January 9, 2020

25 Comments

There is a growing trend for women to give birth standing up. A respected obstetrician attended at thousands of births before realising that putting a pregnant woman in a bed, anesthetised, is more for the doctor’s benefit than the woman’s. He looks at how a growing movement aims to find a middle ground between ‘medical’ and ‘natural’ and make birth more a safe achievement than an ordeal.



Not always the best position for childbirth.
BSIP / Contributor / 151036972

 

I’m an OB/GYN who attended thousands of deliveries before wondering why women give birth in bed

A few years ago I visited Dar a Luz, the only free-standing birth center in New Mexico. It looks nothing like the towering urban hospitals I have spent my career working in. Nestled into a valley at the outskirts of Albuquerque, Dar a Luz is more like an earthy homestead. At the perimeter, a wood fence surrounds a sun-drenched courtyard with a rock garden and a footpath that expecting mothers pace while in labour.

Inside the birthing rooms are bathed in the same natural light, with open spaces designed to encourage continuous movement. Beds are in the corners of the rooms rather than the central feature. Abigail Lanin Eaves, the executive director of the birth center and a certified nurse midwife, explained that, at Dar a Luz, her patients arrive in labour walking – and usually stay that way until after the baby is born. The beds are for resting afterwards, rarely for labour or the birth itself.

Each year approximately 20,000 Americans choose to give birth out of bed, which usually requires giving birth out of hospitals. According to the CDC, centers like Dar a Luz have become 83% more popular over the last decade. Yet millions of Americans still choose to give birth bed-bound, on their backs, with their knees up, legs spread, feet in the air. I attended the deliveries of thousands of babies before I ever wondered why.



The rock garden – lovingly referred to as the labour-inth – at Dar a Luz birth center in Albuquerque, New Mexico.  

Convenient For The Doctor

As an obstetrician/gynecologist, this position is familiar to me. It maximizes exposure to the pelvis during office examinations and gynecological procedures. By extension, it seems to make sense for childbirth as well, particularly from my perspective as the doctor. The work of being on call on the labour floor can be grueling, a constant race from one bed to the next. Having the people I care for remain in bed allows me to sit down, optimize my lighting, and limit the strain on my back and my eyes.

But while convenient for me, few unmedicated people would choose to labour this way. In the absence of anesthesia, it would be too uncomfortable. Movement is an instinctive way of coping with the discomfort of labour. Remaining upright also appears to facilitate labour progress and, aided by gravity, descent of the baby in the birth canal. By contrast, MRI studies suggest that on-the-back positioning may significantly narrow the baby’s pathway through the pelvis.

However, in the presence of anesthesia, standing and walking throughout labour is challenging if not impossible. Turning off the body’s pain receptors requires disconnecting our nerve endings from our perceptions, a process that can remove our ability to move, to remember what happened or both. Anesthesia works by blunting our most fundamental instincts. This dilemma places our desire for comfort at odds with our desire for control.

‘Blessed’ chloroform and twilight sleep

During the mid-19th century, childbirth was not an event many women were eager to actively experience. Under desperate circumstances, physicians were often called upon to surgically rescue deliveries using brute force – to place metal forceps on the baby’s head while still in the birth canal, and to strenuously pull. Even for the steeliest mothers, holding still would have been impossible. By contrast, inhaling chloroform, an early anesthetic, would instantly drop them into a “dreamlike” state, limp and silent, awakening hours later, peacefully and with little memory of what had happened.



Gustave Leonard de Jonghe’s painting, ‘The Young Mother.’ The work was created in the latter half of the 19th century.
Wikimedia

Chloroform was widely welcomed, even garnering an endorsement from Queen Victoria herself, who called it “blessed.” But the crude method of administering it – inhaling vapors from a rag – led to dangerously uneven dosing. If too little was given, the woman would remain awake and in pain. Yet if too much was given, they could permanently stop breathing. As anesthesia became commonplace, many overdosed and died.

A solution to this problem arrived in the early 20th century. The same effects of inhaled anesthesia could be achieved with a combination of morphine and scopolamine, intravenous medications that could be carefully measured in a syringe. This new form of injectable anesthesia was alluringly marketed to pregnant women as “twilight sleep.” And by the 1930s it became the default approach to childbirth in the United States.

