Ep 210: The Freedom to Choose Your Birthing Position with Dr. Rebecca Dekker of Evidence Based Birth

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Dr. Rebecca Dekker is back! You may remember Dr. Rebecca from way, way back in episode 18. Since then, my work and hers have both grown tremendously. If you enjoy what I’m doing here I think you would also enjoy the resources she provides through her organization, Evidence Based Birth.

Today’s conversation is all about the topic she has dedicated so much of her work to: birthing positions. A majority of US births are supine, or on the back. This is what we always see in tv and movies but it’s actually not the ideal, or more importantly, ONLY way to give birth. There isn’t a perfect or best labor position. Instead, what really matters is that you have the freedom and support to move your body and find what works best for you.

In this Episode, You’ll Learn About:

  • What the classifications are for birthing positions
  • What does research show about which positions people opt for if given the choice
  • Why most people in the US give birth on their backs
  • What makes lithotomy/stirrup birth dangerous
  • What evidence says about birth positions with and without an epidural
  • How birth seats are used
  • How medical culture affects birth outcomes

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Keywords

Active birthing positions, Advocating for birthing position choices, Birth on all fours, Birthing positions, Birthing stool positions, Labor positions, Lithotomy birthing position, Movement during labor, Side-lying birthing position, Squatting positions in labor, Supine birthing positions, Upright birthing positions, Water birth positions

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Keywords

Active birthing positions, Advocating for birthing position choices, Birth on all fours, Birthing positions, Birthing stool positions, Labor positions, Lithotomy birthing position, Movement during labor, Side-lying birthing position, Squatting positions in labor, Supine birthing positions, Upright birthing positions, Water birth positions

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Dr.Nicole (00:00): I am so excited to have back to the podcast Dr. Rebecca Decker from Evidence-Based Birth and we are talking all about labor positions. Welcome to the All about Pregnancy and birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy in birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com\ disclaimer. Now, let's get to it.

(00:54): Hello there. Welcome to another episode of the podcast. Whether you are a new listener or a returning listener, I'm so glad that you're spending some of your time with me today. In today's episode of the podcast, we have back to the podcast Dr. Rebecca Ducker. She is a nurse with her PhD and she is the founder and CEO of evidence-based birth, as well as the author of a great book called Babies Are Not Pizzas. They're born, not Delivered. I've actually read the book and it's really good, and if you want to hear her first appearance on the podcast, she was back on the podcast all the way back to episode 18, so you can grab it at my website, dr nicole rankins.com/episode 18, and we chat about how she started evidence-based birth and the journey to get there, and a little bit about evidence-based birth.

(01:46): The mission of the team at Evidence-Based Birth is to work towards a world in which all families have access to safe, respectful, evidence-based and empowering care during pregnancy, birth, and postpartum. They do this by boldly making the research evidence on childbirth freely and publicly accessible. Dr. Decker is also the host of the Evidence-Based Birth podcast with more than 4.5 million downloads. I know a lot of you all who listen to this podcast also listen to her podcast. And in this episode today we are talking about birth positions. So we are going to go through what are the various birth positions really defining what they are, and you're going to learn about the research surrounding birth positions, including what position people choose most often if they have the choice why most people in the US end up giving birth on their backs. We'll chat about some of the dangers or harms of the typical birth position, which is the lithotomy position or stirs.

(02:52): We'll talk about the evidence on birth positions for those giving birth with an epidural as well as without an epidural. And then she shares some advice on what she would tell people who plan to give birth in the hospital about trying to navigate the reality that most doctors and nurses want people to give birth on their backs. That's just the reality of our US healthcare system, and she provides some advice for that. Great episode. I know you are going to enjoy it and learn a lot. Now, something else that you can do in order to really help prepare you and learn about birth positions and how to advocate for yourself within the hospital is childbirth education. That is why I strongly encourage everyone to do some form of childbirth education. I, of course, have an option, the birth preparation course, that's my online childbirth education class that will get you calm, confident and empowered to have a beautiful birth with a focus, especially on hospital birth in helping you navigate the hospital birth system.

(03:58): But really it's so important that you do some sort of childbirth education. Okay, I don't want to say any childbirth education because not all of them are created equal, but do some high quality childbirth education, evidence-based birth has childbirth education options as well. It's just really something that is so, so important. I don't want you to skip it. So if you want to check out the birth preparation course, then do check that out, dr nicole rankins.com/enroll. I would love to serve you and help you there. Okay, let's get into the conversation with Dr. Rebecca Decker from Evidence-Based Birth. Thanks so much, Rebecca, for agreeing to come back on the podcast. I can't believe it's been a long time since you were here on the podcast, but I'm really excited to

Dr. Rebecca Decker (04:43): Have you back. I'm so excited to be back as well. I know your podcast has grown a lot in the last few years, as has ours at eb, so it's fun to be able to collaborate again.

Dr.Nicole (04:52): Yeah, I think lots of people, if they listen to my podcast, they listen to your podcast, so they seem to work well for folks together. So why don't you start off a bit by telling us a bit about yourself and your work and your family if you'd like.

