failure to progress

Failure to progress

Contractions begin in earnest and you drive to the hospital in anticipation. Today is the big day when you get to meet your baby! You get checked in, you change into the hospital gown, your baby is on the monitor, and now you wait. The contractions continue coming every few minutes, but then, for seemingly no reason, they just stop.

Now what? You may be surprised to know, this scenario is actually very common. In fact, the American Congress of Obstetricians and Gynecologists estimates that 60% of all cesareans are due to a complication called labor dystocia. If you find yourself in this situation your doctor may use such terms as failure to progress, cephalo-pelvic disproportion (or CPD), uterine inertia, dysfunctional or arrest of labor or descent, or labor dystocia, but whatever the name, it all means the same thing: no baby.

You should first know there is a wide variation in the normal length of labor. Just because you may not dilate a centimeter per hour doesn’t mean your baby is stuck or your body is broken. To the contrary, the average first time mom can be in active labor (4-10cm) for as much as 20 hours and still have good outcomes. And that’s on top of the hours, or even days, of early labor!

But what happens if you have been having contractions close together for a while (less than five minutes apart and at least 45 minutes long) and they either fade out or they aren’t resulting in labor progress?

The Labor Progress Handbook by Penny Simpkin and Ruth Ancheta identified six causes of dysfunctional labor. Some of the potential causes are identifiable in individual women prior to labor, and some of them are correctable, thus it is important for care providers and women to be on the lookout for these indications for dystocia. These potential causes are not indication for an immediate cesarean, but early recognition of them provides opportunity to correct them before they lead to labor dystocia.

The potential causes are:

  1. Cervical dystocia – posterior unripe cervix at labor onset, scarred, fibrous cervix or ‘rigid os’
  2. Emotional dystocia – maternal distress, exhaustion, severe pain
  3. Fetal dystocia – malposition, asynclitism, large or deflexed head, lack of engagement
  4. Iatrogenic dystocia – misdiagnosis of labor or 2nd stage, inappropriate oxytocin use, maternal immobility, drugs, dehydration, disturbance
  5. Pelvic dystocia – malformation, pelvic shape other than gynecoid, small dimensions
  6. Uterine dystocia – inadequate, or inefficient contractions

To prevent labor dystocia, you should take a close look at each of these potential causes to see if any apply to you, prior to birth. If you are not sure, ask your care provider if they have any particular concerns related to labor dystocia in your case. Remember that with the right care, many women who might be considered “high risk” for failure to progress do have normal births.

Now that you understand the causes, I’ll give you my recommendations as a birth doula and student midwife on how you can prevent the most common causes of failure to progress.

  • With your care provider’s help, use the belly mapping technique described at to ensure your baby is in an ideal position for birth after 34 weeks of pregnancy. If not, use these tips for turning your baby before or during labor.
  • Make sure you feel comfortable with your birthing environment and birth team. Shop around until you feel you have found a place and support team that are conducive to normal birth and your desires for your birthing experience.
  • Do not go to the hospital until active labor is established. This will ensure you don’t go to the hospital when you are only having prelabor, and will help you to get a rythm for coping with contractions in your own safe and comfortable environment. A labor project that offers distraction such as reading, bathing, movies, puzzles, or dinner with friends will help you to relax and pass the time.
  • Do not accept interventions unless they are truly medically indicated. Inductions on an unripe cervix have at least a 40% failure rate and end with a cesarean. This includes having your water broken. Pain medications are also associated with more posterior labors, slower labors, more painful labors, and cesareans.
  • Eat and drink! If you don’t, your uterus will get tired and not work as efficiently or painlessly as it could.
  • Sleep! Rest in early labor to maintain your energy level and strength when labor gets tough – take care of your uterus!
  • Get emotional support from a bith doula. Extreme fear, anxiety, loneliness, stress, or anger can easily result in a slowdown of labor. This is of course not good for getting baby out, but it can also result in birth being an unecessarily emotionally traumatic experience.
  • Stay mobile. Using forward-leaning positions in labor makes birth more comfortable, increases transfer of oxygen to your baby, and makes contractions more efficient because the uterus doesn’t have to work as hard. Pushing in gravity-friendly or gravity-neutral positions (specifically, not on your back) reduces the work it takes to push your baby out as well.
  • Be patient. Birth is hard work, and it takes time. Remember that as long as the baby is not distressed, you don’t have any health problems, and you are tolerating the contractions, there is no medical reason to rush birth. It is designed to be a gradual process so it will be easier on both of you, and with patience, progress will occur almost always without intervention, even if you have already had a cesarean or difficult vaginal birth because of labor dystocia.

Failure to progress can be a scary situation for moms who don’t know what to expect, are tired of the pain, and just want to meet their baby. But a cesarean is not the easy way out that we are led to believe it is. The simple, non-invasive, preventative or corrective measures listed above really do work! And they can mean the difference between a difficult, more painful labor, and a straight-forward, “textbook” birth.

If you have had a personal experience with labor dystocia, please share your story with us!

Thoughts on Birthrape

A couple years ago I was attending the birth of a client who was planning a VBAC with a midwife in the hospital. She had doubts, as is normal for VBAC moms, that she would avoid another cesarean, but her midwife and I did everything we could to help her prepare for a wonderful birth.

