#66 Birthing Positions, the Evidence with Dr. Rebecca Dekker

Justine:
Hi, I’m Justine.

Sarah Lavonne:
And I’m Sarah Lavonne.

Justine:
And we are so glad you’re here.

Sarah Lavonne:
We believe that your life has the potential to make a deep, meaningful impact on the world around you. You as a nurse have the ability to add value to every single person and patient you touch.

Justine:
We want to inspire you with resources, education, and stories to support you to live your absolute best life, both in and outside of work.

Sarah Lavonne:
But don’t expect perfection over here, we’re just here to have some conversations about anything, birth, work, and life, trying to add some happy to your hour as we all grow together.

Justine:
By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses.

Sarah Lavonne:
This guest I feel like is a long time coming. You’ve been on our short list for seasons now. We’re in season four of Happy Hour with Bundle Birth Nurses. I don’t know how we got here and it just didn’t happen, but I am thrilled to have Rebecca Dekker here with me today. Rebecca Dekker is the founder of Evidence Based Birth. So I’m sure you’ve been on her website. I am sure you are referencing her resources here. And so we’re going to learn a little bit about her. And then we are actually going to talk about something very sexy to all of us. One of our main reasons why people come to our physiologic birth class, why you might be in motion, our new app, and that is we are going to demystify alternative birthing positions and talk about their benefits. And what I love about Rebecca is her emphasis on research.
That is her background. She’ll tell you more about that, but I am so excited to learn from you and get your take on our birthing positions, because especially as nurses, this is where we have so much control. This is right in our wheelhouse of where we can help our patients and help labor progress, et cetera, et cetera. And so before we talk about positions, I’d love for you to just introduce yourself, tell me about yourself, and then along those lines, I would love to hear just a little bit about your journey as a nurse. And I think you have a very unique story. When I became a nurse, I pictured myself being at the bedside for the rest of my life, and we both have sort of gone an alternative way in that direction and sort of gotten really creative with our licensure. And so I’d love for you to just tell us a little bit about your story and how you got here.

Rebecca Dekker:
Sure. Thanks Sarah. I’m so happy to be here to chat with you and the nurses who are listening. So I live in Lexington, Kentucky. I graduated from nursing school in 2002 and I worked for several years in Med Surg telemetry. I had a hard time deciding what I wanted to be as a nurse, you have so many options when you graduate, and for me, I ruled out so many things that I did not want to do, and then it just left me with the straightforward path of Med Surg. I had originally thought I wanted to be a pediatric nurse, because that’s what my mom is, but then I did pediatrics and my heart just could not handle seeing…

Sarah Lavonne:
Same.

Rebecca Dekker:
Yeah.

Sarah Lavonne:
Stop it. That is exactly the same as me. I did peds in nursing school.

Rebecca Dekker:
Yeah, [inaudible 00:03:06].

Sarah Lavonne:
Oh, it’s so hard.

Rebecca Dekker:
And I hated seeing them in pain and procedures and there’s a special place for peds nurses, but that was not for me, actually with lab and delivery, the first time I watched a video of a birth, I almost passed out because I was literally feeling her pain. It was a video of an unmedicated birth, and as she was screaming, I felt myself feeling the pain.

Sarah Lavonne:
Oh, wow.

Rebecca Dekker:
So I had to get on the floor and put my head between my knees. That was my first exposure to birth. But then my labor and delivery rotation wasn’t bad. I had a really fantastic patient I really bonded with, but still, I just felt like that’s not for me. And so I didn’t think I was going to have anything to do with birth except for maybe having my own children. So I did go back to school to get my masters, and then I was most of the way through my PhD in nursing when I got pregnant with my first baby, and I had a very healthy pregnancy except for I have really bad migraines in pregnancy. And they’re constant chronic every day and you can’t take many medications during pregnancy. So it was a challenge. But other than that, I was healthy.
So when I went into labor at 39 weeks on my own, my waters ruptured. But then I went into labor, my contractions started. I went to the hospital and I’ll never forget, one of the first things the nurse said to me as she welcomed me to my room was like, “You better go to the bathroom now because you’re not allowed out of bed from here on.” And so I went to the bathroom and then I said, I was really determined to do, as I was told, I wanted to follow all the orders because I didn’t want to be one of those patients at the nurse’s station. And what I didn’t realize is at the time, I was more enmeshed in the cardiovascular side where we were always talking about meta-analyses and what the latest randomized trials showed and what we should be doing.
And I didn’t realize that at that time in that particular labor and delivery unit, it was not like that. It was just like, this is how we do things and you’re going to do things our way or the highway. And so I did as they said, I had to use a bedpan because they wouldn’t let me walk to the bathroom. And I found out later, there was no order for strict bed rest, it was just a belief that that particular nurse had that if your membranes are ruptured, the cord will prolapse even though the baby’s head was engaged. And then I was also told I was not allowed to eat or drink anything. One weird thing that happened to me is I had a lot of heartburn during pregnancy as most of you can probably identify if you’ve had a baby. And they wouldn’t let me take a pill or a chewable or anything for a heartburn. They gave me Reglan IV and I ended up having a really bad neurological reaction to it.
And so I actually list that as an allergy now for myself. It was lots of little things like that that added up. And then at the end when my baby born, they were like, “Well, we have to take her away for observation.” And they ended up taking her out of my room for more than three hours. And I didn’t know why, but I kept pushing my call light because I had an epidural and I couldn’t just get up and run down the hallway to get her. And they said at one point they were like, “Well, we just gave her a bath and her hair’s all wet so you can’t have your baby now because her hair has to dry.” And I said, “Well, that makes sense. She was born with a full head of hair.” And so I was justifying everything they told me to do as if, well, this is in my best interest, but it really wasn’t.
I think it was just a matter of they were short-staffed. It was the middle of the night. They didn’t want to have to bring someone to me to show me how to breastfeed. It was easier to keep her in the nursery. And that was my introduction to parenting. And the nurses really shaped my experience, not necessarily… The weird thing about it though, it was always done in sweetness and in kindness and with a respectful tone. I was never talked down to or scolded or anything, but it was like they were really nice. But doing all these things to me that later on I found out are not evidence based. That’s what took me down a road of researching everything birth and trying to find out what is going on in maternity care units. This was in 2008 when this happened to me.
And so as I began collecting research, I realized a lot of care that was being delivered at the time was really outdated. So I made a birth plan for my next baby and I had a completely different experience, but I had to really work hard to get that experience. It did not come easily or naturally. It was something I had to work for. Then after he was born and I felt the complete opposite, instead of feeling disempowered and like I’m just being told what to do, I was the one in the driver’s seat as the mom. And so that’s when I decided to start publishing what I found because I felt like everybody deserves that kind of care, leave the birthing experience, feeling empowered, feeling informed, you know how to take care of this baby that you were able to do something even if you needed medical intervention, that you made it through and you were supported the whole way and you were making decisions the whole way.
And I felt like everybody deserved that no matter what kind of birth you have. So that’s kind of how Evidence Based Birth got started. And then I was growing it. I was at that time faculty in the College of Nursing. So I was teaching nursing students and doing a lot of research, and I started bending my research more towards maternal health, but then I decided I have to choose between, basically they were turning into two full-time jobs and at that point I had three kids. So I decided to… I made a really difficult decision to leave that field of nursing education and shift into just working for myself. And that’s what Evidence Based Birth. Then we started adding more people to the team. And so it’s myself, my husband, and then about 11 or 12 other people who work at EBB.

