9. doi: 10.1016/j.ajog.2014.08.002. Epub 2014 Aug 6. The risk of prelabor and intrapartum cesarean delivery among overweight and obese women: possible preventive actions. Hermann M1, Le Ray C2, Blondel B3, Goffinet F2, Zeitlin J3. PMID: 25108139
...We modeled relative risks (RRs) and risk differences of prelabor and intrapartum cesarean delivery by prepregnancy body mass index (obese, ≥30 kg/m(2); overweight, 25-29.9 kg/m(2); normal weight, 18.5-24.9 kg/m(2)) in a nationally representative sample of 12,297 French women. Models were stratified by parity and previous cesarean status. Covariates included maternal sociodemographic characteristics, medical conditions, pregnancy complications, and induction of labor. RESULTS:...Increased intrapartum cesarean delivery risks for primiparous women were related to more frequent labor induction (42.6% vs 23.8% for normal-weight women). CONCLUSION: It may be possible to reduce primary and thus repeat cesarean delivery rates among obese women by preventive actions targeting labor induction in primiparous women and prelabor cesarean deliveries in multiparous women. Further research is needed on the impact of limiting inductions on cesarean delivery risks for obese primiparous women.
Acta Obstet Gynecol Scand. 2013 Dec;92(12):1414-8. doi: 10.1111/aogs.12263. Maternal obesity and induction of labor. O'Dwyer V1, O'Kelly S, Monaghan B, Rowan A, Farah N, Turner MJ. PMID: 24116732
...Compared with women with a normal BMI, obese primigravidas but not obese multigravidas were more likely to have labor induced. In primigravidas who had labor induced, the cesarean section rate was 20.6% (91/442) compared with 8.3% (17/206) in multigravidas who had labor induced (p < 0.001). In obese primigravidas, induction of labor was also more likely to be associated with other interventions such as epidural analgesia, fetal blood sampling and emergency cesarean section. In contrast, induction of labor in obese multigravidas was not only less common but also not associated with an increase in other interventions compared with multigravidas with a normal BMI. CONCLUSIONS: Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
J Midwifery Womens Health. 2014 Jan-Feb;59(1):43-53. doi: 10.1111/jmwh.12073. Epub 2014 Jan 8. Intrapartum management associated with obesity in nulliparous women. Carlson NS, Lowe NK. PMID: 24400789
...Intrapartum interventions used significantly more often for healthy, obese nulliparous women when compared with normal-weight women were induction of labor, augmentation of labor, and cesarean birth. It is unclear if assisted vaginal birth occurs more frequently among obese women. Epidural anesthesia, artificial rupture of membranes prior to 6 cm of cervical dilation, and early hospital admission were shown in separate studies to be used more often in obese women. Intrapartum interventions were used more frequently in obese women in a dose-dependent manner by body mass index...Implications for clinical practice from this systematic review are that healthy, nulliparous obese women are exposed to common intrapartum interventions more often than normal-weight women. In the absence of evidence on the use of appropriate use of intrapartum interventions in this population, health care providers should carefully monitor management choices when working with healthy, nulliparous obese women.
BJOG. 2005 Jun;112(6):768-72. Outcome of pregnancy in a woman with an increased body mass index. Usha Kiran TS1, Hemmadi S, Bethel J, Evans J. PMID: 15924535
...The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999...RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events....
J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963
BACKGROUND: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period...RESULTS: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P less than 0.001). CONCLUSION: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.
Aust N Z J Obstet Gynaecol. 2011 Apr;51(2):172-4. Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services. Green C, Shaker D. PMID: 21466521
...We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour....

Monday, April 6, 2015

Prior Cesarean and Ectopic Pregnancy

Ectopic pregnancy, image from Wikimedia Commons.
Blue arrows point to the uterus, while the red arrows
point to a tubal ectopic pregnancy with bleeding
Each year, as part of Cesarean Awareness Month, I highlight how a high cesarean rate often has unforseen implications on public health. Today let's talk about ectopic pregnancy.

Ectopic pregnancy is a pregnancy where the fertilized egg implants outside of the inner uterine lining. Although most are caught early and resolved safely today, it is a potentially life-threatening complication and needs to be taken seriously.

Brand-new research suggests that multiple prior cesarean sections are yet another risk factor for ectopic pregnancy.

Ectopic Pregnancy Primer

Ectopic pregnancies are usually "tubal pregnancies" where the fertilized egg implants in the Fallopian tubes on the way from the ovary to the uterus. However, ectopic pregnancies aren't always tubal. They can also implant in the ovary, cervix, or abdominal cavity.

Because these locations cannot usually accommodate a growing pregnancy for long, the big risk from ectopic pregnancy is rupture and bleeding. If this occurs, it is a true, life-threatening emergency. The American Academy of Family Physicians (AAFP) states that ruptured ectopic pregnancies still accounts for 10-15% of all maternal deaths in pregnancy.

In the developed world, most ectopic pregnancies are caught and treated early, resulting in improved outcomes. However, in the developing world, diagnosis of ruptured ectopic pregnancies is often delayed, and as a result, mortality is much higher. Wikipedia notes that in Africa, "ectopic pregnancies are a major cause of death among childbearing women."

About 1 in 50 pregnancies are ectopic. One source notes:
The major health risk of ectopic pregnancy is rupture leading to internal bleeding. Before the 19th century, the mortality rate (death rate) from ectopic pregnancies exceeded 50%. By the end of the 19th century, the mortality rate dropped to five percent because of surgical intervention. Statistics suggest with current advances in early detection, the mortality rate has improved to less than five in 10,000. The survival rate from ectopic pregnancies is improving even though the incidence of ectopic pregnancies is also increasing. The major reason for a poor outcome is failure to seek early medical attention. Ectopic pregnancy remains the leading cause of pregnancy-related death in the first trimester of pregnancy.
Risk factors for ectopic pregnancy may include:
  • Previous ectopic pregnancy
  • Pelvic Inflammatory Disease (often caused by Sexually Transmitted Diseases such as chlamydia or gonorrhea)
  • Infertility and/or Fertility treatments such as IVF
  • Previous tubal or pelvic surgeries
  • Abnormal Fallopian Tubes (due to congenital abnormalities or exposure to DES)
  • Cigarette smoking
  • Possibly endometriosis
A prior ectopic pregnancy is the greatest risk factor for a current one. However, anything that creates an infection or scarring can interfere with the usual action of the "cilia" (the little hair-like projections along the Fallopian tubes that help push along a fertilized egg to the uterus), causing the fertilized egg to implant too early.

Now it looks like cesareans are also a modest risk factor for ectopic pregnancies. It is unknown why there may be a connection, but the most likely scenario is probably infection.

Another possibility is the development of adhesions (scar tissue), sometimes known as Asherman's Syndrome, which might also predispose the fertilized egg to implant in the Fallopian tubes or cervix. Since Asherman's Syndrome can occur after a D&C, damage to the uterine lining from manual removal of the placenta during a cesarean is also plausible.

It's also important to note that there is another sub-type of ectopic pregnancy where the fertilized egg implants in the cesarean scar itself, called a "cesarean scar pregnancy," which we have written about before. In this situation, if the fertilized egg implants near damage to the uterine lining from the cesarean scar, the placenta may implant too deeply into the uterine wall or the fetus may even extrude into the abdominal cavity. The rate of cesarean scar pregnancy has risen significantly in recent years in conjunction with the rising cesarean rate.

One in a great while, there is also a "heterotopic pregnancy," where one fertilized egg implants normally inside the uterus, while another implants outside of the uterus or in a cesarean scar, threatening the intrauterine pregnancy. Fertility treatments are a significant risk factor.

Cesareans and Ectopic Pregnancy

Now, recent research shows that more than one prior cesarean substantially increases the risk for ectopic pregnancy.

The strength of this study was that its data was drawn from multiple hospitals over several years, so the large data group is more likely to show a real risk relationship. Population-wide studies are needed to confirm this relationship, however.

Some previous studies have shown a modest correlation between prior cesarean and ectopic pregnancy. Other studies have found no correlation. However, these studies were small or of variable quality, and may not have differentiated by number of prior cesareans. This study found a significant risk only after 2 or more prior cesareans.

As always, it's important to keep the numerical risks in perspective. The actual risk isn't huge. Even with multiple prior cesareans, most women will not experience an ectopic pregnancy.

However, the more risk factors you have (number of cesareans, number of D&Cs, whether you experienced an infection after a cesarean, whether you have a history of Pelvic Inflammatory Disease, prior history of ectopic pregnancy, whether you have had fertility treatment like IVF, whether you smoke, etc.) will also impact your risk.

