Positions in Labour
When the big day is nearing your mind begins to turn to how are things going to go in labour. In a previous blog we talked about pain relief in labour. One of the things we mentioned was that different positions can provide relief from certain types of labour pain. So now we are going to look at what those positions might be, when they are most effective, and how they affect the positive progress of your labour.
Fast and Furious
We might think we want to get labour over and done with quickly because we know that it will hurt. But in reality, labour will take as long as it takes, and there are some risks to a very quick labour, not least of which is serious tearing. So what we should be aiming for is strong, steady progress – not a fast and furious race to the finish line.
Generally, you are considered to be in early labour until you are around 3cm dilated, and the mantra here is really, rest, eat, sleep, repeat.
Rest – getting some rest to ensure you have the energy to get through the next phases of labour can be a good idea. The best position here is to lie on your side with your top leg bent and a pillow between your knees. If the contractions aren’t too strong, try and get a little sleep, or meditate.
Eat – aim for something light and nutritious. Try and avoid heavy meals, it’s best to snack. And remember to stay hydrated.
Move – gravity is your best friend in labour, so try to keep moving, Walking – even dancing – will help move put pressure on your cervix, speeding up your dilation and helping the baby get into the right position.
Generally, unless you have a very quick labour, you will have plenty of time for a bit of all three, which is the ideal.
From about 3 to 10cm is known as Active Labour. This is where things really start to ramp up. The aim here is to get the baby into the right position, make sure your contractions are nice and strong, and open your pelvis so the baby doesn’t have too tough a time moving through the birth canal.
There are lots of positions here that will help with all three goals:
- Upright – as in Early Labour, the weight of the baby will help efface the cervix. If the contractions are strong, lean up against your partner, a wall or a piece of furniture. But try to stay as upright as possible, especially in between contractions.
- Hands and Knees – this position helps move the baby to the anterior position if it is in the posterior position, and can provide some relief from lower back pain, It also means you are in a good position for back massage, hot and cold packs. And it allows you to move – swaying to music can be good – all of which help labour progress at a steady pace.
- Kneel or Squat – this allows you to drop the weight of your belly on your legs, but remain upright – there’s that gravity again!
- Sitting – on a bed or a ball. Sitting cross legged on a bed allows you to rest your belly. Rocking on a ball is good. If you are on a ball, make sure you have someone to support your stability during contractions.
- Moving – particularly between contractions, if you can pace, rock or slow dance supported by your birth partner, it will help open your pelvis and allow the baby to move down.
Second Stage – Pushing and Birthing
You will most likely be tired, but if you can get on all fours and keep that pelvis open things will move more quickly. If you don’t think you can manage that, at least try to sit upright, kneel or squat. I can’t stress enough how much gravity will help from beginning to birth!
Sometimes, particularly in hospital births, you will be encouraged to move to what is called a supine position for birth. This means lying down on your back. Whilst this is in some ways the most convenient position for the midwives and doctor, it is not the most efficient position for mum and baby. In fact, in this position, the birth canal curves upwards, so you are fighting against that gravity we have talked about, To see how the baby moves through the pelvis, watch this video: https://www.facebook.com/colchesterbirth/videos/1773156409409529/
Don’t be afraid to speak up and tell your attendants what you would prefer. They will always let you know if there is a medical reason why it’s not a good idea.
What to Try and Avoid
Birth is a very personal experience, and ideally a labouring mum should be able to choose how she approaches it, providing there are no dangers to mum or baby.
However, there is one position, often preferred in hospitals, that should be avoided if possible. The World Health Organisation, in the publication ‘Care in Normal Birth’ says that “women in labour should be allowed to adopt any position they like, while preferably avoiding long periods of lying supine”.
When you lie on your back the weight of the baby can restrict mum’s blood flow, potentially reducing your oxygen, and as mentioned earlier, the upright tilt of the birth canal in this position will show things down. Gravity really is the single most effective tool you can use during your labour.
This is your birth, your body and your baby. Don’t be afraid to tell people what you want and need.
If you would like to talk about the sort of birth you would like, or what benefits a doula can bring to your birthing plan, please get in touch and we can have a chat about your birthing dreams:
A birth that needed a doula
I had my third child when I was 38. Because we had moved I was using a new obstetrician and a new hospital. I didn’t even know what a doula was. But boy do I wish I had had one!
Early in my pregnancy my mother was told the cancer she had undergone surgery for the previous year had spread to her lungs and her liver. It was inoperable, and her condition deteriorated quickly. By September – my baby was due in January – she was unable to leave the house.
I spent my days dropping my children at school and preschool and driving to my parent’s home nearly an hour away, so I could help Dad care for Mum. My 4 year old went from 3 days at preschool to 5, and I had to rely on friends to pick them up if I was running late. A couple of weeks before I was due, Mum was moved to a hospice because Dad could no longer manage her needs.
