Description and Official Rationale
One hardly needs a description of or a rationale for going
to bed in a hospital, for in a hospital,
bed is simply where one is usually supposed to be. Under the
technocratic model women in labor are conceived of as weak and in danger of falling or tiring themselves unduly if they get
out of bed too much to walk the halls during labor. A common complaint
of nurses is that they can't keep track of the whereabouts of "ambulating"
women. Furthermore, staying in bed is necessary when electronic monitors
are attached and is much more practical when fluids are being intravenously
administered than trying to ambulate towing an IV stand.
Although side-lying in bed is a safe position for labor, "dorsal
recumbency" (lying flat on one's back) is still the most common
position in many hospitals. This supine position facilitates both
vaginal exams and the woman's connection to the monitoring equipment.
Shifts in position after the monitors have been hooked up can result
in wild swings on the monitor printouts, leading to potential misdiagnoses
of fetal distress, and can necessitate readjustment of IV lines.
Physiological Effects
The evidence is unequivocal: nonmoving, back-lying positions during
labor are dangerous! In both sitting and reclining positions in bed,
the mother's cardiac output is reduced (Ueland and Hansen 1979), and
the inferior vena cava and the lower aorta are compressed, resulting in
reduced blood cirulation in the mother and reduced blood supply to the
baby (Abitol 1985; Eckstein and Marx 1974), which can lead to fetal
distress and necessitate a rapid Cesarean section. Moreover, contractions
in supine and sitting positions are much less efficient than in side-lying
and standing positions (Roberts et al. 1983), which are by far the most
efficacious for labor (Mendez-Bauer et al. 1975; Roberts et al. 1984):
It was established in 1976 that an increase of 30 to 40 mmHg pressure is
exerted by the fetal head on the cervix as a result of the effects of gravity,
that is, standing instead of lying down. This means that, although the
frequency of the contractions is the same, [their] effectiveness is much
greater, and hence the efficiency and rate of the dilatation of the cervix
is improved (Inch 1984:30).
A number of studies indicate that first-time mothers who stood and/or
walked for most of their labors had significantly shorter labors
(Caldeyro-Barcia et al. 1978, 1979; Diaz et al. 1980; Flynn et al 1978;
Liu 1974; Mitre 1974; Stewart and Calder 1984), and tended to require
less pain medication (Flynn et al. 1978). No adverse effects from
standing or walking (far more common cross-culturally than lying in bed)
during labor have been reported in any clinical trials. In contrast, the
increased pain resulting from lying down throughout labor seems to play
a role in women's demands for analgesia, and the slowness of labor in
supine positions often results in a medical decision to administer
pitocin.
In the medical studies that take maternal preference into account,
most of those mothers who preferred standing or walking in early labor
reported that after they had entered the most active phase of labor
(defined as beginning at 5-6 centimeters dilation), they preferred
side-lying in bed (Calvert et al. 1982; Stewart and Calder 1984;
Williams et al. 1980).
Women's Responses
It's funny--it seems so normal to lie down in labor--just to be in the
hospital seems to mean "to lie down." But as soon as I did, I felt that
I had lost something. I felt defeated. And it seems to me now that my
lying down tacitly permitted the Demerol, or maybe entailed it. And the
Demerol entailed the pitocin, and the pitocin entailed the Cesarean. It
was as if, in laying down my body as I was told to, I also laid down my
autonomy and my right to self-direction.
I walked the halls for most of my labor. It just hurt more when I laid down.
I felt strong and in control when I walked, even though it still hurt, so I
kept on walking, because that was a lot better than being in bed and feeling
like a little sick kid.
I was in labor for a long time. I was stuck in transition at at least 8
centimeters I guess for about six hours and finally wound up having to have
[pitocin and] an epidural to shake the kid out of there. I just laid on my
back in that stupid hospital bed. You know, if I had known to get up and walk,
or turn on my side, or do something, I might could have handled it better.
Well, where else would you be when you are in labor besides in bed? [Betsy
Yellin]
Ritual Purposes
Many a laboring woman wearing a hospital gown at this
moment would perhaps tell us that she believes herself to be healthy and strong.
But this conviction, which the hospital staff may verbally reinforce,
is steadily being undermined by the messages with which the woman's
environment bombards her. Being put to bed, as nearly all laboring
women sooner or later are, intensifies messages already communicated by
the wheelchair and the gown: that she is a patient, that she is sick. Or,
more precisely, it tells her that the hospital conceptualizes her as
sick--a message that, as time passes and labor becomes more intense,
becomes more and more likely to be internalized as "I am sick." Moreover,
going to bed, like sitting in a wheelchair, is a lower structural
positioning of the laboring woman that carries heavy symbolic weight
(Goffman 1961). Level eye contact in American society is a significant
indicator of interactional equality. The fact that the laboring woman
in bed must constantly be talked down to puts her at a significant
conceptual and interactional disadvantage.
Standing or walking during labor have contrasting symbolic ramifications:
the woman who moves and positions herself flexibly, according to her
own comfort and needs, appears powerful, healthy, and in charge of her
own labor and birth, and is the interactional equal of those attending
her. Although today women may often choose to walk around during labor,
the periodic monitoring required in most hospitals necessitates regular
returns to their conceptual locus - the bed and its messages. Although
monitors that work by telemetry have been around for a decade (they
require no wires, and can be attached unobtrusively to the laboring
woman's thigh), we need not wonder why there has been no rush to
incorporate them in most hospitals (McKay and Roberts 1989).
