Why do women use these passive positions and not more active positions like upright, kneeling, squatting, all-fours, side-lying, or asymmetric positions, which have historically been favored by many cultures?Recent research just published shows that these "alternative" positions offer increased room in the pelvis. And many women feel their pain is lessened in these positions. This is probably why they were favored by traditional birthing cultures.A recent Cochrane meta-analysis shows that labors tended to be shorter, the risk for cesarean was lower, and fewer epidurals were used when women in hospitals labored in these positions. So why aren't more women taking advantage of these positions?The main reasons are cultural conditioning (nearly every image of birth in the media involves laying down or semi-sitting positions), because freedom of movement can interfere with labor interventions, because epidurals can restrict movement somewhat, and because some medical personnel discourage alternative positions due to lack of training/comfort with them. Sadly, there are some care providers who actually forbid women to assume other positions for pushing out the baby.In future posts, we will discuss institutional and cultural barriers to using alternative birthing positions, research around use of these positions, and ways to bring more of this positioning into the hospital.But today, let's start by showing standard hospital positions for perspective, then contrast those with illustrations of alternative birth positions from historical artwork. The point is to show the variety of birthing positions used in history and among First Nation peoples today, in contrast to the lack of variety in most hospitals.For some time, I have been collecting illustrations of birthing positions in various cultures and time periods from around the world. It's been a fascinating and educational process. A list of sources for them is available at the bottom of the post in the References section. Note that there are even some plus-sized images!Enjoy these inspiring and beautiful images. May they encourage more women to utilize alternative positions, and may they help care providers provide more support for alternative positioning to birthing women everywhere.In the hospital today, some care providers restrict the mother's position while in labor or while pushing. Many women are required or strongly pressured to lie back or to use a semi-sitting, splayed position with legs raised and pushed back or out. Even when care providers do not specifically restrict birth positions, women still usually end up in positions like the following ones.This is a "lithotomy" or fully reclined position, with legs splayed strongly apart in stirrups to give the doctor as much access as possible. A "dorsal recumbent" position is basically the same, except that the patient's legs are not in stirrups but are flexed and on the bed.Laying back tends to compress the major blood vessels leading to the uterus, potentially leading to restricted blood flow to the baby and fetal distress. This is ironic, since for nine months physicians tell women to avoid sleeping on their backs because this can compromise blood flow to the baby. Yet when women arrive in the hospital to birth the baby, the first thing they often do is to put them on their backs!Most of the time, women give birth these days in the semi-recumbent position, which is basically like a lithotomy position but slightly propped up so the woman is not flat on her back. The knees are splayed widely apart and the legs are either in stirrups, pulled back by the mother, or held up by helpers.One major issue with the lithotomy and semi-recumbent positions is that not only do they not utilize gravity to use the baby's own weight to help it move down, but they actually make the mother workgravity in order to push the baby out.The semi-sitting position came into use in the hospital as a way to get the mother a little bit more upright to make better use of gravity. The position is similar to the semi-recumbent position except that it is just a little bit more upright. However, note that it is not all that upright. Knees are usually splayed and held upright by helpers or the mother, and the back is rounded forward with chin to chest like a "C."Another problem with all of these positions is that they actually decrease the size of the pelvic outlet. The sacrum is against the bed, making it hard for it to move during labor. The direct pressure on the woman's tailbone forces it upwards in a more curved position and into the pelvic outlet space. Pulling the knees strongly apart tends to narrow the pelvic outlet in the back as well. These give less room for the baby to get out. It also tightens the pelvic floor and may make it more likely to tear.One survey of U.S. birthing women reported that as recently as 2005 that "57% gave birth lying on their backs and an additional 35% gave birth propped up in a semi-sitting position."If all those women trulyto give birth in those positions, that's no problem. Some women find them comfortable or useful, and it's perfectly fine to use them if desired. However, many women report wanting to use other positions and being discouraged or even forbidden from using them.

Historic Birth Positions

However, it's always important to point out that there is no one "right" position for laboring or pushing out a baby. All positions have pros and cons.

Squatting





Supported Squatting

Kneeling

Hands and Knees Positions

Upright Sitting

Semi-Reclined

Reclining

Asymmetric Positions

Birth Stools

Birth stool from about 1580

Image from the Wellcome Trust of the U.K.

Standing Positions

Positions Using Counter-Force

Arched Back

The Semi-Sitting Position in the hospital. Note the mother

is encouraged to curl forward into a "C" position

Page 142 from Dr. Engelmann's book

Side-Lying

Videos of Traditional Birthing Positions