Dr. Rebecca Decker (05:05): Sure. So my name's Rebecca and I got into the birth field after my second baby was born. So when my first was born, I was a nurse getting my PhD in nursing and I gave birth at an academic medical center. And at the time, I just really wanted to be a good patient. I wanted the nurses especially to like me. I had a great relationship with my OB and she was going to be the one who was present at my birth. So I felt really fortunate with that. But how my stay itself in the hospital was managed was just really surprising to me. The way I was told I was not allowed out of bed. I was kept on the monitors the whole time, not allowed to eat or drink or even have ice chips at the time. And because I had a long labor, the nurses, nobody ever suggested I reposition.

(06:00): So I laid on my back in bed for the whole 24 hours, including while I was pushing my baby out, and I pushed for three hours and ended up needing both the OB to use their hand to manually turn my baby's head as well as a vacuum for several reasons. One, I was exhausted. Two, my baby was in a less than ideal position probably because I'd been laying on my back the whole time. And third, the epidural had numbed me so much that for the first couple hours that I was pushing, I wasn't really doing anything. And then that exhausted me. And then the third hour, so she was born with the help of a vacuum and then immediately taken away for observation, and I didn't get her back for another three hours even though her Apgars were normal. And that really bothered me. That was the part that bothered me the most.

(06:53): All the restrictions, the not eating was really frustrating, but I could put up with that, right? It was having my baby taken away. That for me was the hardest part. And the part that made me a year later, a lot of people do. I think around the one year anniversary of giving birth, you start to think about your baby's birthday, you start to have some flashbacks and you just start musing on it. And so I started questioning everything that happened. To be honest, I didn't really question anything until that happened. So I made a list of everything that happened to me and I started looking up the research evidence, and I was surprised to find that even though I was giving birth in what was supposed to be a cutting edge academic medical center, a lot of the things that the nurses told me I must do or I was not allowed to do, were not healthy for me or my baby.

(07:48): And obviously taking your baby away, there's no evidence to support that. It can interfere with breastfeeding and bonding. And then with laying on my back the whole time, and I know what we're going to talk about today, there wasn't even the slightest suggestion that I turned to my side. And because I had an epidural, I was just completely motionless from the waist down. I couldn't do anything without help. And they dosed it too high, I guess, because I know with a low dose epidural, that's not necessarily a problem. So I started looking up the research and then I decided to have a completely different experience the next time around. So my first baby only weighed six pounds, eight ounces, and as you can see, it took me three full hours to push her out. My second baby I had with the help of a midwife, and I pushed him out in 10 or 15 minutes and he weighed nine pounds, two ounces. So you can see how I did everything differently the second time around. And it made a huge difference, in particular how my baby was positioned, what positions I used to help my baby get in a better position. And a lot of what I used was the upright birthing positions, which we're going to share about today. And sure, after that I went on to start publishing this research on my blog, evidence-based birth and kind of the rest is history because people really wanted that information.

Dr.Nicole (09:14): Yes, absolutely, absolutely. And of course we'll link evidence-based birth in the show notes and everything, but you all, Rebecca takes it her, she and her team take a very deep dive into evidence and present a balanced. It's not, they present what's there. So it's not biased. It's very, very unbiased information, something that I have gone to many times. So I certainly appreciate your work. So let's start with defining what are the various birth positions in general?

Dr. Rebecca Decker (09:44): Okay, so there's a couple different way that researchers can classify positions. Whether or not you are upright or not is one way you can classify. So upright would include standing or squatting. You might be supported by a partner or a prop kneeling upright or on your hands and knees is considered an upright position as is using a birth seat or a birthing stool, dancing in an upright position that you can labor in as well. And then lying down positions medically are typically called recumbent or semi recumbent, and those include lying on your back, which the metal medical term for that is supine. If you're lying on your back and the head of your bed is elevated, then this might be called semi sitting or semi recumbent. And that's what I picture the position I was in for my whole labor where the head of the bed was raised, but I was lying there.

(10:42): And then the little lithotomy position is also a lying down position. That's when you're lying on your back with your hips and knees flexed your thighs apart, and your legs are either supported in stirs or by people holding your legs in the air. And with that, your head of the bed can also be raised. And then another thing that's interesting is the side lying position is technically a lying down position as well, but that is considered to be a more beneficial lying down position. And so another way you could categorize positions is whether or not you have the weight on your tailbone. So the body weight laying on the sacrum, that's the large kind of plate at the bottom of your spine, towards your pelvis. And then you have the tailbone, which makes up the bottom tip of that. So some positions like kneeling, standing hands and knees, sideline, squatting, and using a birth seat, that sacrum can flex because it's not being pushed into one position.

(11:44): But if you're lying on your back with or without the head of the bed raised up, or if you're semi sitting in bed or in the lithotomy position, typically that sacrum is going to be less flexible. So they've done some computer simulations and M R I studies, and they have found that when that tailbone is allowed to move freely, it can move nearly 16 degrees, which can make quite a difference for the baby's head to be able to come out. And there's been consistent research that when you take the weight off of the tailbone and allow the pelvis to make more room, it makes spontaneous birth without the use of surgery vacuum or forceps more likely. Gotcha. So those are kind of the different categories you can look at. Sure,

Dr.Nicole (12:29): Sure, sure. That's an excellent overview. So when we think about people or when we know about people in the us, how do most people in the US give birth?

