# What's so bad about the lithotomy position



## JSerene (Nov 4, 2004)

This position seems to get a bad rap in natural-birthing circles. I agree with the need to use different positions during labor and birth, but I don't understand the reasoning in specifically avoiding this position. It works great for a lot of people - not using stirrups, but having mom pull her own legs back or having others help hold legs. It is often claimed that this position puts too much pressure on the perineum, leading to tears, but that is often not the case in my experience as a labor nurse. In fact, the birthing stool seems to lead to terrible tears and appears to put way more pressure on the perineum than lithotomy.

Don't get me wrong, I think women should birth in whatever position feels right to them. Lithotomy, hands and knees, or semi-squat seem to work the best for the actual birth for most people. And of course, no one should be forced into this position at the convenience of the person catching the baby, but it is a good position and I was just wondering why so many claim that it's not. Any thoughts? Thanks.

Edited: as explained below, the position I was thinking of is the Fowlers position, not the Lithotomy. Sorry for the confusion.


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## veganf (Dec 12, 2005)

Imagine trying to have a bowel movement on your back; there's no gravity helping, and a baby is way bigger. Plus, being on your back decreases the pelvic outlet slightly.
I birthed my first giant-headed baby on a birthing stool with no tears. The second I was sitting up holding myself off the floor on my husband's legs. Again, no tears with a 9lb5oz huge-headed baby. I think it feels VERY uncomfortable to lay on my back while pregnant, and in labor it would be absolute torture. Plus it decreases oxygen flow to the baby, and I feel like I'm being crushed by the weight of the baby while on my back. All around a very uncomfortable position to add to an already uncomfortable situation.

- Krista


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## cottonwood (Nov 20, 2001)

It doesn't decrease the pelvic outlet _slightly_ -- it decreases it _a lot_. But yeah, what veganf said. It can be better than a semi-reclining position which puts too much pressure on the tailbone and has the baby having to come out upward and around more of a bend. But it is far worse than upright positions.

In an upright position, the pelvis floats freely so can better accomodate whatever the baby's head needs it to do. Gravity can assist, and that's no small thing. Also, in an upright position the baby's head can put pressure equally around the cervix, aiding in dilation and making a "spontaneous ejuection reflex" (see Michel Odent) more likely.

Women birthing instinctively and spontaneously do not often choose a lying-down position, and that's because it's not natural (physiologically advantageous.) This position came into popularity only for the convenience of the attending person (doctors, and later midwives) and has no advantage for the mother or baby.

If the mother is told to push or if she thinks she should push for some reason, her tissues are not going to be ready, and she may push harder than is necessary. This is going to make tearing more likely if she is in an upright position, because a reclining position does significantly slow down the emergence of the baby. If, however, her tissues are fully ready and her body is doing the pushing, she will push only so much as her body needs her to (is compelling her to) and that will not put undue stress on the tissues, and the baby will be born quickly and easily, which is advantageous to the baby.

I birthed my first baby in a semi-reclining position, pushing in an unnormal fashion (at the magic "10 cm" but before my body was ready) at the midwife's direction. I suffered unnecessary vaginal trauma. My next three babies were all allowed to emerge as my body was ready for them to: no cervical checks were done, and no one told me when or how to push. My body wanted me kneeling. There was no vaginal or perineal trauma because my body directed my pushing, not me or anyone else. Only my hands were on my body and no one peering at my genitals, so my tissues had no reason to tense up at a clinical touch or inhibition, which would have made tissue trauma and a prolonged (more than minutes-long) second stage more likely.


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## pigpokey (Feb 23, 2006)

Quote:


Originally Posted by *fourlittlebirds*
It doesn't decrease the pelvic outlet _slightly_ -- it decreases it _a lot_.

I birthed my first baby in a semi-reclining position, pushing in an unnormal fashion (at the magic "10 cm" but before my body was ready) at the midwife's direction. I suffered unnecessary vaginal trauma. My next three babies were all allowed to emerge as my body was ready for them to: no cervical checks were done, and no one told me when or how to push. My body wanted me kneeling. There was no vaginal or perineal trauma because my body directed my pushing, not me or anyone else. Only my hands were on my body and no one peering at my genitals, so my tissues had no reason to tense up at a clinical touch or inhibition, which would have made tissue trauma and a prolonged (more than minutes-long) second stage more likely.

This is what happened to me, and the damage from that first birth is enormous. In my spontaneous birth, I wasn't even swollen or sore.


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## Mama Poot (Jun 12, 2006)

Well, to me its bad because its an undignified, invented-by-a-man way to give birth. A woman laying on her back with shackles on her ankles is not in a very empowered position- not a good thing when SHE'S ABOUT TO HAVE HER BABY!!!! I didn't have to deliver this way, but I was semi-sitting just for the convenience of my doctor. That was bad enough... I've seen pictures of women who have delivered with their feet in stirrups- and it makes me sick. But if someone out there is more comfortable with this position, like you said then they should be able to deliver however they want to. I just cannot imagine anyone requesting this.


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## sapphire_chan (May 2, 2005)

If you think about it, choosing to pull her legs to her chest would put a woman in the same position that being on all fours and sinking backward would. (I know that's a lousy explanation, but if you get on your hands and knees and try it you'll see what I mean.) One difference being face up works against gravity and face down works with gravity. Another difference would be that going on hands and knees would allow the woman to have better control over how far apart her legs were, and how bent, and how much like a squat. There would be no need for a woman in a very vulnerable stage of being about to push to have to leave her labor space and ask the attendents to adjust how her legs are being held.


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## littlebeagle (Aug 19, 2004)

I birthed all 3 of my babies in the laying down, pulling knees back position. I personally found it very uncomfortable to be any other way. I was surprised to see that I actually preferred to be laying down. My first child was 9lbs 6.7oz and he came out fine with only a surface tear (very minor). Do what feels right for you.