Sarah Lavonne:
Amazing. Oh, I have so much compassion and so much respect, more than I would’ve had respect probably five years ago. But now, especially having done that myself, I’m like, “Oh, and how are you? How’s it going?”

Rebecca Dekker:
It’s going good. There have been times leaving a job where you get that regular paycheck, insurance. So I still don’t have health insurance really. I have this temporary insurance. It’s temporary, but we just get it every year and it doesn’t cover most things, but that’s the main drawback. Otherwise, I love being my own boss and I love making my own schedule. So there’s a lot of pros. There’s a few cons, but mostly pros, I think.

Sarah Lavonne:
I’m so curious from your perspective with the research background, again, I love me a research article. I love me a good reference list from a research article. I’m that person that’s like, okay, let me go to that and let me also read that one. And then you end up in the hole, which I’m sure you relate to. When I look at somebody like you that I really, really admire and look up to in the world of research and what you’ve done for our profession as a thought leader in the birth world, I would love if you could just give us what is your global take on the current state of the hospital system?
Let me preface because I’m listening to your story from years ago with your kids and you’re like, there’s so many things that we are doing that are outdated or they didn’t let me out of bed. I’m like, there are still units to this day in my perspective, and maybe a little better in the last few years, thanks to social media, but that are still doing stuff like that. And so I would love what’s your kind of bird’s eye view of what you are seeing, what you’re hearing and where the evidence has gone, and from a big picture where you’d like it to go, what do we need more evidence on or what do you wish we would do better?

Rebecca Dekker:
It’s hard for me to make blanket statements because like you said, every unit is so different. And if I say that this happened to me and I don’t give the context, I’ll have a nurse say, “We would never do that still.”

Sarah Lavonne:
Right.

Rebecca Dekker:
And I’m like, yeah, but just like you I hear from people all over around the world where these things are still happening. So it’s definitely a mixed bag. But when I started Evidence Based Birth in 2012, it took off like a rocket ship. It was like within weeks of starting to post my research, people were just visiting the website from all over the world and following and wanting to participate and give me tips on what I should cover next. And there was this hunger for this information. And I think one of my favorite parts of the whole journey is, I don’t want to say the nurses were the villains in my birth story because I think it was very much a problem with the system in the future of-

Sarah Lavonne:
Totally. Totally.

Rebecca Dekker:
… the unit. But I went from the nursing care that I received, and then within a few years, I started hearing that nurses were printing off my articles and sharing them at the nurse’s station and sitting around talking about them.

Sarah Lavonne:
Me being one of them, by the way.

Rebecca Dekker:
Yes. And I remember the first time somebody emailed me and told me that I was just stunned that it had reached that far. And I was like, well, that’s what we need, because nurses are the backbone of our healthcare system, and if we can get the nurses on board, we can do anything.

Sarah Lavonne:
Yes. Amen. So do you think we’ve progressed?

Rebecca Dekker:
Yes, in many ways. When I first started, most people didn’t know what a doula was. Most people still did not know what a midwife was. And so we have really filled that information gap. And doulas are also out there on the front lines, educating so many families. So there’s things that never happened 12 years ago that are happening maybe 20, 30% of the time now. For example, skin to skin in the operating room was non-existent when I started Evidence Based Birth, and I started hearing about a few cases where it was used and we started looking at the research, I published that info, and at that time, that was really revolutionary. And now in 2024, I see it happening more often, mainly with planned or scheduled cesareans but sometimes with unplanned, and again, it depends on the facility.
There’s other things where I’ve seen improvement. So with eating and drinking, that was one of the first articles I wrote at EBB, was the evidence on eating in labor, because that really bothered me because I ended up fasting for 24 hours, and then by the time I came to push my baby out, I had no energy. And that bothered me as well, being hungry, being forced to forego food when I was hungry was an aspect of my birth story that I felt was a little bit, I don’t know what word I would say, it was definitely contributed to suffering. So now, what I see is more hospitals permitting eating during labor, but not if you have an epidural and not if you’re being induced. So it went from nobody could eat at all to now some people can eat. And so we’re starting to unravel things a little bit. So those are some of the benefits I’ve seen and just more awareness of choices. But yeah, there’s still a lot that needs to improve.