Cruelty in maternity wards

Then, in 1958 the Ladies Home Journal published a disturbing expose called “Cruelty in Maternity Wards.” In a series of letters, American nurses provided direct accounts of labouring women being left alone for hours, strapped down to beds, crying “violently” and involuntarily writhing against the restraints. At that time, fathers and other family members were not allowed in the birthing rooms to bear witness. Under heavy sedation, the memories of the mothers themselves were fuzzy.

The American public was horrified by these descriptions. Pregnant women wanted their voices back. They wanted the capacity to consent. They wanted more control.

By the 1960s, a newer technology – epidural anesthesia – offered an appealing alternative. Administered at the level of the spine, epidurals effectively bypass the brain, allowing mothers to stay awake and alert during labour, to relay their symptoms and participate in care decisions. But they also require a different trade-off. The medicine spreads out to block all nerves that relay and receive signals to and from the pelvis and thighs. These nerves mediate sensation but also control all of the key muscles in that region, from the bladder to the quadriceps.

Women with epidurals are unable to urinate on their own. A catheter must be placed to help them. Otherwise, their bladder will simply distend like a balloon. They are also unable to effectively move their legs and must remain in bed, usually for many hours. Epidurals require more intensive monitoring, a multitude of wires that act as tethers. And by removing pain as a barrier, they bring the potential for more interventions – the same epidurals used for spontaneous vaginal deliveries can be sufficiently dosed for a broad range of procedures, including cesarean sections.

Ceding control (and comfort) on their own terms

Currently, over 70% of birthing women in the U.S. receive epidurals, favoring some measure of comfort over physical control. However, the popularity of Dar a Luz and other birthing centers suggests that growing numbers appear to be choosing the opposite trade-off: participation and movement over medical pain relief. Perhaps, however, the challenge is not born of anesthesia itself but rather a false choice embedded in the way it gets presented, an all-or-nothing dichotomy between “natural” and “medical.”

At birthing centers, epidurals are not available, and as a result, labour looks remarkably different from the hospital equivalent. While the mother may not necessarily look comfortable, her movements and her mindset more closely resemble an athlete accomplishing a feat than a patient undergoing an ordeal. Throughout, midwives are in attendance to provide support, careful monitoring and coaching.

Occasionally, complications develop during labour that make it necessary for these mothers to be transferred to the hospital. This requires acquiescing to changing circumstances and transferring some control to obstetricians and medical technology.

But the expectation of these mothers is not absolute control any more than it is absolute comfort. Most recognize that labour is neither completely controllable nor completely comfortable. They, perhaps like all people giving birth, simply seek to understand these trade-offs and have the opportunity to cede control – or comfort – on their own terms.

[ Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, ever day. ]The Conversation

Neel Shah, Assistant Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Were you happy with how your labour went? Would you have chosen to give birth standing up? Tell us in the comments below.

  • I was happy with the way all four of mine were born.

    Reply

  • I gave birth to my daughter standing, I had to drop down to one knee half way through her coming it as my legs were giving way though. Felt like jelly and shaking.

    Reply

  • Giving birth has certainly come a long way over the years.

    Reply

  • Choosing a birthing position that suits the individual makes the most sense!

    Reply

  • That birth center in New Mexico sounds good !

    Reply

  • I have given birth 3 times all on a bed in varying positions. Kneeling worked well for my last. Some of the historical practices mentioned are horrifying, I’m really grateful for good respectful hospital care

    Reply

  • My first birth I had an epidural, which was turned off unexpectedly (for me) at pushing time. I wish they had told me that was what was going to happen! My 2nd I was fully expecting to have allll the drugs again, but he was in a hurry and I laboured a lot longer at home. I ended up giving birth on my knees on the bed with my husband supporting me and no pain relief. I much preferred the 2nd, and if I was going to do it again (God forbid!) I would put some time into learning about hypno birthing and get a doula and a birthing pool.

    Reply

  • I wasn’t unhappy with my 2 but I think being able to stand would be more natural

    Reply

  • Every labour is diffrent. Whats work for one will be not good for other. My 2nd was perfect but 1st was ao long

    Reply

  • I think women should listen to their body more and flow in the direction that feels natural to them and most comfortable for their body.. the dr and nurses need to assist with this

    Reply

  • why is this even a question, we need to do what is comfortable for us

    Reply

  • At the end of the day you just need to do whats right for you.


    • Listening to your own body makes sense.

    Reply

  • i was happy with mine… loved epidural hahhaa

    Reply

  • I had C-sections, it was not what I wanted if I could choose but I couldn’t and it was ok really.

    Reply

  • I wish I could have done that I got so sick I was put back on the bed to get monitored

    Reply

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