Vertical Birth

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 that the majority of women in the US give birth.  Even if women are semi-sitting, they are still putting pressure on the sacrum and tailbone, thereby reducing the pelvic outlet.

If a woman is given privacy and is able to follow the lead of her body, chances are she will never choose to lie down on a bed. Upright postures during pushing and birth are normal and natural - even if it's on her hands and knees.

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.)

Squatting low over a pillow/cushion/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.  Hands-off while mom is pushing her baby out is the best course of action.  I've seen many women instinctively reach down to support their tissues as the baby crowns.

The disadvantages of pushing while lying down or sitting on the tailbone are:

• 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
• 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

Advantages of an upright birth:

• Squatting increases the pelvic outlet, thereby creating more room for a larger baby or baby with a presentation issue (posterior, asynclitic, etc)
• Gravity  helps baby to 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