Sarah Lavonne:
For sure. I think about over my career because you said you started Evidence Based Birth in 2012, right? So I became a labor and delivery nurse in 2011. So it was from the jump around there. And I think about how just access to information has improved obviously, and technology and sharing of resources. We have better communities. And so I think about these nurses. I would say that most people listening to this podcast in our community or whatever, they’ve heard of you as well or they’ve used your resources. Whether or not it’s being put into practice is another story. But I think just even having them as a resource over the last years, I know for me, I’ve used it with patients. Well, it’s just like now you have this whole library of options for people and for us as nurses, I think what I find is that I don’t know that nurses are that proactive about finding their own evidence or being able to find, or knowing how to find their own evidence, or maybe they don’t have a medical library at their institution, and a lot of these articles are expensive.
You have to pay for subscriptions and stuff. And so I think that’s one of the gaps that I see you filling and your resources filling for all of us that’s like what’s the quick hit? What is the nitty-gritty on skin to skin? And what is the summary and what are the references so that we have so much more power? We got to have these conversations with our administrators, with our managers, with the doctors at the bedside, and we know that the evidence is really what’s going to move our hospital systems. I would love for us to take into account our lived experience and physiology even more as well on top of that. That’s part of my dreams, but that evidence is really, to me, what has power. And I think that’s where and why you’ve been so powerful in our industry. So I’m very grateful for you. Thank you for everything that you’ve done for us.

Rebecca Dekker:
I’m glad it could be helpful.

Sarah Lavonne:
So in transitioning to physicians, let’s break it down. Tell me, what are some common misconceptions about physicians and what is the evidence that you know of? Give us the nitty-gritty on alternative birthing positions so we’re not talking laying on your back the whole time and never shifting. What is the evidence?

Rebecca Dekker:
So two things that I want to point out right away. One is you keep calling them alternative birthing position.

Sarah Lavonne:
Thank you. Yes.

Rebecca Dekker:
But they’re actually the original OGs.

Sarah Lavonne:
Yes.

Rebecca Dekker:
I don’t think most people know that the reason that most people give birth lying down has nothing to do with biology or medicine. It has to do within the 1600s, King Louis XIV of France was obsessed with seeing children be born. He wanted to watch the whole thing, and it was easier for him to watch.

Sarah Lavonne:
I thought it was for visualization for the doctors, but that’s probably more new.

Rebecca Dekker:
And he fathered 22 children.

Sarah Lavonne:
Oh my word.

Rebecca Dekker:
Because it used to be that it occurred on the birthing stool. You can’t really see what’s happening, I think is a benefit for some partners, right? Because it can be a little traumatic to watch. I mean, not that it always is. It can be fine and normal and it is, but like with a water birth, if you actually see the baby’s head coming, it doesn’t feel as scary. It just like all of a sudden, oh, there’s a baby. Whoa. It just appeared so easy. So I just want to correct that misconception. And then the other thing I want to tell you is a little bit before we get into the data and the evidence with my story, I think is a good example, because I was told to get in bed. I was not even allowed to move around outside of the bed, and I mainly laid on my back.
And then when I had my epidural, it was very heavy motor block. I couldn’t really move and nobody helped me move except for my husband from time to time. And so I ended up laying on my back. So by the time it was time for me to push, I did feel an intense pressure to push. So I put my call light on and told the person who answered that I was feeling an urge to push, and they said, “I’m so sorry, you’re going to have to wait because we’re all in report.” And so this was at 7:00 PM, and I was like, “Oh, yeah, you’re right. They’re in report.” So then [inaudible 00:18:33].

Sarah Lavonne:
Oh, how considerate of you?

Rebecca Dekker:
Yeah, my epidural button, I kept pushing it to dose myself to ignore the feeling of pushiness. And then by the time everybody came in my room all gowned up and masked up and everything, I had no urge to push anymore. So I tried for about an hour to push, did not make any progress. And then finally the epidural wore off. I started pushing with a renewed earnestness and nothing happened. And that’s because my baby was posterior. It’s a manual rotation. And then finally for the third hour I could push, but then I got exhausted. And so they had to use a vacuum to get the baby out. So that just goes to show you though I had this baby. It took me pushing more than three hours. She was small for a full term baby. I thought she was six pounds, eight ounces.

Sarah Lavonne:
Perfect.

Rebecca Dekker:
My next birth, I used upright positioning, the whole labor and birth process, and I gave birth kind of kneeling, hanging over the birth tub, and that baby was almost three pounds larger, and I pushed for 15 minutes.

Sarah Lavonne:
Wow.

