If we limit the discussion of birthing positions to those that can be easily described, classified, sketched and/or photographed we have quite an array at our disposal:

standing
Sitting variants
Side-lying
Kneeling
Squatting variants (including lap squatting)
Asymmetrical upright positions (standing, sitting or kneeling)

These are all aptly described and drawn in publications like 'The Labor Progress Handbook' by Penny Simkin and Ruth Ancheta and Robert Felkin's late nineteenth century report, 'Notes on Labor in Central Africa' Edinburgh Medical Journal April 1884. Many of us have seen reprinted sketches in other texts of a woman birthing in a sitting position while a helper exerts pressure on her body from behind, or of a birthing women standing arm in arm between two attendants who support her while she squats to deliver the baby. Another image might feature a birthing woman leaning against a vertical tree trunk while pulling diagonally on an overhead tree branch.

This montage of images depicting a birthing woman tapping into creativity and the liberal use of varying body dynamics represents what I affectionately call the 'Birth Kama Sutra' in homage to the ancient Indian compendium Kama Sutra which includes practical advice on sexual intercourse and describes types of embraces, caressing and kissing in addition to the 64 types of sexual acts. I know that the 800+ women I've attended have used more positions than that because there isn't a single labor position and activity among the 112 entries in Anne Frye's text 'Holistic Midwifery' which I haven't seen utilized.
Contrast this perception with the one in Pritchard & MacDonald's 'Williams Obstetrics' <http://www.acog.org/bookstore/Williams_Obstetrics_23nd_Edit_P425.cfm> in which there doesn't exist even a single index listing for labor position and the photographs are solely of women in the supine position!

Identifying positions, however, is just a point of departure. The manual, textbook, or research study can endorse or describe (or ignore) a specific position, but what follows is a series of nuances as the woman rocks, sways, gyrates and avails herself to the full range of movementwithin each position. Seen in this way the woman is not so much in a 'position' as she is in 'motion' simply thrumming with resonances and moods! Some of this motion is tentative, some is assertive. Even in the moments of stillness, positions are dissolving and shifting, like the out-of-context memories the woman often reports after the birth. Some positions are quite specific in the moment and then evaporate. Ebb and flow... stillness and movement... this is the way I've seen hundreds of women birth. When women hear this description of movement and motion in my consultations or classes they frequently say that it sounds as if I am describing a dance or sexual intercourse. Exactly. And that is before I begin to discuss, describe and demonstrate the often vocal component of the body's urge to push!

With so many options available to birthing women why then continue to use a lithotomy / supine /horizontal position?

In her commentary on Lamaze Care Practice #5 published in the Journal of Perinatal Education, Leah Albers, CNM, DrPH, FACNM, FAAN asks, 'The physiologic benefits of giving birth in positions other than lying on the back are well established. Why, then, are three-quarters of all births in this country performed with the woman lying on her back (Declercq, Sakala, Corry, Applebaum, & Risher, 2002)? Why is evidence-based care not being practiced?'

A similar question of mine is: How is it possible that childbirth education, doula and midwifery training programs all recognize the advantages of non-supine birthing positions and yet the training for obstetricians does not? Why are pregnant women seemingly more knowledgeable about utilizing upright postures than their health care providers? I made a quick internet search with just the key words 'birth plan checklist' and up popped up this encouragement from The Bump.com:

During delivery, I would like to:
[ ] Squat
[ ] Semi-recline
[ ] Lie on my side
[ ] Be on my hands and knees
[ ] Stand
[ ] Lean on my partner
[ ] Use people for leg support
[ ] Use foot pedals for support
[ ] Use a birth bar for support
[ ] Use a birthing stool
[ ] Be in a birthing tub
[ ] Be in the shower

Ever prepared for the facility or the care provider who claims that they don't have the means to provide for these options the checklist continues with:

I will bring a:
[ ] Birthing stool
[ ] Birthing chair
[ ] Squatting bar
[ ] Birthing tub

Then I began to think about the woman who might have already read Healthy Birth Practice # 5 and actually looked for a birth plan that took upright positions into consideration. Typing 'birth plan upright position' the first 'hit' was the following statement from the sample birth plan at Unhindered Living.com - I will not be confined to my bed for any reason other than when I feel the need to rest, or if my body feels most comfortable giving birth that way. I intend, barring some emergency, to give birth in an upright position, preferably squatting, standing supported squat, kneeling or modified kneeling.'

So how does a practitioner who does not attend births except with women lying down or limited to a semi sitting position respond with any kind of evidence based reply?

