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Michael Durtnall's views on Squatting Childbirth: Minimising injury in hospital and homebirth.
Michael Durtnall DC MSc FRCC (Ortho)
Fellow Royal Society of Medicine
Chairman: Sayer Back and Neck Pain Clinics London
The widespread, modern perception of childbirth is primarily ‘fear of pain’. This self-perpetuating reality is due to the very medical practices which have evolved in recent times to avoid it.
We see convenience for birthing professionals with a woman lying on her back, often with legs raised in stirrups with a frequently long, fully-medicalised labour which increasingly culminates in exhaustion and a Caesarian section or forceps, ventouse and episiotomy with varying degrees of trauma to mother and child.
The main problem is that lying on your back or sitting semi-reclined on your sacrum and tailbone causes the bony birth canal opening, the pelvic outlet, to be reduced by as much as 30% in comparison to the size of the pelvic outlet in a natural, squatting, gravity-assisted birth. Homo sapiens uniquely has the problem of very large-brained offspring relative to pelvic outlet. Despite the gradual overlapping to some extent of the cranial bones at the fontanelles, but without the aid of gravity, reclining means 'nothing to push against' whereas squatting or kneeling provides the floor or bed to push against.
Western mothers-to-be are now much older, more overweight and physically weaker than their mothers and grandmothers were at childbirth and so they find pushing difficult and quickly exhausting.
Enhancing the pelvic pathway for the baby's birth is common sense. There is no good medical reason to give birth on your back and every reason to give birth in a safer position that works with gravity, female anatomy and physiology.
Supported squatting or kneeling on all fours allows the sacroiliac joints and sacrococcygeal joints freedom to stretch apart under the influence of the hormone relaxin and lets the unrestricted coccyx move backwards as the baby passes through the widened canal.
This has always happened with all mammals - except for women in the last 200 years in the 'civilised' western world since Emperor Louis 14th decided on supine childbirth so his court could witness the birth of his heir. Strangely it has been the fashion since.
Recent Supine Positioning which narrows the birthing canal, by lying on your back, increases the risk to the baby of:
- need for forceps or vacuum/ventouse delivery
- broken clavicle/collarbone
- pressure on baby’s neck vertebrae
- excessive head moulding
- compression of umbilical cord
- hypoxic stress on baby from poor positioning of baby relative to pelvis
- brachial plexus injury
- broken humerus
- disruption of the baby’s oxygen supply
and increased risk for the mother of:
- less effective contractions
- labour slowing and not progressing
- possible increased hypotension & pregnancy-induced hypertension
- ineffective pushing
- illusion of cephalo-pelvic disproportioin due to reduced pelvic diameters from poor positioning
- increased risk of need for Cesarean section
- increased risk of need for Caesarean section - with all risks of major surgery
- strain and tearing to the maternal tissues
- back pain - risks of epidurals.
- fractured or dislocated coccyx/tailbone - moreso with forceps / ventouse.
Janet Balaskas, recognised pioneer and guru of natural childbirth and author of “Active Birth” reiterated the danger of being in a supine position: “In the semi-sitting or reclining position the mother’s weight rests on her coccyx and sacroiliac joints which are thus immobilised and the pelvic capacity is reduced".
“Your coccyx is designed to move (backwards) out of the way as your baby’s head descends. Sitting on your coccyx during birth restricts the pelvic outlet and can also lead to dislocation of the coccyx, which can be extremely painful for months after the birth.”
My study of sacroiliac movement in squatting childbirth leads me to the following logical mechanism: the squatting mother’s body weight acts down through the abducted hip joints which in tandem with the loosening of the sacroiliac and pubic symphysis ligaments, act to flare the lower pelvic outlet. As delivery nears, the mother squats lower with her legs wider apart. In this position the large thigh adductor muscles gradually and strongly stretch apart the symphysis pubis. Simultaneously the inferior sacrum glides posteriorally nutating relative to the ilia under the pressure of the engaged foetal head bearing constantly down with gravity and maternal contractions, thus further increasing the outlet, dilating the cervix and effectively delivering the babies head. The whole process of cervix dilatation and hormonal release is extremely complex and finely tuned with body movement, gravity and soft-tissue stretching.
This incredible process is completely disrupted by lying supine with an epidural, later frequently followed by injection of syntocinon to kick-start contractions which are slow (due to supine position) against a cervix which hasn't yet dilated sufficiently, causing increased intrauterine pressure, resulting in maternal exhaustion, pelvic and foetal hypoxia) and distress, leading to emergency Caesarian with increased risk of post-surgical infection. This is often followed by mastitis and then antibiotics. This disastrous cascade of medicalised intervention limits the exhausted mother's ability to bond with and breast-feed her baby for the UK typical 6 weeks until they give up - a far cry from two years of optimal breastfeeding.
But this is all considered "normal" in the 'West' and progressively in third-world countries who slavishly follow the 'civilised' modern medical practice of supine childbirth.