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## BelgianSheepDog (Mar 31, 2006)

Not all back positions are "lithotomy"--the term refers specifically to a very extreme variation on laying on one's back.


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## forthebest (Jun 19, 2006)

I had very similar experience to fourlittlebirds(your post is spot on),birthing my 2nd and 3rd child by myself with no interference(as I see it)hands off approach.My first baby was forcibly pushed out, at the midwives insistence!'if we didn't get this baby out soon the doctor was coming'!! resulted in said trauma, surprised I didn't end up doing more damage being forced to push when I had no urge, it was degrading(and labour went on for 36 hours)I had a slipped disc at age36 so who knows. I have always given birth upright and could not be comfortable lying down,felt immediately severely threatenened when asked to try this,semi-recumbant also felt not right to me,I felt disempowered and unnatural like this, I actually managed it for a short time,just to quieten the midwife who seemed far happier with me like that. If women are comfortable doing that it's up to them obviously it may be fine for some folk.But not all. If like pp said baby born with a natural flow(instead of the intense pressure of forced pushing(not something I would do naturally myself)and/or gravity-defying positions,then there will not be tears etc to me being stitched up after forced pushing is bad management,twisted and cruel.







Feet in stirrups....oh help, I don't wanna sink into depression about the oppression of our bodies right now, got to cook dinner!


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## forthebest (Jun 19, 2006)

sappire that is a very good post lol


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## angelpie545 (Feb 23, 2005)

I had waterbirths in a free-standing birth center with both my kids, and I could never imagine being on my back giving birth! NO WAY! Both times I was in kind of an upright, sitting position in the water. What was cool about it was the water kind of lifted gravity off my body, so I wasn't feeling so pulled down, and didn't have to support myself as much. Because of that, I was able to concentrate most of my energy on pushing. The more upright I felt, the better I pushed. Also, being on your back can make you really dizzy because of the weight of the baby pressing down on you. I don't know about other mothers, but it did that to me. I coulld barely have an ultrasound because of that.

I'll illustrate on reason why mother should be upright: During my first labor I made the mistake of lying down. I was on my side, which is better than on my back, but I was still lying down. Because I no longer had gravity on my side, my daughter stopped desceding at the rate she had been and got stuck. As a result, I started to swell. Now if I had been in a hospital they probably would have brought me back for a section. My midwife had the good sense to get me up, and march me around the room. Her insight paid off and my baby dropped, and I dilated to ten very quickly, pushed for about 40 min, and gave birth to my 9lb, 5oz daughter.


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## forthebest (Jun 19, 2006)

Angelpie, I always wished for a water-birth(we were lucky to get a beanbag here!)it just makes so much sense and I bet relieves painful contractions


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## bobandjess99 (Aug 1, 2005)

well, as you can see from the many posts, there are a lot of answers, but for me, the biggest thing is the fact that it decreases *by as much as a THIRD* the size of the pelvic outlet.
It is also, for *most* women, a very uncomfortable, unatural position to birth in. Yes, i know a few women who liked and chose that position, but by far the most do not....


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## JSerene (Nov 4, 2004)

As BelgianSheepDog stated, not all back positions are lithotomy positions (what happened to the quote button?). Thank you for pointing this out, I didn't realize it when I made my OP. Lithotomy is defined as follows: "the posture assumed by the patient lying supine with the hips and knees flexed and the thighs abducted and rotated externally". There is a photo in the dictionary and it looks terribly uncomfortable. I guess what I was thinking of would be defined as the Fowlers position, which is "placement of the patient in an inclined position, with the upper half of the body raised by elevating the head of the bed approximately 45-60 degrees." I'm sorry I was unclear, in doing so I totally misrepresented my point.

Posted by Saphire Chan, "If you think about it, choosing to pull her legs to her chest would put a woman in the same position that being on all fours and sinking backward would. (I know that's a lousy explanation, but if you get on your hands and knees and try it you'll see what I mean.) One difference being face up works against gravity and face down works with gravity. Another difference would be that going on hands and knees would allow the woman to have better control over how far apart her legs were, and how bent, and how much like a squat. There would be no need for a woman in a very vulnerable stage of being about to push to have to leave her labor space and ask the attendents to adjust how her legs are being held."

This is a really good point. I find it interesting that if the shoulders get stuck during the birth and the woman is in the Fowlers position, the head of the bed is dropped flat, straightening the back out. If a woman was on her hands and knees, it would effectively be the same thing as her raising herself up all the way, which is something some women do instinctively, or so I have read in birth stories here, to get the baby "around the corner".

Something else I was thinking about is that most (as in pretty much everyone except the people who choose to birth in water) assume the Fowlers position automatically. They are not give direction to do this, and have to be coached to change positions if they are unable to push effectively in this one. That being the case, (1) do you suppose that its instinctual to lie down to push; or (2) is it more because that's what we see everyone else do (from births we witness personally to what is shown on TV or in birth videos);or (3) the prominant position of the bed in the room; or (4) that's where you were when the midwife or OB checked your cervix so that's where you stayed - ?

Here's another thought: a lot of women are pretty tired out from their labors and this position lets them rest and relax completely between contractions. Squatting can get tiring in the legs.

I've been thinking about all of this lately because as a labor nurse I often find myself suggesting various positions _other_ than Fowlers, even though I defended it in my OP, and I was wondering if I should be doing so. Granted, if a position is working for someone, there's no reason to change, but I often want them to get out of bed or at least off their backs automatically. I was trying to think through whether or not this was justified, because, like I said, it does work well for many people. In fact, I gave birth in this position and found it quiet comfortable.