View from Gunstock Mnt, Gilford NH

Unfortunately there was a hitch: the attending OB who was to be on call during her birth put it in her head that she was going to fail. His last words to her before she went into labor were, “I’ll see you in the O.R.” My client told me his words made her nervous, that she knew he was just pulling scare tactics, but that it made it more difficult for her to have faith in her body and the birthing process.

When my client’s birthing time began, we realized quickly enough that the OB was not going to make it easy on her. I can only describe his behavior like that of a vulture, which may sound extreme, but the stress and fear manifested by both mother and child could only have come from his everwatchful eye, just waiting for her to cry uncle and let him cut her. At one point my client made a complaint about him being there and I knew she had not consented to this kind of care.

When the decision was made to call the OB in to consider a repeat cesaran, his previously rude and grumpy behavior suddenly became quite jovial. He gave no consideration to the disappointment my client was experiencing but assumed a paternalistic role and was obviously happy to take over the show. I was speechless and quite honestly pissed off (can you tell this birth made an impression on me?) though I was compelled by my promise not to interfere to hide behind a smile.

View from Gunstock Mnt, Gilford NH

Yet after the birth, I was surprised at the reversal of my client’s attitude. All of a sudden she was defending her OB, saying that although he was a bit rough during her birth she could understand, and that really he was a very nice guy (if you follow his rules). When she got pregnant again she returned to the same OB and scheduled a cesarean.

Was that birth rape? Since I was not the one under the knife I’d hesitate to say yes, but I know if that was me I would not have been letting it go that easily. Here is a good post about birth rape I found a while ago and linked to my May Favorites. It gives a really good description of what birth rape is, if you haven’t heard of the term before.

One thing I certainly do find comparable between the story I just shared and the experience of rape is that it is not unusual for women who have been raped to downplay the attack and defend the rapist as a way of protecting her own mind from accepting the seriousness of what happened to her. “He really wasn’t that mean”, “He didn’t really hurt me”, “He’s been through a lot so I understand why he’s troubled”.

But here’s the thing. My client was cut, she was bruised, her spirit was broken, she will never again have faith in her body because what little faith she mustered up was ripped out of the soil as soon as it sprouted. What that man did to her I can only hope he will never do again to another woman, but sadly, I know better.

View from Gunstock Mnt, Gilford NH

Women, mothers, girls, please! Protect your bodies! Birth leaves you vulnerable, which is good, but you must choose your care provider with extreme caution! If you are hesitant about your doctor or midwife prior to birth, if you find yourself defending him or her but know deep down you can’t trust them, listen to your intuition! Respond to that voice inside you because pregnancy is the only chance you have to choose birth attendants who will protect you in your vulnerability. You can’t protect yourself while you’re giving birth. That’s how you end up with the fight or flight response causing your labor to not start or to stall or your baby’s precious heart to show signs of stress during labor – because you don’t feel safe! Please, listen to your birthing voice and obey it. It may not be easy to change care providers like this woman did (also see June Favorites), but you’ll thank yourself during and after your birth.

If you have experienced birth rape, felt manipulated or cheated, or forced to do something you didn’t want during your birth, please read this post, and talk to someone about it. You don’t have to protect your abuser, and it is good to stand up for yourself.

View from Gunstock Mnt, Gilford NH

Your baby’s position and how it affects your birth

spaceballI bet you can think of at least one woman you know who had a difficult birth because of a baby in an awkward position and she didn’t even know that’s what the hangup was. Her labor was probably long, she may have had back labor, she either took a long time to dilate or couldn’t push her baby down very well once she did dilate, and may have had a forceps or vaccum extraction birth, or was given a cesarean section. Maybe you had a birth like this yourself.

Oftentimes, women with labors like this are diagnosed with “failure to progress” or “baby too big to fit syndrome” (also known as CPD). They are led to believe that they will never be able to have a normal birth because their pelvises are not “normal” or because they have a history of big babies or whatever. In reality, very few women are unable to deliver their babies vaginally because of a tight fit. There are very simple ways in which to avoid this situation or to overcome it if it should start to happen in labor.

In order for you to understand what is happening, I will first describe how the baby normally maneuvers through his mother’s pelvis to be born. Usually the baby is born head first, with his forehead facing the mother’s tailbone. This is ideal because it allows the largest part of the baby’s head (the back of his head) to move under the mother’s pubic bone and slowely open her cervix with minimal stress on either the mother’s bones or the baby’s bones. Here is what it looks like for a baby being born in a perfect position, medically termed “anterior”.

Sometimes, for reasons I will get into, a baby enters into the pelvis in a less than ideal position. Sometimes posterior, with his forehead facing mom’s pubic bone, sometimes facing side ways, or possibly even angled like this. In a normal labor a baby’s head will turn into a few different positions so that it can “corkscrew” it’s way out of the pelvis, it may enter at a posterior position and end at an anterior position, and as long as progress is being made and mom is comfortable this is fine. But if the baby doesn’t want to turn his head he may have a hard time maneuvering the pelvis, or if the mother has bad posture during pregnancy or is in a less than ideal position during labor it may prevent her baby from being able to turn into a good position for birth, and she may have a long difficult labor.

