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Stand and deliver – upright births best for mum and bub

Think of childbirth and you’re likely to picture a woman lying on her back on a hospital bed. That’s the position most (78%) Australian women adopt to give birth birth, despite growing evidence that being…

Upright births are likely to be shorter, less painful and involve fewer interventions than recumbent births. Image from shutterstock.com

Think of childbirth and you’re likely to picture a woman lying on her back on a hospital bed. That’s the position most (78%) Australian women adopt to give birth birth, despite growing evidence that being upright to give birth can have better outcomes for the mother and baby.

Historical and anthropological literature shows that lying down for birth is a relatively modern phenomenon, as we have moved from a more social to a surgical model of care. As far back as written records, carvings and paintings go, women have given birth upright – whether it was using stacked bricks to create a primitive birthing stool or holding onto leaves and ropes hung from trees. A famous drawing from Egypt depicts Cleopatra (69-30 BC) kneeling to give birth.

The birthing chair or stool dates back to Babylonian times (2000 BC). In cultures where Western medicine has had less of an impact, we still see these practices today. A 1961 survey found that giving birth while laying down was the norm in just 18% of traditional cultures. These findings were similar to those of the anthropologist Engelmann nearly 100 years earlier (1882).

So what happened 300 years ago to change this?

Let’s first look to France, which was the early leader in obstetric practice. In 1598, barber surgeon Jacques Guillemeau (one of the first obstetricians) advocated reclining in a bed for birth. The emergence of obstetric instruments over the next 50 years, along with the use of episiotomy (where the vaginal wall is surgically cut to assist delivery), and finally anaesthetic, facilitated this shift in birth positions.

One of the first hospitals with a maternity section, the famous Paris Hotel Dieu, used a special bed for delivery. Some scholars claim the French King Louis XIV (1637-1709) enjoyed watching women give birth (including his mistresses) and found his view obstructed on the birth stool, so encouraged the use of the lying down position.

The earliest printed textbook for midwives, 1515: a woman gives birth on a chair. Eucharius Rößlin, Der Swangern frawen vnd hebamme(n) roszgarte(n).

However, there were midwives challenging this practice, including the famous French midwife Louise Bourgeois (1563-1636), known as the King’s midwife due to her position as midwife to the royal court:

Vertical positions are the most natural, the most instinctive; gravity seems to aid and hasten the birth…Lying high up on the bed is far less natural….

The movement of birth from home to hospital in most resource-rich countries during the 1900s altered this on a grand scale. And like most things in childbirth, no research was undertaken to see if it was good thing. In the popular King’s Eclectic Obstetrics medical text book published in 1900, the following is written:

I do not think that the delivery proceeds with so much ease and rapidity, nor is it so convenient for the practitioner in every respect, as when the female is placed upon the back.

A better way to deliver

Large reviews of the evidence show labouring upright and giving birth upright have advantages for the mother and baby. Apart from the obvious benefit of gravity to help the baby descend, these include:

  • more efficient contractions
  • shorter labour
  • better oxygenation of the baby in the mother’s uterus, as the vena cava vein and aorta are not compressed by the pregnant uterus
  • increased pelvic diameter, especially in positions such as squatting
  • less maternal pain
  • greater satisfaction
  • fewer forceps, vacuum births and episiotomies.

So why most Australian women give birth on their backs? Curious to understand this, my colleagues and I undertook an ethnographic study (using observations and interviews) looking at how women gave birth in the three different birth settings: hospitals, birth centres and at home.

We discovered that the way we have constructed the birth environment, such as putting the bed in the centre of the room and having little supportive equipment (such as birth balls, birth stools, mats and bean bags) had a major subliminal impact on both the way women and midwives acted.

When the women weren’t directed by midwives or obstetricians, and the environment facilitated their moving about adopting different positions, the majority gave birth upright and forwards leaning - the total opposite to what happens when a woman gives birth on her back on a bed.

Giving women information before the birth and helping them practice different positions also helped facilitate this, as did continuity of midwifery care and creating home-like environments.

While Australia seems to be behind the times, leading international bodies such as National Institute for Health and Care Excellence NICE in the United Kingdom recommend:

Women should be discouraged from lying supine or semi-supine in the second stage of labour and should be encouraged to adopt any other position that they find most comfortable.

So, what began as a change in birth positions for the convenience of men has been shown scientifically to be an inconvenience for women and babies. It’s time for Australian women to stand and deliver once again.

Join the conversation

16 Comments sorted by

  1. Murray Webster

    Forestry-Ecology Consultant/Contractor

    My wife gave birth to our last child whilst on all fours - she preferred it that way and she knew what she was doing; child number five and it was all over in 45 minutes. The midwife did suggest squatting and was very supportive of whatever position my wife wanted to get into.

    This is a very well written article, except for the last paragraph I guess the author just couldn't resist a anti-male jab. It is not "men" - it is SOME men (and a VERY small percentage). E.g the use of the term "men" includes the MALE midwife who assisted my wife's last labour. There are many examples of female midwives being very strict in imposing procedures on inexperienced mothers during birth, (and removing babies from unwed young mothers in the 50's and 60's with accompanying scorn).

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    1. Kate Newton

      logged in via email @ymail.com

      In reply to Murray Webster

      Re your second paragraph: read the article. It is about the historical movement from a "social to a surgical" model of care. Most obstetricians are male!

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    2. Sue Ieraci

      Public hospital clinician

      In reply to Kate Newton

      Kate Newton - obstetrics is one of the most feminised medical specialties, with women now outnumbering men as specialist trainees. According to a 2005 submission to the Productivity Commission by ACOG, "There is an increasing proportion of female Fellows. Amongst the youngest Fellows (those aged in their 30’s) more than 50% of Fellows are female. " (Fellows meaning people with College Fellowship - ie specialty qualifications).