Rebecca Dekker:
It goes to show you that, and you talk about this a lot with fetal positioning, but when you lay on your back, you’re not encouraging the baby to rotate in a positive way. So that’s, first of all, I think important to remember. So we have this supine position laying in your back, if they’re elevating the head of the bed, that might be called semi sitting or semi recumbent. And some people think that’s upright, but it’s not, mainly because you’re putting pressure on the tailbone and the sacrum so that the pelvis cannot expand to its full width. Then we have lithotomy position lying on your back in a supine position with your hips and knees flexed. And then we have lateral positions. Those are all kind of lying down positions, although lateral is considered to be beneficial because the sacrum is flexible. So those are kind of the three lying down positions.
And then the upright birthing positions, which are what I would call our ancestral positions. The positions we usually use before men started interfering with birth is standing, squatting, kneeling upright or on your hands and knees, and then using a birth seat or a birth stool. And the birth stool is very old. It’s even mentioned in the Bible. So as far back as we know, women have been birthing on these stools, which they actually, because of the way they’re shaped, allow the sacrum to be flexible as well. So those are the positions. But as you know, the most common ones are the ones where you’re lying down or semi sitting. And not many people are encouraged to push and give birth. And when I say give birth, I mean actually deliver in an upright position because one of the things I’m seeing is that nurses may push with their patients, and nurses are often the ones doing that, right? Not the doctors, but then when the OB comes in, they’re put on their back.

Sarah Lavonne:
Yep.

Rebecca Dekker:
Is that something you still hear about?

Sarah Lavonne:
A 100%, yes. That’s our hack for trying to advocate for multiple positions happening if we have providers like that. Yeah.

Rebecca Dekker:
Well, [inaudible 00:21:46] doctors out of the room and then you have to put on their back.

Sarah Lavonne:
Yeah. A lot of times, I will say, I think in the last couple of years, even a closed knee pushing, when I first started teaching physiologic birth, it was like, I’m sorry, what? Aggressive, anti, close need. There is no way. Okay, let’s take a deep breath. Let’s just talk about physiology. How does it work? And now, I think people are getting on board, but I give credit to nurses for being the advocates and saying, I heard about this thing, or let’s try this thing. And then they prove it to their providers, and the providers are like, huh, we just pushed for two hours and then we shifted their position, and all of a sudden the baby came.
Like, huh, there might be something to it, but it’s like your own bias of what you’ve been taught plays into what you’re comfortable with, and then that dictates your care. And so I think things are shifting, but as we know in medicine, my goodness gracious, it just takes so long. And like you said before, there’s so much of this that’s systemic hospital-based cultural stuff going on, not just nursing care. I believe in nurses that we are the change makers. We’re the ones that are going to push the dial forward, and we already are, but it’s just so, so slow.

Rebecca Dekker:
And it’s hard if you’re the only nurse. I don’t know if any of your listeners right now are thinking it would be nice, but I’m the only one.

Sarah Lavonne:
Yes.

Rebecca Dekker:
Right? If you have a core group of really strong advocates, then you can share that heavy weight of having to be an advocate. But if you’re one of only one or two, it’s hard because then there’s a target on your back.

Sarah Lavonne:
Totally. Totally, which again, goes back to the hospital wide issues and cultural stuff going on that slows down our progression of doing better. So it is a bigger picture, and it doesn’t all weigh on those of you listening right now, but we can contribute one starfish at a time. So what does the evidence say? And when we talk about alternative, I use that word, it’s like the uncommon, so not the back and the side, just our typical nursing positions you see in our charting. What do we know? What does the evidence say?

Rebecca Dekker:
So the evidence typically gets bundled into one of two groups, the studies on people without epidurals and studies on people with epidurals. So which do you like me to cover first?

Sarah Lavonne:
Let’s go without first. And then obviously most common for these nurses are going to be with epidurals.

Rebecca Dekker:
So we had a really large meta-analysis published in 2020 where they combined 12 randomized control trials. They were assigning people to upright birth or recumbent birth, but they actually excluded lithotomy, which I think is really interesting. I’m seeing this more often. They don’t include any studies of lithotomy because it’s so harmful that they don’t think it’s ethical to include it in any research anymore. What was it can have serious negative effects on maternal health and are not recommended by many international organizations.

Sarah Lavonne:
Imagine. So why are we still doing it for everybody?

Rebecca Dekker:
With this meta-analysis, they compared the upright versus a combination of lying down or lying on your side or lying with the head of the bed raised up. And they found that upright birthing positions led to less use of forceps and vacuum, a shorter active pushing phase, a substantial decrease in the risk of severe perineal trauma. No difference in the risk of blood loss between groups, no difference in the length of the entire second stage. There was a higher risk of second degree tears with positions of squatting and sitting on a birth seat, and they think that’s the trade-off because there were fewer episiotomies in the upright group.

Sarah Lavonne:
Interesting.

Rebecca Dekker:
Slightly higher rate of those milder tears. And so some people think that’s an acceptable trade-off if you’re avoiding episiotomies. And then in terms of other studies that have looked for other benefits, they found significantly lower rates of pain. So pushing and giving birth in an upright position is less painful. There’s lower rates of shoulder dystocia, which I think is interesting because that’s such a fear of hospital staff. There’s a lower rate of abnormal fetal heart tones, again, important for nursing care and lower rates of emergency cesarean. And as many of your listeners know, being upright, you’re not putting pressure on the aorta with the weight of the baby, so you’re going to have better blood flow and oxygen to the baby.

Sarah Lavonne:
Sounds like a few benefits for patients.

Rebecca Dekker:
I also like to think you could flip that and say the risks of giving birth lying down.

Sarah Lavonne:
Yep.

Rebecca Dekker:
You could say a higher risk of forceps, vacuum a longer pushing phase, a higher risk of severe perineal trauma, a higher pain levels, higher chance of shoulder dystocia, et cetera. So you’re like, you could look at it either way, the benefits of upright birthing positions or the risks of making someone lie on their back.

Sarah Lavonne:
And that’s for non-epiduralized patients?

Rebecca Dekker:
Yes.

