Anybody got any good references on maternal positions in the second stage of labour?
My bible on all positioning matters is Jean Sutton’s Understanding & Teaching Optimal Foetal Positioning
(This book is available online from NCT Maternity Sales (www.nctms.co.uk))
At this address you will find the first of 20 articles on positioning and birth. Click on “related articles to find 126 of them.
Maternal positions in the second stage should be the position that the woman adopts if we do not tell her what to do.
Most women will get on to their hands and knees. Some will get into a squatting position but in my experience few Caucasian women will do this spontaneously, only if they have read it in a book and think they ought to.
Even fewer women will lie on their sides and I have known only one woman want to lie down on her back and that was because she had horrible Varicose veins and piles.
As a first year student of midwifery, I seek the advice of those out there with experience! A great number of the births that I have witnessed have been a result of the mother delivering in the supine position yet all that I have read would suggest that encouraging the mother to adopt the all-fours position would be preferential. ( I realise that not all mothers are happy in this stance). Those that I have delivered like this have expressed delight at the outcome (especially multigravidas who had been flat on their backs for previous deliveries). What are others’ experiences of preferred delivery positions?
I find that if the birth is taking place in hospital, choice of birth position can be facilitated by arranging the room much like the illustration in Caroline Flint’s ‘Sensitive Midwifery’- push bed aside, stool, rocking chair, kitchen type chair available, mat on floor, pillows, cushions and beanbags strewn about – (and not forgetting water, and showers) – I rarely find women opt for that supine position. And at home it’s so much easier for women choose to do what they want and go where they will, anyway.
But I well remember when, as a student midwife, a woman threatened to give birth standing up – how I panicked!! I’d NEVER seen a woman give birth in an alternative position to the ‘semirecumbent grab the back of the thighs and purple push’ type… The woman’s husband and I picked her up and we THREW her on to the bed. Fortunately the woman had a brilliant sense of humour and laughed the baby out. I am mortified that I ever did such a thing – and can catch babies in most positions now. (and the strangest of places!) It was that embarrassing experience which was the catalyst for deliberate efforts to change my practice…
One (of many) positive aspects of labouring on all-fours…
I’ve noticed that every time I get a woman to adopt this posture – usually leaning over the raised head of the hospital delivery bed (yes, I know, I know – why not the floor? – but one has to take these things slowly in the face of conservatism), *without exception*, her partner instantly moves in closer to her, head to head, face to face, in their own little world at the head of the bed – closer than he ever managed with her in any other posture.
I have wondered how best to encourage women to avoid the supine or propped sitting position so many of them seem to end up in (sitting right on their sacrum). Perhaps next time I’ll try rrearranging the furniture. Women who birth their babies in upright or all four positions often comment on what a good position it was. However there seems to be a view that all fours is somehow undignified (?animalistic), and I met a woman who’s husband told their friends and family that she had given birth “like a cow”.
Strange that you should make that comment about the all fours position. I had a lady say that she felt like one of her father’s cattle in that position as well. We tried alternate positions and this helped her through transition, however to birth her baby she felt most comfortable in semi recumbent position. I suppose if it worked for her that is great but I will still advocate all other positions before semi recumbent in the future for other women.
From an anatomical viewpoint and from observing birthing mothers from cultures where this position is common, I always suggest birthing in a squatting position is preferable. Of course many mothers would not be comfortable with this position. If possible I try to suggest early on in the pregnancy that mothers attend a prenatal yoga class and also practise squatting even if they plan to use another position for birth.
Rayner (not a midwife)
I delivered my baby on all fours. I think it is a great position and would highly recommend it, and interestingly, a specialist maternity physiotherapist I spoke to recently, said in terms of damage to the perineum, this is the kindest position to give birth in.
I was in a birthing pool and began my second stage in a semi-squatting position, supporting myself with my arms along the sides of the pool and bracing my legs against the sides. After a short while, my midwives suggested I try turning onto my front, which I did (just because you do do what you are told when you are in labour) and spent the rest of the time until the baby was born in that position.
