Fundamentally, Active birth is a woman’s choice to move freely and adopt any position that she instinctively feels appropriate and to aid her general comfort. Despite the fact that women have adopted more upright positions during labour for thousands of years, since the advent of modern medical practice post-renaissance, the majority of women labour and give birth lying on a bed or in the lithotomy position (Balaskas, 2001 pg.1). Evidence based practice is essential to appropriate maternity care, and during the last thirty years a resurgence of acknowledging childbirth as a normal physiological process and the woman being at the forefront of her care has been confirmed and greatly researched. The majority of women are healthy and deserve a right to make informed choices regarding the manner in which they experience the birthing process (Downe, 2004. pg.ix ). Active birth is simply a woman birthing naturally adopting any position she spontaneously moves to.
Throughout centuries there is a vast quantity of relics and scriptures depicting women birthing physiologically using birthing stools or adopting squatting positions. In the old testament of the bible Exodus even mentions that women used stools during childbirth (Exodus chapter 1, verse 16). As stated in Balaskas’ text New Active Birth, the first recorded birth noted in a recumbent position was the mistress of French King Louis XIV as he wanted to witness his child being born. The Chamberlain brothers later invented the forceps in the 17th century and a woman was to lay on a bed for this procedure. This intervention is still widely used in current medical practice. Midwifery at this time became firmly a medical situation and obstetricians were deemed the appropriate professionals to care for birthing women. During this time a renowned French obstetrician, Francois Mauriceau, discarded the birthing stool and stated that birth attendants should not run around after a woman and she should stay in bed for the entire labour as it is much easier and more comfortable for the doctor (Balaskas, 1989 pg. 8). Until the late 20th century a woman birthing in a bed has been widely accepted as normal practice.
Up until the late 20th century many hospitals in England banned women adopting any other childbirth position except laying in a recumbent or lithotomy position in bed. On the 11th April 1982 over 6000 people in London rallied for women’s rights to be able to birth freely in whatever position they should choose. The Active Birth movement was born lead by leading natural birth advocate Janet Balaskas and French obstetrician Michel Odent who organised and spoke at the rally. The success of this day signified a great change for women and many hospitals lifted their ban on women having to stay in bed.
In 2009 the Royal College of Midwives further encouraged midwives to support women to become more mobile during labour and try and actively ‘Get her off the bed’ (RCM, 2009. pg. 2). Furthermore in 2012, the RCM further reiterated that a birthing mother should be supported by midwives to be mobile and adopt different upright birthing positions (RCM, 2012 pg. 4).
The National Institute of Health and Care Excellence guidelines indicate that a midwife should actively support a woman in labour to move freely into any position that she wishes to adopt, with an aim to refrain from lying on a bed (NICE, 2014. Pg. 48). A midwife should offer individual care during labour and respectfully acknowledge a woman’s choices. Waldenstrom and Gottvall (1991) stated that unless a woman is guided to try different positions she will most likely do just what is expected of her. As an advocate for the birthing mother, a midwife should aid the woman to mobilise and adopt any position that she instinctively feels is appropriate, and help her to explore different positions (NICE, 2007. Pg. 60).
A midwife should offer individual care during labour and by means of a pinard or a handheld doppler ultrasound perform auscultation every quarter of an hour for at least one minute, after a contraction, to check the fetal heartbeat (NICE, 2014. Pg. 33). A form of continuous monitoring called telemetry is available for any woman who wishes to remain mobile. Many UK Maternity units now have this form of continuous monitoring, which provides a fetal heart reading whilst allowing full mobility (Watson et al, 2014. Pg. 1). The midwife’s role overall is to support the woman in labour by being an empowering professional advocate.
Lying in a supine position opposes the pull of gravity, according to Newton’s Laws of Motion. This states that the pull of gravity is vertical to the surface of the earth. If a woman adopts a more upright stance she is naturally employing the benefits of these fundamental laws. If she is horizontal she is working against gravity and therefore requires a great deal more exertion. Acknowledging the benefits of gravity according to Newton’s Law may actually also help the baby adopt an optimal presentation for their passage through the birth canal downwards rather than sideways (MIDIRS, 2008).
Circulatory system
If a woman lies on her back for a considerable amount of time it can affect the entire circulatory system, as there is more pressure on the arteries, of the heart and blood supply to the uterus (Myles, 2014. 16th edition. Pg.343). The baby’s circulation may also be affected, according to findings in the Cochrane report in 2013. This paper identifies that laying down during labour could affect the blood flow to and from the placenta which may have a negative impact on neonatal wellbeing (Lawrence et al, 2013. Pg. 1).
In an upright position the pelvis can be fully free to move without any exerted restriction, which is where the study of Obstetric Pelvimetry becomes relevant. Obstetric pelvimetry is the study of the measurements of the female pelvis to predict whether the size of the baby’s head can adequately fit through a birthing mother’s pelvis. Although pelvimetry is usually not calculated as there is very little research regarding the benefits (Pattison et al, 2017. Pg. 1), women despite any negative pelvimetry results should indeed be allowed a chance to labour physiologically.