Dr. Rebecca Decker (12:39): And it's not just the us. This is a problem in many countries around the world that is, that it is, it's thought that most healthcare workers around the world encourage people to birth in backline or semis sitting positions for the convenience for the healthcare worker. And there's been studies on that in the us but also India is another example of a country where most people still use lithotomy as the most common position with your feet up in stirs. So I think in the US it's about 68% are lying on their backs, and another 23% are in a semi sitting position. So both of those are considered the recumbent or lying down positions. And when you're looking at hospital births, the last data we have on this, unfortunately from nine years ago, but only about 3% were using sideline 4%, we were using squatting or sitting in 1%, we're using hands or knees.

(13:40): Now, if you contrast that with free-standing birth centers or home births, and you talk to a home birth midwife, they'll often tell you it's very rare for them to see anybody spontaneously choose a lying down position when they're at home or in a birth center. When someone has freedom of movement and they feel comfortable in their environment, they almost always will instinctively choose an upright position or a sacrum flexible position. Now, there's some people, for whatever reason, they feel more comfortable pushing on their backs, and sometimes that ends up being chosen, but most of the time it's not. Right.

Dr.Nicole (14:15): Right. And as you said, this is mostly due to for convenience of the attendant at birth.

Dr. Rebecca Decker (14:23): And convenience can mean a lot of different things. So it's more convenient to do fetal monitoring with the belts. If someone is in bed on their back, it's more convenient because that's how most healthcare workers are trained. So even when they simulate birth with mannequins, they're doing it with the mannequin on their back. And so a lot of healthcare workers feel uncertain or afraid if somebody's on their hands and knees, for example, because they feel like the birth is happening upside down, they haven't been trained to see a head emerge from that angle. And so when the head's coming out, they're kind of like, wait, where? Where's the baby? What's going on? So it's less fear inducing for the healthcare provider. And then if you have an epidural, it's obviously more convenient for the patient to be on their back because it's harder to move them around, especially if the there's a high dose epidural. And then there's just a lot of importance placed on having the patient in the bed so that you can control or manage the delivery. So all those factors come together to make it seem like a no-brainer in most hospitals, this is the way we do it. This is easier for us and in their mind because it's how they see birth happen. They feel like they can handle complications better in that way.

(15:41): Whereas an upright birth, say somebody's standing at the side of the bed and their baby's coming out while they're standing on the hospital floor, that seems really risky or scary plus inconvenient.

Dr.Nicole (15:53): Sure. Yeah. Yeah, absolutely. But however, as you said, research research shows that for people, and I guess, I dunno if we should qualify this without an epidural or unmedicated birth, most often people will choose an upright position. Is that fair to say?

Dr. Rebecca Decker (16:10): I think so. In some countries, they might choose lying down or semi sitting because they know that's expected of them. So in some of the guidelines for midwives and providers who are trying to support upright birth, they often say sometimes you have to encourage people to do an upright position simply because that's all they see in the movies and on TV is women giving birth on their back, and they just assume that that's how it has to be done. Sure. And there's no other way to do it. Sure. So yeah, I think if somebody is trained in that mindset, they might choose that position because they think that's what they're supposed to do.

Dr.Nicole (16:52): Yeah, that makes sense. So let's go through the different birth positions. And I actually first want to start with, because you've talked about this on your podcast and in your work about the specific dangers of the position that most often people give birth in or very frequently give birth in the us, the dangers of being in lithotomy and stirs.

Dr. Rebecca Decker (17:15): Yeah. It's interesting because you can frame it in two ways. You can frame the benefits of upright positions, or you could talk about the risks of the non upright positions. And I think that the lithotomy is a really interesting position to examine because it's gotten to the point where it's still probably one of the most common birthing positions used around the world, but it's considered to be so dangerous that researchers won't include it in studies anymore. So in one of the largest reviews ever published on this subject, when they're looking at people without epidurals, and they actually exclude any study that used the lithotomy and the authors were Zang at all, they wrote, these horizontal positions can have serious negative effects on maternal health and are not recommended by many international organizations. And then when you go to people with epidurals, there is a lot of recent research on lithotomy finding that it can be quite harmful.

(18:24): And one of the ways that it's harmful is, first of all, it can be more painful. Second of all, it is considered unethical because it is like a restraint because you can't really get out of that position if people are holding your legs or your feet, feet are in the stirs and everybody's surrounding you. Sure. But also the perineal integrity. So the perineum is a diamond shaped area of tissue between your legs. And when you have a lithotomy, you're much, much more likely to have a severe tear or to be cut with an episiotomy, which can be equivalent to having a severe tear in some circumstances. And so if you want to lower your chances of having a severe tear or an episiotomy, the most important thing you can do is to not give birth in the lithotomy position. It leaves you to exposed to interference. And when healthcare workers interfere, when there's no medical need to interfere, that's when you're having lots of preventable complications.