Personally speaking, I had 2 prior cesareans and never experienced an ectopic pregnancy. Of course, I did not have any other risk factors besides the cesareans, so that might have helped. Either way, I'm glad I had VBACs (Vaginal Birth After Cesarean) with babies #3 and #4 so I did not accrue the risks of additional cesareans. Of course, I might have been fine even if I'd had additional cesareans, but I'm glad to have reduced the likelihood anyhow.

VBAC access may be particularly important for women with multiple risk factors for ectopic pregnancy.

Summary

Ectopic pregnancies are a serious health risk. Although some resolve spontaneously without surgical intervention, those that rupture can have serious consequences, including hemorrhage, infection, and death.

If multiple cesareans are indeed another risk factor for ectopic pregnancy, then the high rate of cesareans and current ban on VBACs in many hospitals has important downstream public health implications.

Ectopic pregnancies are yet another reason why lowering the cesarean rate and improving access to VBACs is such an important goal in improving women's health.


Reference

Am J Perinatol. 2015 Jan 21. [Epub ahead of print] Cesarean Delivery and Risk for Subsequent Ectopic Pregnancy. Bowman ZS1, Smith KR2, Silver RM1. PMID: 25607224
OBJECTIVE: This study aims to examine the risk for subsequent ectopic pregnancy in women with prior cesarean delivery. STUDY DESIGN: Women with a history of at least one cesarean delivery in the state of Utah during 1996 to 2011 were identified and compared with women with vaginal delivery only. The primary outcome was subsequent ectopic pregnancy. Data were analyzed by multivariate logistic regression and stratified by first, second, or third live births. Model covariates included maternal age, ethnicity, marital status, education level, gravidity, and prior ectopic pregnancy. RESULTS: Overall, 260,249 women with at least one live birth were identified. After exclusions, 255,082, 154,930, and 70,228 women had at least one, two, and three prior live births that lead to 531, 199, and 62 subsequent ectopic pregnancies, respectively. Women who had one prior cesarean delivery were not at increased risk for subsequent ectopic pregnancy in relation to women with no prior cesarean delivery. However, women with two of two, two of three, or three of three prior cesareans had increased risk for subsequent ectopic pregnancy with odds ratios (95% confidence interval) of 1.54 (1.06-2.22), 3.50 (1.49-8.24), and 1.99 (1.00-3.98), respectively. CONCLUSION: History of two or three cesarean deliveries is associated with increased risk for subsequent ectopic pregnancy.

Thursday, April 2, 2015

Give Blood for Those Who Give Life

Accreta Awareness Blood Drive - this month
April is Cesarean Awareness Month.

One of the results of a high cesarean rate is an increase in the risk for Placenta Accreta, where the placenta attaches too deeply into the uterus. This means the placenta has difficulty separating after the birth, greatly increasing the risk for life-threatening hemorrhage, hysterectomy, prematurity, and even death. 

Most people recognize the immediate risks of cesarean, which basically are the risks of any surgery: infection, bleeding, scar tissue, anesthesia problems. However, what many are not aware of are late complications from cesareans, those that occur in future pregnancies after a cesarean. In particular, the risk for abnormal placentation rises with each successive cesarean. These include:
  • placental abruption (the placenta shearing off before the baby is ready to be born) 
  • placenta previa (a low-lying placenta that covers or nearly covers the cervix)
  • placenta accreta (an abnormally attached placenta that has difficulty detaching after birth)
All of these can be life-threatening to both mother and baby, but placenta accreta is particularly serious. I've written about Placenta Accreta before in a 4-part series:
  • Part One - What Is Placenta Accreta?
  • Part Two - Life-Threatening Complication of Prior Cesarean 
  • Part Three - Risks to Mother and Baby
  • Part Four - Diagnosis, Treatment, and a Cautionary Story
Placenta Accreta is a real problem and one that is increasing all the time because the underlying cesarean rate is so high in some areas.

Keep in mind that the absolute numerical risk is low; most women who have had cesareans will not experience an accreta. However, the more cesareans you have had, the more at-risk for accreta you are. That's why it's so important that women not be forced into an automatic repeat c-section after a first cesarean, as women in many areas are due to VBAC bans in hospitals.

Some data indicates that the accreta rate has risen from about 1 in 4000 in the 1970s to about 1 in 533 these days. The main culprit in this is the increase in the number of cesareans, both primary but especially in repeat cesareans.

It's one thing when a cesarean truly saves a life; no one begrudges a truly necessary cesarean. It's a miracle that such technology and skill exists and it's a blessed intervention when applied appropriately. It's the cesarean done without medical indication that is the real problem, and VBAC bans in particular are putting more and more mothers and babies at risk.

Accreta Awareness Blood Drive

Brandy and her miracle baby
after a life-threatening accreta
I followed up my accreta series last year with Brandy's Story, where I told the story of an online friend who developed Placenta Accreta and hemorrhaged badly.

Normal blood loss in a vaginal birth is 500 ml; 1000 ml in a cesarean. Brandy lost 7,500 ml. That's seven THOUSAND five hundred; in other words, she had more than seven times the normal blood loss for a cesarean. Because the main artery of her placenta had burrowed deep into her cervix, she ended up losing her uterus. Thank goodness Brandy's baby survived, but Brandy lost her uterus, her future fertility, and nearly her life because previous doctors had pressured her into some cesareans she didn't truly need. 

Placenta Accreta is real and affects real women and babies. Do enough cesareans, and increasing numbers of women will face this devastating and life-threatening complication. 

As I've noted before, I've known several women now who have been affected by accreta; all suffered severe hemorrhages and several lost their fertility and uteri forever.

A different acquaintance of mine lost her baby and very nearly her life too. If she hadn't been transferred to a major regional hospital with a protocol and resources for extreme blood loss, she almost surely would have died (she came very close to death even with that protocol and multiple blood transfusions).

Although most women with accreta do survive, many suffer significant health consequences. And of course, occasionally women do die, usually of blood loss. Nationwide, we have seen a number of women who have lost their lives (or had near misses) from accreta.

Brandy almost lost her life too; she survived only because of massive blood transfusions. As a thank-you to the care providers who heroically helped save her life during her accreta surgery and as a thank-you to those who saved her life by giving blood previously, she started an Accreta Awareness Blood Drive.

So in April, in honor of Cesarean Awareness Month and all the mothers who have experienced accreta, please consider donating blood to the American Red Cross. Do it for the mothers who may experience severe bleeding during pregnancy due to accreta or other complications. Do it for the fathers, so they don't lose their wives. Do it for the families, so the children don't grow up without their mothers.

[Below is the publicity release from ICAN and places where you can donate to this specific campaign. Of course, if you don't have a Hope for Accreta Awareness campaign event near you or cannot donate this month, you can always call the Red Cross and just donate blood at one of their regular events.] 
The International Cesarean Awareness Network is pleased to be participating in this year's Accreta Awareness Blood Drive occurring nationwide on April 3rd in support of the Hope for Accreta Foundation.  
The purpose of this blood drive is to raise awareness of placenta accreta, a condition in which the placenta attaches itself too deeply into the uterus. Placenta accreta is also a risk of repeat cesarean whose treatment often requires emergency blood transfusion after birth.

In July of 2012, the American College of Obstetricians and Gynecologists issued a committee opinion on placenta accreta. It stated that "the incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate." Additionally, they also stated that "women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either anterior or posterior placenta previa overlying the uterine scar. The authors of one study found that in the presence of a placenta previa, the risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries, respectively." (1)

In light of this, it is now more important than ever that women be made fully aware of placenta accreta. Find a blood drive near you! Click here for a list of blood drives available. 
Support Groups for Women with Accreta:
*post edited 4/3/15 to include some additional links

Friday, March 27, 2015

Barriers to Alternative Birth Positions

The view most women have during birth in most hospitals
We have been talking about birthing positions, both for labor (first stage) and for pushing out the baby (second stage).

Specifically, we are most interested in "alternative" birth positions, ones that are under-utilized in the hospital.

Part One of this series discussed Historical and Traditional Birth Positions because in ancient times and in traditional cultures, birth positions were typically more varied. Upright positions were common, although all positions can be found in ancient artwork.

In contrast, in hospitals today, most women give birth in very limited positions, usually one of three ─ either completely lying back ("lithotomy," "supine," or "dorsal recumbent"), partially reclined ("Semi-Fowlers" or "semi-recumbent"), or semi-sitting with knees widely abducted and pulled back and the chest and head rounded forward ("C" position).

Uniformity of Positions in the Hospital

Most women in the hospital give birth like this
Sadly, while care providers pay lip service to mobility in labor, their actions speak differently. Most women in labor are encouraged to lay back in labor in either a slightly reclined or semi-sitting position. Laying on the side is well-accepted in most hospitals but is often under-utilized.