Michel et al, 2002 analysed the effects of different labour positions on the pelvic inlet and outlet in a trial in Switzerland. The trial supported evidence that the pelvic outlet increased in a kneeling or squatting position, allowing optimal capacity for the baby to pass through the pelvis. This scientific imaging study acknowledges that an optimal expansion of a female pelvis can certainly aid the process of labour (Michel et al, 2002. Pg. 2). Another study by Hemmerich et al in 2018 concluded that the squatting position was the most favourable position to optimize the best pelvic movement and capacity during labour.
The main hormones that are released during pregnancy and labour are oxytocin, beta-endorphins, epinephrine, norepinephrine, progesterone, oestrogen, prostaglandin and prolactin. Many situations can affect this delicate balance of normal biological hormone production during childbirth. Sarah Buckley (2015) analysed the effects of intervention and disruption of the normal physiological birth hormones. Oxytocin has a crucial role during labour and production of this hormone can be inhibited by adrenaline. If a mother is experiencing high levels of emotional stress during labour then her oxytocin levels will be seriously affected. Oxytocin has a major role in the strength of uterine contractions, calming the mother and aiding mother and baby bonding post birth. If a woman can ambulate freely and adopt more upright positions during labour, in a calm relaxed atmosphere, her body can produce the optimum levels of hormones needed for a healthy physiological birth (Buckley, 2015). In Michel Odent’s book ‘The Scientification of Love’ (Odent, 2001) he explores in great detail the powerful action of oxytocin in sexual activity, orgasm, parturition and infant feeding. Beta-endorphin is a hormone that acts as a natural pain killer. In a natural physiological birth this hormone augments not only providing analgesic properties but also aids the woman’s body to produce prolactin. Prolactin is vital for the production of breast milk (Buckley, 2015).
Even stretching of the perineum and optimal dilation of the cervix
In an active birth where a woman adopts a more vertical stance, the weight of the baby can be evenly exerted on the cervix allowing optimum pressure to efficaciously help dilate the cervix. The perineum is a layer of fibromuscular subcutaneous tissue that is located between the vagina and the anus. During pregnancy the perineum, and other bodily tissues and ligaments, can already stretch more due to hormonal changes in the woman’s body (Myles, 16 ed. Pg. 360). When the perineum is stretched evenly it may help prevent any possible tearing during the second stage of labour (Balaskas, 2001. Pg. 2).
The World Health Organisation states that low risk women freely able to move and adopting different upright positions during labour could indeed potentially shorten the labour by an average of 1.36 hours, and were less likely to need a caesarean section or epidural (WHO, 2014. Pg. 1-3).
A Cochrane report in 2014 by Opiyo, also concluded that there was significant evidence that if a woman moves freely during the first stage of labour and is more horizontal then she could certainly be less likely to request an epidural analgesia and ultimately need a caesarean section. This randomised controlled trial of over 2500 low risk women certainly supports the benefits of an Active birth as opposed to birthing in a supine position. Lawrence et al conducted another randomised trial in their Cochrane review in 2013. The trial contains 25 individual studies with 5218 women participating. The study supports findings that when women are free to ambulate in order to personally increase their own individual level of comfort then the labour could be shorter and there may be a much lower need for analgesia and intervention. This particular study also indicates that a woman should be allowed to move freely and that there is not a sole position that supersedes any other position during the first stage of labour (Lawrence et al, 2013).
Even dating back as to 1978 Flynn et al supports the theory that recumbent positions during labour are more likely to require further analgesia to cope with the pain. Concluding that moving around freely during labour should be actively encouraged to help obtain better uterine contractions and may help maintain a healthy fetal heart rate.
Gizzo et al conducted an observational study on low risk women in Italy between 2013 and 2014. The results were analysed and the findings supported evidence that if a parturient was able to ambulate freely in less recumbent poses it would lead to several advantages including ’…reducing intrapartum maternal and neonatal complications.’ (Gizzo, et al, 2014. Pg. 6). Many women reported a greater feeling of general empowerment and overall contentment. The study also acknowledged the benefits of using gravity to aid contractions, fetal adjustment to optimal angle of descent, and increased pelvic capacity.
A meta-analysis report by Jonge and colleagues in 2004 indicates that women that were recumbent during labour were at higher risk of intervention, episiotomies and postpartum haemorrhage than women that were able to freely move into more horizontal positions. This study also concluded that during the second stage of labour women reported a reduction in pain as opposed to women laying in a recumbent position. 6481 birthing women during the second stage of labour took part in a Cochrane study in 2017 by Tort et al. The results evidenced a statistical difference supporting active labour as opposed to supine or lithotomy poses. Women in less recumbent positions were less likely to need any intervention. Evidence that ambulation aids the process of labour regarding pain management and women’s empowerment has also been researched in Brasil by Miquelutti and colleagues in 2009, concluding that upright positions are favourable for mother and baby for optimal birth outcomes emotionally and physically.
08.03.2019