We started this week joining the celebration of the #WorldWeekofRespectfulChildbirthAnd Nati told us that the process of implementing the WHO recommendations on the use of technology during childbirth was slow. We remembered then that It is possible to take into account the woman's preferences y reduce interventionism, for the benefit of both the mother and the baby.
A few days later, Valeria opened our eyes with this reality"Women experience humiliation and depersonalization" at such an intimate, vulnerable, and IMPORTANT moment as the birth of their children. He indicated the lithotomy position which many of us have experienced, and have seen in movies: lying on delivery tables that sometimes resemble torture racks. It's not the only hospital protocol that can hinder the progress of a normal delivery, but the fact is that it's logical to think about the vertical position as facilitatorSince gravity helps to naturally assist the baby's pushing movements. If you'd like to know more, I'll delve deeper into this type of birth.
A brief note: we read in an entry in The delivery is ours that: “The delivery table was invented for the comfort of the healthcare professionals who are assisting.” (Well, sometimes they actually influence) childbirth. And now I invite you to ask yourselves Why have women historically given birth in more or less vertical trunk positions?. Well, it turns out that It shortens and widens the birth canal. (by allowing greater opening of the joints), It facilitates the expulsion with less effort., and let the mother witness the birth of the child.
Therefore, the technification and instrumentalization of childbirth is not always positive for those who give birth (let's not forget that's us); but in any case, as Nati said: It's about being able to choose not only the posturebut all aspects related to that crucial moment in life. From who accompanies us, to whether we want to eat or drink, or walk between contractions; including shaving or the right to scream if we feel like it (and without anyone inhibiting us).
Being in a vertical position is considered to be squatting, sitting or semi-sitting (with the thighs on the abdomen).
If for so many centuries we have given birth vertically, we can still do it
In 2005, the Peruvian Ministry of Health published a technical standard for vertical childbirth care. The document (MINSA – Technical Standard for Vertical Childbirth Care) states that there was a disagreement among the staff attending births (obstetricians, midwives) and the mothers, since the former had been trained to attend to the mother while she was in the lithotomy position, and The latter refused to be assisted in health facilitiesbecause they preferred to give birth vertically.
The aim of the regulation was to strike a balance between the modern clinical care and the meaning of the act for the mothersIn the Andean country there was also (as in many Western countries today) evidence that vertical childbirth is more physiological and facilitative.
Is it better to give birth vertically? In the following sections, we will take a detailed look at the advantages and also the possible disadvantages of this position. The modernization of science sometimes leads us to believe that traditional practices are no longer valid. even when its effectiveness has been provenBut it's not just a matter of speaking in highly technical terms, because what we're talking about here is giving birth, something that women can and know how to do if we trust our bodies; and with these kinds of articles (necessary, I'm not denying that) we want to justify what should justify itself.
Engelman (in 1882) described in a classic document How did the position adopted by the women we refer to as primitive allow them to change when they wished, always avoiding lying down? considerable advantages for labor.
The gallery below shows three images of vertical Parthians immortalized by sculptures or drawings of different civilizations. They have been obtained at The Well Rounded Mama.
What does vertical birth really consist of?
When we talk about vertical birth, we are not referring to a single rigid position, but to a set of positions in which the The mother's spine remains upright to a greater or lesser degree and the gravity acts in favor of birthThis means that the woman is not lying on her back during the second stage of labor (the expulsive stage), but rather adopts positions such as:
- Standing, still or walking, leaning on your partner, on a bar or on the bed.
- Sitting, on a birthing chair, a reclining chair, a special stool or even on an obstetric ball.
- Squattingwith heels supported and knees highly flexed, using hand support, ropes or bars.
- Kneeling or semi-squattingsometimes supporting the torso on the bed, a ball or a padded support.
All these variations share a common principle: the sacrum is freerThe pelvis can open more easily, and the baby descends following the direction of gravity. This is why many current clinical practice guidelines encourage this approach. freedom of movement and position throughout labor, encouraging the avoidance of completely supine positions when not necessary.
History of vertical versus horizontal childbirth
Although current popular culture suggests that giving birth lying down is "normal," history and anthropology show the exact opposite. It has been documented in many civilizations that women gave birth in vertical or semi-flexed postures:
- At the Ancient EgyptVarious hieroglyphs and pictograms show women squatting or sitting in special birthing chairs.
- At Classic Greece and in the Roman empire Births were also depicted with the woman sitting or kneeling, supported by servants or relatives.