Although progress has been made and some providers now "allow" women to labor or push in any position, their tune often changes when it's time for the baby to actually come out. At that point, most women are required (or so strongly pressured that it's basically a requirement) to lie back or to use a semi-sitting, knees-back position.

As we mentioned in Part One of the series, one survey of U.S. birthing women as recently as 2005 reported that 92% of the women gave birth in either semi-reclining/reclining or semi-sitting positions.

If all those women find these positions comfortable and truly want to give birth in them, that's no problem. However, many women report wanting to use other positions and being actively discouraged or even forbidden from using them. [I know I was actively discouraged from other positions in one of my hospital births.]

This practice is so widespread that many medical students never see a birth in any position other than lying back or semi-sitting. One medical student reported in 2013 (my emphasis):
I finished my Obstetrics and Gynecology clerkship 5 weeks ago. I did my clerkship at a large, and rather posh, private hospital that is affiliated with my medical school. There are some great doctors there, but I was sometimes aghast at the rather aggressive approach to delivery that many took. The cesarean section rate for the last year was 47%, well above the national average of 33%, and most labors were artificially augmented. I did not witness a single VBAC (Vaginal Birth After Cesarean), and was told that only one of the house attendings would perform them.

On the first day of my clerkship, I asked the clerkship director if women delivered in a variety of positions or if they were restricted to delivering in lithotomy (what many today think of as the “traditional” birthing position with the mother on her back with her feet in stirrups). The director seems to be a rather progressive woman...and she gave me a rather knowing look and said “I know what you’re getting at, but unfortunately everyone here delivers lying down”.

Indeed, as I went through my rotation, all the vaginal deliveries I saw were done in the semi-reclined position that is common in western hospitals.
Although there are hospital care providers out there that are comfortable attending births in alternate positions, the vast majority of hospital births, even today, are in the un-physiological laying back or semi-sitting positions.

These positions are less than ideal because they:

  • make the mother work against gravity
  • decrease the pelvic outlet by restricting free movement of the sacrum and tailbone during birth
  • compress the main artery that brings blood to the uterus, causing a tendency towards low oxygen to the baby, fetal distress, and maternal "supine hypotension"

These are not ideal circumstances for a safer and easier birth. Despite this, it has been very difficult to get alternative positions accepted into regular practice in many hospitals.


Barriers to Alternative Positions

There are many cultural and technological factors that influence birth position. But if "alternative" positions used to be the norm, why has cultural practice changed so markedly? Frankly, there are a number of factors at work here, including:

  • Recent Historical Precedent
  • Pervasive Cultural Image of Birth
  • Ease of Interventions
  • Care Provider Comfort and Convenience
  • Care Provider Training

Let's take a closer look at each one of these.

Historical Precedent

Historical medical factors are central to why women no longer birth in upright positions most of the time.

These factors are no longer relevant, yet the tradition of reclining birth became so strongly ingrained that this position is considered the norm for childbirth even now.

Hospital birth in the old days
When birth came into the hospital, women usually gave birth lying down because they were heavily drugged. Many were even tied down during contractions. As a result, women were usually flat on their backs with their legs strapped into stirrups because they could not hold their legs up themselves. Doctors often had to use forceps to help the baby negotiate its way out, and they needed the women in a position that gave them maximum access to the perineum. 

Modern hospital birth, still ready for the episiotomy
Furthermore, because of the forceps and the heavy-duty drugs given to laboring women, an episiotomy to speed up the birth was considered mandatory in many hospitals, and this was easier in a prone or lying-back position. Sadly, ease of episiotomy is still one of the reasons doctors like the lithotomy or semi-sitting position today, as the modern picture above shows.

Most women these days are not so drugged that they need to be prone in bed, forceps have mostly fallen out of use, and research has shown over and over how harmful routine episiotomies are. There is little need for women to be prone in bed for birth anymore, yet the tradition persists. 

Although historically it is understandable that this tradition of lying/sitting for birth developed in the highly-technological and interventive hospital births of the mid-20th century, there really is no good reason to insist on these positions for all births anymore.

Pervasive Cultural Image of Birth 
 
Sadly, this historical precedent for reclining birth became programmed into our media images of birth until it has become our pervasive cultural image of birth. This is one of the strongest influences on maternal positioning today


In movies and on TV, women almost always give birth in the prone or semi-sitting position, probably because it's all the writers and viewers know from their own lives and the lives of their friends and relatives.


Years ago, I worked on a play which had a birth scene in it from the pioneer days. The director had the woman on her back, knees flexed and back, like the usual media images of a hospital birth. I pointed out that most women in that era didn't birth like that and provided documentation. The director incorporated my input into rehearsal, but decided that nobody in the audience would understand because she “didn't look like she was giving birth.” We found a compromise (the actress "labored" in a semi-recumbent position but rose to a supported squat for the actual "birth") but it was frustrating that the recumbent position is so ingrained into our cultural expectations that anything else was seen as confusing to the audience. That is difficult to overcome.

As the pioneering film, Laboring Under An Illusion: Mass Media Childbirth vs. The Real Thing by anthropologist Vicki Elson points out, this pervasive culture image makes it difficult for women (and care providers) to envision any other position for birth, and often unwilling to even try it, even when equipment for other positions is provided and they are encouraged to be mobile.

Thus this position has become a self-perpetuating custom. But it doesn't have to stay that way!

Ease of Interventions

Electronic Fetal Monitoring
One practical barrier to alternative positions is that the recumbent positions make some common labor interventions easier. 

Birthing women are dealing with a hospital medical culture that has a very high rate of labor interventions (like induction and augmentation) that necessitate extremely close monitoring of fetal and maternal well-being. Procedures like fetal monitoring, IV fluids, and vaginal exams are easier when the mother is reclining. In addition, labor interventions that strengthen contractions raise the need for epidurals, which then often results in the mother laboring in a reclining position.

All of these things combine to create a powerful hospital culture that encourages a reclining, passive position for labor and birth. The mother is the passive patient that is having interventions done to her, the care providers are the active ones who are directing the labor. Even the language reinforces this; the doctor "delivers" the baby, rather than the woman "gives birth" to her child. As one researcher states:
Lithotomy position is not based on evidence and it comes with multitude of poor factors. This position is illogical, making the birth needlessly complicated, expensive, turning natural process into medical event and the laboring women to become simply the body on the delivery table to be relieved of their contents.
The best option against all of this is to opt for a more natural childbirth where the mother is an active participant in birth instead of a passive patient who is being delivered. Women who go into labor spontaneously and who progress along their own bodies' timeline instead of being pushed to labor faster find it easier to assume the positions that their bodies tell them are needed, and they don't have to deal with most of the interventions that tend to force women into reclining positions.

Campaign for Normal Birth, Royal College of Midwives

However, the reality is that an intervention-free childbirth is uncommon in the hospital, sometimes interventions are truly medically necessary, and many women choose interventions like epidurals or inductions. Although more intervention-free childbirth is a worthy goal, greater variety in birthing positions does not depend on it. Alternative birth positions can still be used in women with interventions.

Fetal monitoring in an upright sitting position on a birth ball
For example, although outcomes are not improved with the use of EFM, most hospitals feel they still have to use it as a defense against lawsuits. But while it can be more challenging to use EFM in "alternative" positions, it can and has been done.

EFM, induction, augmentation, IV fluids, and epidurals do not have to be a barrier to alternative positioning. It just requires being a little more creative. (A doula can be very helpful in this process.)

Care Provider Comfort and Convenience


Sadly, care provider comfort and convenience is a huge factor influencing maternal positioning.

Some care providers tell women they can use any position that they like in labor ("You can even stand on your head if you want"), but that for actually pushing out the baby, they have to be on their back or semi-sitting with knees apart or pulled back. Much of this is for the comfort of the provider, so they can be sitting comfortably or stand just as the baby is born.


But while it is understandable that providers want to stay within their comfort level, why should a care provider's comfort level take priority over the well-being and comfort of mother and baby? The top priority should be the mother and the baby, not the provider's comfort.

However, of course providers absolutely need to keep themselves safe too. They may be afraid they will strain their back or knees in another position, which is understandable.

Alternative positions do not have to mean back strain for the attendant
Providers need to find a way to honor the mother's positioning needs while still finding a way to attend those positions in a manner that does not ergonomically hurt themselves.

With a little creativity, the needs of both parties can be served.

Care Provider Training

Another huge barrier to alternative positions is the lack of training for providers in attending any other position. 

Remember the 2013 medical student story from the first part of this post? She went through her entire rotation and NEVER saw any position other than a semi-reclining birth ─ in 2013, in a major hospital training program! This speaks very strongly to how ingrained this is in hospital culture.