Sarah Lavonne:
Yeah. Great. And many of them, we know that if they’re listening to their bodies, it’s less natural, less preferred to a lot of times be on your back in that case as well, especially if we’re talking about pain, it’s less pain to be upright. So they would prefer that a lot of times. I think about your situation, did you prefer to be on your back? Probably not. Yeah.

Rebecca Dekker:
I mean, I think I would’ve been a really good candidate for someone to be having someone help me move from the side and try different positions, et cetera. Yeah. So with epidurals, there is a Cochrane review on that as well. It was dominated by this one trial called the BUMPES trial from the United Kingdom. This was a really large randomized trial, first time births comparing upright versus side lying positions for epidurals. So they ruled out, they didn’t use the back line or semi-sitting, and they randomly assigned people to, if you were an upright group, then you were encouraged to move around on foot, stand, sit, kneel, or use any other upright position. Then the non-upright group was assigned to lie on their side in bed with the head of the hospital bed raised 30 degrees, and they all pretty much had low dose epidurals. They were not using heavy high doses in this study. And they found that the sideline group actually had higher rates of spontaneous vaginal birth than the upright group.

Sarah Lavonne:
Interesting.

Rebecca Dekker:
It was a slight increase. It was 41% spontaneous vaginal birth rate in the sideline group versus 35% in the upright group. And you might be surprised, why are they having such low rates of spontaneous vaginal birth? And that’s because in the United Kingdom, where this study took place, it’s really common to do forceps and vacuum. So in the US, you might see rates of less than 1%, maybe 3 to 4% max. But in this study, the rate of forceps and vacuum assisted births was 55%.

Sarah Lavonne:
Oh, wow.

Rebecca Dekker:
Yeah, for that group.

Sarah Lavonne:
Okay.

Rebecca Dekker:
And so it’s not really clear if this research can be generalized to a different population with very different practices. I think it shows that there weren’t really any other differences between the groups. So both seemed to be pretty equivalent.

Sarah Lavonne:
From low dose epidural sideline versus upright?

Rebecca Dekker:
Yeah, they’re both seem to be good, except a slightly higher rate of forceps or vacuum with the upright positions in this environment where they were using forceps and vacuum left and right.

Sarah Lavonne:
Yep.

Rebecca Dekker:
I’m trying to see. There is a few more studies that have come out and they have found, again, sideline positions to be beneficial in comparison to the lithotomy position. So there was one really interesting study looking at about 200 people giving birth in Spain. And the sideline position had a 20% of an assisted delivery compared to 42% in the lithotomy group.

Sarah Lavonne:
Wow.

Rebecca Dekker:
And then intact perineum was 40% in the sideline group versus 12% in the lithotomy position. And another study also found fewer cesareans in the people who were allowed to move around in the second stage. So there’s fewer episiotomies as well. So there seems to be some benefits. There’s something particularly risky about the lithotomy position that really increases your chances of lots of different things happening that you don’t want. Nobody wants to have a severe perineal tear.

Sarah Lavonne:
Yeah, totally.

Rebecca Dekker:
Yeah. Again, it’s not considered ethical. And I’ve talked with some nurses who believe it’s a restraint because it’s hard to get out of it.

Sarah Lavonne:
Yeah. I know.

Rebecca Dekker:
Big eek. I would be curious if people are listening, oh, we never use that anymore.

Sarah Lavonne:
For lithotomy?

Rebecca Dekker:
Yeah, or some people say it’s used all the time, or maybe it’s only certain providers that want to use it.

Sarah Lavonne:
I’d still say it’s at least 80%.

Rebecca Dekker:
Wow.

Sarah Lavonne:
Yeah. And the fact that you’re saying it that strongly is honestly, I’m a little like, oh, okay. But I mean, it makes sense.

Rebecca Dekker:
It’s not just the US too, but around the world. It’s a [inaudible 00:31:10] issue.

Sarah Lavonne:
Fair. Fair.

Rebecca Dekker:
That’s how many healthcare workers are trained and they don’t… Many healthcare workers in many locations around the world don’t believe that women should have a choice. But the World Health Organization is actually said, it’s like a right, you’re right. It’s like breaking the [inaudible 00:31:26]-

Sarah Lavonne:
ACOG says that in their position statement.

Rebecca Dekker:
… and setting up the stirrups like a matter of routine, automatically increasing the risk of harm. And I know a lot of nurses, they think of themselves as having two patients or more if there’s multiples, and you’re literally improving the chances of bad outcomes for the mother and the baby with this position.

Sarah Lavonne:
Well, and I think your story is very powerful in that for us as nurses to pay attention to, because you were trying to be the good patient. And you were like, I trust you, and the nurses were nice. They didn’t bully you into lithotomy or to not use the bathroom or something. You were like, “Yeah, I’m going to listen. Of course, I’m going to do it that way.” And so it just reminds me, again, of the power that we have in terms of where we can help make change advocate for our patients and give them that element of control even of what feels good, I don’t know, well, evidence shows if we can… Let’s move to your side, it’s better for your pelvic floor. And if we’re here for 10 minutes while the doctor’s in the room, then okay.
But in the grand scheme of things, motion is lotion. Hence, why we named our app motion because we want to keep them lotioning and lubricating those babies out. We also know from a physiology perspective that the more you move them, the more it supports the physiology that already exists. You talk about the sacrum and the tailbone moving out of the way. That’s just mutation. That’s the way that the pelvis is designed in order to move and make space to allow the baby through. So not only does the evidence align, it’s like, of course, my brain’s physiology brain, and the physiology, it’s common sense at this point.

