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Birth Positions

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Vertical Birthing in Peru - Peru's health ministry has said vertical birthing positions can be healthier for women by reducing pressure on the uterus and large blood vessels that can affect the amount of oxygen going to the baby.

Postpartum outcomes in supine delivery by physicians vs nonsupine delivery by midwives.
Terry RR, Westcott J, O'Shea L, Kelly F.
J Am Osteopath Assoc. 2006 Apr;106(4):199-202.

CONCLUSION: Nonsupine positions during labor and delivery were found to have clinical advantages without risk to mother or infant. Enhanced maternal outcomes included improved perineal integrity, less vulvar edema, and less blood loss.

Anal sphincter lacerations and upright delivery postures-a risk analysis from a randomized controlled trial.
Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE.
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 25

CONCLUSION: Obstetrical anal sphincter lacerations did not differ significantly between a kneeling or sitting upright delivery posture. Episiotomy was more common after a sitting delivery posture, which may be associated with an increased risk of anal sphincter lacerations. Upright delivery postures may be encouraged in healthy women with normal, full-term pregnancy.

Birth Trauma Revisited - Theresa Warner, DC & Stuart Warner, DC

Kneeling Birth

This is my favorite position for women in the tub.  I make sure we've got towels or spa pillows against the side so they don't bruise their forearms.  It opens the pelvis a little bit like a squat but is easier for non-squatters to hold for a long period of time.  And I find it easier to see what's going on (with a mirror) than for moms in a squat.  If there's room, I try to guide the baby between the mom's legs so she can reach down in front to bring her baby out of the water.  (Otherwise, you have a challenge with getting the cord around her legs - just be careful not to pull on the cord/placenta when you do this.)

Int Urogynecol J Pelvic Floor Dysfunct. 2006 Apr 25; [Epub ahead of print]  Related Articles, Links

    Anal sphincter lacerations and upright delivery postures-a risk analysis from a randomized controlled trial.

    Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE.

    Pelvic Floor Center, Department of Obstetrics and Gynecology, Karolinska Institute Danderyd Hospital, Stockholm, Sweden.

    OBJECTIVE: To evaluate obstetric sphincter lacerations after a kneeling or sitting position at second stage of labor in a multivariate risk analysis model. MATERIALS AND METHODS: Two hundred and seventy-one primiparous women with normal pregnancies and spontaneous labor were randomized, 138 to a kneeling position and 133 to a sitting position. Medical data were retrieved from delivery charts and partograms. Risk factors were tested in a multivariate logistic regression model in a stepwise manner. RESULTS: The trial was completed by 106 subjects in the kneeling group and 112 subjects in the sitting group. There were no significant differences with regard to duration of second stage of labor or pre-trial maternal characteristics between the two groups. Obstetrical sphincter tears did not differ significantly between the two groups but an intact perineum was more common in the kneeling group (p<0.03) and episiotomy (mediolateral) was more common in the sitting group (p<0.05). Three grade IV sphincter lacerations occurred in the sitting group compared to none in the kneeling group (NS). Multivariate risk analysis indicated that prolonged duration of second stage of labor and episiotomy were associated with an increased risk of third- or fourth-degree sphincter tears (p<0.01 and p<0.05, respectively). Delivery posture, maternal age, fetal weight, use of oxytocin, and use of epidural analgesia did not increase the risk of obstetrical anal sphincter lacerations in the two upright postures. CONCLUSION: Obstetrical anal sphincter lacerations did not differ significantly between a kneeling or sitting upright delivery posture. Episiotomy was more common after a sitting delivery posture, which may be associated with an increased risk of anal sphincter lacerations. Upright delivery postures may be encouraged in healthy women with normal, full-term pregnancy.

Delivery less painful in kneeling position - Last Updated: 2006-03-07 13:22:06 -0400 (Reuters Health)

"Several studies have already reported the advantages of an upright delivery position compared to one lying down, such as less pain and more efficient contractions. However, this is the first time researchers compared the two most common upright delivery positions - kneeling and sitting."