Virtually all of the illustrations of birth that doctors see in their training involve the woman in the reclined or semi-sitting position. Notice the diagram above has the woman flat on her back. This is common in medical illustrations in obstetric textbooks.

Image from Royal College of Midwives.
Notice how passive the mother seems, and how hands-on
the doctor is. He might not have been trained how to do these 
manipulations if the mother was in a different position
Sadly, most care providers (and especially doctors) rarely see any position other than semi-sitting or reclining in their training, and they are taught to be very hands-on in manipulating the head and shoulders during birth. This makes them unsure how to do manipulations or to handle issues like shoulder dystocia when the physical orientation is different. As a result, some are very inflexible about letting the mother try different positions for the actual pushing out of the baby; they are afraid they will make a mistake when it counts most.

Baby being birthed in an all-fours position. Notice the opposite
orientation in this position, which is confusing for some providers
It is completely understandable that providers don't want to make a mistake that might harm a baby, but really, it's not that hard to re-educate oneself towards a different spatial orientation. All it takes is a willingness to learn about how to handle a different orientation, and a hospital and medical school culture that is willing to encourage such learning.

Medical schools would probably find that more mobility and more patience in labor would mean that less manipulation during birth would be needed. But because they come from a historical tradition of drugged mothers and drugged babies, they have been taught to use lots of hands-on manipulation during birth, and to fear positions that they see as interfering with their ability to do this manipulation.

Illustrations from Canadian Family Physician article, 1988
Medical schools have much to teach their students in the few years they have them, but there is no good reason except tradition that handling alternative birth positions is not a meaningful part of the curriculum. 

Compared to some of the other complex skills that doctors learn, learning about different spatial orientations for birth manipulations (when needed) would be relatively easy. Change would really take place if medical schools would just include this as part of the regular curriculum (more than just a brief mention, but actual practice with it). But when the teachers have rarely seen a birth outside of the usual positions, how are they going to teach meaningfully about it? And thus birthing position becomes a never-changing tradition in many hospitals.
Illustrations from Canadian Family Physician article, 1988
There are some articles for doctors in the literature on how to re-orient themselves to attend births in different positions (see the free Canadian Family Physician article shown above), yet the information in them seems to be widely ignored in teaching and in practice.

It is LONG past time for medical school curriculum and residency programs to address alternative birth positions in a more meaningful way.

Conclusion

The vast majority of women in U.S. hospitals give birth in reclining or semi-sitting positions. This is not because their care providers are mean or wish them harm, it is because these positions have become rigidly ingrained into medical training, hospital culture, and popular culture. But it doesn't have to stay that way. 



Although reclining positions are still seen frequently in many European and Australian hospitals too, alternative positions are more encouraged and accepted in these areas. In fact, most recent research on "alternative" positions is being done in Europe or Australia.

German hospital birthing room
Look at some of the birthing room equipment available in the British labor ward video and the German birthing room picture above. Why isn't this standard in most U.S. hospitals?

[To be fair, some of it IS in some U.S. hospitals. But often it's only available on request or in a special room, not just a routine part of every birthing room. And too often, it's only for labor, not for the actual birth.]

A hospital midwife attending a woman using a birth stool 
Although research on utilization of birthing positions is sparse, it suggests that the pervasive image of birth in the media and established hospital culture subtly influence women towards reclining positions. It also suggests that certain models of care (such as birth clinics and births attended by midwives) tend to utilize higher levels of alternative positions for birth.

Hospital birth in an all-fours position, attended by a family doctor.
Photography from Canadian Family Physician, 1988
Of course, it's not just midwives who attend these births; there are some absolutely awesome OBs and family docs out there too who are attending births in all kinds of positions. The title of the birth attendant is less important than their philosophy.

Women are more likely to find support for using alternative positions if their care provider believes strongly in physiologic birth, is supportive of natural childbirth, and has low intervention rates in labor.

Even if you are planning on having an epidural or are being induced, having a provider comfortable with natural childbirth increases your chances of using alternative positions despite these interventions.

To find out how supportive your care provider truly is of alternative positions, ask them to estimate what percentage of the births they've attended have been in non-recumbent positions. (Not labored in, but actually pushed the baby out in. Remember, many attendants are fine with mobility in labor but require women to be sitting or reclining for the actual "delivery" of the baby. You are looking for the ones that have experience and comfort with alternative positions for the actual birth too.)

It is mostly tradition, training, and comfort levels that keep reclining positions as the standard of care in many hospitals. But with education and flexibility, caregivers in the hospital can become more open to other positions and accommodate them in a way that respects the mother's needs as well as their own needs.

Dangling and Supported Squat position in a hospital birth clinic in Peru
Hospital caregivers CAN learn to safely attend births in alternative positions, and research suggests that doing so may help improve some birth outcomes, as well as helping labor to be less painful for the mother.

It's about time these "alternative" positions became more widespread in medical schools, hospitals, and birthing clinics all around the world. 


References

Position Ideas and Pictures
Evidence Summaries on Birth Positions
    Studies

    Pract Midwife. 2014 Apr;17(4):24-6. Mobility and upright positioning in labour. Westbury B. PMID: 24804420
    SUMMARY: A study by the Royal College of Midwives (RCM) (2010) concluded that 49 per cent of women gave birth in the supine position. The RCM advocates getting women 'off the bed' in its campaign for normal birth. There has been much speculation as to why women labour on the bed, with some suggesting it is because women feel it is expected of them. Mobility and upright positioning in labour have countless benefits, with or without epidural anaesthesia, for both woman and fetus. The National Institute of Health and Care Excellence (NICE) supports the adoption of positions that women find most comfortable. Both midwives and students should fully explain the benefits of mobility and upright positioning in labour to women, preferably antenatally, to enable them to make informed decisions as to the positions they wish to adopt when in labour.
    Women Birth. 2012 Sep;25(3):100-6. doi: 10.1016/j.wombi.2011.05.001. Epub 2011 Jun 12.
    What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature. Priddis H1, Dahlen H, Schmied V. PMID: 21664208
    BACKGROUND: From the historical literature it is apparent that birthing in an upright position was once common practice while today it appears that the majority of women within Western cultures give birth in a semi-recumbent position...RESULTS: The literature reports both the physical and psychological benefits for women when they are able to adopt physiological positions in labour, and birth in an upright position of their choice. Women who utilise upright positions during labour have a shorter duration of the first and second stage of labour, experience less intervention, and report less severe pain and increased satisfaction with their childbirth experience than women in a semi recumbent or supine/lithotomy position. Increased blood loss during third stage is the only disadvantage identified but this may be due to increased perineal oedema associated with upright positions. There is a lack of research into factors and/or practices within the current health system that facilitate or inhibit women to adopt various positions during labour andbirth. Upright birth positioning appears to occur more often within certain models of care, and birth settings, compared to others. The preferences for positions, and the philosophies of health professionals, are also reported to impact upon the position that women adopt during birth. CONCLUSION: Understanding the facilitators and inhibitors of physiological birth positioning, the impact of birth settings and how midwives and women perceive physiological birth positions, and how beliefs are translated into practice needs to be researched.

    Wednesday, March 18, 2015

    Historical and Traditional Birthing Positions

    Birth statue from the Kraja people of the Amazon
    In hospitals of the "developed" world, the vast majority of women give birth in a flat-on-the-back, semi-reclining, or semi-sitting position. 

    Why do women use these passive positions and not more active positions like upright, kneeling, squatting, all-fours, side-lying, or asymmetric positions, which have historically been favored by many cultures?

    Recent research just published shows that these "alternative" positions offer increased room in the pelvis. And many women feel their pain is lessened in these positions. This is probably why they were favored by traditional birthing cultures.

    A recent Cochrane meta-analysis shows that labors tended to be shorter, the risk for cesarean was lower, and fewer epidurals were used when women in hospitals labored in these positions. So why aren't more women taking advantage of these positions?

    The main reasons are cultural conditioning (nearly every image of birth in the media involves laying down or semi-sitting positions), because freedom of movement can interfere with labor interventions, because epidurals can restrict movement somewhat, and because some medical personnel discourage alternative positions due to lack of training/comfort with them. Sadly, there are some care providers who actually forbid women to assume other positions for pushing out the baby.

    Women should be able to choose their position for labor and birth freely and without restriction from their providers, yet this is often not the case, even today.

    In future posts, we will discuss institutional and cultural barriers to using alternative birthing positions, research around use of these positions, and ways to bring more of this positioning into the hospital.

    But today, let's start by showing standard hospital positions for perspective, then contrast those with illustrations of alternative birth positions from historical artwork. The point is to show the variety of birthing positions used in history and among First Nation peoples today, in contrast to the lack of variety in most hospitals.