Dr.Nicole (19:32): Sure, sure. Okay. That makes sense. That definitely makes sense. So let's talk about some of the other birth positions and the evidence about those. And I think it's helpful to separate out into without an epidural and with an epidural because it can be different in your options for what you can move into are different. So let's start with without an epidural. What does the research show about benefits and even if there are any potential risk of different birth positions without an epidural?

Dr. Rebecca Decker (20:02): So the study I referenced earlier where they excluded the lithotomy position that was done by Zang at all and published in 2020, they have 12 randomized controlled trials with about 4,300 participants. And they separated, separated everyone. And two, those who are randomly assigned to be upright versus those who were assigned to be lying down, upright included semi sitting, but they actually didn't have any studies with semi sitting in it. Basically, we had walking, standing, leaning, using a birth chair, squatting and kneeling versus lying down or lying down with the head of the bed raised up. And they found that you're much less likely to have forceps or vacuum use on you if you're upright when you're birthing. Your active pushing phase is going to be shorter, especially if you use squatting that shortens it by more. There is a really substantial decrease in the risk of having severe trauma to your perineum, that tissue integrity that we talked about earlier.

(21:04): And there's no difference in blood loss between upright versus lying down. And there was a higher risk of having what we call a second degree tear if you were squatting or sitting on the birth seat. And they think that's probably because there's a trade off between you. You're less likely to have an episiotomy, but you might be more likely to have a first or second degree tear, which is considered to be better than having an AP episiotomy. So it's a little bit of a good trade off. They think. In terms of episiotomies, we're not really sure because every study, the AP episiotomy rates are so different. In some hospitals, episiotomy rates are like 0%, and in some hospitals it's like a hundred percent. So it's really hard to tease that out in a review. But other researchers have also found that in individual studies, one of the benefits that people don't think about is that it's significantly less painful to give birth in an upright position, which of course, if you don't have an epidural, is important. Sure. There's also at least one study that's found you're less likely to have the shoulders get stuck when the baby comes out. You're less likely to need an emergency cesarean or to have abnormal fetal heart tones, which makes sense physiologically, because if you're lying on your back, you're compressing the aorta, which is the large vessel that brings the oxygenated blood to the fetus. So if you're upright, you're getting the full blood flow through your body.

Dr.Nicole (22:30): Absolutely. Now, when we look at where these studies are done, how many of them are in the US and how do you feel like the studies apply to our population?

Dr. Rebecca Decker (22:42): Okay. Yeah. So with that one, the Zang study took place in the United Kingdom, Finland, Brazil, China, Ireland, Turkey, and South Africa. There were not any studies done on this subject in the us, but like I said, the whole concept of birthing positions is a pretty global issue. In some areas, you'll find that upright positions are still quite common, but in many countries, because the Western model of care has spread around the world, it's very common for people to lie in their backs. I think the main thing that's hard to generalize is the use of episiotomy. And so that, like I said, that's why they can't really figure out the episiotomy rates because it's so dependent on the provider in the hospital.

Dr.Nicole (23:31): Yeah. It's interesting to me though. I know some of the studies show, like you said, really high episiotomy rates and it seems, I don't know what the conflicting in a way that on the one hand you're comfortable supporting upright birth, but then you have a 70% episiotomy rate that just seems to sort of conflict with what you would expect. It just

Dr. Rebecca Decker (23:58): Shows you that so much of medical practice is cultural and training. So if that was what was modeled to you as a provider, and it's what you've done your whole career, it's really hard to hold back from doing something that you were taught was helpful and you thought you were doing good all that time. It's really hard to all of a sudden be like, oh, wait, hands off. I don't use the scissors. I can just see. It's a a paradigm shift, and you're not going to see that everybody being able to do that. And that's why I think upright positions, some of the reasons you still see episiotomies is because in some of these studies, they will maybe allow you to push in an upright position, but then they make you get on your back for the delivery. And so you have to look at each study individually when you're looking at a episiotomy rates and be like, all right, did they make them get on the lithotomy position for the moment of birth?

(24:55): And very often that's the case. Gotcha. So we don't have a ton of good quality research where people were permitted to follow their urges and push in whatever positions they want. And that's another problem with these studies is nobody really wants to just push in one position. You might be on your back for a little bit, then get up and then move over, especially if you don't have an epidural. So if it can be hard to put numbers and statistics on things, but sure. I don't know if you would agree as a provider, but I think it would be harder to cut someone if they were standing

Dr.Nicole (25:27): 1000%. Yes. You have to

Dr. Rebecca Decker (25:32): Be able to visualize what you're doing.

Dr.Nicole (25:33): Yes. You can't. It's absolutely true that if someone is in upright position, you just cannot, can't intervene as much because you aren't able to be in a position to do so. I absolutely agree that is the case.

Dr. Rebecca Decker (25:50): And I think that's one of the problems though that we face is that I've seen more and more nurses and obs become more comfortable with the idea of letting someone, or letting, yeah.

Dr.Nicole (26:01): Yes.

Dr. Rebecca Decker (26:03): Push in whatever positions they want, but when it gets close to delivery than they want the patient in the bed on their back. And that erases some, but not all of the benefits because you still get the benefits of a shorter pushing phase. Baby's in a better position, you have less pain. But then by making them get on their back, that introduces the risk of either more severe peroneal tears or an episiotomy. Sure.