"Women in a seated position reported a higher level of pain, less comfort giving birth and 'more frequent feelings of vulnerability and
exposure' than women in the kneeling position, the authors write; . . . women in the kneeling position reported significantly less pain after delivery than those in the sitting position. "This might be explained by the kneeling position being more flexible when it comes to moving the lower back, diverting some of the pressure toward the lower spine," the authors suggest. In addition, the researchers detected no adverse effects on the fetus for either delivery position.

Comparison of the maternal experience and duration of labour in two upright delivery positions--a randomised controlled trial.
Ragnar I, Altman D, Tyden T, Olsson SE.
BJOG. 2006 Feb;113(2):165-70.

CONCLUSIONS: Kneeling and sitting upright during the second stage of labour do not significantly differ from one another in duration of the second stage of labour. In healthy primiparous women, a kneeling position was associated with a more favourable maternal experience and less pain compared with a sitting position.

Standing Birth

Our practice has had a series of "Stand and Deliver" moms -- many have been among the "best" births i have ever been privileged to witness/assist -- & all without incident. Several of them were video taped and brief clips of the standing birth have been used in various TV shows/news broadcasts in the Bay area -- all without any out cry from either the physician or midwifery community.

Janet Ashford has a "Birth Art" slide presentation which includes historical pictures of standing mothers from other cultures and time periods. Michael Odent not only does and recommends such a position for spontaneous birth but his tape "Birth Reborn" includes a delivery of a breech with the mother standing. It is no harder on or dangerous to the mother, the baby, or the perineum.

As a "expert witness" it would be my testimony in court, were i to be asked, that such a posture was one of many "normal" variations on the theme of spontaneous birth. Just as in every other facet of midwifery care, there may be times and/or circumstances when such a position would be contra-indicated but then that is also true for births in the dorsal recumbent or lithotomy position. In the absence of such factors, "Stand and Delivery" utilizes gravity effectively, opens the pelvis maximally (no counter pressure reducing pelvic outlet from weight born by the sacrum), promotes good pelvic rocking and other maneuverability by the mother, gives the mother a chance to feel really powerful and competent, is modest and generally serves the childbearing couple (mom and babe).

I chart this position as the "goddess stance" (in honor of the Hindu goddess Kali - the one with the 6 arms -- who stands with her knees flexed and splayed in this same birthing position). I'm fond of saying "Birth is not something to be done laying down" and so many of our mother stand up on their own two feet and push that little one right into my hands as women having been doing for thousands of years. It's a class act -- a form of poetry in motion much appreciated by your truly.

Only three standing births. No tears either one, One of them orgasmed as the baby came. Seemed like a good thing to me...

I really like the standing births, too. I don't do compresses or perineal massage as much with these. It always seems to me that the "stand and deliverers" are in an independent and kind of inward mode, and I don't want to interfere with that energy. I usually stand away and observe, gloved, and with a baby blanket over my hands, ready to catch. The blanket prevents the slipperiness.

One of my most memorable " standing" births was another lady who seemed to want to escape her body. She kept walking away, and finally ended up walking into the bathroom -- you aren't going to believe this, and you'll think I'm awful for "allowing" this--she climbed up onto the toilet, and kept trying to escape. It's my strong policy that the woman deliver where she wants, so I just go along. Anyway, she had one foot on the toilet seat and the other on the side of the tub! At that time, I had Brenda with me- a big ,strong assistant who did concrete construction on her off days. She got into the (empty) tub, and held our client steady. I stood under her and caught the baby. It was a riot! Then Brenda helped her down and she kind of lay back against the tub to deliver the placenta and meet her baby. Bathroom births are great because you've already got the bed made up, and linoleum is quick to clean. Really cuts back on the laundry!

Also... it's interesting that you brought up the sexual aspect of the standing birth. I've seen several of the standing ladies ease pain by using pressure on the clitoris. I haven't seen this in other birthing positions. Has anyone else seen this?

One of the standing births I did had a tremendous fan shaped tear of her vagina.

I asked the question at our local midwives' meeting Friday "What's your experience with standing births and tears".

Quick as a flash someone said "It increases second and third degree tears". So I said something like "Yeah, I know many of us were taught that, but what have we actually SEEN in the standing births we've attended?"