    For some time, I have been collecting illustrations of birthing positions in various cultures and time periods from around the world. It's been a fascinating and educational process. A list of sources for them is available at the bottom of the post in the References section. Note that there are even some plus-sized images!

    Enjoy these inspiring and beautiful images. May they encourage more women to utilize alternative positions, and may they help care providers provide more support for alternative positioning to birthing women everywhere.
    NSFW Warning: Birthing pictures tend to be graphic. Proceed at your own discretion. 
    Modern Institutional Birth Positions

    In the hospital today, some care providers restrict the mother's position while in labor or while pushing. Many women are required or strongly pressured to lie back or to use a semi-sitting, splayed position with legs raised and pushed back or out. Even when care providers do not specifically restrict birth positions, women still usually end up in positions like the following ones.

    The "lithotomy" position, legs in stirrups
    This is a "lithotomy" or fully reclined position, with legs splayed strongly apart in stirrups to give the doctor as much access as possible. A "dorsal recumbent" position is basically the same, except that the patient's legs are not in stirrups but are flexed and on the bed.

    Laying back tends to compress the major blood vessels leading to the uterus, potentially leading to restricted blood flow to the baby and fetal distress. This is ironic, since for nine months physicians tell women to avoid sleeping on their backs because this can compromise blood flow to the baby. Yet when women arrive in the hospital to birth the baby, the first thing they often do is to put them on their backs!

    A semi-recumbent position, very similar
    to lithotomy but the back is propped up somewhat
    Most of the time, women give birth these days in the semi-recumbent position, which is basically like a lithotomy position but slightly propped up so the woman is not flat on her back. The knees are splayed widely apart and the legs are either in stirrups, pulled back by the mother, or held up by helpers.

    One major issue with the lithotomy and semi-recumbent positions is that not only do they not utilize gravity to use the baby's own weight to help it move down, but they actually make the mother work against gravity in order to push the baby out.

    The Semi-Sitting (or Semi-Fowler's) Position, with
    the mother propped up at about a 45 degree angle
    The semi-sitting position came into use in the hospital as a way to get the mother a little bit more upright to make better use of gravity. The position is similar to the semi-recumbent position except that it is just a little bit more upright. However, note that it is not all that upright. Knees are usually splayed and held upright by helpers or the mother, and the back is rounded forward with chin to chest like a "C."

    Another problem with all of these positions is that they actually decrease the size of the pelvic outlet. The sacrum is against the bed, making it hard for it to move during labor. The direct pressure on the woman's tailbone forces it upwards in a more curved position and into the pelvic outlet space. Pulling the knees strongly apart tends to narrow the pelvic outlet in the back as well. These give less room for the baby to get out. It also tightens the pelvic floor and may make it more likely to tear.

    One survey of U.S. birthing women reported that as recently as 2005 that "57% gave birth lying on their backs and an additional 35% gave birth propped up in a semi-sitting position." In other words, 92% of the women gave birth in either semi-reclining/reclining or semi-sitting positions.

    If all those women truly want to give birth in those positions, that's no problem. Some women find them comfortable or useful, and it's perfectly fine to use them if desired. However, many women report wanting to use other positions and being discouraged or even forbidden from using them.

    Historic Birth Positions

    Although most women envision birth in a semi-reclining or semi-sitting position these days, there are many other possible positions in which to give birth.

    However, it's always important to point out that there is no one "right" position for laboring or pushing out a baby. All positions have pros and cons.

    Care providers should encourage women to experiment with different positions and then trust that the woman's body will tell her the right position for her needs. If a woman is not making progress with a certain position, encourage her to try other positions, as these may help the baby move down or turn to help labor progress, but in the end it is the mother who should have the ultimate say in her position.

    If the traditional semi-reclining or semi-sitting positions feel "right" to you, there is nothing wrong with that. Many babies have been born that way just fine. If you like that position and your baby is well-positioned and descending just fine, there is no need to alter that.

    However, many women want to move into other positions in labor and while pushing, or their babies are not descending well in the usual positions and might benefit from a position change ─ yet they are often actively discouraged from changing positions. This is short-sighted because it does not heed the physics of pelvic structure (the extra room for fetal descent in different positions) or the maternal pain relief that different positions can bring.

    In non-Western countries (and outside the hospital in Western countries), many women give birth in so-called "alternative" positions, like squatting, standing, semi-squatting, kneeling, asymmetric (one leg up and one down), all-fours, back arched, or side-lying.

    While you can find pictures of all birthing positions (including reclining) in ancient art, most art from ancient cultures did not show women birthing while lying down.

    This is a strong statement about the differences in birthing culture then and now. Most likely there is a strong physiological reason why most of these women did not birth lying down.

    Let's review a few of these "alternative" positions.

    Squatting


    Squatting is a position seen in a great deal of artwork from many societies, such as this Persian birth scene. The mother is on a very low birth stool but is basically in a full squat.


    Check out this peaceful Filipino woman, also giving birth in a full squatting position (art credit: Alicdang of Sagada).


    Many tribal societies, from Native Americans to African tribes, have illustrations or statues of women squatting to give birth, like this pottery illustration from the Mimbres Pueblo tribe. Notice that the mother's knees are far apart.


    In this Egyptian carving, the woman is squatting to push, while bracing herself on helpers and furniture of some sort. Notice her knees are closer together than in the other pictures. Many childbirth educators have observed that the back half of the pelvic outlet in the squatting position actually increases more when the knees are a bit closer together than farther apart.


    This classic birth statue of an Aztec goddess pushing out her baby while squatting seems to reflect that. Her knees are not widely spread. Her face certainly shows the intensity of pushing!


    Regardless of whether the knees are far apart or not, squatting is a position that is shown in a great deal of artwork from ancient or traditional societies, as in this illustration of a birthing woman from the Tonkawa Indian tribe of North America.

    Supported Squatting

    Some women find squatting too tiring to sustain during birth. Many utilize what is called a "Supported Squat" position instead. The most common way to help sustain a squat is to lean on something or to hold onto other people, one on each side.


    In this South Indian carving, for example, a woman gives birth in a standing squat, holding on to women on each side of her. The midwife's size below shows her relative unimportance in the artist's mind compared to the mother. Notice that the mother is shown as the largest and most powerful figure in the carving, probably as a commentary on the power of the birthing woman.


    In this ancient Greek relief, a woman is shown squatting on a birth stool with arms around helpers on each side while the midwife catches the baby from below.


    In this carving from ancient Egypt, the mother also gives birth while holding onto attendants on either side. She uses a stool for stability but her position is very much a supported squat.

    Kneeling 

    A position very similar to squatting is kneeling. Birth art from many different cultures depicts kneeling for birth, either on both knees or asymmetrically with one knee up and one knee down.


    Basically it's pretty close to squatting in many ways, except the mother is on her knees instead of her feet, and she is fairly close to the ground, as in this statue from Costa Rica.


    Many Egyptian carvings show women giving birth in a kneeling position, like this one.


    This illustration of a kneeling position, supposedly of Cleopatra, is also from Ancient Egypt. Notice that she is being helped to hold her arms up to give her some counter-force (more on that later).


    It's difficult to tell the birth position in this Japanese illustration, but it certainly looks like she is kneeling.


    And this pre-Columbian Jalisco statue also appears to use a kneeling position.


    So does this statue from the Kraja people of the Amazon...


    ...and this African statue from Cameroon.


    Many First Nation peoples from North America used kneeling positions for birth. This Inuit statue shows a mother and her birth support person behind her, both kneeling.


    In this illustration of a kneeling position of the Blackfoot Indian tribe of North America, the woman uses a pole in the ground to help give her support while kneeling.


    In this woodcut illustration of the birthing practices of the Comanche tribe, a series of poles were driven into the ground, outside a circular temporary shelter. The woman in labor would walk back and forth along this line of poles, kneeling and leaning forward onto a pole during contractions. Her labor support person would massage or give quick shaking motions to her belly during contractions (this is rumored to help encourage babies into more optimal positions for birth).

    Sometimes she would go into the privacy of the shelter and squat over holes with hot stones (heat can be comforting in labor) and aromatic herbs. She might have given birth in any of these spots but she likely was in a kneeling or squatting position when she did give birth.

    Hands and Knees Positions

    Another position that was popular was a variation of the kneeling position. Today we call this the all-fours or hands-and-knees position, although the mother wasn't always completely on her hands and knees.

    For example, in this illustration of an 1800s African-American woman from the American South, the mother labors while kneeling on the floor but leaning on a chair so she could rock back and forth during labor. Notice that the position of her legs is a bit asymmetrical.