Rebecca Dekker:
Yeah, and the whole pain thing, that to me is a big deal, because if you have an epidural, you might not be feeling anything anyways. I would see the harms mainly being the longer second stage, the higher risk of a episiotomy and severe tears. But if you’re having an unmedicated birth, it’s actually really contributing to pain and suffering by forcing someone or coercing them or telling them they have to get on their back. So as a nurse, I would feel not okay with supporting somebody being coerced. And one of the things I’m seeing, again, this tends to come more from providers, is that they will say anything to get someone on their back.

Sarah Lavonne:
Yes.

Rebecca Dekker:
We need to decrease the risk of shoulder dystocia or we need to do this. And they’ll throw out these scary things when actually the upright birthing position would be more protective, but it’s just not what they’re used to. So they’ll do whatever they can to get it back in their comfort zone. But one other birthing position I haven’t really mentioned with the research, I would also be curious to know how many of your listeners have seen birth seats used in their hospital?

Sarah Lavonne:
I’m actually hearing about it more, especially in DMs. It was, gosh, I did something the other day where it was a little mini case study, not a tracing Tuesdays, where we were talking about what do you use? And there were multiple DMs of people. We have a CUB, we have a stool that we pull out.

Rebecca Dekker:
Yeah, I think is another one. And this really great home birth midwife brought me several very old wooden birth stools to look at one time, and you can see them in really old artwork. It’s cool. They’ve been used for thousands of years. And we had some studies done on this in 2006 and 2009 in Sweden. And so they actually enrolled more than a thousand participants who were giving birth vaginally for the first time. About half of them had epidurals, and then they were randomly assigned to either give birth on the special birth seat or whatever position they chose.
And they found the birth seat resulted in a shorter second stage, less use of Pitocin for augmentation. And there’s no difference with perineal tears. But there were fewer episiotomies on the birth seat, and there was no difference in hemoglobin levels postpartum. There was a slightly increased risk of postpartum blood loss, but that’s a controversial subject in terms of measuring postpartum blood loss. And they also found this interesting finding. They said that the participants who gave birth on the birth seat were more likely to report that they felt powerful, protected, and self-confident.

Sarah Lavonne:
Oh, that’s so beautiful.

Rebecca Dekker:
Yeah. I was like, you don’t often hear… Would you hear that about the lithotomy?

Sarah Lavonne:
Yeah.

Rebecca Dekker:
Powerful, protected and self-confident?

Sarah Lavonne:
No.

Rebecca Dekker:
One time I was giving a talk about birth at a brewery, which I know is really weird, but they invited me to come. They had this science and suds night or something.

Sarah Lavonne:
Cute.

Rebecca Dekker:
Yeah. I came and I was talking about birth, and I brought all my childbirth education tools, and then I asked for a male volunteer to come up, and I made him lay down on the table in front of everyone and put his legs in a lithotomy position. And then I said something like, “Now, poop, we’re now push out a baby or something.” And it was a very interesting, very visual demonstration of how vulnerable you feel when you’re in that position. And how we would never ask men to do that. But it’s a very gendered thing that we ask women to get into that position.

Sarah Lavonne:
Well, and I think about even just being exposed, talk about… I mean, medically, we’ll say visualization of the perineum and visualization of the perineum is a straight shot into the most vulnerable area of your body. And just being out there for everyone to see. I don’t know if I’ve ever thought about it that way, versus I suppose if I was upright, I feel a little more protected. I don’t feel as exposed. I feel like it’s mine down there and I am over it versus here you go and let me hand it over. And I don’t know if I’ve ever thought about it that way. That’s…

Rebecca Dekker:
In terms of a trauma-informed approach.

Sarah Lavonne:
Yes.

Rebecca Dekker:
As a nurse, you have to assume that your patient has trauma because they’re not always going to disclose that they’re a survivor or victim of sexual assault. So letting them choose the position of their choice where they feel more protected, less exposed, less vulnerable is really an important component of trauma-informed nursing care. So I think, I love hearing that nurses are starting to see the birth seats. I like that there’s these options now of these ones that are cleanable, reusable. It’s a little bit more difficult with a wooden stool. I can’t see that getting pass infection control.

Sarah Lavonne:
No, no.

Rebecca Dekker:
But that’s exciting to hear that more places are using that, water in addition water birth, if your facility supports that is a really easy way to get someone into an upright position. From talking with midwives who do home births and birth centers, the most common position they see is draped over the edge of the tub, like leaning on it. So it’s like you’re in a supported kneeling position.

Sarah Lavonne:
Yep. Yeah, or an upright all fours is what I would picture in my head for those of you nurses that need that visual or over the back of the bed would be the same angle.

Rebecca Dekker:
Exactly. But then you get the benefit of the soothing feeling of the water and you’re more buoyant and you can move around more easily. But it’s really interesting that part of the benefit is hiding the perineum from the provider. I don’t know if that’s a benefit or if it’s more like the mechanism of how the benefits work, because they’re less likely to mess around with perineum because they can’t see it.

Sarah Lavonne:
Yep. Well, and you have agency in that case, they can’t get up in there and dig around and stretch you or whatever. It’s all you, and yeah, I don’t know if I’ve ever pictured it that way in terms of the power dynamic.

Rebecca Dekker:
That’s where it makes the provider feel more vulnerable, right? Because then they don’t feel in control.

Sarah Lavonne:
Yes.

