Dynamic Positions in Birth

A Fresh Look at How Women's Bodies Work in Labour

Margaret Jowitt

• Publisher: Pinter & Martin Limited
• Year: 2020
• eBook ISBN: 9781780666938
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Most women give birth in hospitals, institutions modelled around the needs of the people who work there. The delivery room is designed around the obstetric bed which was designed for the benefit of the obstetrician rather than the woman giving birth. Despite research showing the benefit of upright positions in labour and birth, most women in the UK still give birth in the semi-reclined position, pushing their baby out against the forces of gravity. Jowitt argues that unnatural positions make labour and birth more painful and difficult for modern women than it was for their ancestors. How did we come to put the needs of care givers above those of the labouring woman? Is there anything that can be done?

Starting with a short history of birth furniture, Dynamic Positions in Birth goes on to explore the anatomy and physiology of labour from an evolutionary perspective. This updated edition expands Jowitt's new biomechanical model of how the uterus works first published in the British Journal of Obstetrics and Gynaecology in 2018 which has profound implications for giving mothers freedom of movement in labour and birth. It explores how rethinking positions for labour and birth could benefit mothers and their babies.

Equally important is the need to change attitudes to birth so that women are encouraged to play a more active part in the birth of their babies instead of being subjected to clinical interventions designed to mitigate the adverse effects of labouring in a starkly unnatural environment. Jowitt argues that it is possible to give women labouring in hospital a better chance of giving birth naturally. The book concludes by calling for a fresh look at the environment for birth. Delivery rooms can be made more user friendly by introducing furniture designed around women's need for physical support during labour as well as for the birth, and by hiding away the more alarming technology unless it is needed. Women need a less forbidding environment and more encouragement to move freely and adopt positions which will enhance their chance of achieving a normal birth.

1Introduction

Birth is an earthquake of an event in a woman’s life. Her body experiences the greatest upheaval it has undergone since she herself was born and her psyche gains another layer of womanhood. She is transformed into a mother – a 24/7 job for the next few years. Every baby is a miracle. Every birth is miraculous. We can’t get away from the fact that birth is undoubtedly an ‘animal’ event, but an event so significant that it acquired cultural meaning from the very beginnings of human consciousness. For hundreds of thousands of years birth was a woman’s business, taking place in the domestic setting. The labouring woman was surrounded by family members and women with experience of birth and a gift for supporting women in labour, for consciousness brought with it the fear of death and the need for emotional support. Consciousness led to the need for the rituals of religion, a way of dealing with the fears conjured up by the unpredictability of the forces of nature, birth being a prime example.

For millennia the physical, emotional and spiritual needs of a woman giving birth were intertwined but after the mind/body split enunciated in the philosophy of Descartes in the first half of the seventeenth century there was an increasing tendency to see the body as a machine, with faults which could be remedied or bypassed mechanically. Sometimes they could. The invention of the obstetrical forceps brought first man-midwives and then doctors into the birth room. Men of science started to challenge the authority of the Church. The doctor was to become the expert, the midwife to become his assistant. It took 250 years for doctors to gain supremacy over midwifery education with the passing of the Midwives Act in 1902 and another 70 years before hospital birth was recommended for all (Short Report, 1970) but the midwifery profession continues to advocate a role for emotional support (Association of Radical Midwives, 2013) and even spirituality (Hall, 2000) and organisations such as the Association for Improvements in the Maternity Services and the National Childbirth Trust carry on campaigning for holistic care in childbirth).

Twentieth-century mainstream obstetrics is predicated entirely upon Cartesian principles and pays only lip service to the emotional aspects of birth. The few obstetricians who attempt to practise a more woman-centred approach risk professional isolation (Savage, 2007; Morrow, 2013). The mind/body split in medicine led directly to the current obstetric view that describes childbirth by means of the powers (the muscular force of the uterus), the passage (the bony pelvis) and the passenger (the fetus). While obstetrics acknowledges that women should have the continuous presence of a midwife, the role of the midwife is chiefly to observe, monitor and call for obstetric help should labour deviate from numerical norms such as the rate of dilatation of the cervix, fetal heart rate patterns, maternal pulse rate or temperature. Machines can now record many of these things; midwives are required to record the rest on the partogram, a chart of progress in labour. In the modern large-scale birth factory system, the midwife becomes a machine minder in the eyes of the management team and is employed on a shift system – any midwife will do. Midwives facing Fitness to Practise hearings at their regulatory body, the Nursing and Midwifery Council (NMC), find themselves faced with lists of shortcomings based on their failure to follow guidelines based on obstetric numerology. Sometimes a successful defence can be mounted in terms of the ‘informed refusal’ of the woman but even then midwives can face accusations that they did not try hard enough to convince women of the folly of their choices. Apart from the requirement to give respectful and dignified care, the emotional aspects of support in labour are underrated; until Better Births in 2016, commissioners of maternity care in the UK resisted calls for continuity of care from a known midwife, despite evidence showing that clinical outcomes are improved (Weston, 2014).

