I was really happy with my birth experience overall. I had a doula and a birth plan and the hospital staff was really supportive, but when the time came to push, they wanted me to lay on my back to deliver, which went against everything my body was telling me. Hands and knees had been the most comfortable position for me throughout the labor and I really did not want to turn around, but my doctor had never delivered a baby in that position and didn’t feel like it was safe.
—D. H., new mother
The most common positions for delivery remain dorsal lithotomy (68% of vaginal deliveries) and semi-seated (23% of vaginal deliveries).1 In the dorsal lithotomy position, the delivering woman is flat on the back with the legs widely spread, flexed at the knee and the hip, and raised with the help of labor assistants or stirrups. The semi-seated position is similar to dorsal lithotomy, except the head of the bed is raised approximately 45 degrees and legs are often not as elevated (Figure 7-1).
There are several reasons the majority of women deliver in these position, the first being that the majority of women have epidurals which simply limit their ability to deliver in alternative positions, as they are immobilized from the waist down. Second, due to this overwhelming percentage of women delivering with epidurals and the history of obstetrics that saw the majority of deliveries occurring with the aid of forceps, which necessitated a dorsal lithotomy position, most obstetricians are exclusively taught to deliver babies in a supine position and are only comfortable delivering in this manner. There is also a commonly expressed concern among obstetricians that if a complication arose, such as a shoulder dystocia or an umbilical cord around the neck, it could not be easily remedied in an alternative position. Finally, supine positions for delivery facilitate continuous electronic fetal monitoring.
Unfortunately, supine positions have been shown to have several disadvantages and there are benefits associated with alternative positions, such as side-lying, squatting, and hands-and-knees positioning. There is a higher incidence of vaginal lacerations, including severe tears that injure the anal sphincter, and episiotomies in patients in lithotomy positions. Lateral, or side-lying, positions have been shown to have a decreased rate of perineal lacerations and squatting and up-right positions for delivery have been shown to shorten the second stage of labor, especially with the aid of a birth stool.2–4 Less fetal heart rate changes have also been noted with alternative positions, which rotate the baby off the large vessels of the pelvis, maximizing blood flow to the baby. A large, randomized trial in China demonstrated a lower incidence of lacerations and episiotomies with hands-and-knees positioning as well, without any negative associations besides a longer second stage of labor, and other studies have shown less discomfort in this position as well.5 The research to date is not considered sufficient to recommend one particular delivery position, but does demonstrate that alternative positions can be every bit as safe and efficacious as supine positions and should be used much more routinely.
The ability for women to participate in decision making regarding pushing positions is also beneficial. Women who feel they have influence on their birthing position are more likely to feel they have control over their birth experience and report a positive birth experience.6 Doctors and midwives can best assist women in pushing by using a shared decision-making model. In this model, the provider offers instruction regarding how to best push in various positions and feedback about how each position is working, while empathetically listening and responding to how each position is feeling for the laboring mother.7 In most natural labors, the mother and her provider will not simply choose one consistent position throughout the pushing phase, but rather alternate between them depending on the effectiveness of the pushing, the mother’s comfort, and the mother’s fatigue level. Flexibility and openness to trying different things or returning to a previous position are essential in helping a mother through an unmedicated second stage. Patience and positive verbal feedback are also incredibly important to help the mother psychologically through what can be a hard and frustrating process.
In the side-lying or lateral position, the mother lies on the side of her preference, bending both knees and bringing them toward her chest (Figure 7-2). During contractions, the outside leg is relaxed outwards and flexed at the hip as the mother pulls back on it by reaching under the thigh with one or both hands. This position tends to be more comfortable than supine positions, especially for mothers with malpositioned babies, and is associated with less perineal tearing. This position can also be a good option for mothers who are too fatigued to support their body weight in either an upright or hands-and-knees position. It can be combined with a pulling technique, by placing a squat bar on the bed and securing a towel or sheet to it, which the mother can then pull on during pushing while bracing her outer foot on the bar or having it held by an attendant. If delivery is performed in this position, the same maneuvers used in a supine delivery are utilized, however at a diagonal angle in keeping with the direction of the maternal pelvis. The doctor or midwife would usually deliver from the side of the bed, rather than the foot of the bed, on the same side as the outer leg.