So how does your position during pregnancy affect your baby’s position, and what can you do to encourage him or her to adopt a good position for birth? The way you sit and stand during pregnancy affects what part of your pelvis has the most room, and as your baby gets bigger, he will curl up wherever there is the most room. For example, spending a lot of time in a lazy-boy will cause the weight of your baby’s head to sink toward your spine, resulting in a posterior position. Slouching lessons the amount of space in your abdomen for your baby to have options and he could easily end up lying sideways in your uterus, or with his head at an uncomfortable angle in your pelvis. has some wonderful tips for encouraging your baby to turn head down and face backwards by the time your labor starts. And if for some reason labor starts with baby in an awkward position, these same tips can help to turn him in labor to make pushing more effective and less difficult for you.

These tips include:

  1. Use good maternal positioning – Rest Smart
  2. Move symmetrically, don’t twist to view a computer, lift or lean to hold a child. Balance by shifting to the other side when you do favor a side.
  3. Shift with the Rebozo – you need a friend to help with the Rebozo scarf
  4. At least one forward leaning inversion every day – see the one I mean
  5. Pelvic exercises – also known as kegals
  6. Drink plenty of fresh, clean water and eat nutritious foods that nourish your muscles and ligaments. Have the required amount of Vitamin D, E, C, and minerals such as Selenium, Magnesium, Calcium and Iodine. Fatty acids and Omega oils help, too, by helping your hormones.
  7. Learn how balance, gravity, and movement affect your baby’s position

Starting early in pregnancy, or as soon as you read this, will increase your chances of having your baby in a favorable position for an easier birth. If you are unsure of where to start, call your doula or another person who understands fetal positioning to help you get started. For more information on how fetal positioning affects birth, I highly recommend this book by Penny Simpkin.

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The Monthly Doula Vol 1 Issue 12 June 2009

The Monthly Doula

A newsletter by Birth a Miracle Services

Volume 1 Issue 12 June 2009

How to have an easier, faster, and safer birth

Mission Statement: My goal is to educate and inform all parents and future parents of their rights and responsibilities of bearing children and of the truth and wonder of birth. My mission is to inspire them to enjoy their pregnancies and to look forward to bringing their children into the world.


Letter from the Editor

In the News

Quote of the Month

Benefits of a Natural Birth

How Giving Birth on All-Fours Could Be Better For You

Enough Room in the Womb by Lenore ZurWelle

Website of the Month

Book of the Month

Online Video of the Month

What is Birth a Miracle Services?

Inspired Birth

Request for Contributions


Letter From the Editor

The reaction to childbirth activists’ protests includes the accusation that if “normal birth” is better than your standard hospital birth, that women who have epidurals, cesarean sections, or give birth with a male obstetrician, are somehow “less than” those who have normal, natural births, maybe even at home. And while I am sorry to say that there are women so passionate about what they promote that they do not consider the feelings of those who are hesitant about normal birth, that is not at all the purpose of the movement.

Normal birth is about promoting safe, healthy, and empowering birth experiences for the mother, the baby, and the rest of their family. It is about learning how our bodies will function well if they are nourished and taken care of, it is about celebrating the birth of a child, it is about incorporating birth into the rest of ones life. I hope that my newsletters will inspire women to choose options which promote normal birth. This issue includes very “non-standard” ideas that promote safe and more comfortable birth. If you have any questions about what you read here, do feel free to contact me or visit my blog for more information on normal birth at


Naomi Kilbreth, CD

Birth a Miracle Services

36 Greenwood Street

West Paris, ME 04289

(207) 754-8875

In the News:

Freebirth: In January 2009, ABC did a special on the growing number of women who choose to give birth at home, even unassisted by a midwife.

Should the AMA and ACOG get to decide where we give birth? Talk about removing constitutional rights! See the full story here:

Looking for alternative remedies for healing of childbearing issues? Homeopathy may be the answer you’re looking for:

Quote of the Month:

“Dilation, effacement, and cardinal movements are the mechanics of birth, but the mechanics are only one piece of the story of normal birth. Another piece is the incredible hormonal orchestration of labor and birth. Oxytocin causes uterine contractions; the higher the levels of oxytocin, the stronger and more effective the contractions are. When the pain of strong contractions reaches a certain level, endophins are released and pain moderates. Women go into themselves and respond to contractions in more intuitive ways. When women give birth with high levels of both oxytocin and endorphins, catacholamines are released. These hormones work together to insure that mother greets her baby in an alert, interested, and transformed manner.” ~ Judith A. Lothian, RN, PhD, LCCE, FACCE. From Promoting, Protecting, and Supporting Normal Birth J Perinat Educ. 2002 Summer Copyright 2002 A Lamaze International Publication

Benefits of a Natural Birth

By Naomi Kilbreth

Some feel that “going natural” is a rite of passage in life, and offers empowerment to those women who experience a normal labor and birth. While this is true for many women who experience it, still others claim a similar experience after having a medically managed delivery. So for the purpose of this article I will discuss the physical aspects only of how starting labor on your own can start you on the path to having a normal birth.

In essence, induction of labor is a symptom of a culture that is taught not to trust our bodies. The 2005 Listening to Mothers II study suggested that 41% of women are induced into labor, and still more are given drugs or procedures to “hurry things along”. Some of the most common reasons for inducing labor are actually the most questionable, even according to the American College of Obstetricians and Gynecologists, and highly reputable books like A Guide to Effective Care in Pregnancy and Childbirth. These are five of the most common, yet questionable, reasons for inducing labor:

1. “Baby is getting too big” – The prospect of pushing out a larger than average baby can be enough to scare a woman into accepting an induction, but there are a few reasons why this practice is an unacceptable standard. For one, babies do not have hardened skulls until several weeks after delivery, they are designed to mold and and form to the shape of a woman’s pelvis, no matter the size of either one. Also, the fear that a big baby could make birth dangerous is unfounded because half of shoulder dystocia cases (where the baby’s shoulders get stuck after delivery of the head) occur with average sized babies. Other reasons why “macrosomia” is not a medical indication for induction: fetal size appears to level off after 40 weeks gestation, ultrasound measurements of fetal size are likely to be inaccurate when a baby is larger than average and can be misleading by up to a pound smaller or larger than the actual size, and induced labor is actually contraindicated for large babies.