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## jennica (Aug 10, 2005)

Quote:


Originally Posted by *JSerene*
Something else I was thinking about is that most (as in pretty much everyone except the people who choose to birth in water) assume the Fowlers position automatically. They are not give direction to do this, and have to be coached to change positions if they are unable to push effectively in this one. That being the case, (1) do you suppose that its instinctual to lie down to push; or (2) is it more because that's what we see everyone else do (from births we witness personally to what is shown on TV or in birth videos);or (3) the prominant position of the bed in the room; or (4) that's where you were when the midwife or OB checked your cervix so that's where you stayed - ?

Here's another thought: a lot of women are pretty tired out from their labors and this position lets them rest and relax completely between contractions. Squatting can get tiring in the legs.

I find it hard to believe that most people assume this position with no direction at all. Are you saying the woman climbs into bed, lies down on her back, requests that the back of the bed be elevated 45 degrees, and then begins spontaniously pushing? Maybe no one says "lay down in bed now, and then get on your back to push", but they probably say, "lay down and let me check you" and then "okay, you can push now". Of course, to be checked, the woman is already laying down, she is already on her back, and so when she is given the go ahead to push, being in a highly suggestable state, she will push were she feels she is being told to push. So to answer your original question, what is wrong with this position is that a woman left on her own, a woman who is not checked constantly and checked before she is allowed to push, or directed in any way at all, would generally never choose this position. I also think that the reason you are seeing more tears in the upright positions is that gravity is at work, so if a woman is also being told "push, push, push" or even "push into the pain" or whatever, she will push harder and faster than what her body is telling her to do, therefore tearing when she normally would not have if she was simply left alone to push when she had the urge. Also, if anyone is trying to massage the perinium or has their hands in there for any reason, a tear is more likely.


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## forthebest (Jun 19, 2006)

There is I think a point where you may need to take a rest from squatting during labour but I honestly think lying down and /or reclining is a convenience thing,eye level for docs, some women feel more comfortable like this rather than squatting but lots of women prefer squatting. In my hospital birth experience I was shocked at all the women lying around on drugs, possibly unnable to have a very active birth. After they harrassed me for hours to take drugs I gave in to get some quiet,probably the same reason they wanted me to take them! People just don't seem very cool with women being upright but of course it is essential to be up and around during labour as suits the woman but I really feel that giving birth has become a medicalized procedure and the natural process seems more scarey for some than lying about being a patient.I was told by a doc that most women want a medicalized birth because it makes them feel safe!Depends what's fashionable at that moment,breastfed good/breastfed bad,co-sleep/no co-sleep,baby to bed on stomach/baby to bed on back,to squat or to lie down.







: To have a happy birthing is vital.


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## orangefoot (Oct 8, 2004)

This reminds me of a previous thread.

http://www.mothering.com/discussions...d.php?t=461378

A hospital bed is there to be laid on, head raised or not. If there is nothing else in the room but a bed where can you go? I wouldn't want to birth on the floor of any hospital here as they aren't clean. At home I might choose to use my bed but I doubt I would choose to lie down on it on my back.

Quote:

Here's another thought: a lot of women are pretty tired out from their labors and this position lets them rest and relax completely between contractions.
What about left lateral then? Better for feto-maternal blood flow and less constricting of the pelvis.

Quote:

but they probably say, "lay down and let me check you" and then "okay, you can push now". Of course, to be checked, the woman is already laying down, she is already on her back, and so when she is given the go ahead to push, being in a highly suggestable state, she will push were she feels she is being told to push.








: To me its all about suggestion, both verbally and by the context itself. I don't do lithotomy or Fowlers (never heard of that - I presume its a man's surname) well as I get terrible cramps in my thighs just having my legs bent. Maybe this is a spontaneous desire to not have all and sundry looking at my vulva?


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## doctorjen (May 29, 2003)

Quote:


Originally Posted by *orangefoot*
A hospital bed is there to be laid on, head raised or not. If there is nothing else in the room but a bed where can you go?

I think this is the truth. Also, most of my clients watch "A Baby Story" where they have learned that the way to deliver a baby is to lie on your back with 2 people holding your legs, and a gowned, masked, and shoe covered person pulling on the perineum.

I tend to have a lot of teenagers as clients, and one of the things I enjoy most about them is that they don't know yet how they are "supposed" to birth. They tend to push when they want to, wherever they want to. I have had births on the floor, lots in hands and knees, and one lovely young woman who put the foot of the bed all the way down, curled up on her side on it, and rested her upper leg and arm on the bed. She was a tiny person (4'10", probably 100 lbs at the birth) and fit entirely on the foot of the bed that way, and promptly pushed out a 7 lb baby over an intact perineum this way. Another favorite teen was pushing on her side on the bed, and we were just starting to see peeks of the top of baby's head when she said "Oh man, I gotta pee" and promptly hopped up, ran into the bathroom, peed like a race horse, and then crawled back on the bed in hands and knees and pushed her baby right out in like 2 pushes. Women who've had some indoctrination into standard medical birth don't do those things!

I do think laboring women are very susceptible to our expectations and feelings, no matter where they are or who the attendant is. I've even heard home birth midwives talk about how women tend to go where you lay down a pad, or seem to be "setting up." Not "setting up" for the birth seems to help folks feel free to choose positions. I don't think anymore of getting someone in a position to push - they just push when they want to, and I find that most women naturally choose something like hands and knees, kneeling, or standing and leaning over the bed. Many really tired folks seem to like side lying. I do still see some semi sitting, particularly among folks who are pretty mainstream and medically minded, or someone who is really tired.


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## Melinda77 (Feb 3, 2002)

I've been thinking about this too, after my son's recent homebirth.

When I was expecting, my mom reminded me (again, as she did with each of my pgs) that for her, the MOST comfortable way to push was semi-reclined, feet resting on the stirrups so that when she lifted her head during a push, her knees were near her ears. She said again and again, that it was the best place for her, and that pushing that way, I was out easily.