The natural childbirth movement tends to focus its attention on midwifery care in birth centres and at home because these are the places where women – mothers and midwives – are still largely in control of birth, but only 2.5% of women give birth at home and another 5% choose freestanding birth centres. Women who have experienced this type of care cannot speak highly enough of its benefits to themselves and their babies; it eases the transition to motherhood and leads to far less surgical intervention (Birthplace Study Collaboration Team, 2011). At least half of all women are at low risk of complications and could give birth in such places but such is the fear that has been generated around birth that most choose obstetric units.

Despite the clinical and economic benefits of midwifery care shown by the Birthplace Study, the organisation of maternity care in the UK is unlikely to change any time soon and it is time to consider the needs of women choosing to labour in hospital, where the vast majority of women give birth. The western birth culture takes women out of a comfortable place where they make their own rules (home) and turns them into patients in hospital, a place dominated by rules and regulations, policies, protocols and guidelines produced by people wanting to control the behaviour of staff and ‘patient’ alike. In hospitals care is organised according to medical protocols required by the Clinical Negligence Scheme for Trusts (CNST) which is the ‘insurance’ arm of the NHS. Maternity hospitals are getting larger and larger as smaller units merge and in these straitened economic times there is pressure to make the most efficient use of bed space in the delivery suite and postnatal ward.

The hospital environment depicted in TV programmes such as One Born Every Minute seems very stark to any woman who has laboured and given birth at home or in a birth centre under the care of a midwife. One aspect seems particularly problematic – the bed takes centre stage. Women were not designed by evolution to labour and give birth propped up semi-sitting or lying on their backs. The hospital bed can turn a healthy active woman who is quite capable of trusting her body to give birth by itself into a passive patient hooked up to machines which immobilise her and increase her pain. The obstetric bed dominates the labour room in delivery suites up and down the country and although midwives are well aware of the need to get women off the bed, it is easier said than done when the only alternatives are a large plastic gym ball, a bean bag and perhaps a floor mat. The problem is also one of expectations: women expect to use the bed, and some midwives prefer them to be on it. In fact, labour and birth in any position other than on the bed is usually described as ‘alternative’. There is no reason why the bed should not be used mainly for its original purpose – for sleeping – and when necessary for clinical examination. It is easier for a midwife to palpate the abdomen to ascertain the position of the fetus when a woman is supine but labour is easier for women when they can move around freely. Despite its claim to be based on science, the hospital approach to birth knows virtually nothing about the two major influences on how women’s bodies work in childbirth – her state of mind and how she and her baby move in the bony spaces that nature has provided.

I find myself in the somewhat paradoxical position of being intensely fascinated by the minutiae of the anatomy and physiology of birth while at the same time believing that birth is best viewed holistically. I believe that the birth of a baby through the extraordinarily shaped human pelvis is an instinctive process written deep into our genes and that the hospital culture both denies and disrupts the instinctive process. This is the behaviour that is elicited during birth when there is no outside interference to disrupt the process as it unfolds – when there is no expectation of labouring on a bed, when there are no machines impeding instinctive movement.

In my last book I considered the hormones of birth and the effect of the psychological environment; in this one I concentrate on the biomechanics of birth. Having accused obstetrics of having too mechanistic a view of birth, I hope I can escape accusations of being a Cartesian dualist myself by including maternal instinct in biomechanics; one cannot argue from science without adopting some of its principles and nothing but an argument from science has any hope of changing anything in that temple of scientific medicine, the hospital. I think we need to go back to first principles, to strip away the cultural paraphernalia that surrounds birth and return to basic biology, anatomy and physiology.

Problems in human childbirth are attributed to upright walking and having to give birth to a baby with too large a head. Evolutionary theorists call this the obstetric dilemma; ‘Nature is a bad obstetrician’, they say. Are they right? We all know that birth is not always a success story. I once saw a photograph of the skeletal remains of a failed breech birth. The mother and child were buried together with the fetal head still inside the maternal pelvis. The large head only just fits through the pelvis and birth is usually safer when the head is leading the way. Natural breech birth is usually possible but becomes more difficult when attempted under laboratory conditions in hospital; the obstetric solution is to bypass the pelvis and deliver by caesarean section.