2. Gestational Diabetes – Women who have high intakes of sugar in their diet often have larger babies. However, new research suggests that there is no such thing as gestational diabetes, rather that a pregnant woman’s metabolism changes, and thus her sugar levels appear higher than normal, even if she is in good health. Obviously, a good diet is beneficial to a good birth, but even if a woman is diagnosed with gestational diabetes, it doesn’t mean that labor induction is medically indicated.

3. Too little or too much amniotic fluid – This one is becoming more common in my experience. A woman goes in for a routine ultrasound late in pregnancy and she is told that her amniotic fluid level is a bit higher or lower than average. She is then scheduled for an induction, since a low or high level could indicate that the placenta is getting “old”. In reality, amniotic fluid is only an indicator of placental troubles if it is at a significantly abnormal level. Dehydration of the mother could in itself cause the fluid level to be a little low. Plus, the test is questionable in it’s accuracy, since it is more a guestimate that anything else.

4. “Failure to progress” in labor – This diagnosis is based on the concept that labor and birth must be quick, but in fact there is no prescribed length of normal labor. If mom and baby are doing well, than there is no reason to rush her to delivery. There are several ways that a woman progresses through labor, not just in cervical dilation, and sometimes a baby just needs a bit more time to turn into the right position for birth.

5. Convenience, for mother or caregiver – Your caregiver may come up with a questionable reason to induce because induction is more convenient, and some women prefer to schedule their baby’s birth date. In 2004, 12,000 babies were born every weekday, compared to 8,000 on days of the weekend. Unless there is a very good medical indication, the risks of induction far outweigh the benefits of inducing for convenience.

Risks of inducing or augmenting labor (Pitocin, prostaglandins, amniotomy, and herbs when used inappropriately):

Increased pain

Intrauterine infection


Early decels in fetal heart rate

Fetal distress

Cord prolapse

Reduced fetal oxygenation

Fetal bleeding

Cervical bleeding

Placental bleeding

Water retention




Maternal death

Fetal death

Water intoxication

Uterine hyperstimulation

Uterine rupture

Newborn jaundice





Rise in leucocyte level




Amniotic fluid embolism

Fetal brain damage

Increased instrumental and cesarean deliveries

Interference in bonding and breastfeeding

Failure to progress in labor

Although these risks can be serious, the benefits of using them appropriately may outweigh the risks when used for very good medical reasons. Only 5-10% of pregnancies normally fit this description and include the following indications:

1. Gestation past 42 weeks – The due date should really be a “due month” because a healthy baby can be born between 38 and 42 weeks, and sometimes even outside this time period. As Dr. Michel Odent has said, you don’t pick all your apples on the same day. Approximately 3% of pregnancies, if left alone, would go beyond the 42 week mark, and only about 10% of babies get into trouble after 43 weeks of pregnancies, so although a truly postdate pregnancy is reason to consider induction, other aspects of the mother’s and baby’s health should be considered as well, to make sure that the benefits of induction outweigh the risks.

2. Evidence of placental malfunction – Sometimes a placenta will gradually stop functioning well before the baby is ready to be born. Obviously this is not a good situation for the baby, so it would be better to cut the pregnancy short in this case. Placental malfunction can’t be diagnosed until after the birth, but signs of it occuring include a significantly declining fetal growth rate, and little fetal movement. It is reassuring to know that even at 42 weeks, 95% of placentas are functioning just fine.

3. Too small for gestational age – although some babies are born small because of genetics, this can be a sign of placental malfunction.

4. Preeclampsia – This prenatal health condition indicates stress on the mother’s body, it’s way of saying “I’ve had enough!” If not monitored carefully, and induced if symptoms are reaching dangerous levels, serious consequences could result. However, mild pregnancy-induced hypertension (moderately high blood pressure) is not an indication for induction.

5. Premature rupture of membranes – If the mother’s water breaks before contractions start, it is safe to wait 48 hours before inducing, unless there are signs of infection. One 1996 study said there was no increased rate of infection up to four days following rupture of membranes! If this happens to you, you can reduce your chance of getting a uterine infection by abstaining from sex, showering instead of bathing, keeping vaginal exams to an absolute minimum, and not inserting anything else into your vagina either. Your vagina is a sterile environment until something is inserted, and even sterile gloves inserted can carry bacteria from the vaginal outlet up the vaginal canal.

6. Fetal hypoxia in labor – If the heart rate of the baby starts reacting negatively to contractions, it can be an indicator that he is not getting enough oxygen and the labor is stressing him out. Although electronic fetal monitors have high false positive rates for fetal distress, a clear pattern of hypoxia is a strong indicator for hurrying labor along (if close to birth) or for cesarean section (if birth is not imminent). Fetal hypoxia and distress rarely happen when a woman goes into labor on her own and she is given no drugs whatsoever during labor.