Rebecca Dekker:
So I think what we’re primarily seeing when you see hesitancy about supporting upright birthing positions is that perceived lack of control. I don’t know how to handle an emergency. I can’t see an emergency if it’s happening, et cetera, et cetera. Like you were saying though, that’s because the control is back in the woman’s body or the birthing person’s body. It’s a different scenario and it takes a certain level of experience and trust and also trust in your own skills that you could handle an emergency in an upright birthing position. And I think one of the reasons we still don’t see a lot of upright birth is because we need every doctor who’s practicing obstetrics in our country needs to have witnessed upright births in training so that they feel confident and comfortable with it.

Sarah Lavonne:
Yep, absolutely.

Rebecca Dekker:
And midwives, the research shows that midwives have higher rates of upright births. So if every resident shadowed or trained under a midwife, within about 30 or 40 years, we’ll have them solved, but…

Sarah Lavonne:
By then, I will be dead or relaxing on a beach somewhere, but I hope to live to see the day when that is the case. So I’m just thinking about, and we’ll wrap it up in a second, but I’m thinking about these nurses and all of this. I can picture our community and they’re like, “Yeah, oh my gosh, amazing. I love this evidence. Super helpful. I agree. Let’s do it.” And then they walk in their units and they’re faced with the system. They’re faced with their providers. They’re faced with other nurses that are uncomfortable with doing anything different. If this is something I think about the birthing stool, by the way, if you’re looking for a leading change project, I think that would be a very simple but really interesting project for your units. I’m going to throw that out there. Have at it, y’all. What sort of advice? Any tips, any thoughts, any encouragement you have for these nurses that are listening, and they’re like, yeah, oh, and they’re hit with that resistance, how do we navigate that and how do we continue to push the dial forward?

Rebecca Dekker:
I think any of your nurses who are childbirth educators as well have a unique power in that you can educate your clients before they’re in the hospital. So including upright birthing positions in your childbirth classes, and also practicing, getting people to practice the positions while they’re pregnant and put it on their birth plan what their preferred birthing positions are. For staff nurses, you can ask if it’s not on the birth plan, what position would you like to be in when the baby comes out? What positions would you like to push in? And try to ask those earlier before the pushing phase so that you have an idea of their preferences, and then you can simply support what they want. Nurses can physically assist patients into a variety of positions using all the props and tools that they have at their fingertips. So making suggestions, because I think a lot of people, all they’ve ever seen is the birth in the movies knocked up, up in stirrups [inaudible 00:42:15]-

Sarah Lavonne:
Courtney Kardashian.

Rebecca Dekker:
… patients don’t even know that it’s helpful to get in positions and they don’t realize you can get into positions with an epidural. So getting the peanut balls, making sure you’re educating early before the pushing phase about all the benefits of being on your side or getting on your hands and knees and how great it is for the baby and how it’s going to make the birth go smoother. So just continually educating throughout the birth. And then in terms of the provider aspect, when the provider walks in the room, if you know your client wants to give birth in an upright position, pulling that provider aside or letting them know in advance if you can, that this is something your patient has requested and how can I help you be more comfortable with that? Because this is something that they’re requesting.

Sarah Lavonne:
Yep. How can I help you feel more comfortable with that? In the ACOG, one of their ACOG statements, it says that no one birthing position needs to be prescribed nor mandated.

Rebecca Dekker:
Yeah, you got that memorized, Sarah.

Sarah Lavonne:
I do because I use it.

Rebecca Dekker:
Yeah, I do it, too.

Sarah Lavonne:
Yeah. So I think also knowing that evidence and knowing how to speak their language, we talk about that in physiologic birth, that I agree with all of that. It’s almost like I imagine based on what you’re saying is coming in and just saying, this is how it is and this is what the patient wants. It’s not you. And if they’re blaming you, I don’t care how they… Whatever they want, I’m here to advocate for their preferences. And then also as the patient then feeling like they’re not alone in those preferences and that they have that support from the medical side to say, I’m not crazy for wanting this, or I’m not crazy for actually tapping into my instinct and saying, it feels better to be leaning over the bed. And then you advocate for that with your providers and we’ll see how it goes. I think, too…

Rebecca Dekker:
Every provider is different, and I think that also goes down to your communication skills and your ability to build rapport with providers. I do have to share one more story, and that was that a family member’s birth, and she ended up on her knees leaning over the top of the bed, and the doctors had never seen anyone birth like that before. And as she was pushing and the baby’s head was emerging, they’re looking at the landmarks on the baby’s head, and they were like, “Wait a second, it’s all upside down.” Because [inaudible 00:44:41].

Sarah Lavonne:
It was a different orientation. Yeah.

Rebecca Dekker:
What is that? 180 degree orientation?

Sarah Lavonne:
Yeah, a full flip.

Rebecca Dekker:
Yeah. And so they were like, wait a second, which way is this baby coming out? And they couldn’t figure it out. Anyways, the baby ended up coming out just fine.

Sarah Lavonne:
Imagine.

Rebecca Dekker:
It made me realize there is this knowledge gap. If the patients don’t see it, they don’t understand it, they’re afraid of it. So there might need to be something more like a team effort among the nurses at your hospital to get some continuing education to your physicians about it so that they feel like they could handle an emergency or a shoulder dystocia if it occurred.

Sarah Lavonne:
Well, and to bring it back, thank you for that segue. I’m like, if we understood the physiology versus just the mechanics of being a provider, being a nurse, being a doctor, delivering a baby, and we actually knew the full picture, we could adapt. When I think about how the baby’s coming out, I can tell you the position based on, no matter what position they’re in, because I know the physiology so well. And that’s where CMQCC, there are five ways that we decrease our NTSV C-section rates, is one of them is bridge the provider knowledge and skills gap with a wellness and physiology approach. That’s why we have the physiologic birth class. That’s why you need to be encouraging your residents and doctors to come to the class as well.
But that’s where that knowledge gap is not anybody’s fault. It’s just how we’re socialized and how we’re trained in the medical system. And I really believe that if we were able to approach it and understand the physiology, it doesn’t matter what position we’re in because we know exactly how the baby navigates the pelvis. We know what’s happening with the pelvic floor, the ligaments, the pelvis in general, how that shifts and the sacrum, nutates, et cetera, et cetera, and stretches. And then you adjust and you go, “Oh, it makes logical sense that an upright position would be beneficial.” Not because we need a study, but because of the physiology matching what makes common sense.

