Friday, February 11, 2011

Positions in Labour

When I meet people who are interested in working with me as a doula or childbirth educator, one of their burning questions is: "Are you going to teach me about positions to use in labour to make me more comfortable?"



While I may do the briefest of overviews to show what many women enjoy doing positionally with their contractions, asking them and their partners to try them out so they can feel comfortable knowing what they are doing is totally normal once they're in labour, positions for comfort is actually something I don't focus on a lot. I tend to find most women know what to do in normal, ummedicated, physiological labour to make their contractions more efficient and comfortable. If we provide fancy charts of positions that are helpful to birthing women, it assumes they will be using their intellect during labour to mentally bring up the image of the "menu" of positions (or check their notes while actually in labour), and select which might work for their particular scenario. While this may help in early labour (or not, as I tend to recommend the "don't focus on early labour and find something to distract yourself with" approach rather than the "focus on the early sensations with all kinds of positioning and massage so you're at a loss as to what to use to help when things really get cooking" approach), the kinds of contractions that have you drifting away on an endorphin cloud to lala land are simply not conducive to the mental gymnastics of cross referencing.

I have actually not seen a labouring woman with back pain NOT lean over or go on her hands and knees to take that desperate pressure off her sacrum. I often see women who are being monitored while lying on a bed rip off the transducers and stand up because they simply cannot lie there any longer. They can't tell you why, they just know they cannot bear that position anymore. Their bodies are guiding them intuitively, their babies whispering from the inside, "Mama, I need some more space...move this way."

I have had women yell in transition, "Tell me what to do! What do I do?!" and I'll make a suggestion, but inevitably they do what they want. I remember a woman asking her midwife what to do and the midwife suggested she sit on the toilet. It's a great suggestion...the opening of the legs, the safety of the toilet, the squatting position putting pressure of the baby's head on the stretchy cervix, helping it to open perhaps more quickly. There's no need to explain all of that to the labouring mom , as it's too much information for her to process. All she wants is some direction on which to anchor her hopes that this will all be over soon. Despite the midwife's simple suggestion, the mom just stood over the toilet. All she wanted to do was stand, so finally after being asked several times what she should do, the midwife validated that clearly what this woman wanted to do was stand, and to trust that. When she started grasping and pulling down on the shower rod, we guided her out of the bath (where she was standing) so she could grab onto the trapeze bar provided for that purpose. She birthed beautifully hanging from the bar. That would have happened whether she had been educated about positions in advance or not.

Labouring mothers often do some strange things to comfort themselves in labour, and it's all good. I've seen women lie down on the bare hospital floor because it felt cool, stand up on a chair because the floor felt too hard, or walk like an elephant on all fours swaying to and fro with their heads. All a mom needs to know is that if it feels good, she can go for it.

Where positioning education comes in very handy is when the mother has an epidural. Because many of her body instincts are numbed by the medications and positioning of the baby can become misaligned with the pelvic structure, suggestions of position changes help a lot. And because the mother is capable with the reduction or absense of pain and endorphins to draw upon her intellectual capacities, a check list she's learned in advance of positions to increase labour's efficacy can be extremely useful if she doesn't have anyone around to guide her with this.

When labour is NOT going normally and clearly the baby needs to do some shifting to create a better fit with Mom's pelvis, positioning can be extremely helpful. I had a mom once whose back was so sore and stiff from a long hard labour that she couldn't sit down. She wanted to, but the aching prevented her from acting out her intuition. Her husband and I tried to guide her to sit on the toilet, but she just couldn't bend her knees. Her poor back was raw from all our rubbing. Her poor bum muscles were so tight from all the pain, so my instinct was to grab them and shake them out. I did this for a good minute, just jiggling those bum cheeks. We were all giggling a little. Finally the mom sat down, and things got moving immediately. She ran to the bed, got on all fours, and was found to be fully dilated. Again, we could teach all that in childbirth ed, but really, when in the throes of labour, without some skilled direction, she and her stressed out partner probably won't think about all the possibilities or receive support. This is why good childbirth education AND good doula support create better outcomes than just education.

Positions for rest are something I like to talk about. Sometimes moms get really tired, but cannot stay in a position during contractions that they really like between them. So knowing how to rest and contract in one position for a bit while she regains her energy is useful. I like using a yoga ball and edge of a bed or counter to lean over on for resting and contracting, or hanging out in the bath. It's important that the skill of how to rest and chill out in labour is as important as riding the waves of contractions.

Another area in which discussiong positions is useful is when it comes to the second stage of labour. I love to watch people's faces as I demonstrate what a normal labouring woman often loves to do when that fetal ejection reflex kicks in...butt juts outward, arms reach up to grasp, torso leans way forward. I gently and slowly tip myself backwards without moving any limbs, just letting my hands grasp my knees, and it really hits home how, when you adopt the stranded beetle position, a woman is asked to do the EXACT opposite in most OB assisted births of what Nature asks, effectively mobilizing the sacrum (which dearly wants to be able to stretch and yield to the babe's extending head), perhaps necessitating circus style pushing to compensate for the smaller space created in the pelvis, and potentially wreaking all kinds of nasty havoc. Telling women that there is a good possibility of their not feeling great being on their backs while pushing (as many don't know this is not the real "way" the body likes to deliver babies), and that their instincts to do otherwise are spot on regardless of what they're directed, helps them to know they're not "bad" patients or somehow abnormal. And it's also helpful for them to know that there is no black and white, and that if they do happen to feel good on their backs, then this is absolutely fine too. Just because it may not be an ideal position for some, it may certainly be for others. I have seen women whose babies are exiting with great speed (myself included) throw themselves spontaneously on their backs. Perhaps this is how we are intuively guided to slow things down a little.

It is important to remember that birth is not intellectual from the birthing woman's point of view. The more charts and diagrams a woman has to look at and follow, the more she gets caught in wondering, "okay at what point do I do this, what sensation necessitates this position, etc." This is exactly where we do NOT want labouring ladies to be...in their heads worrying about what is "right". If they seem as happy as they can be in super active labour and things are going well, then it's right. The most useful tools in childbirth education are not the fancy tricks that are learned involving balls and positions, but the practice of relaxation, release of tension through whatever means the mother prefers, and the ability to stay with the sensations confidently as opposed to reacting to them with fear.