It is NOT normal - and needs a total rethink based on tens of thousands of years of erect human childbirth. Even our smaller-brained and smaller-pelvised mammalian relatives squat to deliver.
Midwives well-trained and confident in natural childbirth acting with the back-up of modern emergency medicine is the optimal path.
I have been fascinated by genetic variation across the world in collagen and joint hypermobility for many years. I studied at University College London with Professor Rodney Grahame, the world's leading expert on hypermobility. With this in mind and in view of my experience in treating pregnant women suffering sacroiliac subluxations, coccyx dislocation and fracture it is clear that most mothers at childbirth are much OLDER now than ever before at childbirth in the history of mankind. Collagenous ligaments, tendons and therefore joints lose flexibility progressively with age
So, 21st century mothers in their 30's and 40's have LESS FLEXIBILITY and their sacroiliac, pubic and coccygeal range of movement is significantly reduced in comparison with mothers in their teens and early twenties which had always been the norm through millennia until the 1970/80's. This followed the advent of 'The Pill', widely available contraception, which allowed women to delay having children later and later.
As joint and collagen flexibility reduces with age, childbirth has become far more challenging than in the past due to the older age of mothers in recent decades. Also, far more women have been sedentary at desk jobs with administrative computer and laptop work in offices from school and college days until their first maternity in their late 30s and they are often very unfit, overweight and stiff jointed. Add to this the comparatively recently concept of giving birth semi-reclining or supine and there you have the reasons for a continuing rise in rates of Caesarian section ... around 30% of all UK births. Especially in genetically stiffer NORTHERN European more hypomobile people.
Most people's of the world... Indians, Arabs, Africans and Chinese are generally at the more HYPERMOBILE end of the spectrum of tissue and joint mobility and most living in rural areas still give birth squatting. Northern European Caucasians, Celts, Germans, Scandinavians as well as peoples from mountainous regions in China and Northern Pakistan are ranged generally towards the less flexible or hypomobile end of the spectrum ... making childbirth, particularly in now much OLDER mothers, much more challenging. All the more reason to bring back squatting in the west as the norm for safer, quicker, less injurious and 'mother in-control' childbirth.
There are also four main variations in pelvic shape from Anthropoid, Gynaecoid, Platypelloid who tend to give birth vaginally, ranging to the 5% Android (male-shaped) pelvis types in women who almost certainly cannot give birth vaginally.
The sacrococcygeal joint, the joint between the sacrum and the coccyx or tailbone and inter-coccygeal joints, also soften in pregnancy; it is designed to swivel backwards to widen the outlet of the pelvis as the baby emerges. Clearly, this is impossible if the mother is sitting or semi-reclining on her coccyx.
Benefits of Proper Positioning
Opening the birth canal 'outlet' by adopting positions which support a woman’s anatomy reduces risks of trauma to baby and mother. Moving around during labour and using the birthing position of partner sitting on a bed with woman facing him/her and arms hanging onto his /her shoulders or around his/her neck or kneeling and leaning forward against a support or simply squatting or on all fours offer huge benefits:
Freedom to move to use GRAVITY with, instead of against, you and intermittently changing position during the first and second stages of labour allows the pelvic joints, the sacroiliac joints, under the influence of relaxin hormone to loosen and separate along with the pubic symphysis joint at the front of the pelvic ring.
This will further increase the pelvic outlet and volume and space for the babies large head to turn and pass through the pelvis and can dramatically reduce the incidence of infant shoulder dystocia with:
- less pain and less maternal exhaustion
- greater maternal control and involvement in the birth
- more effective contractions and progression of labour
- baby descending and presenting in an optimal position
- gravity helping pelvic mechanical flaring
- improved pelvic bloodflow and oxygen supply to the baby
Progression of labour is enhanced by constantly changing position with swaying pelvic movement from side to side, backwards and forwards in a legs-wide-apart, knees-bent stance. These movements allow the pelvis to subtly adapt shape and size so the baby's head can move to the ideal position during first stage of labour and for the baby's head to rotate and descend during the second stage of labour. Movement and an upright position helps the frequency, length, and efficiency of contractions. Gravity helps the baby descend more rapidly while constantly changing position maternal and movement helps ensure a continuous oxygen supply to the baby.
[“There is evidence to suggest that if the mother lies flat on her back then vena caval compression is increased, resulting in hypotension. This can lead to reduced placental perfusion and diminished foetal oxygenation. The efficiency of uterine contractions may also be reduced”
The Squatting Position for the Second Stage of labour: Effects on labour and on Maternal and Foetal Well-Being Jane Golay MSN, CNM1,*, Saraswathi Vedam MSN, CNM2, Leo Sorger MD, FACOG3 Article first published online: 2 APR 2007 Birth Volume 20, Issue 2, pages 73–78, June 1993]
A cohort study was designed to assess the effects of maternal squatting position for the second stage of labor on the evolution and progress of labour, and on maternal and foetal well-being. Outcomes from 200 squatting births, randomly selected from a sample of 1000, were compared with 100 semirecumbent births, randomly selected from a sample of 300. Data collection was by chart review. The two groups were similar with respect to most antepartal, intrapartal, and socioeconomic variables likely to affect labor outcomes. The mean length of the second stage of labor was 23 minutes shorter in squatting primiparas and 13 minutes shorter in squatting multiparas than in semirecumbent women.