      Murray is right - in a public hospital system where the provider for uncomplicated birth is a midwife, most birth attendants are female.

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  2. Sian Scott
    Sian Scott is a Friend of The Conversation.

    Internal Communications Officer

    Well-written article, and very interesting findings. Something to consider if I ever have a child, although the idea of standing up to give birth is kind of terrifying.

    But I agree with Murray that the last paragraph feels unnecessary.

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  3. Catherine McInerney

    Environmental Water Resources Officer

    Do you think it's got anything to do with pain relief offered/used?

    I had two babies standing/kneeling without pain relief, and laying on a bed was the most painful position I could be in.

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    1. Julie Leslie

      GIS Coordinator

      In reply to Catherine McInerney

      Definitely. If you have an epidural you can't stand anymore and often it slows everything down too. For a posterior birth there is generally no position that is comfortable (every position was painful) and for a long labour you have no energy left to stand.

      The above article can be helpful, but there comes a time when it is not possible to do that anymore and while lying down is sub-optimal it is not terrible either.

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    2. Alice Garner

      Researcher in history and education

      In reply to Catherine McInerney

      I agree with you Catherine. I had three babies quite quickly (5 hours average) with no pain relief (in a family birth centre in a hospital) and was most comfortable on all fours in the bath or leaning against the bed. When I had to lie on my back briefly for a cervical check it was agonising and I got back upright as quickly as possible.

      When I see documentaries now, showing women in labour, I can't bear to see them on their backs because it is SUCH an uncomfortable position to be in.

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  4. Jennifer James

    Dr at RMIT University

    Love the title Hannah... says it like it is! physiologically, women are meant to be upright to facilitate the widest openings for the fetus to travel. Laying down was imposed on women a long time ago to allow for better access by doctors and also recognising that in Queen Victoria times up until the second half of last century women were doped up on drugs and could not semi recline let alone squat or stand.
    am really not sure why being upright would be scarey... surely anything that supports a natural normal birth is something to be confident in... lying down is much scarier... and more likely to prolong the labour leading to more interventions and increase the likelihood of an emergency c/section.

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  5. Lynne Newington
    Lynne Newington is a Friend of The Conversation.

    Researcher

    Things are far less formal in delivery suites these day's.
    As late in life mother [46] it was free as you ago, whatever serves you best and an unforgetable experience to go out on.
    Thanks to St John of God and Sarto Salmon.

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  6. Paul Richards

    integral operating system

    Hannah Dahlen wrote: Stand and deliver – upright births best for mum" Fantastic, those wayward doctors who wrote "Monty Python's The Meaning of Life (1983)" with the sketch of the Catholic mother standing and delivering were on the mark. The memory of that will forever be attached to your article, priceless.

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  7. Colin Truslove

    Self employed at Australia Shopping World GmbH

    In reply to Murray and in support of Kate:
    If Kate had written "Most obstetricians were male!" I think Hannah's final comment might well have remained uncommented on. I think historically speaking Hannah is justified to make that comment, after all she was talking about the beginnings of obstetrics.
    But I am pleased to read how many obstetricians are now female!

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  8. Kate Murray

    logged in via Facebook

    Great article!
    I had a slow labor with my first baby nine years ago and ended up- against my wishes- on my back on what seemed seemed like an impossibly high, hard bed with a really cold bit of plastic behind me and attached to all sorts of cables. It was actually quite hideous.
    I had my second baby six years ago at a family birthing centre and was told that it was against hospital policy to encourage mothers to give birth upright as it might cause back problems for the midwives. The midwife who told me this seemed fairly dubious about this policy and said she thought that the use of a mirror cancelled out any risks of that sort. My daughter was born while I was sitting on a birthing stool. It was still really painful, but it was altogether a much more more positive and less exhausting experience.

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  9. Paul McGurgan

    Assoc Prof Ob/Gyn at University of Western Australia

    This article should use the Cochrane info below to provide more accurate info on the advantages and potential disadvantages of labouring upright.

    Cochrane Database Syst Rev. 2012 May 16;5:CD002006. doi: 10.1002/14651858.CD002006.pub3.
    Position in the second stage of labour for women without epidural anaesthesia.
    Gupta JK, Hofmeyr GJ, Shehmar M.
    SourceAcademic Department of Obstetrics and Gynaecology, University of Birmingham, Birmingham, UK. j.k.gupta@bham.ac.uk.

    Abstract
    BACKGROUND: For…

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    1. Julie Leslie

      GIS Coordinator

      In reply to Paul McGurgan

      +1

      I went into labour well prepared; months and hours of physio, yoga and much research into how to birth in the most efficient way possible. I had the birth centre booked, a kit full of props and a steely resolution, which ultimately came to nothing. I had a posterior birth, but this was ok because I had prepared mentally for this.

      A posterior birth is so long and painful that standing up/squatting/ being on all fours is not longer a 'choice'. By the time that most women have delivered fully…

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    2. Sue Ieraci

      Public hospital clinician

      In reply to Julie Leslie

      Well said, Julie.

      As you found out, the most healthy, fit and apparently low-risk mother can have unpredictable mechanical or bleeding complications during labour and birth. That's why hospital birth with modern midwifery and obstetrics has dramatically improved outcomes for both mothers and babies.

      Childbirth is physiological, but not reliable. Nobody should have to feel a lack of "achievement'' from a non-ideal birth process or from the use of sophisticated pain relief. Sometimes standing up is better, sometimes it's not. Birth should not be a contest.

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