Dr.Nicole (26:32): Or

Dr. Rebecca Decker (26:32): More pain. Right,

Dr.Nicole (26:33): Right. I do think, or I know that we certainly in the US have come a long way in terms of episiotomy rates and they're actually pretty low, but it's still very much so provider dependent on what happens. So it's certainly different factors to consider. And the culture, your point about cultural practice is really, really, really important that you can be in a place that, oh, we support upright birth, but we're so used to doing a episiotomy that that's what we do. Same thing happens in the us. People do what they are trained to do and what they see around them. And we very often practice in silos where we don't see other options for what can be done. And cultural practice plays a huge role in people's experience. So then let's talk about birth positions with an epidural. What are risk benefits? The things around birth positions with an epidural?

Dr. Rebecca Decker (27:29): So we don't have as much good evidence on this. There's one really large study that kind of dominates the research on this topic. It's called the BUMPIES trial, or bumps, I don't know how they pronounce it. It was done in the United Kingdom. And that one, they were comparing upright versus sideline positions with an epidural. And if you had to guess, which one do you think would be more beneficial

Dr.Nicole (27:56): Up? I would say upright. But is it side? Is it sideline that's most beneficial?

Dr. Rebecca Decker (28:02): Yeah. So interestingly, they found the sideline position to be more beneficial. Now, they were not using any backline, semi sitting or limy positions. Upright group was either on foot standing, sitting or kneeling. And then the non upright group of sideline group, they were sidelined with the head of the bed raised up 30 degrees, and most of these people had really low dose epidurals. They were able to move around pretty freely, unlike me when I had my epidural. And they found that fewer people in the upright position had a spontaneous vaginal birth. It was 35% of them had a spontaneous vaginal birth versus 41% in the sideline group. But the problem with this study is that the rate of vacuum and forceps was more than 50% in both groups.

Dr.Nicole (28:54): See,

Dr. Rebecca Decker (28:54): This is

Dr.Nicole (28:55): So perplexing to me. I know. Because that's just not common. So

Dr. Rebecca Decker (29:02): Yeah, it's like, it's another cultural thing. We have very high cesarean rates, whereas another country might have very high vacuum and forceps delivery rates. So it's not really clear. I really don't think that we could use this study to truly generalize the findings. Both are probably acceptable, both upright and sideline positions. I did find two other studies on the lithotomy position with epidurals, and they found, like I mentioned earlier, that the lithotomy position was, had many more risks than any other position. So there are other smaller studies on that subject. But yeah, we don't have a lot of research on that. We do have one other study though on using birth seats. And for your listeners who aren't familiar with that, you can Google different kinds of birth seats. And I have a video on our YouTube channel that kind of shows the different types of birthing stools.

(30:01): I can send you that link. Sure. But there is one study on using, often these birth seats are like U-shaped, and they make room for the tailbone to still be flexible while you're kind of sitting on them. And then the provider can access the baby coming out through the front, the U part. And the researchers in these were in Sweden, they had more than a thousand people giving birth for the first time. And about half of them had epidurals. So half had epidurals and half didn't. And they found that using a birth seat was led to a shorter pushing phase, less US pitocin and fewer episiotomies. There was, however, a slightly higher risk of losing blood postpartum, but this did not affect any long-term outcomes. And there was no difference in the rate of forceps or vacuum assistance being used. But one of the interesting things about the study is the participants were more likely to report if they used a birth seat, that they felt powerful, protected, and self-confident. Huh.

Dr.Nicole (31:06): Which

Dr. Rebecca Decker (31:07): I thought was interesting. Cause a lot of time in these research studies, we just have statistics on different health outcomes, but nobody actually asks people, what was your experience? How do

Dr.Nicole (31:15): You feel? Yes, yes.

Dr. Rebecca Decker (31:16): Yeah. So I thought that was really, I, it's really cool to know that something as simple as having these special birth seats can make such a difference in your satisfaction and how you feel about yourself as you're giving birth. And I still have found it's not that common where I live in Kentucky, unless you bring your own birthing stool, they're not widely available where I live.

Dr.Nicole (31:42): Not, I mean, I've worked in several hospitals during my career and I've seen it in one, but even people using them, it's just not very common. So I agree. Yeah. I have never attended a birth with someone on a birth stool. Certainly done in upright positions, but not on a birth stool. So it's not very common.

Dr. Rebecca Decker (32:03): And there are ones you can bring that are inflatable, and there's plastic ones that can be easily sanitized in between patients. So it doesn't have to be just the old-fashioned kind of wooden stool, which there's a long history though of wooden birthing stools. I mean, it goes as far back as the Bible. There's a Bible verse about midwives attending to the Hebrew women on the birthing stool. So it's a very ancient practice, and there's probably a good reason for it that a lot of people have been attracted to it. But again, it goes back to culture as culture shifts and people don't see it anymore. They think it's this outlandish weird thing when it actually is something that's been passed down through the ages.

Dr.Nicole (32:48): Absolutely. All right. So the reality is that especially here in the US that most people give birth in the hospital, which often or is very likely going to mean giving birth or at least doctors wanting, nurses wanting you to be on your back. So what advice would you give to someone who's having a baby and plans to give birth in the hospital about trying to navigate that reality?

