Cheyenne: From Richmond, Virginia this is How Many Weeks — I’m Cheyenne Varner
Francie: And I’m Francie Webb!
This season is sponsored by Manhattan Birth.
Manhattan Birth is a loving and nonjudgmental community delivering no-nonsense childbirth education and always-encouraging newborn care. They demystify the changes and triumphs of the childbearing year, help birthing folks advocate for the birth experience they deserve, while offering support through the joys and frustrations of new and early parenthood. Manhattan Birth offers a variety of virtual classes for pregnant folks, new parents and birth workers in addition to a concierge style doula matching service, 12-month doula mentorship and lactation specialist training program.
As a sponsor of How Many Weeks, Manhattan Birth is thrilled to offer listeners the promo code mbspecial for 20% off any course! You can find them at manhattanbirth.com.
Francie: My name is Francie Webb, my pronouns are she/her. I am the mother of three kids, and a professional certified birth and postpartum doula, an International Board Certified Lactation Consultant-in-training, and the founder of Go Milk Yourself[1]. At Go Milk Yourself, we teach lactating people, and the professionals who support them, to hand express milk, with confidence. I teach people to do things they think are impossible, and I’m committed to a world in which every person really gets how powerful they are.
Cheyenne: My name is Cheyenne Varner, my pronouns are she/her, and I am a professional certified birth and postpartum doula and I’m the founder of The Educated Birth[2]. At TEB we create intersectional reproductive health educational content, from online articles to social media posts to digital and print teaching tools. We also publish Everyday Birth Magazine[3], a print and digital magazine with the same mission, to make information and education about pregnancy, postpartum, and more, inclusive.
Cheyenne: So now it’s time for How Many Weeks and we want you to know right away that we want to talk with you!
Francie: Call in to share your comments, questions and stories with us, and maybe even to come on the air with us sometime… our number is 804-601-6065
Cheyenne: Alright so, we’re here today to dig a little deeper into a topic that’s a pretty big part of birthing, and that’s lithotomy position —
Francie: That sounds like lobotomy.
Cheyenne: It does — it does — it does sound like lobotomy actually — I didn’t even know the definition of lithotomy before we looked into this — and we will all become introduced to some fascinating history and physiological things as well today!
Francie: Here’s what we’re not going to talk about. We’re not going to talk about good vs bad or right vs wrong in the context of giving birth. And this isn’t a conversation about what you should do or what you should not do. This is a deeper look at a position that many people birth in — why it’s been so encouraged, sometimes even required — overall we’re going to touch on the history of birthing positions, how we got to where we are today, and how different positions can be productive for our labors.
Cheyenne: So Francie, imagine you’re in labor —
Francie: I can totally imagine that —
Cheyenne: You’re feeling these waves of sensation right and they’re growing and building, more intense, more intense, coming quicker, and you hit this moment — where — you feel something in your bottom — and so now it’s decision time — this baby is coming out and they’re coming out of your body and the question is — what are you doing to do with your body? What position are you going to get into?
Francie: You know that’s actually a very real moment in labor Cheyenne there have been moments in labors where I’ve thought this isn’t where I want to be — or I want to be — I don’t know, like I had in mind I was going to be on my hands and knees for my third baby because that’s where I was for my first and second, but when the time came and I was like oh my God this baby’s really coming out I stayed put exactly where I was, which was just with my butt on the bottom of the birth tub and I didn’t want to be anywhere else.
Cheyenne: Yeah, even though I haven’t felt that in my body yet, I’ve definitely watched many people grapple with that moment and what I’ve found is that often a care provider or nurses will chime in and suggest what to do and I’d say — definitely more than half the time — that suggestion is lie back on the bed and lets lift those legs up into stirrups or to be held by a partner and by me.
Francie: Sometimes it’s not even a suggestion, sometimes people are just physically moved into that position by a medical provider or a nurse.
Cheyenne: Yeah true.
Francie: When we’re talking about positions, there are two umbrellas — recumbent positions and upright ones. Recumbent and semi-recumbent positions are the ones where you are lying on your back or on your side. Upright positions include standing, squatting, kneeling, hands and knees, or sitting on a birth stool [4].
Cheyenne: Lithotomy position is specifically lying on your back with your legs up, flexed 90 degrees at your hips, and your knees will be bent at 70 to 90 degrees, and feet are often in foot rests, or legs are held by folks nearby [5].