Many women find squatting to be an instinctual position for pushing. In this position, the legs are opened wide, with knees bent and hips fully flexed, while the weight of the woman is supported on flat feet (Figure 7-3). Most women feel the need to lean over on something to balance in this position, and a squat bar, a partner, a raised bed, or the raised back of the bed, with the woman facing inwards rather than the standard outwards, can all be utilized for this support. Squatting assists in opening the pelvis and bringing the baby to a lower station; however, it can be tiring to maintain for long periods of time.8 Birthing tubs facilitate women birthing in this position due to the buoyancy of the water. Supported squatting, in which the woman is held by birth attendants on either side or within the lap of a partner, can also make the position less fatiguing. If the woman is delivering in this position, delivery can be performed either from the front, using standard delivery maneuvers, or the back, using the same maneuvers utilized in the hands-and-knees delivery, depending on which side is more easily accessible. If the woman is using a labor bed, the foot portion of the bed can be lowered to facilitate delivery. If the woman is squatting outside of the bed, the doctor or midwife can usually most easily deliver simply by sitting on the floor. Some studies have demonstrated a higher rate of tearing when mothers who have had a previous vaginal delivery utilize this position for the actual delivery, likely due to a more rapid descent and crowning of the fetal head and the direction of force on the perineum.2
There are several types of birth stools and they provide for a supported squatting position for delivery, opening the pelvis and facilitating decent. The woman sits wide legged on the stool, either leaning back on her partner for support, grasping the back of the stool for pushing leverage, or curling forward, grasping the front of the stool or the back of her thighs for leverage (Figure 7-4). Both birth stool positions are efficacious and the woman should be encouraged to do what feels best to her. Delivery on a birth stool is less technically challenging for the doctor or midwife than a squatting position, due to the raised position of the mother and the cut out in the stool for the delivering the baby’s head; however, most stools are still low enough to allow the woman to secure her feet on the ground, still requiring the practitioner to deliver kneeling or sitting on the floor. The maneuvers for a birth stool delivery are no different than in a supine delivery.
Hands-and-knees positioning is another common position women assume when they are not guided to any specific pushing position.9 Women using this position may assume a straight back position, with the arms straight and the hips unflexed, or they may assume more of a child’s pose positioning, where the hips are flexed and the upper body is supported (Figure 7-5). Modern labor beds can easily assist women in assuming this later positioning, either by bringing the lower third section of the bed completely down and allowing the woman to kneel on this portion facing inwards, while completely resting her upper body on the middle section of the bed, or completely raising the head of the bed, which the woman can lean over or hang from while kneeling on the middle portion facing inwards. Women report that hands-and-knees positioning is more comfortable, particularly with malpositioned babies, and possibly makes for more effective pushing and even rotation of the fetal head in women with babies in less ideal positions.10 While studies have not demonstrated that this translates into lower rates of cesarean, the studies examining this have been plagued by small numbers and high rates of epidural, thus limiting their ability to effectively evaluate the benefits of this position for naturally laboring women.
When delivery is performed in this position, the provider must utilize a slightly different set of maneuvers. Delivery is most easily performed with the provider in a seated position behind the woman, with the entire bed raised so the woman is at the provider’s arm level. Continuous fetal heart rate monitoring is challenging in this position but intermittent auscultation of the fetal heart is easily performed by the provider from underneath. It is not uncommon to feel a small anterior lip of cervix when the woman is in the hands-and-knees position, but if the woman has a strong urge to push, she most often will easily push the baby’s head past this lip in one to two pushes and should not be discouraged from trying to do so. During crowning, the baby’s head should be supported with an open palmed hand and attempts to stretch or support the perineum are unnecessary, as gravity is pulling the weight of the baby away from the perineum. Encouraging the woman to blow out during crowning can also help control the delivery, as often gravity can lead to a precipitous crowning process in this position. Once the head is delivered, the delivery maneuvers are then done backwards, first gently pulling up and delivering what is now the bottom shoulder (which is the traditional anterior shoulder beneath the pubic symphysis) and then gently pulling down to deliver the top shoulder (which is the traditional posterior shoulder).
