Description and Official Rationale
The majority of hospitals and obstetricians in this country (still)
insist on a birthing position that quite literally makes the baby,
following the curve of the birth canal, be born heading upwards.
States Williams: "The most widely used and often the most satisfactory
[position for delivery] is the dorsal lithotomy position on a delivery
table with leg supports" (Cunningham et al. 1989:315). No reasons why this
position is "the most satisfactory" are given, but a strong clue is provided
in an earlier text:
The lithotomy position is the best. Here the patient lies with her legs in
stirrups and her buttocks close to the lower edge of the table. The patient
is in the ideal position for the attendant to deal with any complications
which may arise (Oxorn and Foote 1975:110)
This position, in other words, is the easiest for performing obstetric
interventions, including maintaining sterility, monitoring fetal heart
rate, administering anesthetics, and performing and repairing episiotomies
(McKay and Mahan 1984:111).
Roberto Caldeyro-Barcia, past president of the International Federation
of Obstetricians and Gynecologists, states unequivocally, "Except for
being hanged by the feet, the supine position is the worst conceivable
position for labor and delivery" (1975:11). There are a number of
problems generated by this position: (1) it focuses most of the woman's
body weight squarely on her tailbone, forcing it forward and thereby
narrowing the pelvic outlet, which both increases the length of labor
and makes delivery more difficult (Balaskas and Balaskas 1983:8); (2)
it compresses major blood vessels, interfering with circulation and
decreasing blood pressure, which in turn lowers oxygen supply to the
fetus (for example, several studies have reported that in the majority
of women delivering in the lithotomy position, there was a 91% decrease
in fetal transcutaneous oxygen saturation (Humphrey et al. 1973, 1974;
Johnstone et al. 1987; Kurz et al. 1982); (3) contractions tend to be
weaker, less frequent, and more irregular in this position, and pushing
is harder to do because increased force is needed to work against
gravity (Hugo 1977), making forceps extraction more likely and increasing
the potential for physical injury to the baby; (4) placing the legs wide
apart in stirrups can result in venous thrombosis or nerve compression
from the pressure of the leg supports, while increasing both the need
for episiotomy and the likelihood of tears because of excessive
stretching of the perineal tissue and tension on the pelvic floor
(McKay and Mahan 1984).
Studies comparing women's preferences for supine vs. upright positions
for delivery reported, without exception, more positive responses from
women using the upright position. These women tended to experience more
ease in pushing, less pain during pushing, fewer backaches, shorter second
stages, fewer forceps deliveries, and fewer perineal tears (Gardosi et
al. 1989; Liddell and Fisher 1985; Stewart et al. 1983; van Lier 1985).
Advantages for the baby included higher levels of oxygen in the umbilical
cord and higher Apgar scores than babies whose mothers delivered them in
the lithotomy position. There were no adverse effects from delivering in
the upright position, "although a few birth attendants reported that this
position was inconvenient for them" (McKay and Roberts 1989:23). In one
study, by far the most popular upright position among women given the
option was the supported squat, in which the woman gives birth on a bed
supported in a squatting position by a special "birth cushion," which
allows most of the woman's weight to rest on her thighs instead of her
feet. 95% of the subjects in this study wanted to use this position in
subsequent births; the researchers found that if women not originally
assigned to the study heard about the birth cushion from others, they
would often request it for themselves (Gardosi et al. 1989).
Most of the hospital-birthers in my study expected to be in the lithotomy
position for birth; the idea of
an alternative occurred only to those who
delivered in birthing suites or utilized the services of a nurse-midwife who would let them give birth in the labor room in almost any position
they wanted. As a result of this expectation, the comments made to me
about the lithotomy position had more to do with how women worked to
adapt to that position, than with the position itself:
I just simply felt like I had to be sitting up to push, so I refused to
push until Lenny got behind me and held me up, pushed my shoulders up off
the delivery table so I could push every time I had a contraction, because
I mean, there was nothing at all to lean on besides him.
My arms were not tied or anything. It was hospital policy to do it, but I
told them I wouldn't go to the hospital if they tied my arms. I didn't mind
if they tied my legs down because I knew I would still be able to push with
my ankles.