So why is this so common today, so ingrained in what we think of when we think of giving birth, as a societal “this is the normal birthing position” — you know, where did that come from?
Cheyenne: I have been waiting for this moment. So long. This is a segment I would like to call How Many Truths? Francie, I’m going to tell you three stories about how birthing positions have changed over time — and particularly the history of the reclining position in birth — and I want you to tell me which you think are true and which you think are false. Ready?
Francie: I’m ready but I’m actually kinda nervous because what if I get it wrong?
Cheyenne: Well you should be nervous because if you win you’re going to win… the naming of my first-born child.
- Starting in 1598, using a reclining birth bed was advocated for by surgeon-obstetricians because it made it easier to perform surgical techniques — and it was touted as more comfortable for women and helpful to the facilitation of labor. The man most widely credited with this change in birth positions however is Francois Mauriceau, who wrote the book “The Diseases of Women with Child and in Child-Bed” in 1668 [6].
Francie: First of all I’m having a reaction to it being called a disease.
Cheyenne: Right? Ain’t that something.
France: It really is. And second I say this is a truth.
Cheyenne: Ding! Ding! Ding! Ding!
Francie: Yay!
Cheyenne: Yes! Correct! Ready for the next one?
Francie: I’m ready! I am so ready to name your first born child.
Cheyenne: Oh God.
Francie: Patrick is looking at me with these “I-do-not-approve” eyes.
Cheyenne: It’s getting a little in over my head. Okay, number two:
- According to some scholars, King Louis XIV (14) enjoyed watching women give birth and it really annoyed him to have his view blocked when they used a birthing stool. So he encouraged the implementation of a reclining birthing position among obstetric surgeons at that time — that’s the mid 1600s to early 1700s or so [6].
Francie: Okay so I’m sitting here like does the King really have that much power? Now I totally believe that Louis XIV did this from vague memories of middle school history class and then I’m also like, would the King have power to guide what doctors do at that time and I actually think yes, the king was a sovereign, and his rule was like the rule, so I think I’m also going with this is a truth.
Cheyenne: According to Snopes fact-checking it is false to say that King Louis XIV influenced the history of birthing positions, although it is true that he did like to watch childbirth and it may be true that he promoted reclined positions when he attended the births of his children [7].
You know, based on what I know about the guy it doesn’t seem like he was necessarily the best partner but I would just like to say for the record that wanting to see your child be born is a beautiful thing!
Francie: Yeah, for sure.
Cheyenne: So basically this one is false — it’s false-ish. Okay, one last chance to name my unborn child, Francie.
Francie: I’m really trying to decide between alveoli and recumbent.
Cheyenne: Alright our third truth or false —
- The phenomenon of placing birthing women flat on their backs began in the U.S. for unclear reasons. A Pennsylvania obstetrician named William Potts Dewees is credited with advocating for it, along with the side-lying position. He is quoted however as having written, “the woman should be placed so as to give the least possible hindrance to the operations of the accoucheur” — which means one who assists birth, or obstetrician, in French. “This is agreed to by all, but there is a diversity of opinion, what position that is" [6].
Francie: I thought you said you didn’t speak French.
Cheyenne: I very clearly do not.
Francie: The way that you said “accoucheur” — like fancy.
Cheyenne: I’ve been to France! Once.
Francie: So I think that’s 100% true. It sounds exactly like something that would have happened.
Cheyenne: Ding! Ding! Ding! You are not naming my baby though.
Birthsmarter is an unbiased, inclusive, award-winning, and game-changing platform that provides practical wisdom and guidance to the next generation of families. Their range of pregnancy and parenting classes, support groups, and curated resources raise the bar for how families can prepare for childbirth and navigate the early days of parenting. Given today’s episode, we want to highlight Birthsmarter’s 2-hour live, virtual Push Prep workshop! This is a must-take for anyone pregnant and wanting to learn more about how to reduce the risk of perineal tearing, shorten the length of time your pushing, and generally prepare and protect the pelvic floor. Use the code howmanyweeks — all lowercase — for 10% off your next virtual or On-Demand Birthsmarter class. You can find all of this and more at birthsmarter.com
Francie: Damn it, Cheyenne!
Cheyenne: I just had to up the ante Francie, I knew that would getcha going.
Francie: It definitely motivated me in the game to think I was going to get to name your child, so thanks for the motivation?