Frankly I don't think they can. After all, I can open ANY of at least 25 books in my library (all written for the general public) and find references for avoiding the supine position in every one of them! On what scientific basis can a woman be denied this request at her birth? Leafing through the volumes I've acquired for childbirth educator, doula and midwifery certification programs I find that every one of them acknowledges some advantage to vertical birthing.

Myles' Textbook for Midwives by Diane M. Fraser PhD MPHil BEd MTD RM RGN states in the chapter on physiology and management of the second stage of labor:
'The mother's personal preference should always be a primary consideration.' and 'Radiological evidence demonstrates an increase of 1cm in the transverse diameter and 2cm in the anteroposterior diameter of the pelvic outlet when the squatting position is adopted. This produces a 28% increase in the overall area of the outlet when comparing the supine with the squatting position, resulting in obvious benefit to the progress and ease of delivery. (Russell 1969)

Opening Heart and Hands: A Midwife's Guide to Pregnancy and Birth by Elizabeth Davis, I am reminded why I carried this volume with me for years: to show residents the detailed line drawing of managing a shoulder dystocia with the mother in a hands and knees posture. Davis later writes, 'The supine position is contrary to the laws of gravity and bad for the baby due to compression of the maternal vena cava and reduced blood flow to the placenta. Side lying with one leg raised can reduce strain on the perineum... Hands and knees is particularly good for mothers with big babies... Squatting or standing allows the mother to see what is going on and touch or lift the baby as it is being born...' One of her direct recommendations for the caregiver: 'Every midwife should visualize and prepare to assist birth in a variety of positions, so she can comfortably follow the mother's lead.'

In Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol. 2: Care of the Mother and Baby from the Onset of Labor Through the First Hours After Birth by Anne Frye we are reminded that:

'An ideal position allows the mother's sacrum and coccyx the freedom to rotate backward, the rest of the pelvis room to open to optimal dimensions to allow for birth, and contractions to remain strong and close together. She (the mother) should choose the position that best enhances the quality of her contractions and her ability to push.'

Her suggestion that readers assume the suggested positions themselves and check their own pelvic bones to note their movement is congruent with the pelvic body work recommended by BirthWorks for their teachers to help women increase confidence and understand their pelvis' ability to help birth their babies.

Freedom of movement merits 5 pages (8 abstracts) of reviews/studies that focus on upright postures and their positive effect on progress of labor, uterine contractility & efficiency, and women's comfort in Henci Goer's Obstetric Myths vs. Research Realities 1995, pp 101-105.

None of this is new of course and I hardly need the benefits of a search engine to find documentation supporting use of anything BUT a horizontal birth position. In fact, the mother's position relative to the baby's well-being has been studied for at least as many years as I've been studying about birth, anatomy and physiology. Here are some of my notes from all those years ago:

• 'Decreased abnormal fetal heart rate patterns with upright rather than recumbent positions' McManus and Calder 1978 Note: they were replicated by Liu in 'The Effects of the Upright Position During Childbirth' Journal of Nursing Scholarship Volume 21, Issue 1, pages 14'18, March 1989

• 'Side-lying has also been shown to result in less fetal stress than a supine position while pushing as demonstrated by improved fetal acid/base balance at birth' Humphrey et al 1973 BJOG

• 'Uterine compression lowers oxygen supply to the fetus and increases the risk of fetal distress and asphyxia' Flynn et al 'Ambulation in labor' Br Med J 26:591, 1978 Humphrey et al - The influence of maternal posture at birth on the fetus J Obstet Gynecol Br Commonwealth 80:1075, 1973

• 'Horizontal position increases the need for episiotomy because of the disproportionate tension on the pelvic floor' Blankfield, A. 'The optimum position for childbirth' Med J Aust 2:666, 1965

• 'Cephalopelvic disproportion is more frequently diagnosed since the baby's passage through the birth canal is against gravity' Ettner, F.M.,Hospital Obstetrics: do the benefits outweigh the risks. In Stewart, D., and Stewart L., eds 21st Century Obstetrics Now! Vol 1 Marble Hill, Mo., 1977, NAPSAC publications

De Jonge, et al provided a more current assessment of second stage positioning in their meta-analysis published in the Journal of Psychosomatic Obstetrics and Gynecology (Mar;25(1):35-45.): 'The routine use of the supine position during the second stage of labor can be considered to be an intervention in the natural course of labor. Their conclusion quite emphatically points the way towards the utilization of alternatives: 'The results do not justify the continuation of the routine use of the supine position during the second stage of labor.'

Posted by: Joni Nichols, BS, MS, CCE Informed Homebirth/Informed Birth & Parenting (ALACE), CD(DONA), CBI

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