New Active Birth: A Concise Guide to Natural Childbirth. Janet Balaskas

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      Implications

      Based on research findings, various up-to-date studies and ancestral instinct, it is foreseeable that widespread changes with respect to labour and birth positions are inevitable in the management of labour and in the preparation of women for childbirth (27-30).

      As changes in position help to increase the strength and effectiveness of contractions, allowing a woman to be up and to walk about in early labour, especially if there are no complications, seems rational and good practice. A woman’s own instincts dictate to her that she should move around. Standing, walking about and assuming various sitting, kneeling and squatting positions, with any suitable means of support, causes the uterus to exert more pressure on the foetus and in turn on the cervix. Women should be guided more by their own feelings, comfort and need rather than by hospital convenience and obstetric fashion. Freedom of one’s body is necessary to find those positions which traditionally have been used to facilitate labour and delivery; positions which will assist one to attain maximum comfort, relaxation, ease and control.

      There is an infinite range of possible positions and no constant chronological order. It is the need to search for the most effective, efficient and comfortable positions that is common. The common need amongst women instinctively to keep changing positions will one day have to be universally recognised. This involves a different attitude to the management of labour, to maternity care generally and to antenatal preparation.

      A prospective mother needs not only knowledge of pregnancy, labour and delivery and the growth and development of babies, but also adequate physical preparation concerning the effects of varying upright positions and the cultivation of ease and comfort in them, so that she can actively and effectively help herself during labour. The emphasis during pregnancy will need to be on developing trust and confidence in her own body and on learning to discover her instinctive potential for childbirth and mothering. Her emotional and physical readiness for birth and her self-empowerment in pregnancy will become as important as good medical care in the antenatal clinic.

      Squatting

      Freedom to change position is more important than a single, optimal or best position during labour. It is unlikely that any woman would elect to remain in one position throughout labour. However, squatting is closest to nature’s laws and is known as the physiological position. A position is physiologically effective:

       when there is no compression on the vena cava and the aorta

       when the pelvis becomes fully mobilised

      Supported squatting seems to be especially efficient at the end of the second stage when the baby is being born. The squatting position produces:

       maximum pressure inside the pelvis

       minimal muscular effort

       optimal relaxation of the perineum

       optimal foetal oxygenation

       a perfect angle of descent in relation to gravity

      A supported squat is essential in a breech delivery as it reduces delay between delivery of the umbilicus and the head.

      Another useful position is the all fours position. The presenting part rotates inside the pelvis more easily when a woman is on all fours. This position can be especially useful if the baby is lying posterior or the birth is very fast.

      None of the women in all the recent studies were prenatally prepared to gain ease and comfort in the squatting, kneeling, crouching and all fours position. How much better would the upright groups of women have fared if they had the additional benefit of physical preparation. (A controlled study of this kind has not yet been done.)

      Ideal Maternity in Pithiviers, France

      Michel Odent and his staff have provided a setting for women to be active in labour at the maternity unit in the general hospital in Pithiviers in France. Here, for two decades, women in labour have had the freedom to follow their instincts in walking about and finding positions that are suitable and comfortable. He and his midwives, together with expectant mothers, have discovered many means of physical support during labour and delivery which have proved, over the years, to be a tremendous advantage in easing labour and especially delivery. They do not use continuous foetal monitoring, Pethidine, epidurals or forceps. Few episiotomies are given and induction is very rare. Their concept of obstetrics, to try not to disturb the normal physiology, is very different from conventional practice aimed at control. Also the physical and the human environment is very different – the birthing room has a home-like rather than a hospital atmosphere.

      In this unit there are about 1,000 deliveries a year. Professional care is the responsibility of Dr Odent and six midwives. The midwives work in pairs for forty-eight hours at a time followed by four days off. Each woman is given her own room throughout her stay and there are few rules. As labour advances, she walks to the birth room which has a low-level platform with many cushions, and a wooden squatting stool. There she is encouraged to remain active and change her position as many times as she wishes.

      Most women prefer to walk about, sit on the birthstool, kneel on all fours, squat and lean on their husband or the midwifes for physical support. Water is regarded as important and women, if they like, may take a warm bath or relax in a small pool which is available. No drugs are used, the membranes are not artificially ruptured. Most women adopt an upright position for delivery, usually a supported squat; others give birth on the birthstool or on the low double bed and some give birth in water. With the appropriate supported squat and the minimum disturbance of the expulsive reflex, there are no unnecessary perineal tears and episiotomies are rare.

      After the birth, the baby’s bath and the delivery of the placenta, the mother walks with her husband and her newborn back to her own room. Of the 1,000 births that took place in Pithiviers in 1981, only eight babies needed intensive care.

      Here is a maternity-care setting close to ideal. It has the safety of hospital delivery as well as the relaxed atmosphere of a comfortable and homely birth room. It is free of the frustrating regulations or limitations of routine hospital practices and is based on understanding of the instinctive behaviour of a woman in labour and her needs. They have a positive approach to an active, physiological birth with a natural outcome. The attendants are well-known to the mother and are constantly available during labour and delivery. Fathers participate and give their support. Women are given the freedom to move and adopt any position they find comfortable and the minimum use of drugs and interventions during labour are needed.

      If the majority of women at Pithiviers can experience Active Birth safely and naturally in such a unit, why not elsewhere?

      

      RESULTS OF 898 BIRTHS AT PITHIVIERS IN 1980

      Since the time of writing, Michel Odent is no longer living in France and is based in London where his work continues with women giving birth at home. There are now many similar units and the results of their work reflect the same striking contrast to hospitals where obstetric management is still routine.

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