Currently, many positions are underutilized when it comes to women pushing during the second stage. The typical position is on the back with the legs held up or in stirrups. But more and more, we are understanding, and women are demanding that different positions should be used.
We know that upright positioning and movement are two ways that help us have an easier birth. We also know that the women’s pelvis has greater mobility and functional capacity to give birth than we are currently utilizing in mainstream medicine.
Mandy Rempfer-Kuncio, a pelvic health physiotherapist and birth doula, came to speak with our students on facebook about that topic and has agreed to let us share that with in our blog.
Q: “[There are a] huge variety of pushing options for a woman that want to squat! I’m curious what Mandy has to say about pelvic alignment in that sense”
A: I have to admit I’m a bit of a nay-sayer when it comes to squatting as a birthing position so let me explain why.
A truly optimal squat position for birth needs to have a number of characteristics:
1) Ideally, your feet should be flat on the ground in order to support you the best – you need to be able to fully relax your pelvic floor when pushing and this doesn’t happen when you are up on your toes, using your leg muscles to support you. A woman should be able to be “passive” in the squat, not “actively” using her muscles to hold her up.
2) Your tailbone and pelvis need to be untucked. This facilitates length and relaxation in the pelvic floor muscles and keeps the pelvic outlet widened and open. When we tuck our bums under, we start closing the pelvic outlet. We don’t want to push a baby out through a closed door.
3) Ideally, your feet should be at least parallel, or heels slightly wider than your toes (remember the video about opening the pelvic floor door). The opposite, heels in and toes out, shortens the pelvic floor and starts closing the pelvic outlet.
“In my experience, most north American women cannot do this adequately enough for me to recommend squatting as a stage 2 position.”
There is an easy test – mothers can simply try it and see! (preferably before birth)
Alternatively, in places and cultures where women have been squatting since birth and squatting to toilet – then squatting is a beautiful position for pushing.
However, the pelvis literally develops differently in shape in females who do that much squatting, particularly through their growth and adolescence. For most western women, we have not been practicing a deeply relaxed squat like that and our pelvises can literally be a different shape from all the chair and toilet sitting we do.
One workaround for this is to use a supported squat – either with the squat bar on the hospital bed, or suspension like with a rebozo, or a partner supported squat. However, the woman needs to be able to fully relax her pelvic floor, and ideally most of her leg muscles (particularly the hamstrings and hip flexors).
This is still REALLY hard to do, even in a supported squat. That’s why I think there is some research to suggest that squatting is associated with increased rates of perineal injury in American and Canadian women.
Q: “ Would it benefit American women who want to squat, to practice and get their body used to it? Is that possible in pregnancy?”
A: Practice would definitely help! But I think it should be started ideally before even pregnant, or in the first trimester at the latest – if the intention is to use it for birth (squatting is still a great activity for strength building throughout pregnancy).
This is because the further into pregnancy you get, the more hormonal influence there is on the connective tissue. However, the hormonal influence does not seem to affect muscle tissue in the same way. I would be worried about deep squatting started later in pregnancy because once the muscles hit their endpoint, you could very well be pushing into connective tissue and causing damage/pain in the pelvis, or somewhere else like the lower spine or knees.
(I find this a risk with some prenatal yoga too). I always tell my clients you should feel the sensations of stretch in the big muscle bellies, and not in joints. If you are feeling it in your pubic bone, SIJs, knees, or other joints, you need to back off.
Q: “What positions do you recommend for when the baby is still at a high station and you want to open the top of the pelvis?”
1) The first thing I would say is an upright position, with the belly positioned up over the pelvic inlet. This can utilize gravity to help pull baby down. Be wary of positions with a forward lean. If the belly is hanging out over space, baby is hanging out over space. Line the baby up with the exit.
2) The leg position is actually opposite from the video I made when we want baby to first drop into the pelvic inlet. [You can find that video on Mandy’s blog]. You can imagine this as “closing” the legs, or bringing the foot inside of the knee (closing the pelvic floor door). This will assist in opening the top. I’ve also heard this described as “ballet shoes”.
Q: What are the pros and cons of side lying?
Pros: Sacrum and tailbone are free to move, and it’s fairly easy to open the pelvic floor door. I would also say it’s good for tall-back positioning, as in keeping a long spine to facilitate lung oxygenation and good diaphragmatic excursion for pushing.
I really don’t think there are many downsides to side lying, except perhaps that its gravity-neutral (so gravity would not help quite so much). Side-lying is also good for slowing the pushing phase down. This can be helpful for multip women, or women who are worried about prolapse and pushing with too much force.
From a pelvic floor perspective, it’s protective to have a pushing phase that’s a little longer if it’s more gentle. Precipitous birth is a big risk factor for pelvic floor injury.