    A hands-and-knees position is different than the upright kneeling positions seen in the kneeling illustrations in the previous section. The hands-and-knees position is not an upright position, but rather a kneeling one with the mother at a significantly inclined angle.


    Here is a Persian woman, using stones to help her assume an elevated variation of a position somewhere between the all-fours position and the supported squat.


    In this small section of a larger painting from a temple in Bhutan, the mother gives birth on her knees and elbows (sometimes called a knee-chest position). This can be a particularly good position for a mother who is experiencing a really painful back labor.

    Upright Sitting


    A lot of ancient birth art showed women in a mostly upright, semi-squatting/semi-sitting pose, such as in this Roman carving. Note the position is far more upright than traditional Western semi-sitting positions.


    Here is an illustration of a sitting position from a Tibetan temple. Notice how upright the mother is, even as the baby is coming out.


    In this statue from Burkina Faso from Africa, the mother is sitting, but she is mostly upright. Notice that this baby is even coming out breech (not head-first)!

    Semi-Reclined

    Of course, some positions were more than a little reclined. They were usually not flat on their back like a lithotomy position, mind, but were a bit more recumbent than those above.


    Here is an illustration from a Persian mirror case. The mother is a little more reclined in this one, but is not totally reclined either.

    Here is a semi-reclined position from some Mexican pottery.


    This statue from Costa Rica also is semi-recumbent, but without abducting the legs so far apart and elevated, like hospital positions often are. The back also looks a little arched (see below).


    Here is a similar statue from Ecuador. Again, notice the more natural position of the legs, rather than having them lifted and strongly abducted.

    Reclining

    Although it is harder to find historical artwork of women giving birth in a very reclined position, there are some records of that position too.


    This Cameroon woman from Africa is giving birth fully reclined on a "maternity couch."


    This illustration is of a French Canadian woman propped up in a mostly reclining position on a mattress over an upside-down chair. Notice, though, that her knees are not splayed or pushed back.

    Note that even though semi-sitting, semi-recumbent, and reclining postures were seen among older cultures, there were some important differences to the ones seen in many hospitals now. Their semi-sitting positions were often more upright than ours, and when they laid back, their legs were not usually as elevated and splayed as they are in most semi-recumbent and recumbent hospital positions today.

    Asymmetric Positions

    Another variation on these positions is the asymmetric position.

    Having each leg on a different level (whether during a semi-sitting, reclining, kneeling, or all-fours position) makes one side of the pelvis higher than the other. This opens the pelvis on one side, making more room for a baby to turn from a less-than-optimal position. This can be a powerful tool in a non-progressive labor. 



    Here is a painting, possibly from Finland, showing the woman sitting near the edge of a bed or stool. At first it looks like the usual semi-leaning back position. However, notice that one leg is up on a stool while the other is down. This makes it an asymmetric position.


    This Indian painting shows a reclined woman giving birth on a bed, though her head is raised a bit. Notice that one of her legs is propped on the midwife's shoulder while the other is down, giving her an asymmetric position while lying down.


    Many women who give birth quickly or unattended assume an asymmetric position naturally. This woman from Mexico assumed an asymmetric position (one leg up and the other leg down) instinctively in a recent U.K. birth that occurred so fast she gave birth on the lawn outside the clinic.

    Birth Stools


    Many women over time have used a a birth stool, as in the Ancient Greek carving above, because birth stools allow women to stand, squat, or semi-squat while actively pushing, then to sit back and relax between contractions.

    If the mother stays seated the whole time she is pushing out the baby, a birth stool has the same disadvantages of the semi-sitting position (pushing the tailbone into the pelvic outlet and making it smaller). However, if the mother uses it to give support between shifting positions, it combines the best advantages of both the sitting and squatting positions.

    Birth stool from about 1580

    Here is an illustration of a birth stool in use in Europe about 1580. The use of a birth stool was extremely common in many European cultures.


    Here is another birth stool birth from Europe, about the same time period, and the mother is even plus-sized!


    Birth stools of various sorts have been very popular throughout history. Sometimes the care provider would bring the birthing stool with them to births....


    ...while other birth stools were family heirlooms, handed down through the family.


    Often birth stools were close to the floor and without arms, but sometimes they were full-on chairs with backs, sides, and footrests, as in this European illustration.


    Each type of birth stool has advantages and disadvantages, and some midwives and doctors had birth stools custom-made for them based on their preferences.

    Image from the Wellcome Trust of the U.K.

    In this more recent Greek illustration, a woman is held by her husband on a birthing stool, while the midwife crouches before them on a low stool.

    There are many, many other illustrations of births on birth stools available. In the interests of space I will not post them all, but if you are interested you can find many additional images.


    If you didn't have a birth stool, sometimes you improvised your own version. Lap-sitting on someone's lap was another very popular alternative, as shown here in an early American illustration. This position was very common among the settlers along the frontier.

    The husband sat on a chair, and another chair was placed on its front on the floor in front of the first chair to support the mother. This created a sort of poor woman's birth stool. (Alternatively, a sheet was placed over the husband's lap to create a sling for the mother to sit on.) The birth attendant sat on a smaller improvised stool in front of the mother. The husband helped support the mother as she shifted between semi-sitting, semi-squatting, and standing positions.

    Standing Positions

    Standing and walking during labor is extremely common in many cultures, but women often shifted position for the actual final pushing out of the baby. However, birth while standing up did happen at times too.



    For example, in this illustration of a birth scene from the Western African tribe of the Wakambas, the mother gives birth standing up, attended by 3 other women.


    In this relief carving from India, the mother is assisted to birth in a standing position by helpers on either side.


    In this image from Angola in Africa, the mother is shown giving birth standing. (Statues in certain African cultures were often given elongated forms.)


    In this illustration of the Kiowa Indian tribe from the North American plains, a helper in front blows into the mouth of a mother standing to birth, while the midwife catches the baby from behind. It is not clear what the blowing is for, but probably was used as a focus or distraction technique, to help with breathing techniques for pain relief, or as a symbolic "blowing in" of strength.


    Here is a similar scene from the Sioux Indians [some sources list it as being from the Iroquois]. The woman holds onto someone in front in a half-standing/half supported-squat while the midwife catches the baby from behind. Some accounts say that the tall supporter role in front was often given to a young bachelor male of the tribe, rather than the father. Presumably this was so that the father could see his baby be born, and so that young men developed an understanding of the potential consequences of sex!

    Positions Using Counter-Force

    Many women over time have found that having something to actively pull or push against while birthing the baby was helpful. Thus many traditional birth positions combined squatting, birth stools, kneeling, standing, or other positions with a way to let the mother utilize a counter-force.


    For example, as this "Pioneer Birth Scene" illustration shows, women would often sit on their husband's lap to imitate a birth stool, half-stand or pull against someone in front of them during a contraction, then lean back and rest on their husband between contractions.


    Some cultures used a rope tied to a tree or a cloth tied to something, as in the above illustration of an African American woman from the South. This helped the woman to be in a standing squat position. The rope helped support her weight so her legs wouldn't get as tired.


    Here is a Sioux Indian woman from North America, using a rope tied around a tree to pull against for sideways counter-force.


    In this illustration of Oronoko Indians from South America, the woman uses a sling and her helper to help support her semi-standing, semi-dangling squat position.


    Here is another illustration of a dangling position, this time using a rope to help the woman relieve the pressure in a kneeling position. In this illustration of a scene from Mexico, the labor helpers are using their hands to massage and shake the woman to try to reposition the baby during a difficult labor.


    This South Indian carving also shows the mother putting one hand down on a support and the other hand pulling on a vine or some sort of rope to birth her baby in a supported squat position.


    Sometimes pushing away from something feels better. In this carving from Peru, the mother sits back against someone in the semi-squatting position. In that way, she can lean back and use counter-force the other way.


    In this illustration of the birth traditions of the North American Pawnee tribe, the mother leans back and pushes against someone else while in the squatting position. The person behind her provides both stability and something to push against when needed. [Again, blowing on the mother seems to be part of the tradition of some Plains Indians. Aromatic smoke to the belly or perineum was used by several other indigenous peoples.]


    In this Andamanese labor scene, the woman is in a supported semi-sitting position, but she uses her feet to push against a wall for more leverage. [The Andamese were a tribal people who lived on the small islands between India and Burma. They are nearly extinct now.]


    Some cultures used a stick to dangle from, as in the illustration from Mexico above and also this African illustration from Angola. In this one, the mother stands with her back pushing against a tree, and also dangles from a stick placed at an angle to the tree. In this way, she gets counter-force both from behind and above.

    Arched Back

    Dr. George Engelmann, a physician who wrote a book in 1884 about birthing practices around the world (from which many of these illustrations are taken), notes that dangling or upright kneeling positions were common among many tribal peoples, and nearly always involved a change in the direction of the body's axis as the birth neared.