We can all be grateful that modern surgery has the means to rescue nature’s mistakes but has the female body become so dysfunctional that it can no longer give birth even to babies coming head first through a healthy normal pelvis? Natural selection – the survival and reproduction of the fittest – must have solved each problem as it arrived or we wouldn’t be here. Until very recently all humans had to pass through the bottleneck of the female pelvis to be born and, for breastfeeding mammals, survival after birth is heavily dependent upon the survival of the mother, so the vast majority of our great-great-great… grandmothers lived to tell the tale. We have the ‘right’ genes for successful birth. Whatever convolutions and contortions the body went through on its way to its current form, women evolved to give birth and survive the experience. So why has it all gone so wrong? Today 25% of women in the UK, the country with the best nationalised health service in the world, have to give birth by caesarean section and another 12% with the help of forceps or vacuum extraction.

According to current medical opinion, today’s rising caesarean section rate is the consequence of mothers leaving it later to have their first child and maternal obesity. Did evolution ‘weed out’ older and larger mothers in the past? But older and larger mothers can’t account for all today’s extra caesareans, and the perinatal mortality rate (the proportion of babies stillborn or not surviving the first week of life) has not fallen commensurately with the rising caesarean rate.

I have been lucky enough to have given birth to four children without any problem and in three of those births it was readily apparent that I needed to adopt a particular position either during the labour or for the birth itself: sitting, squatting, kneeling – and even lying on my side on a bed. Most of these positions weren’t to be found in obstetric textbooks although there was much talk about them in the midwifery and childbirth literature. Three positions were labelled ‘alternative’. I decided to investigate further and found that there is so much more movement involved in birth than I could have thought possible, and yet so little of it is to be found in the textbooks. Starting from an intuitive instinct derived from my own experience and reinforced by watching such TV programmes as One Born Every Minute, I reached a deeper understanding of how the body works in labour.

The illustrations in textbooks are largely limited to an obstetrician’s eye view of the mother – or rather parts of her, her uterus and her pelvis. At first they made the problem appear insurmountable – I started to get a real feel for the obstetric dilemma. Unlike other mammals, our babies do not have a direct tunnel from their mother’s abdomen to the outside world – our babies have to negotiate a 120-degree bend. This was the core of the obstetric problem but textbooks gave no clues as to how humankind had solved it in deep history. It was time to investigate the anthropological literature and look at what happens in other cultures. Sheila Kitzinger, the doyenne of childbirth anthropology, quoted Jamaican midwives saying that women have to ‘open their backs’ to give birth (Kitzinger, 1993). Opening the back implies making more space in the pelvis, making more room for a baby to move through it. But opening the back also destabilises the pelvis – the legs can no longer be trusted to support the weight of the body. For the moment of birth itself perhaps we need to become quadrupeds again for a little while; we need the weight of our body to be supported by something other than just our legs. Humans thus appear to need physical support as well as emotional support in birth – our bodies need to be supported in positions which will make that journey easier for us and our babies.

This rang bells for me. Twenty years ago, when my second son was a few days old, I moved awkwardly and put my back out. My legs and pelvis would no longer support my body weight; I needed to use my arms as well. Pregnancy and birth had loosened my pelvic joints and they had not yet returned to pre-pregnancy stability; a sudden awkward movement destabilised my pelvis. Luckily a previous job working for Physiotherapy journal had given me the knowledge to seek out a physiotherapist as soon as possible. She realigned the joint and I had no further problems for twenty years. To understand human childbirth we need to explore the function of the pelvis, beginning with the changes to the pelvis that occurred in the journey from walking on all fours to walking on two legs and exploring the means by which the baby might negotiate the bend in the pelvis.

How can a woman’s back ‘open’ if she is lying on it? Women didn’t always give birth on their backs. In Europe and in the USA they used to give birth on a birthing stool. The gradual transformation of the birthing stool, a midwifery tool, into the obstetric bed directly mirrors the gradual transcendence of obstetrics over midwifery. A simple portable device carried to the mother’s home by a midwife gradually evolved into an obstetric bed designed for operative delivery. The birth itself is the most dramatic part of labour and specialist furniture, high- or low-tech, was designed to help someone do their job, whether it was the mother, the midwife or the obstetrician. The transformation of the birthing stool into the obstetric bed involved a move from home to hospital. The modern obstetric bed has been specifically designed for childbirth in hospital and yet (if the Jamaican midwives are right) it takes no account of a woman’s need to open her back. Birth chairs were standard equipment from ancient Egypt right up until the middle of the nineteenth century but as more and more doctors became involved in birth they were forgotten. As far as the physiology of birth was concerned, this was a bit like forgetting the invention of the wheel – or was it? Even a chair restricts the movement of the pelvis.

