Why is it that OBGYNs tend to only use one birthing model?

[brotherbloat]

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Hello,

As a pre-med and woman planning to get pregnant soon, I have been doing some research on birth. Why is it that OBGYNs seem less likely to offer alternative birthing positions, such as squatting or in a chair or in a tub of water than the traditional lithotomy birthing position? In my research, it seems that this position is the worst for the mother, in terms of gravity not helping, but is most convenient for the Dr. Why isn't some sort of semi-sitting position or squatting made more available for women who want to deliver with an OB, but don't necessarily want to be confined to what looks like a less effective birthing position?

Thanks,

BB

 

[jvarga]

This is a common misconception. Many OBs today are receptive to individual requests for birthing positions and even birthing plans. Of course, these requets have to be made with plenty anticipation and have to meet the approval of the birthing facility (ie hospital) and nursing staff. If no requests are made, then most OBs prefer to deliver in the standard lithotomy position since this is the most frequently used position worldwide. Many arguments have been made for alternate birthing positions, but no consistent clinical data has supported its use. Just remember, all positions have inherent risks and benefits and all of them are equally "natural". Which position you may end up delivering in is highly dependent on your talks with the professional (midwife vs md) who manages your pregnancy. Good luck.

 

[brotherbloat]

How can all of them be equally natural when it makes sense that if gravity assists you, you have fewer tears and an easier time pushing (i.e. squatting or semi-sitting, rather than flat on the back?) I guess I don't understand why lithotomy is even used anymore, other than for the Dr.'s convenience. Why is this position so widely used in the US? What are it's benefits for the woman over alternative positions?

 

[fuzzyerin]

From what I've seen and what I understand, it's not gravity that gets these babies out ~ it's a very strong contraction of the uterus in combination with bearing down and lots and lots of pushing. The baby does not drop out of the uterus by gravity. It isn't going to fall out of the uterus. If you are comfortable squatting and pushing at the same time, while keeping your balance or having multiple people prop you up, then it might be worth trying. I am partial to the idea of lying down on my back in lithotomy position because I personally think that would be easier for me. It also gives the doctor accessibility to stretch the vagina with his/her fingers in preparation for the delivery. Also, it gives the doctor the best view to catch the baby, which is immensely important. Yes, this is the way it has traditionally been done and some of the reason that persists is quite possibly the current litiginous nature of the general population against ob's. Regardless, it is an individual decision.

I'd caution you about just reading what you find on websites. See if there are any clinical studies that show less tearing and greater ease of birth based on the position (and if there's not, this could be a very interesting study to be done!). Antedotal information is not what you should base your decision on.

And if you really want to give birth in a tub or some other variation, why don't you consider a midwife or alternative birthing center? They are more open minded about non-traditional ways.

 

[minime]

Although I've had only a limited experience with patients with birth plans (I'm an MS4, have done five months of OB and about 60-70 deliveries) I have seen 4 or 5 pts. with birth plans and 3 of them had bad experiences. Don't set yourself up for disappointment by having unrealistic expectations.

One mother insisted that her baby not be taken to the warmer after delivery. It got cold and developed transient tachypnea and was admitted to the NICU.

Don't get me wrong-I'm going into OB and will let my pts. do what they want, but from my experiences thus far we do deliveries in a hospital setting the same way every time for a reason....

 

[NewGuyBob]

Most patients get epidurals for pain management. This limits the number of positions you can try. It's hard to squat if you can't feel or control your legs 😉

 

[DrBuzzLightYear]

is there any data on birthing into pools of water? this sounds like a REALLY bad idea to me.

 

[neilc]

How can all of them be equally natural when it makes sense that if gravity assists you, you have fewer tears and an easier time pushing (i.e. squatting or semi-sitting, rather than flat on the back?) I guess I don't understand why lithotomy is even used anymore, other than for the Dr.'s convenience. Why is this position so widely used in the US? What are it's benefits for the woman over alternative positions?

i actually just read a review article on perineal lacs. based on the current literature, the patients position has no effect on incidence of perineal lacs. i can try to dig up the reference, it was a great article. according to the article, the only effective modality for decreasing incidence of perineal tears is perineal massage, and it is only effective in primips.

as far as why the position is used...it seems that in instances of shoulder dystocia, you would want to be able to throw the hips up, get some suprapubic pressure on board, etc. basically, the whole reason for delivering in the hospital is to be there for the rare complications, and the lithotomy position seems the best when potential complications and interventions are kept in mind.

is there any data out that compares lithotomy vs. other models? i think if there is a lack of data, then you will have a hard time convincing folks to change the standard of care.