Cheyenne: Stakes matter. So fun fact though, Mauriceau — the guy who wrote the book about diseases “of women with child” also referred to pregnancy as a “tumor of the Belly" [6].
Francie: Well that’s lovely.
Cheyenne: Yeah, so, you know, all of this said, basically there’s a lot of speculation and there are theories about how giving birth on our backs has become so common — but it’s really not so simple — we can’t really identify a sudden moment in history where this position became “the thing” — and it’s really not clear how and we definitely don’t know exactly why. Like we know the medicalization of birth definitely has something to do with it, and that it is a pretty convenient positions for medical professionals to have folks in, but there’s just no clear why — even the obstetric textbooks say that upright birthing positions are more beneficial.
Francie: And it’s also worth mentioning that midwifery has long been associated with upright birthing positions. Midwives have been around forever — that history is a whole other episode. But as it relates to birthing positions, the earliest records often show people squatting or kneeling with midwives attending them and today midwives are still known for being more familiar with upright birth than our friends in obstetrics — although it really depends on the OB! Some are familiar with upright birth positions — and that’s why we ask our providers questions, like:
“What is your approach to positions and movement during labor?”
“Have you attended births where pushing was done in a different position than on your back?”
“Are you comfortable with that?”
“Is there a specific situation in which there’s a medical reason I should be on my back and can you help me understand what that reason would be?”
Cheyenne: Yeah it’s always important to just talk to our providers and really understand their philosophy, their values, their experience where they’re coming from because it’s not a blanket statement.
Francie: Well one thing to add too is, our providers want us to be able to have a good experience. They want our babies to be safe and they want us to be safe, and also if we had another baby, most providers would want us to come back to them, you know. So getting our questions answered can really create that relationship where we feel empowered and satisfied with their care and they have the opportunity to provide care that works for us.
Cheyenne: Yeah, absolutely. So, one reason recumbent or lying back positions may be so common, particularly in hospital settings, is our use of interventions also in that space. For example, being on our backs makes traditional continuous fetal monitoring a little bit easier to facilitate — nurses can track the baby’s heart rate more easily the whole time if that pregnant person is lying on their back...
Francie: Yeah. But real talk — There are different ways to monitor a baby during labor — the traditional form that we’re referencing above and that is most common in hospitals in the US is a machine that involves placing two sensors on the belly of the laboring person. So there are these two sensors on the belly and they’re connected via long wires to a machine that records all the data and prints it out — and the data is the baby’s heart rate and the data is also the frequency and intensity of contractions — and that means if you’re being monitored this way, you really need to stay put. And sometimes you’re being monitored this way continuously, so the monitor stays on the whole time and sometimes you’re being monitored this way intermittently, so there’s a period of time where you wear the monitor [8] — like for me it was supposed to be 20 minutes of every 60 because my baby was measuring small throughout pregnancy.
Cheyenne: Yeah, I’ve had some clients with this type of monitoring not stay in the bed exactly, like maybe get on a birth ball, or on the floor, but there isn’t full freedom of movement. You’re kind of — you’re on a wire, you know, you’re attached.
Francie: Yes and one of the problems is that moving around can mess up the monitor. It can be as simple as I leaned over during a contraction and the monitor slipped and then we had to start the 20 minutes over again.
Cheyenne: Yes, true.
Francie: It’s really not the smartest tech. To set things up so that someone in labor has to stay still — it just doesn’t make sense.
Cheyenne: Well that’s a really solid point because electronic fetal monitoring was brought into labor rooms in the 70s despite the fact that there was no research evidence to show that it was safe or effective [8]. So there’s a lot of questioning of the purpose and what it brings to us in that space versus potentially some of the cons that it brings to the laboring process. So it is really important that folks understand and talk to their support team and care providers about the risk benefit analysis and how to use it in a way that’s going to be effective and productive.
Francie: Yeah that makes sense. And in general what we’re suggesting is nothing has to be a default in your birth or labor — everything gets to be a conversation and an opportunity for you to get the information you need to feel comfortable with the choices made.
Cheyenne: While we’re on the topic of this kind of monitoring it’s worth covering that there’s another type that can be wireless, and can sometimes even go in the water, which is really nice — you can get that data and still have more freedom of movement.
Francie: And so with a wireless monitor people essentially have like sticky patches that are on their bodies, so the monitor rests on their belly like a little pack.