So, here I was, at home, with a pool and a birth stool available. I *hated* the birth stool. Tried pushing on it, and really, really did NOT like it, and was not pushing effectively. In the pool, I just couldn't find a way to stop pushing with my feet/legs. So, my midwife mentioned that I had a lot of "room" at the back of my vagina, and that I might prefere semi-reclining, knees up. Nothing to lose, I tried it, and it worked! Suddenly I was making progress, streached nice a slowly (one small labial split, no other trauma).







I guess it works for some of us.


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## boscopup (Jul 15, 2005)

Quote:


Originally Posted by *doctorjen*
I think this is the truth. Also, most of my clients watch "A Baby Story" where they have learned that the way to deliver a baby is to lie on your back with 2 people holding your legs, and a gowned, masked, and shoe covered person pulling on the perineum.

I think this is probably why alot of women lay on their backs to deliver. It's all they know to do, as it's all they've seen on TV! I know that's how I thought babies were delivered until I started doing research into natural birth and found out about alternate positions. I never would have thought of squatting to give birth! Or hands and knees!







I had been indoctrinated with laying down in bed on your back with feet in stirrups or legs being held back by attendants. Ah... the power of suggestion!

Interestingly, when I was going into transition, I wanted to be UPRIGHT. It was killing me to lay on my back. Of course, I was not "allowed" to get out of bed unless I needed to have a BM, since I had had PPROM 4 days earlier. In hindsight, I should have said "shove it" and just gotten up. I'm 99.9% sure baby was engaged, so cord prolapse wasn't happening! Now I know better. Anyway, when I had the urge to have a BM and got to make that glorious trip to the toilet, I felt SOOOOOO much better. Of course, I still had to get back in bed after that, but then they found the head "right there" and raced me to the LDR where I got to birth in the typical position as seen on TV. My DH helped me get as upright as I could get in that bed. My baby came very fast, and I tore even though he was not even 4 lbs, but I think that has more to do with directed pushing than pushing position. I was NOT feeling an urge to push for that 2nd push (where his head came out). I think my body was telling me to wait so it could stretch. *sigh* Again, now I know better.







If I PPROM again with this pregnancy, I will be telling my OB that I will NOT labor in bed if the baby is engaged, and I will NOT birth on my back again. And I will NOT do directed pushing. I don't think he'll have a problem with that (he says he's "gullible"... I say he's "openminded"







).


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## tash11 (Mar 12, 2006)

I gave birth standing up.

not squatting, no stool. just standing.

I did not want to be in any variation of laying on my back. I didnt even want to do semi-sitting. The biggest reason was I didnt like the idea of it. It seemed so powerless, so submissive. There was no way I would subject myself to that. I thought I would give birth kneeling or on my hands and knees. But my legs didnt like that idea so I stood up, and she basicly fell out. I was a little sore but no tears and it was great. I walked to my bed and the placenta came out a few min later.


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## huggerwocky (Jun 21, 2004)

I find being halfway on my back even not in labour unbaerable at this stage, I can't imagine ever choosing it to give birth







: It makes about every ache I have ten times as bad, at least!

Now leaning over a ball or something, THAT really brings relieve!

According to my midwife who has attented more than 800 births most women go on all fours or choose to stand. That makes sense to me, as I said, leaning over the ball or something else feels great...


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## annakiss (Apr 4, 2003)

Quote:


Originally Posted by *JSerene*
Here's another thought: a lot of women are pretty tired out from their labors and this position lets them rest and relax completely between contractions. Squatting can get tiring in the legs.

I think generally that a woman left to go into labor on her own when she and her baby were ready would not likely have such a terribly long labor that would leave her completely exhausted. Add to that that women left to push when they are ready will usually enjoy a rest before the hormones needed for pushing are released giving the mother a burst of energy. If you're witnessing women completely exhausted and finding that laying down is good for resting, you may want to just let them sleep a bit, as they're working against their bodies.


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## DreamsInDigital (Sep 18, 2003)

When allowed to birth as I wanted, I naturally assumed a semi-upright squat to push out my 10 lb. baby. I couldn't even fathom laying down in any position, as the pressure I felt at my tailbone was really intense.


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## mamaverdi (Apr 5, 2005)

I pushed out baby #1 lying on my right side...he was coming so fast....I just wanted a little rest.

And second baby arrived with me in hands and knees...

I labored in various positions. And took a nap during my second labor.

mv


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## doctorjen (May 29, 2003)

Quote:


Originally Posted by *boscopup*
If I PPROM again with this pregnancy, I will be telling my OB that I will NOT labor in bed if the baby is engaged, and I will NOT birth on my back again.

I think this is another one of those standard medical wisdom things that doesn't make sense. I don't see what could be protective about lying down if your water is broken and the head is not engaged, vs standing.
(I don't mean to say that you shouldn't bedrest with PPROM, I'm talking about ruptured membranes in general, at term.)
If the baby is floating and the water is broken, how does lying down keep the cord from prolapsing? Since the baby is heavier than the cord, it seems to me that being upright is more likely to bring the head down into the pelvis than lying down is. Doesn't make sense to me to make someone lie down, making it harder for the baby to slide down into the pelvis.


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## veganf (Dec 12, 2005)

Quote:


Originally Posted by *JSerene*
Something else I was thinking about is that most (as in pretty much everyone except the people who choose to birth in water) assume the Fowlers position automatically. They are not give direction to do this, and have to be coached to change positions if they are unable to push effectively in this one. That being the case, (1) do you suppose that its instinctual to lie down to push; or (2) is it more because that's what we see everyone else do (from births we witness personally to what is shown on TV or in birth videos);or (3) the prominant position of the bed in the room; or (4) that's where you were when the midwife or OB checked your cervix so that's where you stayed - ?

Here's another thought: a lot of women are pretty tired out from their labors and this position lets them rest and relax completely between contractions. Squatting can get tiring in the legs.