Providing beds for labour is a historical accident. It is the consequence of sending women to hospital for birth. Hospitals revolve around providing beds for patients, and they measure their capacity in ‘beds’. If you hospitalise a woman for the second stage of labour, the birth itself, you have to hospitalise her for the first stage as well. You have to advise her to come in when she is having regular painful contractions, so many minutes apart and lasting so long (the numerology at work again). Even if you advise her to stay at home for as long as possible, she would rather get to a safe place in time for the birth than risk giving birth away from the medical attention that she is told she and her baby need for safety. Anyway travelling in advanced labour is distinctly uncomfortable, so women will arrive sooner rather than later and if labour is advanced enough they will be given a room with a bed in it and a midwife to look after them. And if there is a bed in the room they expect to use it, particularly if they have learned what to expect during labour by watching main channel TV programmes. (They will also expect labour to be excruciatingly painful.) Perhaps scriptwriters have based their scenarios on this:

‘Conventional’ childbirth. In this choice, the woman is admitted to the maternity ward … She is content to leave the process of childbirth in the care of the obstetric team, and to accept, without question, their management. … She is cared for with skill but does not participate in the process of childbirth. (Llewellyn-Jones, 1990) (my italics)

The caesarean section rate has doubled in the UK since this was written, although three years later Changing Childbirth (DoH, 1993) was to recommend that women should participate in childbirth: ‘the woman should be made the centre of her care’ and there have been numerous initiatives to normalise birth but none has worked. The latest reorganisation of the NHS was brought in under the mantra of: ‘No decision about me without me’ but doesn’t always appear to apply to childbirth in hospital. The Birthrights survey of 2013 found that 11% of respondents overall considered that they had not been given information about each examination or procedure before it had been performed; this figure rose to 24% for women having forceps or vacuum (ventouse) deliveries.

Doctors and midwives were trained to ‘deliver’ women on beds but why should it be assumed that a bed is needed for the first stage of labour, when the cervix is opening up? Lying on a bed for labour is a relatively recent practice largely restricted to hospitals. For millennia midwives helped women cope with labour and give birth in their own homes, from cave to cottage, from tenement to suburban semi. If a mother called a midwife too early it was no big deal for the midwife to go away and do her antenatal clinic or do her postnatal visits and come back later. And even if a woman did end up in her bedroom to give birth on a bed, because that was how midwives were trained to ‘deliver’, she went there only when the birth was imminent. Once a woman has been admitted to hospital there is nothing for her to do but to be a ‘patient’ and await the birth of her child. There is nothing to distract her from the pain. (As I write this my gaze alights on the second edition of a book entitled Active Management of Labour (O’Driscoll and Meagher, 1986), and it seems ironic that the cover picture is of a woman lying on her left side in bed being touched by a nurse, nothing very active about that. A quick internet search search showed me the cover picture of the fourth edition (2003), a woman in bed, head and shoulders raised on pillows, touching the arm of a nurse. The obstetric bed has become standard equipment for every maternity hospital room in the UK but it turns the labouring mother into a passive patient. It is difficult to see someone confined to bed as doing any work at all. The ‘message’ of the obstetric bed is that a labouring woman is sick and needs people to do things to her to enable her baby to be born.

Unless you consider a woman’s needs for labour separately from her needs for giving birth (or rather the doctor’s needs for delivering a baby), you are almost guaranteed to increase her pain by restricting her physical movement and placing limits on her creature comforts – at home she has her own space, her sofa, her kitchen worktops, her bath, her shower. You are also restricting her physical activity. She can’t make a cup of tea, and you are denying her the chance to act on her nest-building instincts and scrub the kitchen floor or clean the oven. She can’t do the washing up in hospital, and she can’t take her ironing board in with her. She can’t carry on with life as normal, stopping in her tracks and finding a handy place to lean on as a contraction makes itself manifest. Not only do such activities offer a welcome distraction from labour but they play a part in finding comfortable positions for the mother and, more to the point, they have a chance of optimising the baby’s position for the journey to the outside world.

However much hospitals try to create a welcoming atmosphere, clinical concerns about infection control and safety must take priority in the high-risk environment of a hospital. Delivery rooms have become stark, unfriendly places with no soft furnishings – apparently even pillows are nearly always in short supply. As well as the state-of-the-art obstetric bed, the room is full of machines, wires, tubes and buzzers and, of c...

Table of contents

• Cover
• About the Author
• Title Page
• Copyright
• Contents
• Dedication
• Preface
• Preface to the second editon
• 1. Introduction
• 2. Birth furniture through the ages
• 3. Research evidence
• 4. The active uterus
• 5. The choreography of the uterus in labour and birth
• 6. The science behind the choreography
• 7. The unique human pelvis
• 8. Travelling through the pelvis
• 9. The hazards of technological birth
• 10. Making birth better
• Acknowledgements
• Image credits
• References
• Index