    In other words, many women changed from leaning backwards to leaning forwards, or from leaning forwards to leaning back. This probably helped work the baby down through the pelvis or created more room for the cardinal movements of birth (turns and twists a baby must make to successfully navigate through the pelvis).
    The Semi-Sitting Position in the hospital. Note the mother
    is encouraged to curl forward into a "C" position
    In most hospitals, women are encouraged to round their backs forward and put their chins to their chests to assume what some call the "C" position. This is thought to help the baby move towards the more roomy back section of the pelvic inlet, negotiate the curves of the pelvis, and make more room for the baby engage and move down. And indeed, many historical birthing positions make use of a forward-leaning (if more upright) tilt.

    Yet many women instinctively try to change their axis and arch their backs in the opposition direction instead, especially at the last moment as they are pushing the baby out. Historical art shows several examples of this instinct.


    Notice that in this statue from the Congo, the woman is in the common semi-sitting position, but she is arching her back strongly. As noted, in the hospital this is often discouraged and women are told to curl forward instead..all with the best of intentions. Yet arching the back may help move the sacrum and tailbone out of the way, tilt the public symphysis, and help create more space for the baby to move or for the shoulders to turn when needed.


    In this variation on the Aztec squatting statue from above, note that the mother throws her head back and seems to have more of a slight arch to her back than a rounded forward back like hospitals recommend.


    If you look closely, this ancient Cyprus birthing scene shows the mother lying back and arching her back somewhat. Certainly she is not curled forward into a "C" position. Although this is right after the birth of the baby and she could just be lying back to rest, her position suggests that this is how she actually pushed out the baby.


    Sometimes women get in some seemingly strange positions while pushing, as in this Italian illustration. Lying back and dangling the legs over the side of the bed is one of these, but in some obstetric texts this position was listed as another remedy for shoulder dystocia (where the shoulders get stuck).

    In the above and below illustrations, this extreme position was recommended especially for "corpulent" women as a way to get the weight of the abdomen off of the uterus and birth canal, an old variation on the "fat vagina" theory we still hear spouted today. <insert eye roll>


    Obviously, take that one with a grain of salt. Women of size successfully give birth vaginally in many positions, and many women of different sizes try to arch their backs as they are expelling the baby. Likely there is more to it than such simplistic stereotypes.

    However, that doesn't mean that this position is not potentially useful for other birth situations. In fact, a German doctor named Gustav Walcher described a similar position over a century ago. The website, Spinning Babies, has a whole page devoted to Walcher's Position, with several illustrations and historical details.

    In Walcher's Position, the woman is scooted to the edge of a high bed, arches her back, and lets her legs passively hang over the edge of the bed and dangle. If a high-enough bed is not available, extra cushions or a trochanter roll (such as those used in yoga or massage) are put under her hips to create the needed angle of arch. This is supposed to be an excellent position for helping a high baby engage into the pelvis and to open up the pelvic brim. They also note that the position is sometimes used for breech births or for resolving shoulder dystocia.


    Something similar to this position seems to be suggested by this carving of childbirth from Peru. Notice the angle of the mother.

    I have heard OB nurses note that many women in modern hospital births try to lift their bottoms off the bed and/or arch backwards a bit, especially at the last minute as the baby is about to come out.

    Page 142 from Dr. Engelmann's book
    Dr. Engelmann also noted this tendency among many of his European-American recumbent births last century. As shown in this illustration from his book, the European-American mothers he attended who labored in in a reclining position often found a way to pull up and raise themselves for the actual birth of the baby. He called this a semi-recumbent position, but if you look closer, she is certainly not in the curled forward "C" position of most modern semi-recumbent labors; she is pulling backwards and arching away as she pulls on the bedsheet.

    This may well be a woman instinctively trying to get the sacrum and tailbone out of the way at the last minute so the baby can come out more easily. Sadly, many hospitals actively discourage this back-arching movement. They mean well, believing arching back inhibits the baby negotiating the pelvis properly, but this ignores the fact that not every woman is alike and some may have a unique pelvic structure that benefits from an arched back at some point. Some may need the extra room that getting off the tailbone provides; others may simply find that the arched back position offers less discomfort.

    It's one thing to encourage a rounded back and forward-leaning posture because that may help most babies engage or move down better in general, but it's another to discourage or forbid a back-arching movement to women whose bodies are telling them that they need to do this. Care providers need to trust more in women's instinctive moves in labor instead of imposing one way of doing things. If a woman feels she needs to arch her back in labor or pushing, she should give it a try and see if it is helpful. The proof is in the results; if it doesn't help she can always go back to the "C" position.

    [This is a personal pet peeve for me because arching the back is what my body wanted to do with my third baby. The nurses (who were very nice and who meant well) prevented me from leaning back and arching my back. They forced me instead into a "C" position. I made NO progress in that position. When I finally leaned back and arched my back despite them, the baby came very quickly. Moral of the story: If the mother's body is telling her to move a certain way while pushing out the baby, there's probably a good reason for that!]

    Side-Lying 

    An excellent alternative position if the mother is tired or feels more comfortable lying down is the side-lying or lateral position. The mother's top leg can be abducted and propped up by a helper or squat bar, or rolled far over the other to create a kind of asymmetric position (called a Sim's position in modern obstetric literature). In this way, pressure on the sacrum and tailbone can be avoided, room in the pelvis can be maximized, yet the mother can still rest lying down between contractions.


    This painting of a sidelying position is from a Buddhist temple painting in Bhutan. Notice how one leg is thrown very far over the other to create a more asymmetric position and almost an all-fours position.

    Interestingly, this position is not seen often in ancient birth art, but it was used. Dr. Engelmann notes that many Nez Perce Indian women assumed a side-lying position for pushing out the baby, although they usually squatted or stood for labor.

    The sidelying position has also been documented at times among the Laguna Pueblo Indians of New Mexico and the Kootenai Indians of the Pacific Northwest in North America.

    It is one of the few alternative positions that is well-accepted and regularly utilized in the hospital, especially in women with epidurals. There is good research showing advantages to this position in hospital settings.

    Videos of Traditional Birthing Positions

    Here are two videos of ancient art demonstrating various traditional birth positions. You will see some of the images above in the videos, but you will see others as well.



    Here is another video with more images from various sources, including Native Americans and pioneers in the U.S., as well as tribal peoples from Africa and other areas.



    Summary

    Artwork from the past and from traditional cultures shows that women historically gave birth in a wider variety of positions than the usual lithotomy, semi-reclining, or semi-sitting positions that most hospital births use today.

    Happily, many care providers have developed more flexibility about positions in labor these days, yet research shows that the majority of American women are not actually pushing out the baby in them.

    Instead, during pushing, most women are pressured to be on their backs in the "stranded beetle" lithotomy position, or forced to curl forward in a semi-sitting C position, reducing the room available in the pelvic outlet. They are strongly directed to engage in forceful "purple pushing" that often bursts capillaries in the eyes, exhausts the mother, and reduces oxygen levels to the baby. This is not good for either mother or baby. Alternative birth positions and less directed pushing offers the advantage of a more physiological and effective pushing.

    Of course, the point must be made that just because traditional cultures used alternative birthing positions doesn't automatically make those positions better. Many questionable and even harmful practices were used across a variety of cultures and time periods; older or "traditional" doesn't necessarily mean better. It is important to subject traditional practices to research to see if they are beneficial or not.

    However, a fair amount of research suggests that there ARE significant benefits to upright, sidelying, kneeling, squatting, or other alternative positioning, both during the first stage of labor and during pushing. (Some references below; more on this research in future posts in the series.)

    It's very telling that when a woman is given the freedom to move in labor and is not told what position to use, she often moves into these alternative positions. And as Dr. Engelmann noted, even women laboring while lying down will often instinctively try to alter their position near the end of labor by raising up, arching their back or lifting their bottoms, or otherwise altering the axis of their bodies.

    Many birth attendants can testify that some non-progressive labors suddenly get "unstuck" and progress quickly once the mother is able to move freely in birth. What may seem like random or counter-productive movements to the observer may actually be just what the mother needs to free up a shoulder or help a baby finish turning to an easier position for birth.

