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March 8, 2015

For an evidence-based birth, get off the bed

Despite the evidence, the majority of women still give birth on a bed.  Midwife Howes is not happy.

The bellowing voice of the labour ward sister shouting “Midwife Howes get your woman into bed!” still has the capacity to ring loudly in my ears even now, 17 years later but I am pleased to say she and her sisters in practice no longer walk the labour wards.  Now we have the evidence base to NOT get women into bed to have a baby. Now we know that beds are not good apparatus for the vast majority of women, don’t we?  Well yes we do KNOW, but do we always implement what we know?

“of the less than 3% of women who do not enter the hospital to give birth, the majority never go anywhere near the bed”

So how and where do most women give birth? Where do the majority of labouring women labour, despite all the evidence, give birth? Yes, it is STILL in the stranded beetle position or semi sitting on a bed. I say “still” because I bet there is not a birth professional out there in the big old birthy world that if questioned would not know that laying down or semi recumbent on a bed is not the best physiological or psychological position a woman can be in to give birth.

“But we don’t tell them what position to get into”, I hear some midwives cry. “They WANT to lay down” I hear them lament. Really? We don’t tell them? They WANT to lay down? Then how come is it that of the less than 3% of women who do not enter the hospital to give birth, the majority never go anywhere near the bed. At a home birth there are plenty of beds around but few give birth on one.

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It looks more like this

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or this…

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or this

 

You see fellow midwives, with the best will in the world we DO tell them to lay down on a bed, without even opening our mouths. When those women walk into a hospital birth room, when we lead the way and open the door, the bed is sitting there in the middle of the room seducing the already conditioned women, calling to her in her scared, disempowered moment, “come to me my dear this is where you give birth”.  And why else would the bed be the focal point if it was not an important and worthy piece of equipment in a birthing room?

“And this is not the first time she has been told how she should give birth. She has learnt the skill from the TV, ‘One Born Every Minute’ shows exactly how it is done!”

And this is not the first time she has been told how she should give birth. She has learnt the skill from the TV, ‘One Born Every Minute’ shows exactly how it is done! Eastenders has told her and Coronation Street has told her, the Daily Mail tells her often, as well as every comedy or documentary on the TV featuring a birth.  Books, TV, Magazines, all the places women learn about birth, demonstrates to them how it’s done. I would like to bet that if I did a survey, 95% of that learning will be from a beds eye view.

birth

In our western society the fact is it is still culturally normal to lay down to give birth. So if we professionals know that laying down on beds is not good for giving birth why do women still do it and midwives and doctors, albeit subtly, still promote it? Is it because the culture concerning birth is stronger than the evidence we have?

“The midwives’ rules indicate we can be judged on care given or care omitted so if we omit to encourage a woman OFF of a bed are we giving less than the best of care? I believe we are indeed.”

And do all those women really WANT to lay down as I often hear it said or, as I suspect, is it a case of once laying down they think that they can’t possibly move? Having had four babies I certainly have this scenario in my memory. Lying on the bed in about as much pain as I could bear, the thought of moving felt akin to dying, so if anyone had suggested it I would have thought them quite mad. But of course I didn’t know then what I know now. I hadn’t experienced, albeit from another perspective, birth like I have experienced it now. I had not experienced birth as a knowledgeable, evidenced based, primarily hands off, promoter of physiological birth type midwife.

The midwives’ rules indicate we can be judged on care given or care omitted so if we omit to encourage a woman OFF of a bed are we giving less than the best of care? I believe we are indeed.

Having just come from a home birth the memory of the labouring woman’s words “I can’t move” are still ringing in my ears. Yes it would have been so easy to leave her in the position I found her in and call it her choice, or let myself off the hook by saying it was cruel to encourage her to move when in such discomfort but I was acting in her best interest and trying to give the best care I knew how so I told her, “yes you can, you think you can’t move but I know you can and once you do it will feel so much better”. A few minutes later found her to be in a much more comfortable position and one which was conducive to an easier physiological birth.

When a woman is in labour for 2 hours or 20, the natural hormones will deliberately make her feel very tired. She is not physically exhausted, it is nature’s way of birth. When that baby is born she will be so awake, will be so unable to sleep it will be hardly fathomable that the earlier assumption of tiredness was possible. Of course she can rest between contractions but rest can be with just head down at times not necessarily the whole body. If a woman does lay down for short periods its fine of course but limit the time in one position.

Sitting on a simple birthing stool. For me, poised in front of her I had a bird’s eyes view of an advancing head, a stretching perineum and a bump easy accessible to auscultate a fetal heat. It was easier to make eye contact. For her in her elevated position, me slightly lower she was the empowered one. She had physiology on her side as her pelvis opened and stretched to its full capacity to allow the baby to be born with ease.  Both of us sitting in comfort, all three of us on an unfolding journey of life.

Midwives

– Highlight the issue; take on a project to move the bed from birth rooms or run a fund raiser to buy alternative birth equipment.  Either push the bed away or when you walk into a room with a woman or you sit on the bed so she can’t then you can talk to her about staying off it.
– Tell the women when they walk through the door “the bed is only for emergencies, you are not an emergency are you?

Top Tip for all: read the evidence of just how bigger the pelvis gets when NOT laying or semi recumbent you will be amazed and determined to approach birth differently

Women

– The birth room is yours the bed is on wheels push it into the corner and just use its cushions for the floor.
– Do some leg and body core strengthening exercise or join a pregnancy yoga class where not only will you grow physically stronger but this message will be reinforced.
– Take some pillows or a yoga mat and piece of plastic with you to hospital, tell them you want to use your own things. Put “please remove the bed from the room” on your birth plan. It may not be possible due to available storage space but it will open up the conversation for staying off the bed.
– You will feel tired, you may feel like you can’t move. Remember you CAN move tell yourself over and over “I am a strong women, I am I can I will.

All

– Off the bed birthing is not just for low risk women and despite wires, lines, catheters and no end of essential paraphernalia the optimal care is still given to birthing women, off the bed.
– Throw those cushions at the TV next time you see a woman laying down or semi recumbent to keep the issue uppermost in your mind

Despite the evidence, the majority of women still give birth on a bed.  Midwife Howes is not happy. The bellowing voice of the labour ward sister shouting “Midwife Howes get your woman into bed!” still has the capacity to ring loudly in my ears even now, 17 years later but I am pleased to say […]

 
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