If you do consent to an induction or augmentation, NEVER allow your doctor or midwife to give you Cytotec. This drug is very dangerous because it frequently causes hyper-stimulation of the uterus, which can easily lead to fetal distress and uterine rupture, and has a much higher rate of fetal and maternal death than other induction drugs. This drug is not approved by the FDA or it’s manufacturer for the purpose of labor induction, but sadly it is still used in many hospitals across the United States.

If your doctor or midwife suggests that you be induced or given drugs or herbs to augment labor, ask questions like these to make sure that you are fully informed of the pros and cons to the decision that you make (specific information on labor inducing drugs can be found on the NIH or CDC websites. You can also check my references for more information):

1. Why are you suggesting this? Is it medically indicated?

2. Is the drug FDA approved for inducing labor?

3. How will it help me?

4. What are the risks and consequences associated with it?

5. How often do your patients need an epidural after this drug is used?

6. How often do your patients need an instrumental or cesarean section after this drug is used?

7. What are the alternatives and their pros and cons?

8. What happens if I don’t get induced?

Safer alternatives to drugs and herbs for inducing labor, if it is medically indicated, include nipple and clitoral stimulation, unprotected sex, long walks, gravity, and spicy food.

Now, after scaring you about inductions and bad births, I will tell you what a woman’s body will most likely do if she is left alone and trusted to do what she needs to do.

There are several theories as to what starts labor, and no one knows for sure how to explain this mystery of nature. Most likely this is about what happens. The pregnancy is a time of creating and developing the baby’s organ systems and all the intricacies that allow the baby to survive outside the womb. Near the end of pregnancy, as the baby’s lungs (the last to finish development), or the adrenal glands, send enzymes and chemicals to the mother’s brain through their blood supply. This enzyme and/or chemical signal tells the woman’s body that it is time and she begins to produce prostanglandins that soften and loosen her cervix, and oxytocin (the body’s natural version of Pitocin) to begin effective contractions that will open her cervix.

As the contractions increase in frequency and strength, they force the baby to move downward against the cervix, which triggers the release of more oxytocin, which causes contractions that open the cervix and push the baby down. It becomes a natural cycle of labor, and the majority of women will do this on their own within a safe time period if they are “allowed” the opportunity.


“Creating Your Birth Plan” by Marsden Wagner, M.D., M.S.\

“A Guide to Effective Care in Pregnancy and Childbirth” Second Edition, by Enkin, Keirse, Renfrew, and Neilson

“Pushed” by Jennifer Block

“Born in the USA” by Marsden Wagner, M.D., M.S.

Copyright 2009 Associated Content

How Giving Birth on All-Fours Could Be Better For You

By Naomi Kilbreth

More and more research is being conducted on the benefits of upright birth positions versus the semirecumbant and lithotomy birth positions. Although the latter have been most common in the United States for the past 100 years, success stories from other countries and minorities within our own have led researchers to question the common practice.

What other countries (with lower birth mortality rates than our own) have been finding is that women who give birth upright or in the all-fours position have less pain in labor and birth, have shorter labors and pushing times, less shoulder dystocia (where the baby’s shoulders get stuck in the pelvis), and fewer perineal tears.

In addition to all of the above benefits, current American-based studies also suggest the following benefits to giving birth on hands and knees: fewer maternal and infant injuries and infant deaths related to shoulder dystocia1, less painful and more efficient contractions2, impressive rate of rotating posterior babies to anterior within 10 minutes3, shorter labor4, and the potential to decrease risk of both instrumental and cesarean deliveries5.

The question becomes, why is the all-fours position helpful, and since it is, why are not all women delivering this way? The explanation for why it is helpful probably lies in the increased freedom of movement within the pelvis. A woman’s pelvis is made of three sections, joined together by flexible cartilage, so that it can move easily. When a laboring woman lies on her back, her pelvis is constricted to a certain space. However, the all-fours position allows her pelvis to open 1-2cm, allowing adequate room for even a large baby to pass through6.

As for why this position is not used more frequently, the answer is complicated. Births that take place outside of the hospital generally result in this position being used more freqently, presumably because the mother is encouraged to choose the most comfortable position for her. Within the hospital, there may be several reasons for the lack of use of the all-fours position. These may include: patient risk factors that necessitate intervention, which is easier to use on a patient lying down, assumption that the patient is supposed to be on her back, preference of the hospital staff, or routine interventions (whether necessary or not) that require a lithotomy position.

An all-fours position may not be appropriate for all women. If she is tired, on pain meds, or has certain health conditions, lying on her side may be a better option for her.

Considering the definite benefits, however, all women should consider the all-fours position, among other upright positions, to be useful for them in labor and birth. Speak to your care provider to learn if this is a good option for you, and don’t be afraid to ask for a second opinion if your care provider is unfamiliar with this practice.


1, 6 – “A New (Old) Maneuver for the Management of Shoulder Dystocia” by Meenan, Gaskin, Hunt, and

2 –

3 – “Baby Malpositions: Implications for Birth” by KMom.

4, 5 – “A Meta-Analysis of Upright Positions in the Second Stage to Reduce Instrumental Deliveries in Women with Epidural Analgesia” by Roberts, Alger, Cameron, and Torvaldsen. Acta Obstet Gynecol Scan. 2005 Aug; 84(8):794-8.

