A Mommybites reader asked:
My doctor told me that I’d be giving birth lying on my back. Are there any other positions in which I can push out my baby?
I am often a bit surprised by how many mothers-to-be aren’t aware of the option to push their babies out in a position other than on their back. The other day in class, this subject came up and one mother honestly said, “It didn’t occur to me that I could do it any other way since that is how my doctor told me to do it the first time.”
So let’s discuss why this technique is so often used, why the lithotomy position (lying down on the back) is NOT ideal for birth and what other options are there.
Why is the lithotomy position most often used during labor?
There are a few factors as to why to this approach of having the mother push on her back is so common. First, approximately 3/4 of women giving birth in the US are taking epidurals which restrict movement and require full time fetal monitoring. In this position, the belly is very accessible for the monitors and it requires little mobility from the mother.
Another reason is that this position gives the care provider/doctor the “best view” in order to “catch” the baby. This is how many doctors are taught to catch a baby and this is the perspective of the woman’s vagina that is most familiar to them. Some doctors just simply do not have the experience, knowledge or confidence to see the mother’s anatomy and the emerging baby from a different perspective.
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Why is the lithotomy position NOT ideal for birth?
One would think since the lithotomy position is the most common birthing position it is the most advantageous for both mother and baby, when in reality it is the least effective for birthing. Strictly from an anatomical view point, laying flat on the back results in the NARROWEST pelvic opening and places pressure on the sacrum and tailbone. Logically, it would seem best to find a position that creates the MOST space in the pelvic outlet, which is squatting. Squatting opens the pelvic outlet an average of 28% wider than a supine position.
With a flat back position, pressure is exerted on the sacrum and tailbone. For mothers who suffer from pelvic pain, specifically tailbone issues and sacroiliac dysfunction, the lithotomy position will only exacerbate the situation. It can be more painful for the mother and also create asymmetry in the pelvic outlet. If a mother is suffering from sacroiliac pain, it usually means one side of her sacrum is tipped more forward then the other side. This will decrease the space in the pelvic outlet and possibly prevent her baby from descending and rotating properly for a vaginal birth. This could result in the care provider’s determination that the baby is too big for the mother’s pelvis, when in reality a different position could have provided the space and mobility for a vaginal birth.
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Other reasons to opt out of the lithotomy position include:
- Mothers that are flat on their back are also fighting against gravity, since the baby has to basically go uphill to be birthed.
- Laying flat on the back can put pressure on the vena cava which restricts venous return to the mother’s heart which compromises the oxygen supply to the baby. This is the whole reason why women are told to sleep on their left side during pregnancy.
- Studies have shown there is greater risk of perineal damage when birthing supine and greater discomfort is reported from women in the recumbent position. “A Cochrane review on this topic combined data from 20 clinical trials that included 6135 women. Compared with women who gave birth in supine or lithotomy positions, women who were upright or side-lying reported greater comfort, had fewer episiotomies (RR = 0.83; 95% CI, 0.75-0.92), and had a slightly shorter second stage of labor (mean = 4.3 min; 95% CI, 2.9-5.6). (1)
- Those birthing on their back are 23% more likely to have a forceps or vacuum-assisted delivery then those in upright positions. (2)
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What other options are there?
If a mother has an epidural, she is a bit more limited in options, but can still try side lying or a more upright seated position. Many of the women I have worked with as a doula were encouraged to let the epidural wear off for the pushing stage. This allows them to try squatting with a squatting bar on the hospital bed or even all 4s or kneeling if they can bear their own weight.
There is also a position I learned many years ago from a Labor and Delivery nurse called the ‘tug of war.’ This is done by placing the squatting bar on the bed. The mother is in an upright seated position with her feet on the sides of the squatting bar. A towel or sheet is then wrapped around the squatting bar, the mother is holding one end while her doula, nurse or partner holds the other end. During the contraction, the mother is pulling on the towel while pushing her baby out. The pulling aspect of this technique engages the mom’s back and abdominal muscles which can be useful in helping her push.
For those birthing unmedicated, there are a few more options since movement is not restricted. The mother could try squatting, a birth stool, upright and leaning forward, hands and knees, kneeling or using birthing tub.
Here is a link to some pictures of birthing positions you may want to consider.
The message of this article is to encourage women to push in whatever position they find most effective, comfortable and beneficial. Don’t be afraid to experiment with different pushing positions during the second stage of labor! It may take a bit of time to find the best position for you.
1) Journal of Midwifery & Women’s Health
Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth
Leah L. Albers, CNM, DrPH, Noelle Borders, CNM, MSN
2) What is the Evidence for Pushing Positions?
© 2012 Rebecca Dekker, PhD, RN, APRN
Debra Flashenberg, CD(DONA), LCCE, E-RYT 500 is the director of the Prenatal Yoga Center. She has spent most of her life performing and was introduced to yoga through a choreographer in 1997. After several years as a yoga student, she decided to continue her education and became certified as a Bikram Yoga instructor. After being witness to several “typical” hospital births, Debra felt it was important to move beyond the yoga room and be present in the birthing room. In 2006, Debra received her certification as a Lamaze® Certified Childbirth Educator. In September of 2007, Debra completed a Midwife Assistant Program with Ina May Gaskin, Pamela Hunt and many of the other Farm Midwives at The Farm Midwifery Center in Tennessee. Drawing on her experience as a prenatal yoga teacher, labor support doula and childbirth educator, Debra looks to establish safe and effective classes for pregnancy and beyond.
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The views and opinions expressed on this blog are purely the blog contributor’s. Any product claim, statistic, quote or other representation about a product or service should be verified with the manufacturer or provider. Writers may have conflicts of interest, and their opinions are their own.