Rebecca Dekker:
I love that you’re out there educating physicians and practitioners.

Sarah Lavonne:
I mean, we’re trying, the physicians are the ones or the dream. There’s some things coming down the pipeline better in the works for that because we all know that these nurses, they come to the class and they got it. They use motion and they got it, but it’s the physicians that are uncomfortable and we’re still misaligned in that. And so we mentioned continuing education, like yeah, we just all need to be on the same page. And the evidence is also clear in that.

Rebecca Dekker:
[Inaudible 00:47:07] random suggestion.

Sarah Lavonne:
Tell me.

Rebecca Dekker:
People work for one nurse.

Sarah Lavonne:
I love it.

Rebecca Dekker:
If you have midwives on your unit, and most midwives that I meet in the US are supportive of upright birth. Not every country is like that though, I will say, if you have midwives that are supportive and you have a doctor who seems hesitant or unsure, what if you were like, I have a great idea to help you be more comfortable next time we have a patient who says that they want a birth in an upright position. Would you mind coming into this room and just watching this midwife do an upright birth?

Sarah Lavonne:
Yeah.

Rebecca Dekker:
I don’t know. Is that too out of the… Would a physician be totally-

Sarah Lavonne:
I think it depends on the physician.

Rebecca Dekker:
… insulted? It really depends on how open they are to learning. But you could just do me a favor, please, for the next time we do birth together where there’s an upright birth, can you come watch this one? It might help. Because I think all they need to do is see one go well, and it will change their mind.

Sarah Lavonne:
Well, and that means too, I think in the moment, and especially because of the power dynamics and ego in the room, to have these conversations in front of a patient is not going to be the most effective, but stimulate a conversation at the nurse’s station when you’re sitting around your providers, you know who your providers are that really need to hear this, or even you could… I mean, there’s strategy in both, the ones that are very, very old school and the ones that are pretty open, but maybe uncomfortable. To me, I’m like the open and uncomfortable ones. They see one midwife do it and they can see the mechanics of how they deliver a baby in an upright position or all fours. And then how it transitions to the chest and to the patient, they may feel more comfortable, and all of a sudden you now have a physician advocate that does it, well, so-and-so is doing it. And now, I feel pressure to keep up with the times what other people are doing. I think there’s strategy there.

Rebecca Dekker:
My sister is a physician who’s attended many births, and she always shares the story because you’re talking about the old school. I think there’s the old, old school that always did birth upright, and then there’s old…

Sarah Lavonne:
Yes. Yeah, there’s that gap, totally.

Rebecca Dekker:
Yeah, she was trained under an old, old school who’d done obstetrics a long time ago.

Sarah Lavonne:
And like breech births and all that?

Rebecca Dekker:
Yeah. She said he and taught her, and this was in her medical school rotation to just let the baby emerge onto the bed without touching it, so she didn’t actually catch the baby. I don’t know if it was side lying or lying on their back without stirrups, but the baby just slid out onto the bed and then…

Sarah Lavonne:
Wow. And then they just pick it up?

Rebecca Dekker:
Yeah, and that’s where my sister-

Sarah Lavonne:
Interesting.

Rebecca Dekker:
… learned that you don’t need usually…

Sarah Lavonne:
Don’t touch it.

Rebecca Dekker:
Yeah, you don’t have to.

Sarah Lavonne:
Leave it alone.

Rebecca Dekker:
And it really opened her eyes because there still are reasons to touch and catch and do [inaudible 00:50:00], but it opened her eyes to the fact that it happens without intervention, and then she was like, oh, it was all these light bulbs went off. I thought it was interesting.

Sarah Lavonne:
Super interesting.

Rebecca Dekker:
Yeah. All she had to do was see it once and then it blew her mind. Yeah.

Sarah Lavonne:
Thank you so much, Rebecca, for being here and for sharing your knowledge with our audience. So thank you for everything that you’ve poured into this community in this episode and what you do for the birthing world at large.

Rebecca Dekker:
Thank you so much, Sarah. And I hope that your listeners learn something and maybe some of the things I said people disagree with, but I just hope it sparked some discussion at the nurse’s station.

Sarah Lavonne:
For sure. I think it will. If you want more from us, I can’t help but plug our physiologic birth class. In this episode, I think that not only do we talk about pushing positions and upright positions and the evidence on all of that, but understanding that physiology is the foundation of your practice. If you do not know the ins and the outs and you can’t picture what’s happening inside the body throughout labor, this class is for you. And then please invite your physicians to it, invite your residents, your midwives, and everyone then can be speaking the same language. We do have hospital packages available. We fulfill purchase orders, so if your units want to be fully trained and all on the same page, there’s so much evidence just about knowing the physiology of labor, and that’s one of the ways that we are trying to help make a change as we grow as a profession, we’re better and better for our patients.
Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you liked what you heard, it helps us both if you subscribe, rate, leave a raving review and share this episode with a friend. If you want more from us, head to Bundlebirthnurses.com or follow us on Instagram. Now, it’s your turn to go and try another position outside of lithotomy while pushing with your patients. We’ll see you next time.