- Numerous pre-Columbian cultures They maintained the birth in a squatting or semi-seated position, with great participation from traditional midwives.
Historical literature describes how, for many centuries, Giving birth vertically was the norm for most women. The significant shift towards lying down for childbirth began when birth It moved from homes to the medical field and assistance by male surgeons and obstetricians became widespread.
The supine position and the lithotomy position (lying face up, with legs raised and separated) offered greater visibility and control for the professionalThey facilitated the use of instruments such as forceps or vacuum extraction, and were integrated into the logic of a highly medicalized birth. However, various modern studies and reviews have shown that, for low-risk deliveriesThis position does not offer the best results for mother and baby.
Some indigenous cultures, especially in rural areas of Latin America, Africa, or Asia, They continue to maintain spontaneously Vertical childbirth as a common practice. In several countries, guidelines and standards have been developed for integrating vertical birthing in hospitalswith a humanized and intercultural approach: women's customs are respected and, at the same time, medical resources are available if needed.
The upright posture is more natural and more physiological.
La Guide to normal childbirth care from the Ministry of Health This summarizes the evidence associated with vertical childbirth: Vertical or lateral positions, compared to the lithotomy position, are associated with a shorter duration of the second stage of labor., fewer assisted births, lower rates of episiotomies and certain improvements in maternal well-being.
The West has become accustomed to wanting to prove even the obvious, and in the case of birthing positions this has a lot to do with the Medicalization and instrumentalization of birthThere is still a way to go before those who attend births relinquish control over every detail and truly give the leading role to the mothers, without giving up intervening when necessary for safety.
From a biomechanical point of view, In a vertical position, the pelvic canal and the woman's torso form a more favorable angle. with respect to the horizontal plane. The sacrum can shift backward, the pelvis widens, and the baby aligns better with the birth canal. The most common upright position in the hospital setting is usually the sitting or semi-seated (in a reclining chair, birthing chair or obstetric stool), but ideally the pregnant woman should be able to choose at any given time:
- Sit down, squat down, kneel down, or stand up.
- Lean on your partner, on a bar or on the bed.
- Balancing the pelvis, change sides or walk between contractions.
All of this contributes to a more comfortable birth experience. more active and participatory on the part of the mother, and not a passive process in which "it is allowed to happen."
Main vertical positions during childbirth and how they are experienced
Within the concept of vertical birth, we can distinguish several positions with different characteristics and sensations. Knowing them helps each woman to... imagine her body in them and know what options you want to include in your birth plan.
Upright standing position
The woman stands, walks, or remains still, often supported by her partnerThis position is typically used during the dilation phase, but can also be maintained during the expulsion phase if the mother feels stable.
- Walking produces an effect Relaxing and regulating breathingWhen moving, one inhales and exhales more rhythmically.
- When the contraction arrives, many women stop, They bend their knees slightly and they better support the weight to help with the pain.
- This movement and rhythmic breathing facilitate the endorphin release, the body's natural painkillers.
Upright seated position
In this position, the torso remains upright, but without putting weight on the legs and without needing to support the body with the leg muscles. A [supplement/support] can be used birthing chair, a reclining chair that rises up to 90 degrees or a special bench.
- For many mothers it is a position very comfortable and stablewhich allows rest between contractions.
- Modern birthing chairs allow adjust the tilt angleHold onto side or top bars, and push off with your feet on firm footrests.
- This position combines the advantage of the gravity in favor with good support for the back and pelvis.
Squatting or curled-up position
The woman squats with her heels on the ground, knees bent sharply, and torso leaning forward. She can support herself with her arms on her thighs, a bar, the bed, or a person for support.
- As the weight on the femurs increases, it widens the pelvic diameter to the maximumwhich facilitates the rotation and descent of the baby.
- It's a very powerful position from a mechanical point of view, but it requires certain muscle training in legs and pelvic floor to be able to maintain it.
- In some women, this position is alternated with short breaks sitting or kneeling to avoid excessive fatigue.
Semi-crouched and sustained vertical position
Here the woman maintains the fairly upright backWith her legs bent and slightly apart, and her belly supported on a support (for example, a raised bed or a large ball). One or two people help the mother by supporting her under the armpits or by the hips.
- The pressure needed to push is usually slightly less than in a deep squatwhich may be more bearable.
- There is slightly less pressure exerted on the baby's head, and the pushes may be slightly less effective, but more sustainable for the mother.
- La birthing bench It is a variation of this position: a small bench with a central hole open at the front, where the pelvis is supported while the baby descends.