My second baby had been quite big – 4.4kg – and his shoulders got stuck. So the doctor decided to induce me. I agreed to the prostaglandin gel, but not to any further intervention. Shortly after we arrived at the hospital and the gel had been inserted Dad called to say Mum’s doctor had told him it would not be long and he should come right away. There was nothing I could do but wait for a birth, and a death.
By early evening I was not even in first stage labour and I was frustrated. Signing myself out of the hospital, I went to visit my mother to say goodbye. Since it was my third baby, I could tell labour was not far off, and since Mum was not conscious, I said a brief farewell and went home to wait.
We arrived back at the hospital in the early hours of the following morning. After being admitted I was told if I wanted an epidural I would have to have it now as the anaesthetist was going home. Since my previous births had been very long, I agreed even though I wasn’t ready.
Just as the anaesthetist was finishing my epidural a woman arrived who was in active delivery in her car. Everybody rushed out to help. The emotion of the day had taken its toll and my husband and I dozed off. I woke some time later unable to feel anything at all from the waist down. In the chaos of the emergency arrival, the midwife had forgotten to lower the level on the epidural drip. I begged them to stop the drip and eventually they did, but I felt completely disconnected from my body and what was happening.
Joy and Grief
Hours later I delivered a healthy baby boy. Knowing my Dad and brother were with my Mum, I asked my husband to call them so they could let her know, even though she wasn’t conscious. An hour later she passed.
I was an emotional wreck. My husband had to go home to our two older children, my Dad and brother were making arrangements for my Mum and I was alone in the hospital with a beautiful new baby boy, grief and joy at war.
The nurses were kind, but they were run off their feet. Despite being a well known and respected hospital, they were understaffed. Being a third time mum I was left pretty much to my own devices. Obs were taken, but the nurses were in and out in a flash. And while they were with me their pagers were constantly going off, distracting them. I needed someone to talk to, but there was nobody.
The following day I began spiking a fever that caused me to shake uncontrollably. I couldn’t even hold the baby. Blood was taken, but they couldn’t find the cause. The doctor wouldn’t allow me to go home until I had gone 12 hours without a spike. But I had a funeral to go to.
Finally, at 10:30 the night before my mother’s funeral the doctor gave the OK for me to leave. I had taken a lovely little navy and white suit to bring my baby home in, but it was late at night, raining and unseasonably cold. My husband brought a warmer suit from home. It might sound silly with everything that had happened, but he grabbed a worn out handed down growsuit from the bottom drawer – two sizes too big. I cried. My beautiful baby was going home from the hospital in a faded onesie with the sleeves rolled up and legs dangling empty.
The next morning I was up and out of the house with two children and a brand new baby, attending my mother’s funeral in a fog of confusion, grief and exhaustion.
If only I had a Doula
Having a doula would have made all the difference. Someone would have been awake to alert the midwife that the epidural drip needed to be turned down. Someone would have been there to support me and my husband when Dad rang to tell us mum had passed. Someone would have been there making sure I was not alone in my room in the days following the birth. And someone would have made sure that the warm outfit brought to the hospital for my dear little boy to wear home would fit!
In the days following I would have given just about anything for someone I trusted to take the baby for a walk so I could grieve in solitude, if only for a little while. And maybe take care of a meal or two so I could take some time to help my older children understand the incredible shift in their world. If only I had known about Doulas.
My daughter – the oldest – is now 23, and I hope I will be there to help her when she eventually has her first baby. But even if I am, my gift to her won’t be an expensive pram, or carseat. It will be the gift of a doula. That kind of help is priceless.
Tearing – Prevention and Cure
One of the things that most concerns women when thinking about labour – apart from the contractions of course – is ‘tearing’. This refers to the tearing of the perineum and is unfortunately often part of giving birth. But there are a number of things you can do to avoid, or at least reduce tearing.
What is the perineum?
The perineum is the muscular area between the vagina and the anus. It supports the posterior (rear) wall of the vagina. During childbirth this area needs to soften and stretch to allow the head and shoulders of the baby to emerge safely.
For many years it was common practice to perform an episiotomy, a cut in the perineum either directly towards the anus, or angled down and away to the side, to help make room for the baby and avoid ‘tearing’. This is no longer standard practice unless there are real medical reasons as research has proved a natural tear carries less risks and heals better. These days episiotomies are only done if the baby is in distress and needs a quick delivery with forceps or vacuum, the cord is being crushed, or the labour has been very quick and the perineum has not had time to stretch at all.
How to Avoid Both
So how can you prepare your perineum for all the stretching it will have to do and hopefully avoid both tearing and an episiotomy?