Delivery complications can also be managed effectively from this position and fear of this need not be a reason to restrict a woman from birthing on all fours if she prefers it. In the event of a nuchal cord, one may simply attempt to reduce it; however, if gentle traction is applied to the cord, creating a bit of slack, most often the baby can easily be delivered through the cord, as a lesser degree of cord tension is observed on hands and knees than in the supine position. Doctors also frequently express concern about how a shoulder dystocia could be managed on hands and knees; however, much of that concern is probably unwarranted. For one, the patient only needs to completely squat down, completely flexing the hips, to achieve the standard McRobert’s positioning and internal or external rotation is easily achieved in this position, as there is more often more room and flexibility when the mother is on hands and knees. The posterior shoulder is also more easily delivered, as it is on the top in this delivery position. Finally, hands-and-knees positioning, in and of itself, is also a known technique for relieving a shoulder dystocia, so while not shown in the evidence to date, it can be surmised that the incidence of shoulder dystocia in hands-and-knees deliveries may be significantly less than that observed in supine positions and, if a shoulder is unable to be reduced, the woman can simply be turned to a supine position for additional maneuvers.11
Hanging or pulling to create counter force during pushing was common in many cultures for generations.12 Most often, a rope was tied to a tree or large pole and the mother would hang or pull against it. This motion can easily be recreated in modern maternity units with the aid of modern labor beds and a simple long sheet. The bed is put into an upright, seating position and the woman secures her feat against either the small lower handrails or the foot rests while she and an assistant engage in a game of tug-of-war with a sheet (Figure 7-6). The sheet is generally folded in half and the woman holds the “U” side of the sheet, while the assistant holds the two ends of the sheet in each hand, leaning back and pulling with their body weight. Alternatively, the sheet can be secured to the squat bar or the back of the bed for the woman to pull against or hang from. Breathing techniques are still utilized during pushing with this method and generally the lower back of the woman rests against the bed, while the pelvis is slightly tilted forward. This technique can be helpful for women who are having a challenging time coordinating pushing efforts or who find they are “pushing in their face,” as it helps the woman engage the abdominal muscles more effectively. It can even be a very helpful technique in women with epidural anesthesia.
Standing positions require little description and are also commonly utilized by women who are pushing in the position most comfortable for them. Most often, laboring women will want something to lean over, such as a bed, table, or partner and assume a wide-legged stance, often with some degree of hip flexion, similar to the squat position (Figure 7-7). Delivery is most easily facilitated from behind, using the open palm to support the head during crowning and control the delivery of the baby’s head, followed by the same “backward” maneuvers used in hands-and-knees deliveries.
I had envisioned a calm, peaceful birth when I was pregnant with my first child. I had practiced hypnobirthing and spent a lot of time imagining that moment. I even had a specific set of music that I was planning on playing while my daughter was born. When I got to fully dilated and was ready to push, my nurse and another nurse came in and lifted my legs up. They told me to curl around my baby, hold my breath, and push for ten seconds. One of them started counting each push for me, really loudly, while the other kept saying “Push, harder, harder, harder.” It was really stressful. I felt like a football coach had entered my lovely little birth room and was now screaming at me. I think it freaked my husband out too because he never even remembered to turn on my music.
—Y. N., new mother
Typically, maternal pushing is a physician- and nursing-led effort. In the most standard form of pushing, the valsalva or directed pushing technique, the laboring mother is encouraged to fill her lungs with a large breath of air, hold this breath, and bear down into her bottom for a count of 10. This effort is typically repeated three times per contraction, with each push in close succession to the last. In an alternative, spontaneous pushing, the laboring mother follows her own instincts and typically pushes three to five times per contraction. A third alternative, only studied in women with epidurals, valsalva pushing is delayed until the mother has a strong urge to push or the fetal head is on the perineum.
All of the evidence to date which compared directed to spontaneous pushing is of limited quality; however, several disadvantages to the valsalva technique have been documented. A significant decrease in fetal cerebral oxygenation has been observed, as well as lower umbilical cord pHs indicative of poor oxygenation and resultant fetal heart rate abnormalities.13–15 In comparison, spontaneous, mother-led pushing has been associated with higher umbilical cord pHs and higher neonatal APGAR scores.16 Maternal concerns regarding valsalva pushing include increased levels of fatigue, as well as pelvic floor damage and resultant bladder control issues. The only benefit that has been demonstrated with the traditional pushing method is a slightly shorter duration of the second stage, as compared to both spontaneous pushing and delayed pushing. However, when the bulk of the evidence is considered, it is not sufficient to recommend one form of pushing over another and, given the possible disadvantages of directed valsalva pushing, current wisdom would support allowing the laboring mother to push using the technique of her preference.17 A woman having difficulty coordinating pushing may be guided to an alternative technique or simply given more time to labor down and develop a stronger instinct to push. Maternal wishes for a quiet, non-coached pushing stage should be respected, as cheerleading and coaching offer no documented benefit to either mother or baby, only perhaps an outlet for the provider’s impatience.