Copyright 2009 Associated Content

Enough Room in the Womb

Learning About Enough Space

By: Lenore ZurWelle

In this world of “bigger is better” and striving for more space we could learn a lesson from a growing fetus in the womb. At each stage of pregnancy, the growing child has all of their needs met. There is just enough room for growth, there is nourishment to sustain life, all the necessities to thrive. Just enough at each stage in the growth to produce a perfect human being. What happens then, when the child is born and is introduced to a far greater world? A room of his own is just a much bigger space to fill. The big crib is spacious compared to the small place of comfort and safety the newborn came from, so we fill it with blankets and stuffed toys to make the space seem more cozy. As parents, we may even move to a bigger home to accommodate the new addition to the family. But is it space and a big room that a newborn really needs? In fact, do any of us really need more space? Maybe we could take a lesson from the newborn child and realize that we all crave closeness in all aspects of our lives. Our babies have something to teach us, even while they are in the womb. Physical and emotional closeness is what make us thrive, not bigger houses. It has been said that the space we need to be comfortable living in is the “7 inches”, that space between our ears or put another way, the space behind our eyebrows. That, like the womb is a very small space but certainly a place where there is room to grow. It is there that our thoughts, feelings, creativity and emotions grow and flourish. If we cannot be comfortable and thrive in this space then there is not enough space in a home or in the universe to satisfy our needs. This is the lesson our babies teach is as they grow inside our bodies. Just enough room is not only just enough, it is all we need. When anticipating the birth of your new little one, let the progression of their growth be an opportunity for learning. It is not the amount of rooms in the house but the amount of love, comfort and nourishment that comes from the parents and family. It doesn’t take much room to give warm hugs and security to your family. That is a lesson that is given to us from our babies even before they are born. A lesson that holds truth and lasts a lifetime.

Website of the Month:

This article is from 2002 but considering the current assault on normal birth, this article is still relevant.

Book of the Month:

Your Best Birth: Know All Your Options, Discover the Natural Choices, Take Back the Birth Experience by Ricki Lake

Online Video of the Month

What is Birth a Miracle Services?

Birth a Miracle Services is the name of the birth doula and childbirth education service that I started in 2002.

A birth doula is a person who offers informational, physical, emotional, spousal, and advocacy support to women through pregnancy, birth, and the early postpartum period. I also offer traditional childbirth preparation classes, birth art classes, and childbirth counseling.

All of this is available to women within an hour of my home in West Paris, Maine for a sliding scale fee. Single, teen, and low-income moms can receive my birth doula support for free.

For more information visit my blog:

Inspired Birth

I am proud to announce the birth of my first book, Inspired Birth: A Fresh Perspective for Christian Maternity Care Providers. It is an inspirational guide for all Christians who attend women in childbirth, with fresh ideas on how to meet the emotional and physical needs of childbearing women while addressing current challenges to American maternity care. This book is still in the editing process and is not currently available for purchase, but if you know any Christians who are doctors, nurses, midwives, or doulas, please let them know that this book is on the way!

Request for Contributions

Next month’s topic is on motherhood and sexuality. If you have anything you would like to contribute, such as how having a baby affected your sexuality, please email your thoughts with the subject line “Monthly Doula” to . Thank you!


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How to Have an Easier, Faster, and Safer Birth

Chances are good that you know someone or have heard of someone who had back labor. If you have, or you have experienced it yourself, you know that back labor can be much more painful than normal labor, even excruciatingly painful. Yet chances are also good that the only fix for back labor that you have been told about is the epidural. The good news is, there is an easier and safer way to avoid or stop back labor, but first you must understand what back labor is, and what causes it.

During most of pregnancy, your baby is small enough that he can do somersaults and stretch his limbs without too much effort. Sometimes he will be head up, sometimes head down, or even sideways, but that’s okay because birth is far enough away that there is plenty of time for him to settle down.

By the last trimester though, your baby will have gotten big enough, and old enough, that he will not be able to do all the gymnastic tricks he had been able to, and he will naturally seek the most comfortable position to stay in. This is essentially the baby’s way of “nesting” in preparation for birth. The normal, best position for him to choose would be head down with his face looking toward your spine (medically termed Occiput Anterior).

Multiple challenges surface if your baby decides that he likes a different position, such as butt down, facing your belly, or lying sideways in your womb. Any one of these would be medically termed “malpositioned”, although the most common malpositions are the baby facing his mother’s belly (Occiput Posterior) or facing her hip (Occiput Transverse). Because pelvis’ come in all shapes and sizes, sometimes a baby in the posterior or transverse position can be born just the way he is with no problems at all. Most of the time, however, moms (especially those having their first baby) have more pain and difficulty in giving birth to them.

Back labor, prolonged labor, lack of cervical dilation, lack of descent on the baby’s part, and fetal distress are all possible complications of labor with a malpositioned baby. Malpositioned babies also have a harder time entering the pelvis and becoming “engaged”, thus prolonging the start of labor, perhaps well beyond the estimated due date. Typically, the plan of action in this case is to provide the mother with an epidural to relieve the back pain and pitocin to speed up the labor. If the baby gets too stressed or no progress is made, a cesarean section is performed. Malposition of the baby is becoming a more and more frequent indication for giving a cesarean section.

Such a situation can not only be painful in several aspects, but it can be stressful, scary, and more dangerous than it has to be. Why? Because as I said before, there is an easier and safer way to avoid or reverse malposition of the baby.