Between three of us we could count about 60 standing births; one midwife remembered one with a severe (second degree) tear.

Another midwife said she thought women were far more likely to tear. She remembered a severe tear and felt that standing birth was a risk --- but realised that she had only done two, which of course equals a 50% tear rate!

The midwife who quoted "increases second and third degree tears" hadn't had any standing births.

This was all done without our records in front of us and relying on our possibly faulty memories -- though I think I can say that severe tears are rare enough that most of us remember them "vividly"!

I'm far from ready to conclude that standing lowers the risk of tears, but I think I'm far enough along to distrust the teaching that the position "increases" the risk of severe tears...

I thought it interesting that we are so ready to defend the things we've been taught without feeling a need to test them...


One of our senior midwives says that when the mom's in a side-lying position, she props up the upper leg with an under-inflated beach
ball between the legs; apparently it works better than pillows.  She says when the mom's on her left, she reaches her left arm around the upper leg to flex the head if she has room; otherwise, she manages everything from the other side.

Birthing with Knees Together

Interestingly, it was in the Amish community that I first saw a birth happen with the mom's knees together (absolutely TOGETHER, mind you!) during the whole ENTIRE process. This was a very enlightening time for me!!!

I'm trying to remember if I have seen any tears when this position is used. I cannot, for the life of me, recall even one! Which is pretty strange, now that I stop to think about it. I never put these two factors together before! I don't even think I recorded leg positioning, thus it would be difficult to compile statistics. :-( But you can bet I'll chart this from now on!

I've considered # of tears in relationship to squatting, kneeling, watering, etc., but not knees together!

One of the midwives that trained me taught me to encourage legs together in the side-lying position, with the top leg if anything flexed a little more than the bottom leg so that the knees aren't exactly together. She told me that having the knees apart was the reason for the near-impossibility of an intact in semifowler and that the closer they were together, the better. To make a vivid point of it, she took a fairly large rubber band that was lying on the countertop on L&D, held it in the air, and told me to pull the two sides apart as far as they would go. Then, she pulled top and bottom as far apart as they could go, which wasn't very far, since the stretch was already maxed out in the lateral direction. Then, she had me let go, and naturally, the AP direction now had all the room in the world. I hope the picture transmits verbally. She taught me to lube the thighs with something warm just before delivery so that babe would slip out nicely. Not sure if that's necessary, but what the heck.

Several posts back someone speculated women may feel less vulnerable with legs together. It wouldn't surprise me if that were true.

I encourage my clients to bring the knees together as the head is crowning to help prevent tears.

Birth Stools

“Aspects to consider for the application of birthing stools to assist women giving birth to their children”
Abridged, with permission, from original article by Kate Tuohy-Main, Physiotherapist, Manual Handling Specialist

Contrary to your colleagues experiences, I don't (at least so far) find an increase in perineal trauma when women use the BirthRite Seat to give birth. Quite the reverse in fact. Somehow the optimal upright position where the sitting bones are held slightly lower than the knee on this carefully designed and comfy seat, seems to help women "know" when and how to ease their babies out. There seems to less effort involved.

The perineum is beautifully visualised by the midwife and it is simple to offer the mother and father (if sitting behind to support and enfold her) a view of crowning with a mirror. It is also easy to apply hot pads to the perineum, but I often don't have time!

Once the vertex is visible, the head and immediately the whole baby emerges straight forward not down so the mother can, if she chooses, assist to bring her babe up into her loving arms.

Third stage has surprised me with its swiftness too. We may be admiring the new baby held skin to skin with mother, and a couple of times I have assumed a PPH was about to start, and the mother says "oo, oo, something's coming" and lo and behold out slithers a placenta! Usually neatly caught in a bowl and EBL then so easily assessed.

I encourage mothers to get up and stretch their legs if they have been on the stool for long (>15 minutes), though babies seem to descend so quickly, this is rarely an issue in multips.

I think the BirthRite Seat is so cleverly designed, it removes many of the problems associated with more simplistic birth stools.