Dr. Rebecca Decker (33:18): Yeah, I think it's important to be upfront and honest with your healthcare team about your birth plan. So if you want to give birth in an upright position, you need to start having conversations with your healthcare provider. And you need to bring up the difference between upright birthing positions during pushing and during delivery. I don't usually use the word delivery as I have a book called Babies Are Not Pizzas. They're born, not Delivered because delivery is a very passive term. I think it gives the power to the provider instead of the parent. I prefer to say when I birth my baby instead of when the doctor delivered my baby. But that's the terminology that most doctors use. And that makes it really clear. What positions do you attend births during the pushing phase? What kinds of positions do you support as a provider during the actual delivery?

(34:12): And I would probably use that exact phrase, the actual delivery to find out what is their comfort level. Because if this is really important to you, it's important then to find a provider who is comfortable with it. Because a lot of providers who are not familiar with upright birth have a lot of fear associated with it. And they will come up with an excuse most of the time to try and get you on your back, not out of some mal intent, but because they're nervous and they don't feel safe. And so most midwives, I would say, can support an upright birth because they're trained in it during school. Not all do it as a normal practice, but kind of finding out what that looks like with your provider and the providers in their practice. So if you know, don't know which provider is going to be at your birth, find out, well, what about your colleagues?

(35:09): How do they like to support the actual delivery? And if you really want to give birth in an upright position, you might have to switch clinics in order to get that, because like I said, they can't force you on your back. Although there are documented cases of people being forced on their backs, that is a form of battery, but it, there's a lot of psychological pressure that can be put on you at the last minute. So if it's important to you, that's what I recommend is finding out what their typical practice is and then deciding is this a negotiable for you or not? If you don't mind, if you're okay with pushing in an upright position and then getting on your back for the delivery, then that's great. But if it's really important to you to have an say you're having an unmedicated birth and pain control is very important to you, getting on your back for the delivery might be incredibly painful. So thinking about what are your wishes and what's negotiable and what's not. If you're giving birth in a freestanding birth center at home, it's typically not going to be an option. Just, and you can ask around doulas in your area. If you have a doula, ask them, what have you seen with the providers from my practice? Do they support upright birth and delivery or not?

Dr.Nicole (36:27): Absolutely. And waiting until you get to the hospital and handing someone your birth plan is entirely too late.

Dr. Rebecca Decker (36:34): Yeah. I mean, technically they should respect it, but also one thing you can do is ask for a nurse when you get there, who enjoys unmedicated birth or upright birth? Another thing you can do to make it more likely that you have upright pushing positions is there are a few hospitals that support waterbirth as an option. And in waterbirth, you almost always give birth in an upright position. So that's something else that can enhance the likelihood. Also, making sure that if you're going to have fetal monitoring, that they have wireless monitors, things that make it easier for you to be mobile during both the laboring phase and the pushing phase. Those are all things that can help. Sure. If that's one of your goals, to have an upright birth.

Dr.Nicole (37:19): And I guess as we wrap up, I think of it this way, that you don't have to give birth in any particular position. The key is that you should have all of the options available to you. So you may find that you want to be on your side. You may find that you want to be on hands and knees. You may find that you want to be kneeling. Occasionally people, like you said, may want to be on their back, but you shouldn't be forced to do any one way. The key is that you should have the options available to you.

Dr. Rebecca Decker (37:52): And if for some reason you end up with a provider who's not supportive of your wishes, that's where you want to have an advocate or two with you who can help speak up for you because it, you're in a very vulnerable situation as a baby is literally emerging from your body. So if they're like, you have to get on your back now, but there's no true medical reason for it, having a partner there who could be like, no, she's staying right where she is, can make the difference for you. And knowing that somebody is speaking up for you when you're in the middle of a contraction or pushing and you can't. Sure.

Dr.Nicole (38:24): Sure.

Dr. Rebecca Decker (38:25): Yeah. And I agree. I have talked with people who have said, I ended up on my back, and that was the most comfortable position for me. And I think it's important for people to know, it really is about your choices and your wishes. That's the whole point. The problem is when we have a norm where everybody's expected to give birth on their back, it's the people who don't want to give birth on their backs that have the hardest time achieving that goal.

Dr.Nicole (38:48): Absolutely. Yeah. So I guess sometimes I just see people see, I'm not supposed to be on my back. I'm not supposed to be on my back. And it's like, that's not what it is. It's really that you are supposed to be how you feel most comfortable, what feels natural to you, whatever that may be. So keep your listen to the instincts of your body and get in the positions that you feel work best for you. And then we, as the people attending the birth, should absolutely support that. The nurses should support that.

Dr. Rebecca Decker (39:16): And I think if you go back to my story and how I laid on my back for so long, at the very minimum, you need to be shifting your position at least every 30 minutes unless you're asleep.

Dr.Nicole (39:30): And how old is your, was this is

Dr. Rebecca Decker (39:32): Your child? Oh, so yeah, she is 14 years old. Okay. So she is a teen, young teen now, but it definitely feels like it was yesterday.