When I was squatting on a birth stool for my first birth, in the actual last few moments of crowning and the baby sliding out, I wasn't so much squatting as standing supported on two kneeling people's shoulders. And yes, it was very tiring on the legs because I pushed for a long time. But I got out of bed (from a side-lying position) shortly after pushing began, and I never had an VE's.

With my second birth I was no where near a bed, no VE's, and I just chose to sit on the floor for pushing, raising my butt off the floor during the final pushes to get baby out, hence straightening my body a bit.

So I suppose what I'm saying is that the most natural thing for me was to straighten near the end to get those giant heads and shoulders out. But laying down on my back would never have occured to me.

- Krista


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## veganf (Dec 12, 2005)

Quote:


Originally Posted by *boscopup*
Interestingly, when I was going into transition, I wanted to be UPRIGHT. It was killing me to lay on my back. Of course, I was not "allowed" to get out of bed unless I needed to have a BM, since I had had PPROM 4 days earlier. In hindsight, I should have said "shove it" and just gotten up. I'm 99.9% sure baby was engaged, so cord prolapse wasn't happening! Now I know better. Anyway, when I had the urge to have a BM and got to make that glorious trip to the toilet, I felt SOOOOOO much better.

LOL, sounds about right! During transition I was jumping around the room like a crazy person trying to crawl out of my own skin. Of course I was totally uninhibited because I was alone (my 15 month old was alseep upstairs). Then I felt like I had to poop. At that moment my husband arrived home, the midwife was on her way, and via the phone she said I probably felt that way because it was the baby's head, and NOT to get on the toilet or I might have the baby in the toilet. Well, I KNEW that wasn't it, but I suddenly had people telling me what to do, so I said to put something on the floor and I'll just poop right there!! So I did, LOL. I knew what I was feeling, but apparently many women mistake the baby's head for a BM.
After that I spent a few minutes on hands and knees before wanting my husband behind me to start pushing. Then the midwives arrived, etc etc and caught the baby, etc etc.

- Krista


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## boscopup (Jul 15, 2005)

Quote:


Originally Posted by *doctorjen*
I think this is another one of those standard medical wisdom things that doesn't make sense. I don't see what could be protective about lying down if your water is broken and the head is not engaged, vs standing.

Interesting. Yeah, if it happens again, I'll definitely discuss it with my OB. He's open minded, so I think he'd be ok with me not laboring in bed. When I was in the hospital with DS, it was the teaching group that I was assigned to, and I never even got to talk to the attendings who make the decisions.







: I liked the residents, but they didn't have much power. And I wasn't educated enough about the situation to know that it was ok for baby if I said "no", as I didn't have good Internet access (my DH used his cell phone with his laptop so he could check e-mail, and let me do the same, but I couldn't sit there and research things for ages... it was just a cell phone connection).

The attending who was on that weekend had even said that I needed to keep the bed FLAT - not upright at all - during my bedrest. Well, talking to other PPROM moms, some leak more when laying down like that and leak less when in a reclined position or even standing! So I think what position a PPROM mom takes for bedrest should depend on how much she leaks in that position. I leaked standing up, so staying in bed was a good idea for me, but I didn't notice any difference in leaking between laying with the head of the bed up a bit and laying with the bed flat. And I still see no reason why I needed to labor in bed (and use that stupid bedpan for peeing - not fun during contractions!!!!!).


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## supahero (May 30, 2005)

I was discussing my labour/birth positioning with one of my midwives at my last appointment. I have a rather large protruding varicose vein at the top of my labia, near my clitoris. She suggested that it will be wise (particularly during the "ring of fire" portion of delivery) that I lay on my back or side to avoid rupturing the vein. I *do not* want that to happen, obviously. So I can see why it would be necessary in this case. Any differing opinions?


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## cottonwood (Nov 20, 2001)

Quote:

Here's another thought: a lot of women are pretty tired out from their labors and this position lets them rest and relax completely between contractions. Squatting can get tiring in the legs.
Sure it can, if you're doing it for the whole labor. But woman won't do that instinctively, they'll move around and assume a fixed position for birthing only just as the baby is coming out. In a normal second stage (where the body directs the pushing) the baby descends very fast, within several minutes at most. I'm a large, out-of-shape woman, but even I can squat for that long. Further, in a normal labor the mother has a surge of adrenaline at the end which literally propels her into a more upright position, giving her energy for it. I'm assuming you haven't seen that much because 1) for the reasons you suggested, women in hospitals feel they are supposed to be lying down and 2) women in hospitals are generally encouraged to push before their bodies are ready, short-circuiting normal hormonal release.

I think far too much emphasis is put on squatting as the ideal position, though. Most women in our culture are not comfortable balancing in a squat, and kneeling or hands-and-knees are generally just as effective. My two spontaneous instinctive births were both in a kneeling position.

I have to add, like other posters have said, that the back position is uncomfortable for me also because it makes me dizzy and makes me feel vulnerable and inhibited. It also gives the birth attendant way too much access to the genitals, when they should not be anywhere near there except in cases of emergency.

Like I said, I gave birth to my first in a Fowler's position. It was comfortable, yes. I love reclining, it's definitely more comfortable than being active.







But it made it *much* harder for me to get my baby out, for the reasons I stated in my first post below. You're just not going to see a spontaneous fetal ejection reflex in a reclining position, all you're going to see is a mama working very, very hard. Working that hard, people assume that getting up would be *more* work. If women knew how much easier babies come out when they're upright, I doubt they'd view vertical positions as being more work.


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## BelgianSheepDog (Mar 31, 2006)

Quote:


Originally Posted by *annakiss*
I think generally that a woman left to go into labor on her own when she and her baby were ready would not likely have such a terribly long labor that would leave her completely exhausted. Add to that that women left to push when they are ready will usually enjoy a rest before the hormones needed for pushing are released giving the mother a burst of energy. If you're witnessing women completely exhausted and finding that laying down is good for resting, you may want to just let them sleep a bit, as they're working against their bodies.