When I had my son, I had a nice doctor, but in the end she cut an episiotomy without really asking. She just said, “I need to make a little room here.” My recovery was really rough. I sat on that stupid balloon pillow for weeks and peeing was torture. When I became pregnant with my second child, episiotomy was my number one concern. In my first visit, I told the doctor I did not want an episiotomy. I put evening primrose oil on my perineum and made my husband do the whole massage thing for weeks before I delivered. I told him if the doctor even made a move towards those scissors, he had to stop him. I think I must have said a hundred times during my labor, “Don’t cut me!” My poor doctor was really reassuring and kept telling me that he had no plans to do an episiotomy. If he truly felt like one was needed, he would only do it with my permission. I tore only a little bit and had a much better recovery the second time around.
—C. W., new mother
The majority of women delivering vaginally have some degree of vaginal tearing. Tears are classified by degree, first degree to fourth degree, according to what structures they involve. Mild tears, first and second degree, involve only the vaginal mucosa or the vaginal mucosa and underlying muscles that support the perineum. Severe tears, third- and fourth-degree tears, extend further into the muscle that controls the anal sphincter or even into the anus and rectum itself. Severe tearing can lead to persistent pelvic pain, pain with intercourse, and flatulence and stool incontinence. All tearing is sutured at the time of delivery and typically require 1 to 2 weeks to heal, or longer in the case of more severe tearing. For mothers without epidurals, local injections of lidocaine are utilized for pain relief during any needed repair.
Episiotomies were introduced to the United States by Dr. Joseph DeLee in the early twentieth century as a means to shorten the second stage of labor, prevent severe perineal injury, and promote better healing, as it was hypothesized that a clean surgical cut of the perineum could be more easily repaired and heal better than an irregular tear.18 By 1980, episiotomies were the most commonly performed obstetrical surgery, performed in 63% of births. However, there was a growing opposition to the practice, with many women feeling traumatized by the procedure, and this was expressed vocally by critics such as Sheila Kitzinger and Penny Simkin. Over the following two decades, scientific evidence against routine episiotomies mounted.19 In the most recent Cochrane Review of 12 different studies, including over 12,000 women, which compared routine episiotomy to selective episiotomy, where an episiotomy is performed only for a prolonged second stage, concern for a significant tear, and/or fetal distress, routine episiotomy was found to actually be associated with more severe perineal lacerations, the very thing it was meant to avoid.20 Furthermore, there were no benefits of routine episiotomy identified in this review to justify the higher risk of third- and fourth-degree perineal lacerations associated with episiotomies. Newer research is even calling into question whether episiotomies should ever be performed for anything other than fetal distress and the initial study, while small in sample size, failed to demonstrate the benefit of even selective episiotomy.21 The American College of Obstetrics and Gynecology has also issued a recent practice guideline that discourages routine episiotomy, as a means to prevent obstetric lacerations.22
While episiotomy rates have been decreasing steadily in response to this evidence and strong expert recommendations, it is still a common procedure. According to a recent cohort of over 2 million women who delivered in 500 different hospitals between 2006 and 2012, 15% of women received an episiotomy, though significant variation between hospitals was observed, with some institutions reporting rates as high as 34%, while others reported rates as low as 2%.23 Few women want an episiotomy and, even more disturbingly, when they are performed, half of women surveyed indicated that they did not feel they were given a choice regarding the procedure.1 The issue of unconsented and forced episiotomies gained national attention when a video of Kimberly Turbin’s birth was made public, which clearly demonstrated an episiotomy being performed, not only without her consent, but with her explicit instruction against it. A suit alleging assault and battery was filed against her physician.24
An episiotomy is not just “making a little room.” An episiotomy is a surgical procedure and consent for the procedure should be no less specifically and formally obtained than for any other surgery, including a thorough description of the procedure, its indications and alternatives, as well as risks and benefits. No woman should ever need to fear that an episiotomy will be performed without her being aware of it and agreeing to it. This should not even need to be included in a birth plan and the fact that it is included in so many is a testament to how much work doctors and hospitals have to do in order to regain women’s trust.
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