Position and movement in labour is an area of fundamental importance which has been, in the past, almost completely neglected by birth attendants in the management of labour, and therefore also prenatal teachers in the preparation of women in birth. The choice of position determines the training of midwives and doctors. It also determines their approach and the kind of environment in which women labour and give birth. It can also determine the successful outcome of the birth and the quality of the experience for both mother and baby.
Modern Western Practice
Obstetric practice in the modern world is usually regarded as a medical, if not surgical, procedure. Until recently, the normal practice in most hospitals has been (and often still is) to place you, when you are in labour, in bed on your back; at best propped up by pillows into a semi-reclining position, where monitors, drips or anaesthetic can be conveniently applied. Later, just before the time of actual birth, you may be transferred to a delivery room and placed on an obstetric table where a forceps delivery, vacuum extraction, episiotomy or Caesarian section can be performed, or, at best, your baby can be most conveniently ‘delivered’ by your attendants,
In many hospitals the choice of birth positions is already predetermined by the approach to maternity care and the routine hospital practices. Usually, the training of midwives and doctors takes the recumbent position for granted in specific obstetric practices, such as:
The continuous assessment of foetal heart tones, uterine and other vital signs during labour and the use of electronic heart monitors which were designed for use in the recumbent position. Paradoxically, these often cause the foetal distress they are meant to detect by the imposition of the supine position for their use (1).
Midwives are usually trained to do periodic vaginal examinations with the mother lying on her back. Where birth is active there is less need for vaginal examinations, as the progress of labour can usually be assessed by the mother’s behaviour. If an internal examination is considered to be necessary, it can usually be done conveniently enough with the mother remaining upright.
The use of sedatives, oxytocin drugs, analgesics and anaesthesia during labour and delivery. If the mother is not lying down in the first place she is less likely to need pain relief or induction.
The use of forceps and/or episiotomy for delivery, or the need for the midwife to routinely ‘control’ the delivery or ‘guard’ the perineum. All these practices are not usually needed in an Active Birth.
When such practices are routinely used, labour and birth are seen from the outset as a potentially pathological situation in which attendants and their attendant technology are in control, rather than the woman herself, her instincts and her biological body.
No one will deny the enormous advantages of the safety net of modern obstetrics when problems occur which may threaten the life of mother or baby, or both. However, the vast majority of labours have the potential to be uncomplicated, and it is clear that common sense in the management of labour has been completely obscured by the routine application of interventive obstetrics to normal labour, resulting in a great increase in the number of forceps deliveries and Caesarean sections.
In many countries in the developed world the majority of babies born in hospital are delivered by forceps, or induced, or both, and the Caesarean rate may be as high as 30 per cent. In the USA, approximately one in four births (25 per cent) result in a Caesarean which reflects a 400 per cent increase in the last 20 years (2). In some hospitals, as many as one in three births are Caesarean, and in some large teaching hospitals the figure is closer to 60 per cent.
Amongst other reasons, the rigid insistence on making women in labour lie on their backs contributes largely to these figures. It seems that a vicious circle arises as soon as we begin to intervene in the natural process – the possibility of complication increases, the need for intervention and for pain-relieving drugs becomes more prevalent. When a labouring woman is immobilised and forced to lie on her back, the natural process is fundamentally disturbed and the likelihood of problems occurring increases.
What is wrong with obstetrically managed birth?
Giving birth can, and usually does involve hours of intense labour and a great deal of pain, effort and endurance on your part. Naturally the prospect is quite awesome and you will probably approach the birth of your child with some fear and apprehension about what is to come.
To many women the prospect of a painless, effortless, managed birth might, at first, seem to be an attractive proposition. After all, you might ask, why suffer needlessly when medication and modern technology is readily available to make the birth easier, quicker and less painful?
Regretably, it is not as simple as all that. Every interventive obstetric technique has known side effects for mother and baby, while many subtle or long-term effects may not yet be apparent. When help is genuinely needed the benefits of the intervention may well outweigh the risks. However, routine use of obstetric management tends to complicate birth unnecessarily.
Doris Haire in her booklet, The Cultural Warping of Childbirth (3), has written an excellent report on obstetrics in the USA where high-tech birth is the norm and more deeply entrenched than in most places, and now provides a model for developing countries where traditional birth practices are disappearing.
Haire points out that the infant mortality rate in the USA is amongst the highest in the world. There is also a staggering incidence of neurological impairment amongst American children which, she feels, is attributable largely to the ‘unphysiological practises which have become so much a part of American obstetric care’. She lists an abundance of scientific literature and research to substantiate her remarks (see Recommended Reading).
We have known since the 1960s that all obstetric medications given to the mother, whether they are used to quell nausea, to induce labour, to relieve pain or to anaesthetise, do cross the placenta and do alter the baby’s environment in the uterus, entering the baby’s circulatory system and hence the baby’s brain within seconds or minutes. Contrary to what many women are told, this includes regional anaesthetics such as epidurals (4).
The baby’s central nervous system forms and develops rapidly in the last part of pregnancy, during the birth itself and during infancy, and is susceptible to the effects of drugs given around the time of birth and after. We have only to recall the thalidomide tragedy to realise that the testing of the safety of these medications is often sorely inadequate. Of course, it is important also to bear in mind that babies vary in their vulnerability to the effects of these drugs and, in instances of real need, the judicious and minimal use of medication is usually successful. However, in antenatal clinics and hospitals, mothers are usually uninformed about the hazards or side effects involved in taking such medications and are deluded into assuming that there are no risks involved.
Let us take a look at some examples of the most widely used medications for labour and birth, and their more common side effects. I have deliberately omitted the more severe and rare complications but readers who are interested can look up the research references listed here.
THE PROMISE OF PAIN RELIEF
Pethidine (Demerol in the USA)
This is a narcotic-like analgesic used to ‘take the edge’ off pain. Given usually as an intramuscular injection, some women find it makes labour more tolerable and others that it causes them to lose control. There are possible side effects to the mother, such as nausea or dizziness, and it will slow down the mother’s breathing and respiration, hence reducing the baby’s oxygen supply. Often Pethidine is mixed with sedatives to reduce nausea and these too will cause sleepiness and enter the baby’s bloodstream.
It is now common knowledge that Pethidine can