This lithotomy position completes the process of symbolic inversion that
has been in motion since the woman was put into that "backwards" hospital
gown. Now we have her normal bodily patterns of relating to the world
quite literally turned upside down: her buttocks at the table's edge,
her legs widespread in the air, her vagina totally exposed. As the
ultimate symbolic inversion, it is ritually appropriate that this
position be reserved for the peak transformational moments of the
initiation experience: the birth itself. The official representative
of society, its institutions, and its core values of science, technology,
and patriarchy stands not at the mother's head nor at her side, but at
her bottom, where the baby's head is beginning to emerge.
Structurally speaking, this position puts the woman's vagina in the
relationship to society (through its representative, the obstetrician)
that her head normally occupies--a total inversion perfectly appropriate
from a societal perspective, as the technocratic model promises us that
we can have babies with our cultural heads instead of our natural
bottoms. The cultural value here is clearly on the baby, who is emerging
at the "top." As Lakoff and Johnson (1980) point out, in this culture,
"up is good; down is bad," so the babes born of science and technology
must be born "up" toward the positively valued cultural world of men,
in opposition to the natural force of gravity, instead of "down" toward
the negatively valued natural world of women. As we perpetuate our society,
we also symbolically enact the driving thrust upwards, in defiance of
earthly gravity, that has characterized it since its inception.
Conceptually speaking, the overthrow of the initiate's category system
is now complete: this position expresses and reinforces her now-total
openness to the new messages she is about to receive and itself
constitutes one of those messages, as it speaks so eloquently to her
of her powerlessness and of the power of society at the supreme moment
of her own individual transformation.
In spite of the strength of these covert symbolic messages, the
technocratic model of birth is overtly predicated on scientific fact.
When the discrepancy between scientific fact and actual practice becomes
as obvious as it is with the lithotomy position, that model must either
be abandoned altogether (as have many such paradigms of the past) or be
expanded to accomodate at least the most compelling pieces of scientific
evidence that challenge its standard operating procedures. For example, as
research showing the benefits of walking during labor gains more acceptance,
it is to be hoped that monitoring by telemetry will gradually replace the
kind that physically ties women down--but the fundamental values and
beliefs that necessitate electronic monitoring in the first place will
not have to change.
So it shall be with birth position. So much evidence has been gathered
that demonstrates the advantages of an upright position for pushing that
science has responded with the development of electronic birthing chairs,
in which the woman sits in a physiologically efficacious position for
pushing with perineum exposed (or covered by a sheet) and legs spread apart
on plastic supports. The symbolic ramifications of this chair are
considerable, as it places the woman higher than the obstetrician as she
delivers the baby, looking almost like a queen on a throne surrounded by
her servants. Yet, because the chair is incorporated into many hospitals
without any fundamental accompanying shift in core values and beliefs,
its potentials for empowerment of the birthing woman are often co-opted.
Placing the woman alone on her technological throne can become almost as
much a symbolic expression of depersonalization and objectification as the
lithotomy position itself. Although women can easily reach the controls on
the chairs to alter their position, medical personnel rarely provide this
information, usually preferring to retain such control. Because the chair
is elevated so high, women cannot get out of it to shift position between
contractions. Several studies show that some women who stayed in the
chairs to push for more than thirty minutes at a time developed hemorrhoids
and perineal swelling. Others complained that the chairs are uncomfortable
and prevented them from rocking their pelvis or otherwise moving during
second stage (McKay and Mahan 1984:113), or that their partners were now
too far away to touch them very much. (Early, low-tech birthing chairs and
hammocks in this country and others were designed to have someone sitting
behind the laboring woman, intimately embracing and supporting her [Ashford
1988; Jordan 1983].)
Thus it would appear that, in spite of the obvious physiological advantages
of the high-tech birth chair over the delivery table, being forcibly locked
into any position during labor is less preferable than being able to freely
change position as desired. Women who birth without technocratic control on
double beds, on stools, on beanbag chairs, on the floor, or in
water
frequently change positions, perhaps resting on their sides between
contractions, perhaps sitting or squatting to push (Ashford 1988;
Engelmann 1977; Jordan 1983; McKay and Mahan 1984; Odent 1984). But
this very unmechanical behavior is too incompatible with the technocratic
model to be a viable delivery option in most hospitals. Moreover, women
themselves have been so conditioned to labor and give birth lying down
that the idea of such alternatives never occurs to many (McKay and Mahan
1984:118). Therefore, though challenged, the dominance of the lithotomy
position continues.