What is this magic fix? Very simple: encourage the baby to find a good position for birth before he settles into your pelvis, and then encourage him to stay there. A woman who already has a malpositioned baby, even in labor, has a very good chance of turning him (87% of babies who are OP at the start labor will turn before birth, Gardberg-1998), if she follows the principles included here.

A group called Spinning Babies discovered that following these three principles can many times turn a baby who is not in the best position for birth:

1. Balance. Years of bad posture and chronic body tension affect the balance of the uterus. When a woman’s body, including the ligaments, muscle, and fascia around her uterus are not aligned well as a result, her baby will naturally mold to this imbalance in her uterus and become “malpositioned”. It has been said that the couch, a contributor to bad posture, is a leading cause of cesarean section.

2. Gravity. If you have been using the first principle to relax your abdominal and pelvic muscles, use of gravity-enhanced positions (i.e. upright positions), especially in labor but throughout pregnancy as well, will encourage your baby to settle head down in your pelvis, and to maneuver the turns through your pelvis to be born.

3. Movement. The pelvis is made up of four different joints, all moveable. Even the sacrum can move if you are not sitting or laying on it. If you are relaxed and balanced, upright, and moving, your pelvis will open easier to turn the baby and move him down and out.

Here are some techniques that Spinning Babies recommends to incorporate the three principles into your every day life, and into your labor and birth experience:

* Spend lots of time kneeling upright, or sitting upright, or on hands and knees. When you sit on a chair, make sure your knees are lower than your pelvis, and your trunk should be tilted slightly forwards.

* Watch TV while kneeling on the floor, over a beanbag or cushions, or sit on a dining chair. Try sitting on a dining chair facing (leaning on) the back as well.

* Use yoga positions while resting, reading or watching TV – for example, tailor pose (sitting with your back upright and soles of the feet together, knees out to the sides)

* Sit on a wedge cushion in the car, so that your pelvis is tilted forwards. Keep the seat back upright.

* Don’t cross your legs! This reduces the space at the front of the pelvis, and opens it up at the back. For good positioning, the baby needs to have lots of space at the front

* Don’t put your feet up! Lying back with your feet up encourages posterior presentation.

* Sleep on your side, not on your back.

* Avoid deep squatting, which opens up the pelvis and encourages the baby to move down, until you know he/she is the right way round. Jean Sutton recommends squatting on a low stool instead, and keeping your spine upright, not leaning forwards.

* Swimming with your belly downwards is said to be very good for positioning babies – not backstroke, but lots of breaststroke and front crawl. Breaststroke in particular is thought to help with good positioning, because all those leg movements help open your pelvis and settle the baby downwards.

* A Birth Ball can encourage good positioning, both before and during labor. Swaying in great circles while sitting on a birthing ball is one way to help the head slip into the pelvis.

* Various exercises done on all fours can help, eg wiggling your hips from side to side, or arching your back like a cat, followed by dropping the spine down (also known as a “pelvic tilt”. This is described in more detail in an article on – ‘Exercise for relieving backache’ by Suzanne Yates.

* Once a woman has a baby or two, or six, relaxation is rarely a problem. She may be too loose. Supporting her belly with a pregnancy belt can substitute for any missing tone in the abdominal muscles. A good pregnancy belt supports the baby’s angle into the pelvis. The belt adds a slope to help the baby to aim and then, later, rotate into a good starting position for labor.

* Walking regularly helps baby make slight adjustments to his position, and encourages him to move down into the pelvis.

* Some women will request that their amniotic sac, or bag of water, not be broken by the doctor or midwife in labor. This will help the baby rotate her head more easily during birth.

* Throughout pregnancy movement and exercise helps improve muscle tone to help with engagement and helps the pelvic joints stretch and relax, which will help descent once labor begins. In labor, movement helps the baby descend through the pelvis.

* Do pelvic rocking any time when your lower back is achy. The movement of your lower back releases strain there. The pelvic tilt is a good comfort measure. Pelvic rocking is more likely to be effective if the abdominal muscles and ligaments are relaxed first. Do about 20-40 pelvic rocking movements each time, 1 or 2 times a day. If you do them while baby is active, there may be more benefit to fetal position improvement. But start early, in the first trimester! Do the pelvic tilts after doing the maternal Inversion exercise.

* Visit a chiropractor who can use the Webster Technique to help turn a baby who is malpositioned, or an osteopathic doctor.

* Ask your doctor/midwife what position the baby is in at each visit after 35 weeks. Don’t be satisfied with just “head down”, ask what direction the baby is facing. You can also check your chart, which you have the right to do. The position will be labeled as LOA, ROA, LOP, ROP, ROT, LOT, LSP, RSA, LMT, or something similar to that. Ask what the abbreviation means, ask your doula, or look it up in a medical dictionary.

* Eat well, avoid eating foods that will encourage a large sized baby (baked goods, potatoes, pastas, sweet dairy products (ice cream, frozen yogurt, milk shakes), and try to choose better protein and veggie choices. Eat enough, but make good choices about the foods you eat.

* The baby’s back is the heaviest side of its body. This means that the back will naturally gravitate towards the lowest side of the mother’s abdomen. So if your tummy is lower than your back, eg you are sitting on a chair leaning forward, then the baby’s back will tend to swing towards your tummy. If your back is lower than your tummy, eg you are lying on your back or leaning back in an armchair, then the baby’s back may swing towards your back. So find resting positions that encourage you to keep the front part of your pelvis open, and your belly leaning forward. Leaning back in armchairs and car seats are good examples, and anything that keeps your knees higher than your pelvis.