Cheyenne: Yeah, yeah.
Francie: It’s almost like a little beeper.
Cheyenne: I don’t know why I’m always thinking of it like a little battery pack. Battery pack on your —
Francie: Well there’s probably a battery in that pack, right?
Cheyenne: I’m sure!
Francie: And then there’s this other kind of monitoring and it’s a lot less common in hospitals that allows the laboring person to move as freely as they’d like. And that’s the doppler. This is a handheld machine that the care provider uses — it’s a little ultrasound machine — and they put the little receiver on the person’s belly and then they can see the data on the screen for that time only. And a lot of people are familiar with dopplers from early checks in pregnancy, like they’ll be used on the outside of the body early in someone’s pregnancy to see on the screen what’s happening with the little baby in there. And people might actually be quite familiar with the doppler from appointments with their doctor earlier in their pregnancy where you’re sitting on the table and you lie down and they put a little jelly on the wand and then they put the wand on you and that’s the doppler — that exact same tool can be used during labor.
Cheyenne: And what’s really interesting about all this is — that we know from the evidence that continuous monitoring with the most common machines that we talked about earlier — that do that continuous monitoring — it really makes no difference in outcomes [8].
Francie: No it doesn’t.
Cheyenne: So hands-on listening, that doppler example, is actually what we know to be more evidence based for folks who might not have a high risk factor going on.
Francie: So I just want to make sure I’m getting this — that the most common method of monitoring, which is the wires attached to the pieces on someone’s belly, actually doesn't create healthier babies or healthier parents who just gave birth.
Cheyenne: Correct, fetal monitoring is a tool and so how helpful it is really depends on how we use it — is it used in a way that leads to additional interventions unnecessarily or is it used in a way that’s really reasonable and responsible and may help foster the safety and progress of a labor?
Francie: So that’s what we mean by there’s no difference in outcomes.
Cheyenne: Another thing that can play into position is the use of another intervention and that’s an IV. When you have IV in your hand it also may be less comfortable then to be on your hands and knees, or do some different positioning things, or when you have an epidural — another intervention — you may not have the ability to shift in the bed and move as much. So these are also reasons that — things that can impact how we position ourselves.
Francie: Yeah they can. And you know, there are reasons we have these interventions. Just like we said earlier this isn’t a conversation about what’s good / bad, right / wrong when it comes to being on our backs — this is something that we really take seriously when we talk about any intervention. It’s really just about context — are the parent’s preferences being respected? Is their autonomy being respected? If there is a medical reason for an intervention is it being communicated? Are the person’s questions about the use of that intervention being answered? It’s really about — is the person in the birthing body comfortable with what’s being done or not done?
Cheyenne: Which reminds me that training definitely plays into this as well, and why even today having midwifery care versus obstetric care can make a difference. Midwives are explicitly trained to understand and be prepared for birth in upright positions whereas most medical students, going on to become labor and delivery nurses, and obstetricians, are not as much. Remember that video of the robot that gives birth?
Francie: Yeah I actually saw that robot at a hospital once when I was at a client’s birth. And the only way this robot can give birth is by lying on their bath and that robot is the only that way medical students in this one particular very large university hospital were trained for birth. We’re going to put information about this robot in the show notes because it’s pretty fascinating and she’s kind of creepy looking [9] [10].
Cheyenne: Fun fact — medical trainees were at my birth. My mom said a whole bunch of them just came in right before she pushed me out — just like flooded the room.
Francie: Wow
Cheyenne: Like 12 of them.
Francie: An audience
Cheyenne: Just yeah — I was born to an audience, which is why I now host a podcast.
Francie: I hope they learned a lot from you just like the rest of us learn a lot from you.
Cheyenne: I’m sure I came out with something to say.
Francie: I have no doubt. So then I also think about how birth is portrayed in the media. Like I cannot think of a single tv show I’ve watched or a movie I’ve watched where a character gave birth in an upright position, can you?
Cheyenne: No, I can’t, and birth like, comes up in tv and movies all the time. And I can think of someone giving birth on their back in hospitals like in Friends [11] and The Office [12], I can think of someone giving birth on their back in an ice cream truck or a food truck, that was in the show Psych [13] —and someone giving birth on their back on the floor — I think that was — what’s that showed called — Frankie and Grace [14] , I think. And then, Brooklyn Nine Nine, giving birth on her back in the police precinct on lockdown [15], like — agh!