 

[neilc]

here is an abstract i pulled up:

Position for women during second stage of labour
Posted 07/01/2004

JK Gupta; GJ Hofmeyr


Date of Most Recent Substantive Amendment: 2003 April 25

Background
For centuries, there has been controversy around whether being upright (sitting, birthing stools, chairs, squatting) or lying down have advantages for women delivering their babies.

Objectives
To assess the benefits and risks of the use of different positions during the second stage of labour (i.e. from full dilatation of the cervix).

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group trials register (16 April 2003).

Selection criteria
Trials that used randomised or quasirandomised allocation and appropriate follow up and compared various positions assumed by pregnant women during the second stage of labour.

Data collection and analysis
We independently assessed the trials for inclusion and extracted the data.

Main results
Results should be interpreted with caution as the methodological quality of the 19 included trials (5764 participants) was variable. Use of any upright or lateral position, compared with supine or lithotomy positions, was associated with: reduced duration of second stage of labour (10 trials: mean 4.29 minutes, 95% confidence interval (CI) 2.95 to 5.64 minutes) this was largely due to a considerable reduction in women allocated to the use of the birth cushion; a small reduction in assisted deliveries (18 trials: relative risk (RR) 0.84, 95% CI 0.73 to 0.98); a reduction in episiotomies (12 trials: RR 0.84, 95% CI 0.79 to 0.91); an increase in second degree perineal tears (11 trials: RR 1.23, 95% CI 1.09 to 1.39); increased estimated blood loss greater than 500 ml (11 trials: RR 1.68, 95% CI 1.32 to 2.15); reduced reporting of severe pain during second stage of labour (1 trial: RR 0.73, 95% CI 0.60 to 0.90); fewer abnormal fetal heart rate patterns (1 trial: RR 0.31, 95% CI 0.08 to 0.98).

Reviewers' conclusions
The tentative findings of this review suggest several possible benefits for upright posture, with the possibility of increased risk of blood loss greater than 500 ml. Women should be encouraged to give birth in the position they find most comfortable. Until such time as the benefits and risks of various delivery positions are estimated with greater certainty, when methodologically stringent trials' data are available, women should be allowed to make informed choices about the birth positions in which they might wish to assume for delivery of their babies.

 

[cdr50]

Unfortunately, NewGuyBob is right. I don't think it's the OBs as much as it's the patients. Predominantly in this country women have alot of anxiety about the discomfort of labor and will be requesting an epidural at the first sign of true labor. After they are numb with an epidural thay won't be doing any squatting. More power to you for wanting to participate in your childrens births.

 

[KidDoc29]

Transient Tachypnea of the Newborn (TTN) is a benign process, the etiology of which is not really understood. Although there are several theories including the most-cited that a C-section doesn't allow for "squeezing" of the neonatal lung tissue which has been posited as an augmentive mechanism for fluid clearnce form the lung (in addition to inhalation and pulmonary vascualture relaxation). Temperature instability, ie from not being taken to an Ohio table, would in no way create TTN.

-Pediatric Resident

 

[PCSOM]

Hello,

As a pre-med and woman planning to get pregnant soon, I have been doing some research on birth. Why is it that OBGYNs seem less likely to offer alternative birthing positions, such as squatting or in a chair or in a tub of water than the traditional lithotomy birthing position? In my research, it seems that this position is the worst for the mother, in terms of gravity not helping, but is most convenient for the Dr. Why isn't some sort of semi-sitting position or squatting made more available for women who want to deliver with an OB, but don't necessarily want to be confined to what looks like a less effective birthing position?