Generally, perhaps. But I don't think the sort of macho attitude about birthing positions is helpful at all to women "in general," either. I think it's best to reject nothing offhand because every woman and every labor is different. I don't think every instance where squatting and other positions very much in vogue this week don't work can be chalked up to medical (mis)management. In Western cultures our squatting muscles aren't generally very well developed and it may indeed be too tiring for a lot of women to sustain such a position long enough to get the job done. And a perfectly natural labor can drag on for a prolonged length of time for a number of reasons, including the baby's position and the peculiarities of an individual woman's anatomy. Maternal exhaustion is nothing to sneeze at and I would rather see a woman laying down to push, if that's what she needs, than getting drugged and cut. Which, I should add, would be the main way to let a woman with constant contractions "sleep a bit."


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## JayGee (Oct 5, 2002)

Purely anecdotal, but I delivered my DD1 on my back, legs held by DH and my doula and had a 3rd degree tear. I delivered my DD2 at home on my knees and leaning over my birth ball without so much as a skidmark. I could have delivered in other positions with my first vaginal birth, but she was posterior and the pain was absolutely excrutiating except when I was on my back.


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## cottonwood (Nov 20, 2001)

Quote:


Originally Posted by *BelgianSheepDog*
the sort of macho attitude about birthing positions

What are you referring to?


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## annakiss (Apr 4, 2003)

Quote:


Originally Posted by *BelgianSheepDog*
But I don't think the sort of macho attitude about birthing positions is helpful at all to women "in general," either.

Indeed, to what fourlittlebirds said, what are you referring to? The macho attitude that men have taken over the last several centuries by interfering with the natural birthing process? That's pretty macho.









But if you're talking to _me_ about allowing a woman to follow her own body??? Then I just have to give you a big ol'







HUH?!?!?

And this:

Quote:

baby's position and the peculiarities of an individual woman's anatomy.
Um, if we let women go into labor naturally on their own and didn't mess with it AT ALL, a lot of the "problems" we see, even at home, would likely disappear.

I have also come to understand - and I don't like to say it because people tend to take it offensively - but a lot of prolonged labors and inefficient labors and whatnot are due to emotional hang-ups in the mother and/or family. It is certainly no one's _fault_, but if a mother is overly scared or if there's relationship problems going on, then this can have a dramatic affect on a birthing woman.


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## Snowdrift (Oct 15, 2005)

I birthed on my back. Similar to another pp, my babe was posterior and while during labor being on my back was unbearable, during pushing I wanted the gentle pressure of the bed against my back. I really didn't want to be touched--the massage that had been so great during most of my labor was suddenly very skin-crawly.

I had planned on birthing in a different postion--I'd always imagined hands and knees, but had talked to my midwives about trying an assymetrical position to prevnet tearing (I had had some yeast infections and BV with a bit of skin damage and felt I was vulnerable to tearing bc of this). I ended up on my back because it felt good. I wanted my back against the bed, my legs felt too weak to support me comfortably in any position but standing (I labored for 33 hours posterior and asynclitic--not the longest labor on record but long enough thst I was pretty tired), and standing hurt my back.

It bugs me that there is a huge presumption that I birthed how my midwfie wanted me to/how the male establishment wanted me to. That somehow I could've/should've found another position by resting or trying more positions or something. The size of m pelvic opening was not an issue. I'm pretty large-boned and DD was very average sized; once DD moved into a better position she moved down and was born within a half hour--long enough to help my soft tissues stretch, but there just was not an issue of needing my pelvis opened up any more. "Pushing against gravity" was ot a problem. My uterus can easily handle moving seven pounds up and well as down and really, i'm glad the birth was not any faster than it was. Half and hour from moving into position to birth (presumably 'full dilation--although I'm counting from when I asked my midwife to check her positon--we weren't counting dilation) was pretty fast and really a bit too fast for me emotionally and physically--after the long back labor the actual pushing/birth was very much a relief and a time for me to reconnect with my body in a more positive way and to get ready for her to really be born, since throughout the lanor it seemed like it was still very far off. I had two small skidmarks, possibly copntributed to by my repeated skin infection.

Empowerment and submission and passivity are all mutable concepts: one woman's empowerment is another woman's exploitation--just look at the plastic surgery issue. If I was in a hospital I would not have felt comfortable in the position I chose, but I was in my home, on my bed, in my room, and everyone else was there only with my permission. That was empowering enough for me to feel free to take wahtever postion felt best to me without leaving me feeling vulnerable or afraid of people touching innapprpriately.

ETA: for the record, no one interfered with when I went into labor. I was not expecting her to be born so early (on her EDD, went into the labor the day before, but first baby, assumed it would be a few more days at least), nor were the midwives. Not sure why somehow my labor/birth was long and the birth was supine is linked to me having "emotional hang-ups." sound slike Ina May's emotional management of labor to me, and I'm not cool with that. Some babies are just not positioned ideally. Sometimes labors, especially first labors, are long and exhausting. Once again, yeah, had things been different, maybe i wouldn't have birthed on my back. Still not sure why I should want things to have been different or to have not birthed on my back







. Other than of course, the vague notion being propogated here that somehow I'm submitting to everyone from Louis XIV to my friendly local specialist in c-sections. If birthing the way I wanted to makes me unfeminist, un-'natural birthing,' or un-anything else, then well, that's pretty sad that ideology comes before comfort and intuition when biirthing.

Sorry I'm getting a bit overwrought about this, but i'm just really tired of reading about how disempowering my birth was.