Francie: So what we see on the screen definitely influences are concept of what’s normal and what we may do in labor regardless of what we’re feeling in our bodies because — you don’t know what you don’t know.
Cheyenne: What’s the first example of birth in TV or in a movie that you think of? Like what —
Francie: I always think of What to Expect When You’re Expecting [16]—
Cheyenne: Ahh, I haven’t seen that.
Francie: Oh my God, I love that movie — People hate it — I love it. They’re a bunch of different — the woman from Bridesmaids who played the rich woman in Bridesmaids, Helen I think — she’s in it and when she — I think of her and several other people in there are giving birth — Katherine Heigl is in it too — and they’re just sitting in bed and they’re screaming and then they’re lying back to have their baby and they just have their baby and you don’t see everything in between but it basically goes from — it’s very, very dramatic and it is lots of screaming and it is lying on your back —
Cheyenne: Yeah
Francie: And then magically there is a baby,
Cheyenne: Yeah
Francie: Which is not how it’s happened for me three out of three times.
Cheyenne: Yeah, I always think of the Friends episodes where Phoebe gives birth and then when Rachel gives birth. Phoebe is just like —
Francie: Did Pheobe have triplets?
Cheyenne: Yeah! Phoebe had triplets! And it’s just like oh one’s born, oh one’s born — she’s just on her back and she’s just like popping babies out
Francie: Like the robot!
Cheyenne: Like the robot and then Rachel like, is in labor for longer than all the other people who come through the shared triage room [17]. So someone comes in and then leaves to go have a baby and then another person comes in and leaves to have a baby and she’s like, “What’s happening?!”
Francie: Just totally maddening right?
Cheyenne: And on her back the whole time.
Francie: Yep.
Cheyenne: So we want to be clear that non-upright positions are not bad. There are a variety of reasons why someone giving birth may really prefer to be on their back — and in the case of an epidural for example, that doesn’t mean movement goes away though [18]. We can still implement different positions that fit that situation. And we can be on our sides, and on our backs in different ways. And of course where medical concerns arise it’s our care providers’ job to recommend positions that will facilitate the safety of birth for parent and baby. So understanding the context is really important and these other factors do probably play a role in what we see as common practice today.
Francie: So basically there’s no one size fits all. That’s like, you know, I find myself saying that about everything. And that is a great lead into a question: What is the modern understanding of birthing positions? We’ve talked a lot about the older understandings and where we’ve come from historically — but now what is our understanding of birthing positions?
Cheyenne: According to Evidence Based Birth, “The bottom line is that people giving birth with or without an epidural have the right to push and give birth in whatever position is most comfortable for them.” [4]
Francie: That’s the bottom line. The American College of Nurse Midwives (ACNM), Midwives Alliance of North America (MANA), and National Association of Certified Professional Midwives (NACPM) — three of the biggest US midwifery organizations have also stated that freedom of movement and the right to choose a birthing position are essential.
Cheyenne: Okay, ethically and according to evidence the position a birthing person wants to give birth in shouldn’t be coerced. Care providers should become familiar with people birthing in a variety of positions and collaborate with each other to support birthing people when they’re not comfortable themselves.
Phew. We really did take a deep dive into birthing positions today.
Francie: Yeah, this was a lot of information!
Cheyenne: And where there’s a lot of information there are a lot of options.
Francie: Amen to that.
Cheyenne: Yeah, so it might be something to go back and listen to again, get some of the little nuggets of info you may have missed the first time.
Francie: And you’re going back to listen to something that was relevant to you or sharing with a friend who can benefit from this information.
Cheyenne: And don’t forget to check out our show notes, which we lovingly put together with transcript and citations.
Credits:
How Many Weeks was created by Francie Webb from Go Milk Yourself + Cheyenne Varner of The Educated Birth and is edited and produced by Leo Mayorga, Patrick Mamou and Cheyenne Varner. Visit www.howmanyweeks.studio for more episodes, call into the How Many Weeks phone line, 804-601-6065 to leave comments, questions, and stories, and email hello@howmanyweeks.studio for media and sponsorship inquiries.
Francie: Thank you for listening!
Cheyenne: I’m Cheyenne!
Francie: And I’m Francie!
Francie/Cheyenne: And this is How Many Weeks.