Dr.Nicole (39:41): Sure. And I know

Dr. Rebecca Decker (39:42): It's still a problem. Yeah,

Dr.Nicole (39:44): It is

Dr. Rebecca Decker (39:44): In my town, so it's not like it's gone away. And I have not worked myself out of a job yet. But I keep trying. I

Dr.Nicole (39:53): I say that all the time. I would love to not have to talk about any of these things and people can just walk into the hospital and know that they're going to be supported. I mean, obviously I know out of hospital birth are options for people, but for people who either want to be in the hospital or need to be in the hospital, everyone should have all of these options available to them. So I'm like, if I would be delighted not to have to talk about these things anymore, but

Dr. Rebecca Decker (40:16): What a difference it would've made for me if a nurse taught me how to use the peanut ball. Yes. Is that peanut shaped birth ball to prop my legs open? Because you can do a kind of squat in the bed lying while lying on your side. And there's all kinds of creative ways you can help someone with an epidural with the bed and the different Absolutely. Positions it can get into. So absolutely. It really was just, it comes down to nursing support because the nurses in the United States are the ones coaching you through most of the pushing until you get close to the delivery. Yeah.

Dr.Nicole (40:49): Yeah. Yes. A nurse is so important. Who is comfortable is trying to, or yes. Yes. Is so important. I will often say literally, millimeters can make a difference in terms of how a baby will fit through a pelvis, and you just have to keep moving and doing the things in order to try to get things. I

Dr. Rebecca Decker (41:11): Mean, my pelvis obviously was perfectly adequate for a nine pound baby. Yes. So why did it take six, or sorry, three hours to push out a six pound eight ounce baby? It was clearly the position was probably the problem. Yeah, absolutely. And so it was preventable. So yeah, I consented. I said, yes, you may do the manual using your hand to move the baby in. And it was a bad experience, but I consented to it and I wanted her to do it. And then I consented to the vacuum. I gave my full informed consent. But I think those things were avoidable. I don't think they had to happen. Yeah,

Dr.Nicole (41:47): I agree.

Dr. Rebecca Decker (41:48): I agree. And then the last thing I would say is if you're planning on giving birth and you're interested in upright birthing, so I did a lot for my second birth of visualization and rehearsing the position I wanted to give birth in. So during all my pregnancies was always most comfortable when I was on my knees with my upper body draped over a birth ball. And that took the pressure off my back, and it just always felt so good on my hips and my back. Right. So I really wanted to give birth on my hands and knees, but with my upper body kind of leaning on something. And so I spent a lot of time in that position towards the end of pregnancy, and I would kind of try and do my deep breathing and relax. And I also visualized my baby coming out while I was in that position. So it really helped me, I think, prep for a completely different experience. Right.

Dr.Nicole (42:44): I love that. I love that. So just as we wrap up, I ask all of my guests, what's the most frustrating part of your work?

Dr. Rebecca Decker (42:50): Oh, I didn't know that. This is a question you ask now. Probably continuing to hear the same complaints 11 years after I started evidence-based birth. And I do see a lot of improvement. I will say that, but I still get stories and I'm like, yep, it's still happening. And so as I talked with you earlier about just the fact that we still have to talk about these things and try and culture change is hard. It is. And that's essentially what you know and I are doing as we're trying to change the culture around birth to make it more supportive and have more options and choices and

Dr.Nicole (43:29): More centered on the person actually giving birth.

Dr. Rebecca Decker (43:32): And I see improvement, but there's very geographic, you know, can have one place that's doing great in another place that's not. And so it's hard for families to, especially when they're blindsided and they didn't see it coming. Sure. So I really, that's the hardest part, but the best part. Yeah. I was

Dr.Nicole (43:51): Going to say on the flip side, what's the most rewarding part of your

Dr. Rebecca Decker (43:53): Work? The most rewarding part is seeing the changes happening and more and more nurses, especially getting empowered. I think that 10 or 11 years ago when I started Evidence-Based Birth, I think doulas were still an unknown group, and they felt helpless in many ways in the face of all these challenges. But I think I see them feeling stronger now and having more power because consumers really trust them. So yeah, I see a lot of improvements as well. Yeah. Yeah.

Dr.Nicole (44:25): So if you had to give one piece of advice to expectant families, what would that one piece of it your favorite piece of advice be?

Dr. Rebecca Decker (44:35): Oh, I always have more than one. No.

Dr.Nicole (44:37): Okay. Maybe two. How about that?

Dr. Rebecca Decker (44:39): Probably if I could only give one, it would probably be to find a doula. Because if you find a doula, they'll help you with the other pieces of advice, which I normally give as well.

Dr.Nicole (44:51): Yes, that is true. Doulas do more than just support during birth. They help you during your pregnancy as well to get prepared for birth. Yeah.

Dr. Rebecca Decker (44:59): They're resource mavens. They're kind of like they know all the people and all the places and can connect you with what you need. Absolutely.

Dr.Nicole (45:08): Absolutely. So then where can people find you and your resources and your book? Her book is great you all. So where can people find you?