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## BelgianSheepDog (Mar 31, 2006)

:

Tie-dyed, I could have practically written that post myself. Except my baby wasn't posterior, she was LOA, yet I still had really awful back pain in labor, possibly because she had her hands near her face (not when she came out, but at points during labor) possibly just because of how I am built. Or possibly because of "emotional issues" on my part, I guess, if they can slow down labor, why couldn't they also cause back pain?







:









But I'll pretty much ditto everything you said there. I also get irked with the "emotional management of labor." Sometimes there might be something to it, but assuming that physical problems women have are always or frequently caused by our emotional "hang-ups" just reeks of patriarchal medicine to me. You know, those cramps are all in your head! And saying to a woman who has been in labor almost 24 hours, is in excruciating pain (oh wait, I forgot, REAL homebirthers don't feel pain, either, right? heh.) and is exhausted to the point of lapsing into REM sleep between contractions, "oh you must just not be ready to be a mother"...what worldly good could that do? I'm glad that instead of stopping to psychoanalyze me my midwives helped me find a way to give birth as safely and easily as was possible under the circumstances. That meant suggesting that I lay back so I could rest and recover my full strength between contractions. And maybe if I had insisted on staying on the birth stool another two hours I wouldn't have torn, but the tear I got is healing a lot faster than the c-section scar I would have had if I had been too stubborn and ideologically fundamentalist to do what was practical in that situation.


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## BelgianSheepDog (Mar 31, 2006)

Oh and re: "macho attitudes," what I mean is this idea that "real homebirthers" or natural birthers or whatever only assume certain pre-approved "good" positions. Are we listening to our instincts and our bodies, or not? Because clearly some women feel that a reclining position has, for whatever reason, been the right thing to do during their labors. Are they all just pawns of the patriarchy or something? I mean really, are we all different and need to listen to our bodies or not? What is with this ridiculous idea that you're automatically "disempowered" if you aren't upright during birth? You're disempowered if you aren't able to do what you need to do because someone else won't let you do it.

After my daughter was born, I felt like I had won a marathon. I did the hardest work of my life and lived through some of the most overwhelming physical sensations (not just pain) I could imagine. And I got a beautiful, huge baby girl out of a body that I was afraid couldn't do it. And I did it all on my terms, with a team of women I trusted and respected, making every choice an informed one, accepting no tests or treatments I didn't also agree to be necessary. I had no induction and no pain relief drugs and no hospital transport. The fact that her head came out of my body while I was laying on my bed really should have no bearing on how I view the situation. It really ticks me off that some birth fundamentalists would decide that I'm some kind of weakling or victim because of that one detail.


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## forthebest (Jun 19, 2006)

Of course women should give birth in whatever position suits them, I think some women can't/don't want to face lying down for whatever reasons and some don't want to or can't stand,squat. There is no way, IF a woman is happy and comfortable lying or semi-reclined, that that in any way disempowers her in her experience or that being upright is in some way more feminist? I think the medical establishment has preferred women to be lying down and imo an extreme form of this would be stirrups and indeed some dubious births where the woman has actually been pushing 'uphill'. I cannot see any good reason for any of these demeaning and potentially dangerous positions.Every birth should be a wonderful and loving event but too often we are treated to conveyer belt,desensitized hospital births where some of the 'routine' practices are just terrible and can easily help promote prolonged,obstructed labours. I think for some of us being upright not just helps our own individual child's descent(most people have a wee lie down at some point,I did on my side, but could not lie on my back at all it was just too painful and I hadn't slept on my back for some months either) and is also a way in this age of medicalized birth that we feel more in tune with the natural process, a way of feeling more in control perhaps,just as a woman who has chosen(not been coerced)to be semi-reclining or lying down will also have an empowering and fulfilling birth experience. I think the midwife who was present at my first childs birth was clueless as to the fundamentals of birthing, she had me pushing for hours till I was exhausted,giving me nasty 'hurry up' looks all the time!, it was completely futile.Maybe in some sort of meditative state you don't even need to push to give birth. I gave birth to my 2nd and 3rd babies with no medical establishment present and felt confident at all times, no probing,no peering,no forced pushing.But thats not to say all women want that and I don't feel like a better person than anyone else for doing so just relieved that I was able to. Funny tho that squatting is seen sometimes as trendy or 'in' at moment but women have been doing it for long,long time


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## doctorjen (May 29, 2003)

The OP asks a question about whether a position should be avoided for birth and mentions that she doesn't see many women wanting another position - but she is talking about hospital births. I don't think anyone is saying that any woman should labor or birth in ANY position she doesn't like - but simply that in most uninterfered with labors women seem to choose more upright positions, and that in the hospital your options are pretty limited if the only thing you have in the room is a hospital bed. Not to mention that there is a cultural perception that this is how birth happens in the hospital. I attend only hospital births and believe me, I see over and over again absolute shock from family members if a woman does anything but lie on the bed because they "know" that's how birth happens. Even when I'm encouraging a laboring woman to make herself comfortable, I often have to contend with the mom or auntie who's trying to get her to go back to bed and lie down like a nice patient.

That does not mean that a woman who chooses to lie down in labor or to push has anything to feel bad about, or needs to defend herself. I just wish all women were free to choose whatever position felt good to them, and to move as often as they wanted, and to not feel judged or forced into different positions as happens so often.

I'm sort of torn on this idea that long labors are caused by emotional issues. On the one hand, I hate the idea of sort of blaming a woman for causing her difficult labor. Some babies are poorly positioned, sometimes mamas start to labor when they are physically run down for some reason, some labors are just long. Telling someone they are having some kind of psych issue while they are trying to birth a baby seems condescending and hurtful.

On the other hand, I do think that women's feelings and thoughts definitely influence her labor. I see many women who have a big pause in their labor when I come into the room - and I think I'm pretty non-threatening! I've seen women really struggle to push out a baby until a certain family member leaves the room, or seen labor stall until a dad can get there. I don't think we can dismiss that the mind and body are a continuous whole and what affects one, affects the other.


