March 2003 Vol
Sheila Kitzinger's Letter from Europe
The Clock, the Bed, the Chair
Many interventions accepted as normal in labour and birth are insidious and hallowed by time. They do not proclaim themselves with new technology, or entail major expenditure, but form part of the conventional environment of birth in Northern industrial countries. Without them, some caregivers would feel unsettled. They provide the basis for other interventions and are unrecorded because they are unseen.
A central item of equipment in childbirth is the clock on the wall. Records are based on the information it provides: the timing and length of contractions, assessment of uterine activity, the parameters of the first, second and third stages, and the Apgar score of the baby.
For some health professionals a birth without a clock would seem a shambles. They would feel out of control. The information produced by the clock is reinforced by the caregiver's watch and a print-out of an electronic fetal monitor which also records time. In retrospect, labour and delivery are defined in terms of the clock: degree of cervical dilatation, membranes ruptured, intravenous catheter inserted, descent of the fetal head, medication given, the infant and placenta delivered at specific times.
For women, too, narratives of hospital birth frequently rate the experience as easy or difficult with reference to the clock.
This is rarely the case with accounts of home births. I studies of womens narratives of birth, comparing those who gave birth at home with others who gave birth in hospital When I did a content analysis of their birth stories it emerged that they made references to time in contrasting ways.
In hospital, birth time was recorded in relation to the clock and the partogram. Sometimes it is clear from the accounts that time dominated the decisions about labour. Everything that occurred in labour happened at specific times, and some women even wrote their stories in the form of a time chart, with the exact time introducing each line or section.
When a woman was transferred from home to hospital the decision was usually made in relation to time. One woman told how the midwife who arrived at their home at 3 p.m. announced,' You must have this baby by six o'clock, because I'm going off duty then, and there's no-one to take over from me.' time, She was transferred to hospital, labour was stimulated by a syntocinon intravenous drip, and she ended up with an emergency Caesarean section on the grounds that labour was prolonged.
Home births were described in relation to natural phenomena, to night and day, dawn and dusk, full light, half-light and darkness, and also with reference to social relationships that impinged on the labour: children waking up, going to school, coming home, neighbours dropping in, and family mealtimes. One woman recorded that she found time to plant out beans in her garden, with the help of her midwife, before labour became too strong to do this any longer. Many home birth mothers told how they prepared meals in advance or baked a cake for the party afterwards.
In hospitals clock-watched labour is so normal that it is unremarked.
The clock is an unevaluated technological intervention that has major impact on the conduct of birth.
Since the 1970s research has revealed that upright positions and mobility enable the uterus to contract more efficiently and reduces perception of pain. 1, 2, 3, 4, 5, 6, 7, 8, 9 Yet in birth rooms around the world a bed is the central piece of furniture and is taken for granted. A bed is for getting into. It implies a certain kind of posture and a certain attitude of mind. Beds are for resting in, for easing aches and pains, and in a hospital for displaying the body to professional gaze in order to examine, diagnose and manipulate. Attendants gather round the bed and look down on to it; lights are directed on to it; electronic equipment is lined up to connect with the body lying on it. The patients body belongs to the bed and the bed to the body.
Bed-bound birth is perceived as normal, even inevitable, in the majority of hospitals everywhere. Any variation on this style of birth is seen as innovative and daring.
When caregivers get women down off the bed other equipment tends to be offered. Rather than open space, a stool or chair is provided. Studies have been published from the 80s on comparing use of a chair or stool with bed birth, but not comparing chair with completely free movement.
Whenever a chair, stool or other apparatus is used it conveys the implicit message, "You sit here, place your feet there and grasp this". The more elaborate the equipment, and the fewer the options available to the woman, the more it restricts movement.
Squatting and kneeling positions have remained some of the most common postures in traditional cultures throughout the world. When doing research in a large Jamaican hospital in the 1960s I witnessed a running battle between labouring women and midwives. The women wanted to get up and crouch down, knees bent, and rock their pelvis forward and back, and the midwives were determined to get them on the bed or delivery table, where they were expected to lie still and be good patients.
Birth stools and chairs have a long history. The medieval birth stool was a horse-shoe or boomerang shaped slab of wood on legs, without a back and without arms. A woman could sit on it and move her pelvis freely. One of the god-sibs (women birth companions) sat behind her cradling against her body and moving with her. It was a familiar, comfortable posture since women were accustomed to sitting crouched on a low stool when milking a cow or goat and spinning or weaving.
Another version, dating from the sixteenth century, was elongated so that a woman could sit behind the mother on the stool, supporting her with her body. Later solid backs were added to birth stools, and subsequently hand grips.,
The birth stool is a development of birth bricks as they were used in Egypt, Persia and India and also of lap-sitting. The latter was common in Africa, Europe and South America. In the early nineteenth century a German carpenter devised a birth stool with a back to it after his wife told other pregnant women in her neighbourhood how easy it had been giving birth sitting between her husbands thighs. As a result women called on him to attend them when they were in labour. He became very popular in the town, to such a degree that he constructed a birth stool to take his place.10
A variation combining lap-sitting and a stool, was developed by settlers in the North American colonies. The woman sat between her husbands thighs on a stool or chair turned on its back so she had space beneath her. She could rock her pelvis and her women helpers sat in front of her so that she could reach and clasp their hands.
Stools became more elaborate with padding, skirting and footrests, and evolved into chairs that resembled domestic chairs in middle class homes, often with extra decorative carving and foot rests.