Advantages of vertical birth for the mother
Comparative studies between vertical and horizontal birthing positions have confirmed many of the advantages that women have suspected for centuries. From a maternal perspective, the evidence points to numerous benefits when there are no medical contraindications.
Greater opening of the birth canal
In upright positions, the weight of the uterus and baby is directed downwards, and the sacrum can shift backwards. This allows for a greater opening of the pelvic diameters, both transverse and anteroposterior.
- It makes it easier for the baby head lace and rotate correctly.
- The need is reduced intense external maneuvers or thrusts directed from the uterine fundus.
- With more space, the perineal tissue stretches more gradual and elastic.
Shorter duration of the second stage of labor
Several systematic reviews have found that, on average, the second stage of labor is shortened in upright positions facing the lithotomy position. The combination of gravity, better alignment of the baby, and more effective pushing makes the expulsion phase more efficient.
- In many studies, the duration of the expulsive phase in the vertical position is lower than that recorded in the supine position.
- An excessively long second stage is associated with increased risk of postpartum hemorrhage, infections and severe trauma, so reducing it physiologically is beneficial.
- When using epidural analgesia, upright positioning (where possible) may be necessary. counteract some of the slowdown that produces anesthesia during contractions and pushing.
Less need for episiotomy and instrumentation
Comparative studies show that, in low-risk vaginal deliveries, the The rate of episiotomies is declining significantly. when the woman is allowed to be in upright or lateral positions instead of systematic lithotomy.
- The restrictive use of episiotomy is associated with less postpartum painlower risk of infection and better pelvic floor function in the medium term.
- With more control over the pushing, the emergence of the head can be more leisurely, which protects the perineum.
In parallel, several works show a less need for instrumentation (forceps, vacuum extraction) in vertical deliveries, provided that the pregnancies are low risk.
- Reducing the use of instruments decreases the risk of neonatal cranial injuries and severe perineal trauma.
- Some studies show no significant differences in the cesarean section rate between vertical and horizontal delivery, indicating that verticality It does not increase the likelihood of a cesarean section when it is correctly indicated.
Better pain management and less need for analgesia
In many women, verticality is associated with a more manageable pain perception during the expulsion phase. There are several factors that explain this:
- The mother can move freely, balance your pelvis, shift your weight from one leg to the other and find the position that provides the best relief.
- Gravity helps with pushing, so the woman you don't have to push against your own weight nor against an unnatural position.
- The uterus stops pressing directly on the lungs, which facilitates deep breathing and improves oxygenation.
In several studies, mothers who opt for upright positions report less need for pharmacological analgesia And, when they do use it, they may require lower doses.
Greater sense of control, freedom, and satisfaction
Beyond the clinical data, research repeatedly highlights a key element: the subjective perception of the motherWomen who have given birth in a vertical position often describe:
- Greater feeling of freedom, by being able to decide how to position oneself at any given moment.
- Feel more protagonists and active, instead of passive patients.
- The possibility of see your baby come out with greater clarity, which provides a very powerful emotional experience.
- One more relationship horizontal with healthcare staff, promoting communication and shared decision-making.
Benefits of vertical birth for the baby
The focus is usually on the mother, but the baby also benefits from an environment in which the The physiology of childbirth is respected and the verticality is taken advantage of.
Better oxygenation and less compression of blood vessels
In supine positions, the weight of the uterus can compress large blood vessels in the abdomen, reducing venous return and potentially leading to maternal blood pressure decreasesThis, in turn, decreases the flow of blood and oxygen to the baby.
In contrast, vertical positions largely avoid this crushing:
- Maternal circulation remains more stable, with improved uteroplacental perfusion.
- Some studies record a lower frequency of abnormal fetal cardiac patterns in vertical births.
- Babies receive a more constant oxygen supply during the process.
More physiological descent and rotation
The baby descends following the direction of gravity and taking advantage of the path of least resistanceThis makes it easier for the baby to use the strongest part of its skull (the occipital region) to progress through the birth canal.
- Proper head rotation and flexion reduces the risk of mechanical dystocia and the need for complex maneuvers.
- The mother's muscular and perineal tissue distends in a way slow and progressiveTherefore, the passage of the head encounters a more elastic barrier.
- Studies show no significant differences in the score of Apgar at one and five minutes between vertical and horizontal delivery, which indicates that, in global terms, verticality is as safe as the lying position for the baby in low-risk pregnancies.