Here are some other good resources on fetal positioning:

1) Go to and use their principles and techniques. They also have a blog here.

2) You can also purchase the booklet Optimal Foetal Positioning which will give you more insight into encouraging your baby to choose a good position for birth, complete with pictures. You can purchase a copy through this website: or http://www.capersbo au/scripts/ shop_item. asp?by=fla& item=334

3) Sit Up and Take Notice by Pauline Scott is another book worth reading.

Here’s a good video I found that shows how to use some excellent positions for labor:

Cephalopelvic Disproportion

 So what is CPD? With the majority of primary cesareans being due to the diagnosis of CPD, it might be wise for women to have a healthy understanding of what CPD really is.

 The medical definition of true CPD is a combination of arrested cervical dilation after 5cm dilation and unresponsiveness to oxytocin augmentation after active dilation, of more than 2cm, in two hours. Therefore, CPD is really a diagnosis of failure to progress (FTP).

 True cases of CPD include medical indications as to why the baby is too big (such as Hydrocephalus) or why the woman’s pelvis is too small (such as malnutrition, pelvic fracture or rickets). Obese women and women small in stature are more likely to be diagnosed with CPD, though both delivery vaginally all of the time.

 It is very important to remember that each baby and pregnancy are unique, so a woman who has her first child by cesarean delivery due to CPD has a very good chance of being able to delivery subsequent children vaginally.

 Taking for example, a study by the National Maternity Hospital and University of Dublin, Ireland, published in Obstet. Gynecol., 92(5): 799-803 in 1998 Nov. This study examined 42,793 women and found only 84 (.002%) who had true CPD. Of the 84 women, 40 participated in the study’s trial of labor for subsequent births. Of the 40, 68% delivered vaginally. Their conclusion: “The strictly defined diagnosis of nulliparous cephalopelvic disproportion should not constitute an automatic ‘recurrent’ indication for cesarean delivery”. Other studies have found similar results.

 What is required for a birth to “work optimally”? A collective opinion of experienced birth professionals concludes that the following guidelines must be met in labor or a difficult birth is more likely to occur:

                  1) Being upright

                  2) Maintaining privacy

                  3) Being on baby’s time vs. hospital time

                  4) Not receving pain killers

                  5) Not being subjected to continuous fetal monitoring

                  6) Reducing the use of Pitocin and other labor inducing/augmenting drugs

                  7) Being aware of the baby’s position and presentation

                  8) Letting labor start on its own

                  9) Being allowed to rest, food and drink, and perhaps most importantly:

                  10) Having a support system who truly believes women are able to give birth, and who are willing to lend encouragement and strength to the birthing woman

 I love what In May Gaskin has to offer women who were previously sectioned for CPD. She tells them that, “they will get big, bigger than the baby. And it works … women are not limited. Mothers get bigger than the baby” (Birthing From Within, England and Horowitz). Women are built to have babies. Their bodies release a significant amount of the hormone, Relaxin, after 34 weeks of pregnancy. This helps their pelvis to loosen and make way for the child in her pelvis. At the time of labor and birth, the pelvis opens at three different points, and the four cranial bones in the baby’s head overlap, so that the baby is able to travel down and out the birth canal.

 Perhaps the best way to encourage women is to share firsthand stories of women who defied the odds that our society has built around them, and gave birth vaginally:

 Laura, who is small in stature, was sectioned with her first baby (9lbs, 14oz) and diagnosed with CPD. She gave birth vaginally to her second child (11lbs) after a four hour labor with no tearing.

 Lisa, who is 4’8″ tall, was told by her medical care providers that her chance of a VBAC with her second child were only 30%, so she searched out midwives to support her, and she gave birth at home with only a half hour of pushing.

 “Sarah”, would almost certainly have been diagnosed with CPD if she had delivered at the hospital. She was so small in stature that she wore size 2 shoes. Instead she found a supportive midwife and gave birth to her 7lb daughter in a watertub at home.

 There are cultures around the world where CPD is the rare phenomenon that it should be. One study showed that women in the United States were six times more likely to be diagnosed with CPD than women in Ireland. In Africa, Pygmy women (who average 4′ tall) give birth all the time to 8lb babyies. That is like a 5’6″ women giving birth to a 14lb baby!

 If you have been diagnosed in the past with CPD and are facing another birth, I encourage you to challange the system and believe in yourself. Find a supportive care provider who sees you as a strong experienced woman, not as a disproportionate pelvis. There are times when true CPD prevents women from giving birth vaginally, but in most cases, the next birth will be completely different. Remember, you have at least a 68% chance of attaining a vaginal birth.



2) (no longer available)

3) American Journal of Obstetrics and Gynecology 2002 Aug; 187(2):312-8; discussion 318-20

4) Acta. Obstet. Gynecol. Scand. 2002 June; 81(6):502-7

5) ICAN Clarion, Sept. 1997



8) “Pelvises I Have Known and Loved” by: Gloria Lemay

9) “CPD and FTP = Bad Practice” by: Gretchen Humphries

10) “Birthin From Within” by: England and Horowitz

11) “Cephalopelvic Disproportion (CPD): Rare, and Massively Over-Diagnosed” by: Gail Hart