Preparation is the key
In the later weeks of your pregnancy – from about 34 weeks on – you can start getting your perineum ready for birth.
Massage – daily massage will help relax and stretch the muscle. Your doula can show you how this is done. You can use vitamin E oil, coconut oil, or Perineal Massage Oil from Blissful Herbs, which contains calendula, rosehip and lavender.
Balloon – some women find massage difficult, and there are now a couple of devices a bit like a balloon on the market that you can insert and inflate to gently stretch the muscles. Your doula can let you know where to get these and how to use them.
Exercises – since your perineum is attached to the pelvic floor, the pelvic floor exercises you are probably already doing will help stretch this muscle. Your doula can recommend additional exercises that will not only relax the tissues of the perineum, but also prepare your body to give birth in an upright position and fully stretch your pelvis.
Protecting your Perineum during Labour
OK – so you’ve done all your exercises and your massage and now you’re in labour. What can you do to continue to protect your perineum?
Upright Birth – an upright position such as kneeling, squatting, standing or even on hands and knees will help the perineum begin to stretch early in labour by putting the pressure of the weight of the baby on the muscle.
Water Birth – a water birth has been shown to reduce the likelihood of tearing as it not only relaxes the perineal muscle, but relaxes the whole body and reduces anxiety.
Perineal Compress – holding warm damp towels against the area, especially during pushing and when the baby is crowning, not only relaxes the muscle but provides it a little extra support.
Baby’s Position – the optimum birth position for your baby is Occiput Anterior. This means head down, facing mum’s spine. In this position the head is at the best angle to come through the birth canal and vagina. If your baby is not in this position it is sometimes possible to ‘spin’ your baby. Your doula or midwife can give you advice on this.
Time – As long as neither you nor your baby are in distress, take your time. Listen to your body. It will tell you when you need to push. When the baby is crowning – the head is coming out – you will probably feel what we call ‘the ring of fire’. If you can, don’t rush this stage, as this is when you are most likely to tear. Allow the tissues time to stretch slowly.
If – despite all your best efforts – you ended up with a perineal tear or an episiotomy, there are a few things you need to know that will help reduce discomfort, and speed up healing.
Inflatable ring – as much as possible, try to sit on an inflatable ring to reduce pressure on the area.
Hygiene – keeping the area clean and dry is really important. It may sting when you you go the toilet. If it does, pour warm water over the area to dilute the urine. After a bath or shower use a hair dryer on the area, not a towel.
Cold packs – can help to reduce swelling.
Wound care – Blissful Herbs have a Soothing Salve and Post Natal Bliss Healing Bath Herbs that can help support the healing of the perineum and reduce pain.
Your doula can help you with ensuring your perineum is in top shape for delivery and help protect it during birth. If you would like to talk about anything related to your pregnancy and birth plans or concerns, I would love to chat with you.
Managing Pain in Childbirth
Childbirth is tough. There’s no getting around it. And it is different for everyone. Some women find it centers in their back, others all in their belly. Some women find they can soldier through with few comfort measures, while others find it just about unbearable. Every woman and every labour is different. Fortunately, there are also many different ways you can manage the challenge.
There is an intimate connection between the mind and the body in labour, and it is well documented that if we can relax one, the other will follow. So it is important to consider both physical and mental comfort when thinking about managing your labour. The first and single most important thing is to choose a birthing environment and team that you feel confident and comfortable with. This will set you up with the best possible chance of achieving the birth you want. Remember, you are the one who is labouring, so the choice is yours.
Non-Medical Pain Relief in Labour
Birthing Doulas are trained in the delivery of a wide range of non-medical relief:
Breathing, Meditation, Mindfulness, Afirmations and Relaxation Exercises
Particularly in the early stages of labour, many women find that breathing exercises, meditation and relaxation exercises help. Not only do they give you something to focus on, but they help reduce anxiety, which in turn helps to reduce discomfort. Practice mindfulness and breathing exercises during your pregnancy so that when you are in labour you can use them when you need them. Your doula will have suggestions, or you can find exercises online.
It is also worthwhile to develop some affirmations that you can use during labour. Write them down, and teach them to your support team. You might not ever use them during your labour, but the act of creating them will impart a positive mindset.
The use of essential oils can help in relaxing the mind and creating the sort of environment in which you want to give birth. Young Living and doTerra create lovely oil blends that are ideal for relaxing. Choose scents that appeal to you, but try to aim for something with lavender, clary sage, bergamot, rose, peppermint or lemon, as they promote calm and relaxation.
Being comfortable in the environment in which you are labouring can help keep you calm and relaxed.
Bright, harsh lights can create stress, so consider the lighting in the room. If you are at home you might like to use candles. Battery-operated LED flameless candles are a practical alternative, and more acceptable in most birthing centres and hospitals.
