ABSTRACT
Progress towards maximising mobility in labour and the adoption of upright posture for birth has been very slow over the past ten years. A national survey of UK maternity units made for depressing reading in this area: 88 per cent of all births occurred on beds and 79 per cent of all birth postures were either sitting or lying (Redshaw et al. 2006). The situ ation in the USA was slightly better with 57 per cent of women surveyed stating they gave birth on a bed in a lying position (Declerq et al. 2006). Alongside these figures sit audit data from small midwifery-led units where upright birth posture rates are around 80 per cent (ISIS 2006) and beds are conspicuous by their absence from birth rooms. The type and amount of evid ence in this area provides compelling evidence for the value of mobility in the first stage of labour and for the adoption of upright birth postures in the second stage of labour. Gupta and Hofmeyr (2006) refer to the different types of evid ence sources in their pre amble to the current Cochrane review on position for birth when they mention early anthropological studies of indi gen ous peoples who, it is docu mented, favoured upright posture for giving birth (Jarcho 1934). Kitzinger (2000), in her beautiful book Rediscovering Birth, devotes an entire chapter to this facet of current indi gen ous practices in varying places of the world, while Coppen’s (2005) im port ant book covers the his tory of childbirth posture in some detail and is an excellent ref er ence for those seeking more detail. It is very rare to see pos it ive comments made about his tor ical birth practices in clinical journals where a certain imperialistic arrogance usually discredits them. However, Lavin and McGregor (1992) tell us in the Journal of Feto-Maternal Medicine that con tempor ary birth care can learn from northern Native Amer ican Indians. They go on to de scribe the technique of the sup ported squat using a sling hung from above. Balaskas (1995) draws on archaeological evid ence from artefacts, cave drawing and writings to reveal the mainstream nature of upright birth in ancient Egyptian, Greek and Roman civilisations. All of these sources pose im port ant questions for con tempor ary birthing practices. Has the physiology of birth changed so much that these sources have nothing worthwhile to say to us today? Or are they communicating a deep and profound wisdom about birth that we ignore at our peril? At one level, thou sands of years of tradition and cross-cultural congruence/consensus on birth posture seems to be far more convincing than fewer than ten research studies spread over the last thirty years. In fact, I am inclined to use these al tern ative sources of evid ence as my touchstone for best evid ence in this area and the research studies as adjuncts and confirmatory. Some of my anti pathy to research in this area arises from the his tory of birth posture over the past 300 years, in par ticu lar, its medicalisation in
westernised coun tries. One of the earliest written records of women being required to lie down for birth is from Mauriceau’s textbook of 1678 (Dunn 1991). But it was the invention of the forceps which estab lished that ubiquitous symbol of modern childbirth, the bed, as central to parturition (Boyle 2000). In so doing, it reversed an ancient maxim that childbirth attendants should fit around the woman so that now the mother took up a position to facilitate the ease of the attendant in delivering the baby. If you asked a group of women to brainstorm for fif teen minutes the worst pos sible birth position, they may well come up with the lithotomy. Yet this became mainstream for not just assisted vaginal birth but also for normal birth. The introduction of anaesthesia and nar cotics confirmed the centrality of the bed for birth, for now women were not safe to mobilise as either their conscious level or motor strength was impaired. The semi-recumbent posture, though adopted at the beginning of the second stage, would often become supine by the time of birth as women slipped down the bed in the pushing phase. By the 1980s and the hos pitalisation of most birth in the Western world, the dangers of supine hypoten sion syndrome for late pregnancy and labour were well known and labour suites addressed this prob lem by the utilisation of soft wedges to tip labouring women off their backs. As student midwives of this time, many of us thought this was a curious way to address a prob lem that was
all about birth room furniture. Our strat egy of getting women off beds or even removing beds from the birth room were not even in the frame for con sideration, so steeped was the birthing culture at the time in managed birth. During the 1970s, Caldeyro-Barcia, working in South Amer ica, conducted his famous physiological studies revealing the dis advant ages of supine postures for labour and birth, par ticu larly for the fetus (Caldeyro-Barcia 1979). It is surprising, therefore, to find that the later studies of mobil isa tion during labour and of the birth posture all tested the ‘experimental’ inter ven tions of freedom of movement or upright birth posture compared with the stand ard, ‘norm ative’ practice of remaining supine on the bed. It shows how far we had moved from Enkin’s funda mental tenet that any inter ven tion should display ad vant age over normal birth physiology before being routinely introduced. In these trials we have the paradox of physiological beha vi ours needing to prove ad vant age over the clearly inferior managed birth model.