I still don't get how MIDWIVES think a semi-sit, where the mom dels sitting on her sacrum, with her sacrum pushed into her birth canal, is "good".  I go for any position where the mom is NOT on her sacrum.

I agree.

I think the position sort of developed as a compromise with the hospital standard delivery table. As a response to the demands of Lamaze moms etc., they began "allowing" moms to have their backs elevated into their version of a semi-sitting position. Many moms greatly preferred it to lithotomy of course, but it is a real long way from a natural position, and I think does reduce the AP diameter by reducing sacral movement.

The data from EFM showed a higher incidence of FH irregularities and lower apgar and higher resuscitation rates with lithotomy over semi-sitting, so that gave a bigger push to semi-sitting. But there are certainly even  better positions than that!

I know a few who claim that this elevated position contributes to both anterior lips and posterior rotation... interesting that it's the common epidural position too.

We used to think in the late '60s, early '70s, that women del'd easiest in the position they had an orgasm the easiest in.  Many women find that to be the "exaggerated lithotomy" position.  I still don't get how MIDWIVES think a semi-sit, where the mom dels sitting on her sacrum, with her sacrum pushed into her birth canal, is "good".  I go for any position where the mom is NOT on her sacrum.  Many of my ladies del on their backs with support for their legs.  They can fall back between conts.

Jamming the Sacral Tip into the Fetal Skull - Todd Gastaldo's Crusade

Todd Gastaldo of the Gastaldo Chiropractic Association has been very active in furthering critical thinking about the importance of maternal position during birth.  His message is controversial but appears well founded.  He says that

MDs are lying, censoring and conducting bogus "scientific research" to cover-up the FACT that they are routinely jamming the sacral tip up to 4 cm into the pelvic outlet - into the fetal skull.
Though the MD-authors of Williams Obstetrics lie to cover-up, they indirectly admit that they are distorting fetal skulls up to 4 cm - as they claim that 0.5 cm of fetal skull distortion can KILL...

(See also the article by Brazilian obstetrician Moysés Paciornik, M.D. in Birth 1990;17:104-5; and see Gastaldo Birth 1992;19:230; and see Gastaldo Mothering Jul/Aug/Sep1997:17, reproduced at the URLs above.)

Action of Pelvis during Labour  (p.11-12)

Understanding and Teaching Optimal Foetal Positioning by Jean Sutton and Pauline Scott)

Although the basic measurements of the pelvis remain the same, when a woman is in labour providing she is using upright and forward leaning postures, the angles and internal dimensions can change dramatically to allow the foetal head to manoevre itself through the pelvis.  For instance:-

  1. The relationship of the pelvic brim to the lumbar spine changes allowing the foetal head to enter the pelvis (which can happen during late pregnancy or as labour begins).
  2. The ischial spines are no longer level, allowing the foetal head to pass by these internal protrusions with ease.
  3. The ligaments connecting the sacrum to the ilia are more flexible which allows them to lift up about 1-2cm straightening the posterior pelvic wall (this area is known as the Rhombus of Michaelis).  THis means that the foetal head, just prior to the beginning of the involuntary pushing urge of the 2nd stage, de-flexes without obstruction.  Many midwives will have observed this occurring when a woman is in the supine position.  The woman tries to lift her bottom off the bed in response to the foetal head pushing on the sacrum.
When a woman is on her hands and knees or standing, the Rhombus of Michaelis can be seen clearly because the pressure from the foetal head (which is, in fact, the chin and face as it de-flexes or extends) lifts the sacrum and coccyx out of the way.  If a woman is in a well supported squat (** this means with knees apart and the bottom not less than  45cm off the ground, as this allows the back to arch in the correct way **) standing and leaning forwards or kneeling and leaning forwards with her arms clutching onto something higher than her waist, she will instinctively arch her back and 'throw' her pelvis out at this stage.  Sheila Kitzinger (** my heroine !! **) describes in her book 'The Experience of Childbirth' how Jamaican peasant women believe that their backs have to 'open up' before their babies can be born.  This is the same phenomenon.  Dr Michel Odent calls it the 'foetal ejection reflex'.


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