    Dr. Engelmann tells a story much like this in his book. On page 73, he recounts a story from another physician:
    …he tells me of attending a lady of good position in society in two labors. ‘In her first labor, delivery was retarded without apparent cause. There was nothing like impaction, or inertia, yet the head did not advance. At every pain she made violent efforts, and would bring her chest forward. I had determined to use the forceps, but just then, in one of the violent pains, she raised herself up in bed and assumed a squatting position, when the most magic effect was produced. It seemed to aid in completing delivery in the most remarkable manner, as the head advanced rapidly, and she soon expelled the child by what appeared to be one prolonged attack of pain. In subsequent parturition [childbirth], labor appeared extremely painful and retarded in the same manner; I allowed her to take the same position as I had remembered her former labor, and she was delivered at once squatting.' 
    I can't end this post without including the beautiful Brazilian film, Birth in the Squatting Position. This doesn't mean that I think squatting is the best way to give birth; some people like to use it, some don't. I think you should move around and find whatever position most suits you ─ and that position may change from birth to birth, depending on the position of the baby.

    But this lovely (if dated) film normalizes one alternative position for giving birth, and this is something that more people need to see. As a bonus, it also has a larger mom giving birth squatting without interference just fine, showing that plus-sized mamas can birth vaginally too ─ without having to be flat on their backs with their legs hanging over the side of the bed!



    [Be aware that this film contains extreme close-ups of both birth and placentas afterwards. Some people are culturally conditioned to see non-sexual images of women's bodies doing what they are biologically programmed to do ─ give birth ─ disturbing. Don't watch if this would bother you. On the other hand, perhaps it's time to challenge your cultural conditioning!]

    In the end, it's important to reiterate that there is no "right" position for birth.

    You don't get extra points for having birthed while squatting or standing up. If the usual hospital positions work well for you, that's just fine. But many women find they have less pain, feel more in control, need less pain medication or other interventions, and give birth more easily in some of these alternative positions. All women should have the option of using them, and care providers should be more encouraging of them in the hospital.

    The position in which we give birth is very influenced by our cultural conditioning. But when we truly listen to our bodies' instinctive needs, we often naturally assume the position that is needed most for that particular birth.

    On the other hand, sometimes we need encouragement to try a different position in labor or birth, and a doula (professional labor support person) can be a wonderful source of ideas and inspiration for this. One consistent image seen in the artwork of many societies is that of the birth helper who assists the mother in her labor position while the midwife or doctor catches the baby. Bring that wisdom from ancient societies into your own modern-day labor ─ use the nurse, a doula, your partner, or a relative to help encourage you to try different positions.

    While pregnant, take time to "practice" labor in many different positions. If you haven't tried the position during pregnancy, chances are you won't try it during birth, especially at the hospital where we are culturally conditioned to be in bed. Schedule a "Labor Rehearsal" and try different positions on to see how they feel in your body. This will give your body a somatic vocabulary and kinesthetic memory of different position possibilities that you can try during labor.

    Once in labor, trust in your body's ability to tell you what you need. Try different positions and adjust as needed. Listen to the dictates of your body but also be willing to try ideas from others to see what works best for you. In the end, though, remember that you are the ultimate authority of what works best for your body and baby.

    Your body was made to birth a baby, but using different positions during labor and pushing may help that process out considerably.


    References

    **Most of the illustrations above are taken from the following resources. [Be aware that these books are products of their times and contain outdated attitudes and language]
    Other images are found uncredited in so many places that it is difficult to know the original source. If you have information on the original source of some of these, please let me know so I can credit them properly.

    Evidence Summaries on Birth Positions
    Position Influence on Pelvic Dimensions

    Am J Obstet Gynecol. 2014 Dec;211(6):662.e1-9. doi: 10.1016/j.ajog.2014.06.029. Epub 2014 Jun 17. Does pregnancy and/or shifting positions create more room in a woman's pelvis? Reitter A1, Daviss BA2, Bisits A3, Schollenberger A4, Vogl T4, Herrmann E5, Louwen F6, Zangos S4. PMID: 24949546
    OBJECTIVE: The purpose of this study was to assess the impact of different positions on pelvic diameters by comparing pregnant and nonpregnant women who assumed a dorsal supine and kneeling squat position. STUDY DESIGN: In this cohort study from a tertiary referral center in Germany, we enrolled 50 pregnant women and 50 nonpregnant women. Pelvic measurements were obtained with obstetric magnetic resonance imaging pelvimetry with the use of a 1.5-T scanner. We compared measurements of the depth (anteroposterior (AP) and width (transverse diameters) of the pelvis between the 2 positions. RESULTS: The most striking finding was a significant 0.9-1.9 cm increase (7-15%) in the average transverse diameters in the kneeling squat position in both pregnant and nonpregnant groups...CONCLUSION: A kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet. Because this indicates that pelvic diameters change when women change positions, the potential for facilitation of delivery of the fetal head suggests further research that will compare maternal delivery positions is warranted.
    AJR Am J Roentgenol. 2002 Oct;179(4):1063-7. MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. Michel SC1, Rake A, Treiber K, Seifert B, Chaoui R, Huch R, Marincek B, Kubik-Huch RA. PMID: 12239066
    OBJECTIVE: The aim of our study was to measure the impact of supine and upright birthing positions on MR pelvimetric dimensions. MATERIALS AND METHODS: MR pelvimetry was performed in 35 nonpregnant female volunteers in an open 0.5-T MR imaging system with patients in the supine, hand-to-knee, and squatting positions. The obstetric conjugate; sagittal outlet; and interspinous, intertuberous, and transverse diameters were compared among positions...CONCLUSION: An upright birthing position significantly expands female pelvic bony dimensions, suggesting facilitation of labor and delivery.
    Historical Perspective on Maternal Positions in Labor and Pushing

    Eur J Obstet Gynecol Reprod Biol. 2000 Oct;92(2):273-7. Maternal posture in labour. Gupta JK1, Nikodem C. PMID: 10996693
    The position adopted naturally by women during birth has been described as early as 1882 by Engelmann. He observed that primitive woman, not influenced by Western conventions would try to avoid the dorsal position and was allowed to change position as and when she wished. Different upright positions could be achieved using posts, slung hammock, furniture, holding on to a rope, knotted piece of cloth, or the woman could kneel, crouch, or squat using bricks, stones, a pile of sand, or a birth stool. Today the majority of women in Western societies deliver in a dorsal, semi-recumbent or lithotomy position. It is claimed that the dorsal position enables the midwife/obstetrician to monitor the fetus better and thus to ensure a safe birth. This paper examines the historical background of the different positions used and its evolution throughout the decades. We have reviewed the available evidence about the effectiveness, benefits and possible disadvantages for the use of different positions during the first and second stage of labour.
    Br J Obstet Gynaecol. 1982 Sep;89(9):712-5. The rationale of primitive delivery positions. Russell JG. PMID: 7052116, abstract here.
    SUMMARY: Women throughout the ages preferred to be delivered with their trunks vertical and most delivery positions illustrated in historical texts indicate that an upright posture with abducted thighs has been the rule. There is evidence that such a position considerably increases the outlet measurement of the pelvis. Primitive delivery positions often accentuate the mechanical forces usually acting on the pelvis.
    Research Reviews on Maternal Position for Labor and Birth

    Cochrane Database Syst Rev. 2013 Oct 9;10:CD003934. doi: 10.1002/14651858.CD003934.pub4. Maternal positions and mobility during first stage labour. Lawrence A1, Lewis L, Hofmeyr GJ, Styles C. PMID: 24105444
    BACKGROUND: It is more common for women in both high- and low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour, and in some women reduce placental blood flow...Results should be interpreted with caution as the methodological quality of the 25 included trials (5218 women) was variable....AUTHORS' CONCLUSIONS: There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers' and babies' well being. Given the great heterogeneity and high performance bias of study situations, better quality trials are still required to confirm with any confidence the true risks and benefits of upright and mobile positions compared with recumbent positions for all women. Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever positions they choose.
    Cochrane Database Syst Rev. 2012 May 16;5:CD002006. doi: 10.1002/14651858.CD002006.pub3. Position in the second stage of labour for women without epidural anaesthesia. Gupta JK1, Hofmeyr GJ, Shehmar M. PMID: 22592681
    ...OBJECTIVES: To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the uterine cervix)...MAIN RESULTS: Results should be interpreted with caution as the methodological quality of the 22 included trials (7280 women) was variable. In all women studied (primigravid and multigravid) there was a non-significant reduction in duration of second stage in the upright group...a significant reduction in assisted deliveries...a reduction in episiotomies ...an increase in second degree perineal tears...increased estimated blood loss greater than 500 ml...fewer abnormal fetal heart rate patterns...In primigravid women the use of any upright compared with supine positions was associated with: non-significant reduction in duration of second stage of labour...this reduction was largely due to women allocated to the use of the birth cushion. AUTHORS' CONCLUSIONS: The findings of this review suggest several possible benefits for upright posture in women without epidural, but with the possibility of increased risk of blood loss greater than 500 mL. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent data from trials are available, women should be allowed to make choices about the birth positions in which they might wish to assume for birth of their babies.