Thanks,

BB

From what I have learned, lithotomy position is widely used in the US due to the fact that when the girl is in that position with legs spread WIIIIDE apart, it gives the physician an easy access to the birth canal. the goal during birth process is to give as much space as possible for the fetus to pass. When the pelvic os is not wide open or may be when the os has less space, the fetus might get trapped and there may be some issues of should dystocia. Bigger the os, the better for baby to pass easily. Also, if pt. chosses to do squatting, sitting, head up side down or whatever other position, and if the infant is stuck, you might face with shoulder dystocia in which the physician has to use McRoberts maneuver. this is maneuver to reduce a fetal shoulder dystocia by flexion of the maternal hips. for this, you need lots of open sapce.

overall, if you talk with a physician, he/she should not mind anyother positions. because the more it's easier for the pt., the faster and easier the delivery would be.

hope this clears some confusion.

ps. gravity has nothing to do with this. and yes, the myth about pushing is wrong. no matter, how much the pt. pushes, the thing is going to do whatever it will do even if the pt. don't push squat. so, you can just sit back, relax, watch a movie, and enjoy pop-corn. btw, congrats...

 

[cdr50]

re:
>"...research on birth... alternative birthing positions... traditional... effective birthing position..."


(interesting to) look at the literature and text on birthing techniques employed by folks outside modern western society. look at methods and techniques used by women throughout the world... throughout history. look at how woman in africa deliver. in nigeria, ethiopia. what positions are used in the middle east, in indonesia, in china and mongolia? what were the preferred positions to woman in tibet throughout the eighteenth century? do preferred techniques today differ from those used in the past?

preferred positions are defined by circumstance. many techniques, methods, and positions have been employed throughout history... and any number of combinations can (and should!) be used ... to improve the efficiency and effectiveness of the birthing process.

delivery can be smooth and natural... with the woman assuming any position she needs...
or
it can get all screwed up with a whole lot o' complications.

(many) modern american womens...
have needs differ'nt than womens throughout the rest of the world (and history).

some women like having everything done for them... and find the whole process of labor and delivery to be inconvenient and unenjoyable... while others find it to be a rich and totally exhilarating process.

positions vary.

whatever the circumstance(s), women (generally) end up supine (in or out of water)... legs spread and pushing... or legs closed with belly openned.


re:
>Why is it that OBGYNs seem less likely to offer alternative birthing positions

time and circumstance, girl.
style.

there aren't a whole lot of options! and

docs are rarely involved with labor! when it comes to delivery, folks 're generally focused on gettin' the job done. folks like to control events. rarely, is fetal delivery allowed to transpire slowly and naturally.

docs like control!


re:
>"...planning to get pregnant soon..."


we should talk more about this!



l

 

[fergusondoc]

I don't think its that OB/Gyn's don't like alternate positions. The problem is that it is very difficult to get the mother back into the lithotomy position when there is NRFHT for an operative delivery. This even more true for shoulder dystocia. The last thing I want to do is to have get more nurses just to get the patient back into a good position. When you have 5-10 minutes to save a life I don't like to waste time.

 

[MaybeBabyDoc]

Though I am a proponent of "different" positions for delivery, in a hospital setting, lithotomy is simply easiest and most efficient.

Positioning while laboring, however, is a different issue. I encourage pts to adopt whatever positioning they are comfortable in, barring fetal distress. Even while pushing, whatever position they feel most powerful and find easiest to "harness" the forces to push I allow them in.

However, unless the pt is extremely uncomfortable or uncooperative, delivery is ultimately accomplished in the lithotomy position. I have had a pt deliver on her side and on her hands and knees.

Bottom line for you dear "pregnant soon" is to thoroughly speak with your provider re: your wishes for the time of delivery. Be clear on whether you will need to accomplish your goals by delivering in a traditional hospital setting, birthing center or at home.
And while you are researching options, please do not be deluded as to storybook outcomes for those with birth plans, or those who deliver at home or in birthing centers. All will have drawbacks AND benefits. It all depends on each individual and each pregnancy. 😉

 

[Diane L. Evans]

lithotomy position used primarily secondary to widespread epidural use and maily is the best position to deliver if one suspects dystocia (large baby small pelvis shoulder getting stuck). Also training is by this method since delivery of anterior and posterior shoulders and reduction of nucal cord (cords around baby's neck) can most easily be detected and removed.

I would get the book what to expect when your expecting and also a labor book so that you can understand the cardinal movements of labor. As far as underwater births they are reserved for low risk multiparous (mom's who have delivered before) as if something happens i.e fetal distress/dystocia it is hard to climb into the tub to salvage the infant.