While the awareness about the dangers and disadvantages of giving birth while lying on one’s back is more widespread, this is still the main position in which the majority of women in the United States give birth.
The disadvantages of pushing while lying on the back include:
Pelvic outlet is reduced, which creates less room for baby
Less urge for the mother to push
Baby takes longer to descend—the “curve of Carus” along the sacrum and tailbone when on the back makes more of an uphill route that baby needs to maneuver before emerging under the pubic bone
Less oxygen to the baby due to increased pressure from the weight of the uterus and baby on the mother’s inferior vena cava (artery)
More difficult for mother to reach down and assist in the birth of her baby
Increased pain for mother
Uterus has to work harder to create contractions to bring baby down
Contractions may slow or stop
Increased risk of further aggravating or creating new hemorrhoids
Greater risk of perineal tears and lacerations
Easier for care provider to perform an episiotomy, if needed
Increased insecurity on the part of the mother, as she cannot as easily see what is being done to her
Greater risk of shoulder dystocia (where the shoulder becomes lodged behind the pubic bone) because of the decreased pelvic outlet
The advantages of pushing while upright and/or squatting include:
Squatting increases size of the pelvic outlet, thereby creating more room for a larger baby or baby with a presentation issue (posterior, asynclitic, etc)
Gravity helps baby descend
The force of the uterus during pushing is helped by being upright—gravity assists in the uterus being able to contract and tilt forward
Baby is better able to present naturally in the mother’s pelvis, and rotates into more favorable positions, if needed, while the mother is upright
Less pain is felt by the mother as the baby descends past the sacrum due to the fact that there is no pressure (by a bed) on this part of her body
Perineal tissues stretch more effectively, often reducing the need for postpartum repairs and/or discomfort
Mother is able to help assist in the delivery of her baby, as well as see her own baby being born
Sacrum is much more flexible and moves with descent of baby’s head
Mother is able to maintain eye contact with care providers (if she desires) and there are no surprises in touch
Even semi-sitting or semi-reclining positions interfere with natural, spontaneous pushing stages. In both the semi-sitting and semi-reclining positions, the sacrum is compressed, thereby reducing the diameter of the pelvic outlet.
Other options include hands and knees, standing, or kneeling. Squatting is easiest on the mother when she is supported and/or in water.
Sitting on the toilet is another fabulous position, as this is the place where we unconsciously relax our pelvic floor muscles. (Some women worry about their babies falling in the toilet, which is rare, but putting a chux pad under the toilet seat will offer some reassurance—as will having another person—preferably the partner—help with the delivery of the baby. Most women will instinctively start to stand as the head emerges.)
Side-lying is a great position because there is no pressure on the sacrum, and it facilitates oxygen flow to the baby and great blood flow to the uterus (positive blood flow to the uterus results in coordinated, efficient contractions). The upper leg can easily be supported by care providers or partners.
Squatting low over a pillow, cushion, or mat is a wonderful way to birth, as the baby can slide right out and the mother can easily pick up her own baby after taking in the entire experience. (This, compared to babies that are “thrown” up on the mother’s belly, seems like a more gentle way for mothers to make the transition after such physical work.)
Above all, just because the cervix is completely dilated does NOT mean a mother needs to push (it’s also normal to have small, involuntary pushes at the peak of a contraction to help with the last couple centimeters of dilation). The uterus will bring the baby down on the pelvic floor with contractions, while the mother breathes or copes with these contractions. After awhile, there will be an overwhelming action of the mother’s body to bear down. Active pushes on the part of the mother should only occur when the mother feels them, and not between contractions. Holding the breath while someone counts will only fatigue the mother, as well as create a risk of fetal distress due to the decreased oxygen. The whole idea is to listen to her body.
Some pushing stages take 20 minutes. Others may take 3 hours. These are all variations of normal and the mother should try a variety of positions that feel good for her, while staying hydrated and emptying her bladder (an empty bladder helps baby move down into the pelvis, as well as helping the uterus contract after the baby and placenta are delivered). Warm compresses over the perineum and rectum may offer some comfort, but hot compresses over a long period of time could swell the perineal tissues. Many midwives put herbs like grated ginger root into a crock-pot for compresses. Plain, boiled water works wonders, too.
For Partners: A hint for long pushing stages: cold cloths. Fill a small bowl with ice and a little bit of water. Get two or three washcloths and immerse them in the ice water, wring them out and use them to stroke the mother’s forehead or place on the back of the neck. These will warm up rather quickly, so replace them often with newly cooled cloths from the bowl. You can also add a little bit of essential oil to the water (lavender or clary sage are two labor favorites).
This article appeared in Pathways to Family Wellness magazine, Issue #13.
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