From there it was only a matter of angle to fix the woman in one position and tip her backward with her legs raised and pinioned The activity of the laboring woman was now replaced by the activity of the accoucheur, and from then on birth chairs and tables were designed to facilitate his manoeuvres without hindrance from the patient.
Today birth chairs range from simple stools, like the plastic New Zealand midwifery stool, which leaves the coccyx free and has a stainless steel dish below for the placenta, to highly elaborate constructions which can be turned to delivery tables complete with lithotomy stirrups, and on which Cesarean sections can be performed
In Switzerland the Maya birth stool is just that, a low, curved stool with a padded cushion on it, and a woman can move her pelvis freely, though she is sitting on her coccyx.
The elegant Roma chair, also Swiss designed, with its circular loops and springy, cushioned seat, suggests activity because it resembles a piece of athletic equipment. But it has foot-rests that indicate where a woman should place her feet. She can press against or pull on the metal bars that soar above her, but cannot kneel, squat or get on all fours.
Medical equipment firms that manufacture modern birth chairs emphasise in their promotional material that a flick of a switch or pressure on a button can either allow the woman to squat grasping a birth bar, with her perineum exposed so that it can be guarded, and the babys head manually rotated, can tip her into the Trendeleberg position, or have her flat on her back for an instrumental delivery or Caesarean section. These birth chairs, though promoted as enabling women to be upright with support, in the final resort are under the control of the obstetrician and enable the birth to be transformed into an obstetric delivery.
At any international birth conference equipment like this can be seen in the exhibition hall. A state-of -the-art Italian birth chair is constructed entirely of stainless steel and black rubber, and advertised as providing "the most favourable position for physiological deliveries". This turns out to be with a woman reclining on her back, legs raised in lithotomy stirrups, her wrists and ankles cuffed, and her shoulders restrained to prevent her from moving her head. Malvestio, (Industrie Guido Malvestio) the manufacturing company promotes it in this way: "Because of its mobility this equipment allows the obstetrician to effectively and rationally intervene on the expectant mother" and with "a single fast clutch-operated movement" the chair will transform into a table on which a Caesarean section can be performed.
Even a recent innovation, the birth pool, does not always permit free movement. In theory, a pool allows a woman, supported by water, to move unencumbered. Or so it might be thought. Though published research often refers to mobility as an advantage of being in a pool, some pools are elaborate constructions with seats, handgrips and foot-rests, and movement in them is restricted. In some centres pools intended for bathing disabled elderly people are used. A purpose-built pool designed as a tub for the frail and elderly is, by its nature, confining. A pool that is embellished with a moulded plastic stool, a ramp, foot supports, shower and handles is equally restrictive.
In many English hospitals a hoist has been erected over the pool so that whenever the midwife wants it the woman's inert body can be raised and lifted onto dry land. In some hospitals on the Continent, in spite of lack of evidence from RCTs that water immersion is safe when the mother has received opiates or regional anesthesia, women may not only be injected with demerol before and after they enter the pool, but be partially immobilised with an epidural. In developing an international waterbirth research data base this information is essential.11
Clock-watched labour, even when a woman has the midwifery care and all the aids to support physiological birth, is labour restricted by management protocols. Moreover, when a labouring woman uses a chair or a pool, it cannot be assumed that she is able to move freely. Comparative research is needed using video to record the range of positions and movements women actually adopt when labouring and giving birth on birth stools, chairs or in a pool. Video should also record the interaction between whoever is assisting at the birth and the mother to reveal whether she is under pressure to perform within a time limit and whether the caregiver expects and suggests specific positions.
Only then can we begin to understand the effects on women's birth experiences and outcomes for mothers and babies of the clock, the bed and the chair.
|1||Liu Y, Effects of an upright position during labor, American Journal of Nursing; 1974 2202-5|
|2||Flynn A, Kelly J, Hollins G, Lynch P.F. Ambulation in labour. British Medical Journal 1978; 2: 591-3|
|3||Caldeyro-Barcia R, The influence of maternal position on time of spontaneous rupture of the membranes, progress of labor and fetal head compression. Birth 1979; 6: 10-18|
|4||Jong P.R., Johanson R. B, Baxen P, Adrians V.D., Westhuisen S, Jones P.W. Randomised trial comparing upright and supine positions for the second stage of labour British Journal of Obstetrics and Gynaecology 1997; 106: 291-2|
|5||Diaz A, Schwartz R, Fescina R, Caldeyro-Barcia R, Vertical position during the first stage of the course of labor and neonatal outcome. European Journal of Obstetrics, Gynecology and Reproductive Biology 1980; II: 1-7|
|6||Chamberlain G, Stewart M, Walking through labour. British Medical Journal 1987; 295: 802|
|7||Roberts,J.Maternal position during the first stage of labour in Chalmers I, Enkin M, Keirse M.J.N.C. Effective Care in Pregnancy and Childbirth, Vol. 2, Oxford University Press, Oxford, 1989: 883-892|
|8||Sleep J, Roberts J, Chalmers I, Care during the second stage of labour in Chalmers I, Enkin M, Kierse M.J.N.C. Effective Care in Pregnancy and Childbirth, Vol 2, Oxford University Press, Oxford 1989: 1130-1134|
|9||Gupta, J.P, Nikodem V.C., Maternal posture in labour. European Journal of Obstetrics, Gynaecology and Reproductive Biology 2000; 92: 273-7|
|10||Engelmann G, Labor Among Primitive Peoples J.H. Chambers, St Louis, 1882|
|11||Burns E, Kitzinger S, Midwifery Guidelines for Use of Water in Labour. OCHRAD, Oxford Brookes University, Oxford, 2001|