The thing that surprised me at the time was that I expected the hands and knees position to feel ineffective because there is nothing to brace against, like there is when you are squatting or reclining against foot rests, but it felt really natural and I found that in this position I didn’t need to brace against anything. I started off kneeling up with my hands on the edge of the pool, but by the end of the second stage I had instinctively stretched my arms out and had my hands flat on the floor (I do have quite long arms!). I think to be comfortable, some women might like something like a stool or chair to lean on, so that they can have their upper body raised if that is what they want. Also I think it would only work on the floor, or possibly on a low double bed, which is sufficiently wide enough for the women to move slightly without falling off. I can’t see it being very safe on a narrow hospital bed, and the women would be higher than the helpers which does seem undignified.
My pool had a piece of foam between the liner and the floor which was really comfortable to kneel on and the all fours position wasn’t tiring on either my legs or arms or my helpers’. I felt fine immediately afterwards, not at all shaky in the legs or anything. I think it is a great position and I think it is great for the baby also, as it follows the text-book recommended exit curve, ie: extending the head backwards over the pubic bone, completely naturally on its own, without needing any rough manipulation or guidance from a third person. Also with the waterbirth, it was even better as my son just swooshed out into the water in a graceful arc ending up under my chest, without anyone attempting to guide or catch him. A friend of mine who used the same style pool had hers pushed up against the end of a sofa and was in a very similar position to me, with her arms resting on the arms of the sofa.
I can see that some people may find the position a little undignified, but surely this is insignificant if it is of as much benefit to both mum and baby as it appears to be? I always make a joke of it if anyone comments, and assume that I know best, as I was the one who actually gave birth to the baby. My husband watched our birth and didn’t find it horrible or undignified at all, and commented afterwards that seeing the baby’s head just before the body was born, seemed really natural and right. Also, in my case because of how I had positioned the pool in the corner of the room, I ended up kneeling at a slight angle to my three helpers who were sitting in a row just to the side of the pool, so no-one was actually staring right up my bottom, but to be honest at that point I was definately past caring. They were also higher up than me as they were sitting on chairs and I was kneeling on the floor level. One funny thing was at one point I asked someone to press my back to apply counterpressure, and one of the midwives leant forward to do it. At the time all I could think was she was pressing nowhere near hard enough, I didn’t register that she had got exactly the right spot first time, and my husband told me later because I had chosen the most convenient end of the pool, she was reaching almost the full length of it (5′) with the sleeves of her jumper trailing in the water and struggling not to fall in herself! Needless to say I didn’t appreciate this at the time!
Can anyone advise me if there is a good midwifery textbook on caring for woman in active labour. I was very happy that the woman today was on all fours and pushing, but I think I could have done with having seen a diagram/read texts of what was happening, rather than just having to ‘reverse’ the standard texts.
Try ‘Heart and Hands’ by Elizabeth Davies. One of the best books on midwifery I’ve ever read, with brilliant illustrations of hands and knees births etc. Glad you’ve had such a brilliant day!
See also ‘Which shoulder is born first?‘ for discussion of birth of the shoulders on all-fours..
Is Lithotomy Always Bad?
Re the case discussed in ‘Horse riding and the Pelvic Floor’:
I detest the lithotomy position with every fibre of my being, but several people have commented that “it always helps”. Is this true? Why/how?
In this instance I feel that lithotomy, by stretching the perineum, enabled an episiotomy to be performed long before it would have been possible in other maternal positions. And it was the episiotomy that was needed.
Who were these people commenting? What is their overall experience of birth? I am willing to answer my own question, place money on the bet that they are people who usually witness only “obstetric” deliveries… To the extent that this position “helps”, couldn’t it be just because in that position it is easier for the obstetric types to do THEIR thing?
Laura the cynic in NYC
I have seen it work brilliantly too, with women who have been trying to push, unsuccessfully, in a semi-recumbent position. Sliding flatter on the delivery bed and raising her legs must free the pelvis/tailbone to move as they should….. think of the number of times women try to lift their bottoms off a bed when trying to deliver a baby sitting down. Some midwives shout “Keep your bottom on the bed, chin on the chest…” etc – I say, stand up, try hands and knees, or simply MOVE – give this baby room to get out and it’ll come! So I figure lithotomy isn’t just for the convenience of the docs…it helps women out the second stage delays we sometimes allow to happen.
Links to other sources of information:
AH updated 13 July 2000