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## annakiss (Apr 4, 2003)

Each individual birth is unique. That is true. Most women feel pain in labor. That is also true. I don't dispute that. The thread, however, was about a general population and that is what I am addressing. I don't put the onus on birthing individuals to buck the entire history of the oppression of women. Not at all. If your unique situation and intuition led you to do something that in _most_ cases would seem counterintuitive, there is absolutely nothing wrong with that. It is not a judgement on you or your experience to say that in most cases those positions are not productive.

I understand completely the frustration with the natural birth movement's varied proponents talking about pain being in your head, the "right" way to birth, etc. I reject those notions along with you. I don't want to commodify the birth experience. My ultimate goal is to simplify it and empower women. I think though that we can have these discussions without it being a personal judgement.

There is a historical context for the lithotomy position that has to do with the oppression of women, and that is something in need of exploring. I was more sensative to what other people had to say about birth when I was more fresh from my own experience. Over time, I have studied much more and I don't take generalizations personally. I apologize if I inadvertantly offended anyone.


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## annakiss (Apr 4, 2003)

Quote:


Originally Posted by *doctorjen*
I'm sort of torn on this idea that long labors are caused by emotional issues. On the one hand, I hate the idea of sort of blaming a woman for causing her difficult labor. Some babies are poorly positioned, sometimes mamas start to labor when they are physically run down for some reason, some labors are just long. Telling someone they are having some kind of psych issue while they are trying to birth a baby seems condescending and hurtful.

On the other hand, I do think that women's feelings and thoughts definitely influence her labor. I see many women who have a big pause in their labor when I come into the room - and I think I'm pretty non-threatening! I've seen women really struggle to push out a baby until a certain family member leaves the room, or seen labor stall until a dad can get there. I don't think we can dismiss that the mind and body are a continuous whole and what affects one, affects the other.

I agree and have this issue as well. I don't want women to feel blamed at all, because we _all_ have issues and it's certainly in large part outside of our control as to how we work through them. But from the studying I've done, it can play a big role. I would never tell someone, "you've got issues," but I can see trying to urge someone to look at them sort of, uh, slyly, I guess. It's a tough line to walk for certain and I DO NOT have it down at all. But, then, I'm not a birth professional either, so I don't have to worry about that atm, I guess.


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## JSerene (Nov 4, 2004)

I have found this discussion very interesting and appreciate everyone's input.

Here's another thought:
The patient population I work with is about 45% hispanic, then equal parts white, african american, african, and somali. There are many cultural differences in how these groups of women give birth. For example, I don't think I've ever seen a hispanic woman not birth on her back. Ever. It just doesn't happen. If the position isn't working, with encouragement she will change positions while pushing, then return to her back for the actual delivery. I don't think this is instinct, but rather cultural. As a group, if these women were going by instinct, it's impossible they would ALL have the same instinct to be semi-reclined with their knees pulled back.

As a group, the Hmong patients tend to squat. In bed, out of bed, on a stool, free-standing, whatever they find comfortable. This, I understand, is the cultural norm for them. What's really interesting is when they will cast aside culture and get into bed because it happens works better for them. They have to look their mothers in the eye and tell them, no, I need to lay down.

Maybe the answer is better education. Let everyone be informed of their choices. Let every woman in birth try out different things and find what works for them. People get hung up on their ideal. For example, I really wanted to give birth in the water. I have witnessed many beautiful waterbirths and that was my birth fantasy. Well, when my labor hit, I hated the water. I had to be moving, contantly. When it was time to give birth I was on my back on the bed. I never imagined it that way, but that's what felt right.


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## boscopup (Jul 15, 2005)

Quote:


Originally Posted by *JSerene*
Maybe the answer is better education. Let everyone be informed of their choices. Let every woman in birth try out different things and find what works for them.









:

My body was screaming for me to be upright, yet I was kept in bed on my back. I didn't want to be there. My body was telling me not to do that. That's just the only choice I was given - basically, no choice. Had I known my birth attendants, I might have had more in me to say what I wanted, but I'm shy and I was not in the right mind to argue with someone anyway. I knew about other positions, but didn't feel like I had a choice of using them at the time. But boy was my body wanting to be upright! I just wasn't prepared to birth in a hospital with OBs I didn't know, and there had been no time to call one of the many doulas that offered to come be with me during labor when they heard about my upcoming preterm birth.

If your body is telling you to lay on your back to push, go for it!!!! Do what your body tells you, not what your care giver says you should do, or your TV has shown you is "the norm", or what "other natural birthers" say you should do. Laying on your back might be the position your body needs to birth that particular baby. That's ok! What I have a problem with is women being FORCED to birth in that position, or at least strongly encouraged to do so, when their bodies are telling them otherwise. And THAT is what happens all too often in hospital births, and even in some homebirths.


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## doctorjen (May 29, 2003)

Quote:


Originally Posted by *JSerene*
For example, I don't think I've ever seen a hispanic woman not birth on her back. Ever. It just doesn't happen. If the position isn't working, with encouragement she will change positions while pushing, then return to her back for the actual delivery.

I wonder if this could be regionally cultural? Most of the Latina clients I have had have ended up side-lying for birth.
Also, they almost universally seem to nurse their babies in side-lying. One lady thought I was absolutely off my rocker for trying to assist her to nurse sitting up. I was surprised at the ease with which she flipped on her side and latched her minutes old baby on. Of course for me, side-lying was an advanced nursing skill, so maybe I was just behind the times!

Funny after all this discussion, the last birth I attended (yesterday morning) the mama chose to birth her baby on her back! She was on her side during transition and flipped onto her back for the 2 minutes it took her to push her baby out. She did NOT want her legs up or even really open much, though, and her baby came out just fine.


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