Squatting women required significantly less labour stimulation by oxytocin during second stage (P = 0.0016), and they showed a trend toward fewer mechanically assisted deliveries. Significantly fewer and less severe perineal lacerations occurred, and fewer episiotomies were performed in the squatting group (P = 0.0001).
Thus a reduction in episiotomies, fourth degree tears and less shoulder dystocia (damage or dislocation) by keeping active and off your back.
The pelvic outlet is as wide as possible, optimal foetal position and an open path through the birth canal, using gravity and constant changes in position and movement to maximise the pelvic outlet. This also allows the mother to be in control of the birth of her child with minimised risk of injury to herself and her baby.
In most cases induction of labour should be avoided, allowing progression to full term, with the 'natural finely-tuned birth process to unfold. Girls and women need to understand and practice fitness, avoidance of obesity, an active lifestyle and the complex pros and cons of a return to younger and natural childbirth.
Vaginal delivery involves stretching and frequently tears or episiotomy of pelvic floor muscles which compromise pelvic stability. Abdominal and pelvic floor strength needs to be addressed to prevent pelvic pain and low back pain and to minimise urinary incontinence and uterine prolapse.
The system of childbirth in UK hospitals needs urgent review and change.
729,000 babies were born in England and Wales in 2012 - a rise of 20% from 2002.
15 women in 100 have an unplanned caesarean and 10 in 100 births are planned caesareans. 2 in 100 deliveries are home births.
Approximately 40 in every 100 deliveries are "normal" births - women who spontaneously go into labour and do not require any real intervention other than support and pain relief.
A home birth carries a higher risk for babies of first-time mothers, according to a landmark study published in the British Medical Journal. However, the chance of any harm to the baby is under 1%, the study of almost 65,000 births in England found. For a second birth there was no difference in the risk to babies between home, a midwife-led unit or a doctor-led hospital unit.
Midwife-led care was in general much more likely to lead to a natural birth.
The Oxford University Birthplace study is the largest carried out into the safety of different maternity settings - comparing births at home, in midwife-led units attached to hospitals, either stand-alone or doctor-led hospital units. All the women followed had healthy pregnancies and began labour with no known risk factors. It found that, overall, birth is very safe wherever it happens. The rates of complications, including stillbirth or other problems affecting the baby, was 5.3 per 1,000 births in hospital compared with 9.3 per 1,000 home births.
Prof Peter Brocklehurst, who led the research, said there were clear differences between women having their first baby and those having subsequent children. He said: "The risk of an adverse outcome for a baby are higher for a woman planning her first baby at home than in all of the other settings, but there was no difference between the midwife and hospital obstetric units." About 45% of women planning to have their first baby at home were transferred during labour, although this was mainly because of delays in giving birth and the need for an epidural pain-relief injection, rather than because the baby was in distress.
Rates of normal birth:
60% hospital obstetric unit
76% hospital midwife unit
83% freestanding midwife unit
90% home birth
There was no difference in risk when women were having their second baby, whether that was at home, in a midwife unit or a traditional hospital setting.
Currently, about 90% of babies are born in medically-led hospital obstetric units. And in many areas women have a limited choice of where to have their baby.
This Oxford University research raises fundamental questions about maternity care in the UK. Nine out of 10 babies are born in medically-led obstetric units. There has been a trend to centralise this into fewer and larger centres to guarantee consultant cover. Many of the decisions have taken place without definitive evidence about the safety for babies and the experience for mothers. This study provides that.
It reveals an unexplained difference in the rate of normal birth between units run by midwives and those run by doctors. The disparity on emergency Caesarean sections is particularly striking. It suggests a different culture in the way midwives and doctors see birth, with doctors concerned about risks and midwives focused on normality.
Mary Newburn, from the National Childbirth Trust (NCT), said this research should drive an an expansion in midwife-led care, either at birth centres or at home for the half of women expected to have a low-risk birth. "It's so disappointing that, at the moment, only 50% of NHS trusts offer midwife-led care and only 3% of births are home births. "We think those figures show women don't really have access to out-of-hospital options."
The research also confirms that midwife-led care is much more likely to lead to a normal birth - without any interventions, including forceps or ventouse. That was true whether the baby was born at home or in a midwife-led unit.
The emergency Caesarean rate for low-risk women in the study was 11% in doctor-led units compared with only 2.8% at home, and 4.4% in a midwife led unit on a hospital site. This research did not involve analysis of squatting or upright birth in comparison with supine birth - useful to help shape practical changes in gravity-aided childbirth.