Description and Official Rationale
The majority of hospitals and obstetricians in this country (still) insist on a birthing position that quite literally makes the baby, following the curve of the birth canal, be born heading upwards. States Williams: "The most widely used and often the most satisfactory [position for delivery] is the dorsal lithotomy position on a delivery table with leg supports" (Cunningham et al. 1989:315). No reasons why this position is "the most satisfactory" are given, but a strong clue is provided in an earlier text:
The lithotomy position is the best. Here the patient lies with her legs in stirrups and her buttocks close to the lower edge of the table. The patient is in the ideal position for the attendant to deal with any complications which may arise (Oxorn and Foote 1975:110)
This position, in other words, is the easiest for performing obstetric interventions, including maintaining sterility, monitoring fetal heart rate, administering anesthetics, and performing and repairing episiotomies (McKay and Mahan 1984:111).
Physiological Effects
Roberto Caldeyro-Barcia, past president of the International Federation of Obstetricians and Gynecologists, states unequivocally, "Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery" (1975:11). There are a number of problems generated by this position: (1) it focuses most of the woman's body weight squarely on her tailbone, forcing it forward and thereby narrowing the pelvic outlet, which both increases the length of labor and makes delivery more difficult (Balaskas and Balaskas 1983:8); (2) it compresses major blood vessels, interfering with circulation and decreasing blood pressure, which in turn lowers oxygen supply to the fetus (for example, several studies have reported that in the majority of women delivering in the lithotomy position, there was a 91% decrease in fetal transcutaneous oxygen saturation (Humphrey et al. 1973, 1974; Johnstone et al. 1987; Kurz et al. 1982); (3) contractions tend to be weaker, less frequent, and more irregular in this position, and pushing is harder to do because increased force is needed to work against gravity (Hugo 1977), making forceps extraction more likely and increasing the potential for physical injury to the baby; (4) placing the legs wide apart in stirrups can result in venous thrombosis or nerve compression from the pressure of the leg supports, while increasing both the need for episiotomy and the likelihood of tears because of excessive stretching of the perineal tissue and tension on the pelvic floor (McKay and Mahan 1984).
Studies comparing women's preferences for supine vs. upright positions for delivery reported, without exception, more positive responses from women using the upright position. These women tended to experience more ease in pushing, less pain during pushing, fewer backaches, shorter second stages, fewer forceps deliveries, and fewer perineal tears (Gardosi et al. 1989; Liddell and Fisher 1985; Stewart et al. 1983; van Lier 1985). Advantages for the baby included higher levels of oxygen in the umbilical cord and higher Apgar scores than babies whose mothers delivered them in the lithotomy position. There were no adverse effects from delivering in the upright position, "although a few birth attendants reported that this position was inconvenient for them" (McKay and Roberts 1989:23). In one study, by far the most popular upright position among women given the option was the supported squat, in which the woman gives birth on a bed supported in a squatting position by a special "birth cushion," which allows most of the woman's weight to rest on her thighs instead of her feet. 95% of the subjects in this study wanted to use this position in subsequent births; the researchers found that if women not originally assigned to the study heard about the birth cushion from others, they would often request it for themselves (Gardosi et al. 1989).
Women's Responses
Most of the hospital-birthers in my study expected to be in the lithotomy position for birth; the idea of an alternative occurred only to those who delivered in birthing suites or utilized the services of a nurse-midwife who would let them give birth in the labor room in almost any position they wanted. As a result of this expectation, the comments made to me about the lithotomy position had more to do with how women worked to adapt to that position, than with the position itself:
I just simply felt like I had to be sitting up to push, so I refused to push until Lenny got behind me and held me up, pushed my shoulders up off the delivery table so I could push every time I had a contraction, because I mean, there was nothing at all to lean on besides him.
-Constance O'Riley
My arms were not tied or anything. It was hospital policy to do it, but I told them I wouldn't go to the hospital if they tied my arms. I didn't mind if they tied my legs down because I knew I would still be able to push with my ankles.