Dr. Rebecca Decker (45:15): So you can, our webs go to our website, evidence-based birth.com, and we have a free crash course on how to get evidence-based care. And then we're on social media. We spend most of our time on Instagram at EB birth. We also have a YouTube channel, and that is at evidence-based birth. And then you can find my book on Amazon or Barnes and Noble or in our shop, and it's called Babies Are Not Pizzas. They're Born, not Delivered.

Dr.Nicole (45:43): All right. Well, thank you so much, Rebecca, for coming onto the podcast. It was great to have you back

Dr. Rebecca Decker (45:48): On. It was an honor to be here.

Dr.Nicole (45:56): All right. Wasn't that a great episode? Lots of evidence around birth positions and I learned something and I knew that you learned something too. All right. Now, after every episode when I have a guest on, I do something called Dr. Nicole's notes where I talk about my top takeaways from the conversation. Here are my Dr. Nicole's notes from my conversation with Rebecca. Number one, we all have to keep an open mind about birth positions and all. I mean you as the person giving birth and us as medical professionals. And let me explain what I mean. This may be a little bit surprising to you. So from the person who is giving birth from your perspective, sometimes I see people who are really, really adamant that they do not want to give birth on their backs. They refuse to even think about it or consider it.

(46:52): And I know we talked about some of the literature in the episode that speaks of harms done and that lithotomy position. However, there are some caveats to that. The research is mostly done in other countries and also under different circumstances surrounding birth. It doesn't sit right with me that some of these studies have really, really high episiotomy rates really high than what we normally see in the us, which is, well, less than 10%. And I also have to think about my own personal experience. That's not research, but my well over a thousand births does count for something, and I have seen hundreds and hundreds and hundreds of women give birth on their backs and things go well. So what the most pressing problem with giving birth on your back is not that it is inherently or autum automatically going to be awful or dangerous or harmful.

(47:54): The most pressing problem with giving birth on your back is when that is the only option that is available to you. That is where we as medical professionals have to support other options as well and be open to learn about supporting different birth positions. The truth is, you don't have to give birth in any specific position, but you should absolutely have all of the options. All right. You should not be forced to give birth on your back. You should have the option to give birth on your side. You should have the option to give birth in hands and knees or squatting. We should have birth stools. Those things aren't readily available, but you should have, at least at minimum in the hospital, the option to give birth on your side. The option to do hands and knees, you absolutely should push in different positions for sure, to help baby get in a better position.

(48:54): So keep an open mind about birth positions because you will actually see some people actually like giving birth on their back. They don't find it problematic, or they find that that's the most comfortable position. So I want you to keep an open mind about it. And then we as medical professional, medical professionals have to keep an open mind and be able to support different options as well. Again, you don't have to give birth in a specific position. You shouldn't cross anything off your list, but you absolutely should have all of the options. And that to me is the most pressing problem about giving birth on your back, is that some people are forced to do that. That is absolutely wrong. That leads me to point number two, which is that cultural practice is so influential. We talked about that in the episode and about cultural practice.

(49:46): I mean, how people learn what they are used to doing, how they are used to approaching birth, just plays such a huge, huge, huge role in your birth experience. And we very much so practice in silos, meaning that you learn a specific way. And once you learn that way, it's not like you see other doctors practicing in order to learn different ways of approaching things. So it can, it's really easy for cultural practices, including bad cultural practices to get ingrained, and it can be challenging for those to change. So the culture of how we practice is just so, so important, which is what leads me to point number three is you have to understand the culture where you are giving birth and understanding that is understanding what questions to ask. So you know how your doctor approaches birth, how the hospital, where you are giving birth approaches, birth.

(50:52): These are crucial things to know, and you have to have these conversations prior to getting to the hospital. You cannot wait until you show up to the hospital in labor and you're like, well, I don't want to push on my back. And they're like, well, we don't know how to do that. Then you're stuck. Okay. So this is again where childbirth education, good childbirth education comes in to help you be prepared and ask the right questions during your prenatal visits. That's one of the things that of course I cover inside of the birth preparation course is questions to ask. So your options and the evidence behind the options as well. So please, again, another plug for childbirth education. It's just I can't overstate how important it is to ask these questions ahead of time so you have a sense for how your doctor and hospital approach birth, so you can plan accordingly.

(51:52): Of course, the birth preparation course is dr nicole rankins.com/enroll, but really look at your options for childbirth education and find something that works for you. Okay, so there you have it. Do me a solid, share this podcast with at least three people. Hit that share button inside of your app, share it with three people. Sharing is caring, sharing helps me to reach and serve more people. I am on a mission to reach and serve as many people as I can through this podcast, through my work. I want to be like the next what to expect when expecting. Okay. That's a common book that people recommend. That's how I want to reach and serve pregnant folks, and I would love your help doing so. Share this podcast with a friend. Also subscribe to the podcast wherever you're listening to me right now, and let me know what you think about the podcast.

(52:39): Shoot me a DM on Instagram. I'm on Instagram at Dr. Nicole Rankins. You should definitely follow me there for pregnancy and birth information beyond what is in the podcast. Of course, that as that beautiful visual, as element, I do videos there as well. So follow me on Instagram at Dr. Nicole Rankins and, shoot me a DM and let me know what you think about the show. Let me know if you have any show ideas. I am always open to hear that. Okay. So that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.

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