Disadvantages and potential risks of vertical birth
Like any option in obstetrics, vertical birth is not without potential drawbacks. Most can be managed with good information, support, and appropriate case selection, but it is important to be aware of them in order to make informed decisions.
Greater bleeding estimated in some studies
Some meta-analyses have described a estimated major bleeding in vertical births compared to horizontal ones. However, this difference seems to be closely linked to several factors:
- Most measurements are performed by visual estimationnot by objective methods, and it is easier to count blood when it flows downwards in vertical positions.
- Some of the additional bleeding is associated with perineal trauma or tears, not to serious uterine bleeding.
- Other studies, using different methodologies, find no relevant differences or even describe slightly less bleeding vertically.
What is clear is that factors such as excessive prolongation of the expulsive phaseHigh fetal weight, primiparity, or the use of oxytocin in the second stage have a greater influence on bleeding than the specific position.
Perineal tears: important nuances
The evidence regarding tears in vertical delivery is nuanced. Some studies show fewer severe tears (third and fourth degree) in vertical positions, although there may be:
- A slight increase in tears of first and second grade (more superficial and with a better prognosis).
- Higher risk of tearing in deep squats in first-time mothers if the emergence of the head is not properly supported.
In any case, the quality of obstetric care, the restrictive use of episiotomiesActive protection of the perineum and the possibility of pushing spontaneously have a much greater impact than the position itself.
Difficulty maintaining posture and fatigue
Some women find difficult to maintain certain upright postures for a long time, especially if they haven't previously worked on their strength and flexibility.
- Squatting or standing positions require a certain muscular state which is not always present in women who are not used to it.
- Epidural analgesia can complicate stability, therefore, further measures are required. additional security measures and physical support.
- Proper preparation during pregnancy (gentle exercises, squatting, leg strengthening) helps the body to be better prepared to maintain verticality.
Greater technical challenge for healthcare personnel
Vertical birth also implies a paradigm shift for those who attend births:
- They can have less direct visibility of the perineum than in lithotomy, therefore they need specific training and adaptation.
- Certain medical procedures, such as some obstetric surgeries or an emergency cesarean section, They cannot be performed vertically.and it would be necessary to knock the woman down quickly.
- The continuous use of certain monitors may be more complex and require wireless devices or adaptations.
Therefore, the generalization of vertical birth requires that midwives and gynecologists are trained In new ways of providing support, learn to respect the mother's postural choice and have access to technical resources (portable monitors, adaptable beds, birthing chairs, etc.).
We do not have to learn to give birth, because we already know how to do it. Or not?
What has happened to us that, despite being designed to effectively play a leading role in the processes of gestation, childbirth and breastfeeding, we are so far removed from our natureThe culture of fear, distrust of the body, and the idea of childbirth as a purely medical act have eroded women's instinctive knowledge.
I once read an interview with the famous obstetrician Michel Odent, whom we know both for his books (“The Baby Is a Mammal,” among others), and for advocating the biological need of mothers and babies to stay together after birth. As you can imagine (if you do not know him) he is an advocate of natural childbirth, and He does not hesitate to point out the artificiality surrounding the birth process. as the cause of possible traumatic situations in the woman and her baby.
In that interview, he explained a disturbing thesis: medicine would be neutralizing some laws of natural selectionby systematically interfering with processes that have been self-regulating for millennia. This author wonders if the progressive loss of the ability to give birth and breastfeed spontaneously could be related to a over-dependence on technology.
Odent also emphasizes something that fits perfectly with vertical birth: the mother must feel safe and secure During childbirth, she needs darkness and silence; and she questions the idea that she “needs support” understood as constant intervention...from professionals and, sometimes, from the partner themselves. Her speech, uncomfortable but insightful, reminds us that good support often means Don't interrupt what works.
The underlying conclusion is that mothers don't intend to shy away from medical advances, but rather want them to be reserve them for when they are really neededWhile respecting our freedom to decide how we want to give birth, vertical birth is one of those tools that helps us reconcile with our ability to give birth.
In a context where more and more women are developing their birth plans, informing themselves and asserting their right to choose their position, companion and level of intervention, verticality is presented as an option consistent with respectful childbirthIt's not about idealizing a single position, but about giving every woman back the possibility of Listen to your body and move as you need.
Having clear information about the Advantages and disadvantages of vertical birthKnowing the available scientific evidence and, at the same time, honoring the age-old experience of women, puts us in a place from which we can calmly decide how we want to experience the birth of our children: with less fear, more freedom of movement, and a renewed confidence that our bodies know how to give birth.