-Teresa Lutzer
Ritual Purposes
This lithotomy position completes the process of symbolic inversion that has been in motion since the woman was put into that "backwards" hospital gown. Now we have her normal bodily patterns of relating to the world quite literally turned upside down: her buttocks at the table's edge, her legs widespread in the air, her vagina totally exposed. As the ultimate symbolic inversion, it is ritually appropriate that this position be reserved for the peak transformational moments of the initiation experience: the birth itself. The official representative of society, its institutions, and its core values of science, technology, and patriarchy stands not at the mother's head nor at her side, but at her bottom, where the baby's head is beginning to emerge. Structurally speaking, this position puts the woman's vagina in the relationship to society (through its representative, the obstetrician) that her head normally occupies--a total inversion perfectly appropriate from a societal perspective, as the technocratic model promises us that we can have babies with our cultural heads instead of our natural bottoms. The cultural value here is clearly on the baby, who is emerging at the "top." As Lakoff and Johnson (1980) point out, in this culture, "up is good; down is bad," so the babes born of science and technology must be born "up" toward the positively valued cultural world of men, in opposition to the natural force of gravity, instead of "down" toward the negatively valued natural world of women. As we perpetuate our society, we also symbolically enact the driving thrust upwards, in defiance of earthly gravity, that has characterized it since its inception. Conceptually speaking, the overthrow of the initiate's category system is now complete: this position expresses and reinforces her now-total openness to the new messages she is about to receive and itself constitutes one of those messages, as it speaks so eloquently to her of her powerlessness and of the power of society at the supreme moment of her own individual transformation.
In spite of the strength of these covert symbolic messages, the technocratic model of birth is overtly predicated on scientific fact. When the discrepancy between scientific fact and actual practice becomes as obvious as it is with the lithotomy position, that model must either be abandoned altogether (as have many such paradigms of the past) or be expanded to accomodate at least the most compelling pieces of scientific evidence that challenge its standard operating procedures. For example, as research showing the benefits of walking during labor gains more acceptance, it is to be hoped that monitoring by telemetry will gradually replace the kind that physically ties women down--but the fundamental values and beliefs that necessitate electronic monitoring in the first place will not have to change.
So it shall be with birth position. So much evidence has been gathered that demonstrates the advantages of an upright position for pushing that science has responded with the development of electronic birthing chairs, in which the woman sits in a physiologically efficacious position for pushing with perineum exposed (or covered by a sheet) and legs spread apart on plastic supports. The symbolic ramifications of this chair are considerable, as it places the woman higher than the obstetrician as she delivers the baby, looking almost like a queen on a throne surrounded by her servants. Yet, because the chair is incorporated into many hospitals without any fundamental accompanying shift in core values and beliefs, its potentials for empowerment of the birthing woman are often co-opted. Placing the woman alone on her technological throne can become almost as much a symbolic expression of depersonalization and objectification as the lithotomy position itself. Although women can easily reach the controls on the chairs to alter their position, medical personnel rarely provide this information, usually preferring to retain such control. Because the chair is elevated so high, women cannot get out of it to shift position between contractions. Several studies show that some women who stayed in the chairs to push for more than thirty minutes at a time developed hemorrhoids and perineal swelling. Others complained that the chairs are uncomfortable and prevented them from rocking their pelvis or otherwise moving during second stage (McKay and Mahan 1984:113), or that their partners were now too far away to touch them very much. (Early, low-tech birthing chairs and hammocks in this country and others were designed to have someone sitting behind the laboring woman, intimately embracing and supporting her [Ashford 1988; Jordan 1983].)
Thus it would appear that, in spite of the obvious physiological advantages of the high-tech birth chair over the delivery table, being forcibly locked into any position during labor is less preferable than being able to freely change position as desired. Women who birth without technocratic control on double beds, on stools, on beanbag chairs, on the floor, or in water frequently change positions, perhaps resting on their sides between contractions, perhaps sitting or squatting to push (Ashford 1988; Engelmann 1977; Jordan 1983; McKay and Mahan 1984; Odent 1984). But this very unmechanical behavior is too incompatible with the technocratic model to be a viable delivery option in most hospitals. Moreover, women themselves have been so conditioned to labor and give birth lying down that the idea of such alternatives never occurs to many (McKay and Mahan 1984:118). Therefore, though challenged, the dominance of the lithotomy position continues.
© Robbie Davis-Floyd PhD, Used with Permission
Robbie Davis-Floyd PhD is a cultural anthropoligist who studies reproduction, focusing on childbirth and midwifery. To learn more about Robbie Davis-Floyd PhD, the work she does and her other projects, please visit her web-site www.davis-floyd.com.
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Excerpted from Birth as an American Rite of Passage
Lithotomy Position