Music can also have a huge effect on the atmosphere in the room. Prior to labour consider what music you might like. Ideally, you should aim for something calming and relaxing. White noise is often a good choice. Waves can also be good as they echo the ebb and flow of contractions.
Hot and Cold Packs
Heat packs are particularly helpful when you are experiencing your labour in your lower back. They can be used on the abdomen, but care should be taken that they are not too hot, and not left on for a prolonged period. A warm compress can also provide relief for the perineum in the early stages of pushing.
Cold packs, or cool damp towels can be comforting on the forehead or back of the neck.
Warm Shower or Bath
A warm shower or bath relaxes the muscles that are working so hard during labour. Buoyancy can help you relax and relieve pressure and discomfort. Allowing a warm shower to fall on your back is particularly good for back pain. Not to mention the overall muscle relaxation of a bath or shower.
A water birth provides you with this comfort throughout your labour, can soften the perineum and provides baby with a peaceful transition from womb to world.
Different positions can provide relief during labour, depending on where you are ‘feeling’ your contractions – what is uncomfortable in one position can be alleviated in another. Generally, the more upright you are able to stay the better. Upright positions work with gravity to help labour progress, and the pressure of the baby’s weight on the birth canal will help you dilate. Leaning forward over the back of a chair or on a beanbag can help, and puts you in a great position for your partner or doula to massage your back.
As with an upright position, moving around if you are able to can help move labour along, and provide some relief, particularly from back pain. Rocking, swaying, walking and dangling often help. Some women even like to dance. Whatever movement helps you is OK.
Massage, Light touch and Effleurage
Some women don’t like to be touched during labour but it can help relax muscles and provide comfort and reassurance. Studies have shown that when we flood the body with pleasurable feelings, painful ones are blocked. This is known as the Gate Control Theory. Massage and Effluerage decreases cortisol (the stress hormone) and increases endorphins, serotonin and dopamine production.
Deep massage through the back and hips can help as the hips expand to allow the baby passage.
Light touch or Effleurage uses gentle strokes without pressure, unlike deeper massage. Stroking down the arms, legs and back can feel lovely, as well as light strokes on the hair and scalp.
TENS stands for Transcutaneous Electrical Nerve Stimulation. Through small electrodes that are placed on the skin a TENS machine provides small electrical pulses that can relieve muscle tension and stimulate production of endorphins. The beauty of this device is that it is portable, so you can move around, and the electrodes are easily relocated if the pain you are experiencing shifts. TENS can be ideal for women who don’t wish to be touched.
If you have had good results with acupuncture during your pregnancy, you may find it helpful in labour. Some hospitals have staff trained in acupuncture, but in general you will need to engage your own practitioner.
If you are uncomfortable with the idea of needles, Acupressure can work just as well, and has the added benefit that you can do it yourself when you feel you need it. You might also like to try counter pressure. If you are feeling your contractions in your back, having one of your support team press firmly on your sacrum while you are on your hands and knees can help enormously.
When we are near someone we love – like a partner – our body releases oxytocin and endorphins, which are ‘feel good’ hormones. Having your partner close, maintaining eye contact, kissing, and even intimate stimulation can help during labour. Some women find this difficult – especially if there is a cast of thousands in the room – but if you are comfortable with the idea, it will very likely speed up labour and reduce discomfort.
Medical Pain Relief in Labour
Often called laughing gas by dentists, Nitrous Oxide has the benefit of being self administered – so you control when you need it. It doesn’t remove all pain but ‘takes the edge off’. It may cause nausea or disorientation, but doesn’t last long in the body. However, for about 30% of women it doesn’t provide much relief.
Pethidine is related to morphine and is generally injected into the thigh or buttock. Whilst it does provide relief, it can also cause dizziness, nausea and disorientation. It does cross the umbilical cord to the baby, and can reduce respiration and reflexes.
An epidural is delivered via the injection of anaesthetic into the lining of your spinal cord through your back. An epidural probably delivers the most effective relief available in labour. You will still feel a sensation of pressure during a contraction, but not pain, and will remain alert. The downside of an epidural is that you will be unable to get up and move around, which reduces the positive effects of gravity. It may also affect your blood pressure, so you are usually given a fluid drip, and a catheter as sensation in your bladder will be affected.
The most important thing when thinking about pain management in labour is to be kind to yourself. Don’t ever feel you are being weak by asking for relief. You are the only one who knows what your labour feels like, so don’t be afraid to ask for what you want, or to change your mind about going drug free if you feel you need to. The aim here is simply to deliver a healthy happy baby to a healthy happy mum.
If you would like to know more about pain relief in labour, or talk about your pregnancy and birthing plans or concerns, I would love to hear from you.