The first record of a woman lying down for birth describes Madame de Montespan, mistress of Louis XIV, who lay down in a recumbent position so that he could watch the birth from behind a curtain. Then in the mid seventeenth century in France, two brothers named Chamberlain invented the forceps. The best position for a forceps delivery is to have the woman lying down. This invention was jealously guarded by the Chamberlains who performed their deliveries shrouded by black drapes, but the obstetric fashion for ladies of quality to give birth in recumbent positions became firmly entrenched, and the physician took over from the midwife in the birth chamber. In the same century, François Mauriceau became the leading figure in French obstetrics. He scorned the use of the birthchair and advocated childbirth in bed, lying on the back. As forceps gained popularity, the birthchair lost favour and, by the end of the eighteenth century, little more was heard of it.
In the nineteenth century, Queen Victoria was the first woman in England to have chloroform while giving birth. Delivery under anaesthetic further established the lying down position on the back or on the side. Birth positions which lend themselves more easily to the convenience of the attendants who perform these procedures became the only choice, and the practice of confining a woman to bed for the major part of her labour and then on to an obstetric table for delivery, eventually spread throughout the West. This practice has become so widespread that the word ‘confinement’ is commonly used to describe the birth process.
The birthchair had given way to the bed and the delivery tables of the nineteenth and twentieth centuries. Women were flat on their backs, a position that made them passive and controllable, and although this offered a fine view to the attendant, it was in total defiance of the active forces of gravity and the joyous independence that comes from naturally and instinctively giving birth actively, on one’s own two feet.
Ethnological Evidence
Primitive tribes have adopted various birth positions through the customs of their tribe but, more important, by their instinct. Some forty positions have been recorded, and their relative merits have been much disputed. Women of different tribes squat, kneel, stand, incline, sit or lie on the belly; so, too, do they vary their positions in various stages of labour and in difficult labours.
Dr G. J. Englemann, in his book Labour Among Primitive Peopleswritten in 1883, was one of the first to investigate the various positions assumed in labour or childbirth by early people, and he found that the four principal positions were squatting, kneeling (including the all fours and knee-chest positions), standing and semi-recumbent.
Ethnologists entirely confirm the evidence of the historians. Whatever the race or the tribe under observation – African, American, Asian and so on, the same upright positions always predominate with a great variety of means of support. Figures reveal that, for the most part, women throughout the world today still labour and deliver in some form of upright or crouching position, usually supported.
Recent studies
Over the last few decades, as disillusionment with the routine application of high-tech obstetrics has increased, researchers all over the world have begun to explore normal physiological birth. Documented evidence has been available for over fifty years as to the physiological advantages of labour in upright, crouching positions. Certain principles of physics apply to childbirth and these are denied or negated when a woman gives birth lying down. The facilitating influence of squatting positions was also radiographically confirmed in the 1930s. It was shown that the cross-sectional surface area of the birth canal may increase by as much as 30 per cent when a woman changes from lying down on her back to the squatting position (19). And it is some twenty years since Scott and Kerr demonstrated the disadvantages of having the weight of a pregnant uterus pressing down on the back. Lying supine, the weight of the contracting uterus reduces the placental blood flow by compressing the large artery of the heart (the descending aorta) and the large veins leading to the heart (inferior vena cava). This is a hard clinical fact which should not be ignored by anyone involved with childbirth (20).
Most recent studies have revealed the definite advantages to a woman when she is walking about assuming upright positions during labour. The few, and they are a very small minority, who have not found any measurable advantage all conclude that there is definitely no disadvantage to being active and using upright positions during labour.
The majority of studies have established a control group and an experimental group. This has usually required that the control group remain supine or in some recumbent position in bed and that the experimental group assume an upright posture, sitting, squatting, kneeling or walking about. But other studies, which seem more convincing, have used the women as their own controls, asking them to alternate every thirty minutes between two positions – horizontal and upright – during the first and second stages of labour. These alternative approaches to examining the effect of position during labour both reveal similar positive results in favour of active upright labour and deliveries.
During the 1970s many studies were carried out in various parts of the world. In 1977, a study in Birmingham Maternity Hospital compared a group of women who walked about during labour with a group that lay down horizontally throughout most of labour. The results showed that the duration of labour was significantly shorter, the need for analgesics far less and the incidence of foetal heart abnormalities markedly smaller in the ambulant group than in the recumbent group. Women walking about also experienced less pain with uterine contractions, and they felt more comfortable upright. They concluded convincingly that walking about during labour, especially early labour, should be encouraged (21).
In Latin America, Dr Roberto Caldeyro-Barcia organised a collaborative study involving two maternity hospitals. Vertical labour positions (sitting and standing) and horizontal positions (side lying and lying on the back) were studied. Their effects on the labour and on the condition of the baby were compared (22). In 1972 in America, Dr Isaac N. Mitie of Indiana compared women in the second stage of labour, half of whom were lying down and the other half in sitting positions (23). Dr Yuen Chou Lui headed a study of sixty women in labour in two hospitals, one in New York City and the other in Washington (24).
These are a few of the many studies giving positive evidence of the benefits of walking about and using upright labour and birth positions. Most studies confirmed that uterine contractions were stronger and more efficient in dilating the cervix. Even though these studies were carried out in birthing environments which could be improved, the results were already impressive when only the attitude to posture was changed.
Results of Modern Research
Most studies reported that when upright and moving about the following advantages ensued:
1 The intensity (strength) of uterine contractions was found to be greater.
2 Greater regularity and frequence of uterine contractions.
3 The dilation or opening of the cervix (the neck of the uterus) was more efficient.
4 More complete relaxation between contractions.
5 The pressure of the baby’s head on the cervix during the resting phase between uterine contractions was consistently higher.
6 The first and second stages of labour were shorter (some comparative studies showed they were over 40 per cent shorter in the upright group).
7 Greater comfort, less stress and pain and so decreased requirement for analgesics.
8 Lower incidence of foetal distress in labour and improved condition of the newborn.
9 Women felt they were contributing something to their labour and felt relieved from the boredom and degradation of lying down connected to equipment.
Why is Active Birth Better?
What explains the fact that women have easier labours and births when they move about and assume upright positions?
Common sense and recent studies suggest that, in upright