Surprise, laboring on your back increases the chance of spontaneous vaginal birth

25301359 - mid adult man looking at doctor delivering baby in hospital

Most of what passes for natural childbirth “knowledge” is entirely made up. Why? Because in large part, natural childbirth advocacy is just reflexive defiance of obstetric practice without any scientific evidence to support it.

The latest natural childbirth claim to bite the dust is the insistence that upright positions improve the chances of vaginal birth.

The authors set out to show that upright position improves the chance of vaginal birth, but instead found the opposite.

According to Lamaze Health Birth Practice #5:

Avoid giving birth on your back and follow your body’s urges to push.

There was never any evidence to support the claim that giving birth on your back impeded vaginal delivery and now there is evidence of the opposite.

The new paper is Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial. The authors set out to show that upright position improves the chances of vaginal birth, but instead found the opposite.

Evidence shows that lying down in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages in relation to short or longer term outcomes for mother or baby.

Surprise!

It shouldn’t have been a surprise because there had never been a study that showed that upright position was superior:

A Cochrane review of position in the second stage of labour in women without epidural showed a reduction in instrumental vaginal delivery in the upright group, although the quality of the included trials was reported to be generally poor… A Cochrane review of position in the second stage of labour for women with epidural analgesia was published in 2017 … This review included trials that compared upright with recumbent positions and suggested no effect. The risk ratio of operative birth (caesarean section or instrumental vaginal delivery) reported in the five included trials, comprising 879 women in total, was 0.97 (95% confidence interval 0.76 to 1.25)…

This is the largest study of its type ever undertaken:

Between 4 October 2010 and 31 January 2014, 3236 women were randomised and 3093 (95.6%) included in the primary analysis (1556 in the upright group and 1537 in the lying down group). Significantly fewer spontaneous vaginal births occurred in women in the upright group: 35.2% (548/1556) compared with 41.1% (632/1537) in the lying down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). This represents a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group (number needed to treat 17, 95% confidence interval 11 to 40). No evidence of differences was found for most of the secondary maternal, neonatal, or longer term outcomes including instrumental vaginal delivery (adjusted risk ratio 1.08, 99% confidence interval 0.99 to 1.18), obstetric anal sphincter injury (1.27, 0.88 to 1.84), infant Apgar score

Although the authors report that there was no difference in most secondary outcomes, they also note:

Of infants born to mothers in the upright group one was a stillbirth, one experienced birth trauma, one had cardiorespiratory collapse one hour post birth, and one had suspected Erb’s palsy.

Moreover:

The duration of the active second stage of labour showed a statistically significant difference at the 1% level, with a shorter duration of labour in the lying down group (median difference of 7 minutes, 99% confidence interval 0 to 13). Other secondary maternal outcomes, such as instrumental vaginal delivery, caesarean section and perineal trauma, were suggestive of an increased risk associated with the upright position, but these differences were not statistically significant at the 1% level. For example, the incidence of episiotomy increased in the upright group (58.8%, 914/1556) compared with the lying down group (54.6%, 838/1537) (although not statistically significant at the 1% level). There seemed to be a higher incidence of obstetric anal sphincter injury in the upright group (6.7%, 104/1556) compared with the lying down group (5.3%, 81/1537), but again this difference was not statistically significant at the 1% level.

The authors conclude:

This study provides evidence that adopting a lying down position in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages for short or longer term outcomes for mother or baby. The intervention seems to be easy to adopt and is cost free. This evidence will allow pregnant women, in consultation with their healthcare providers, to make informed choices about their position in the second stage of labour.

Kudos to the authors for being willing to acknowledge that their hypothesis was disproven. My personal view is that the authors made a bit too much of their data. The actual differences between the upright group and the lying down group were so small as to be trivial. It seems to me that a more accurate conclusion is that position in labor makes no difference to the likelihood of spontaneous birth, so women should be encouraged to adopt the position that they prefer.

We don’t know if the results of the study are generalizable to multiparous women or to women who don’t have epidurals, but as I pointed out above, there’s never been any evidence that position makes any difference for those groups either.

The bottom line is that another piece of natural childbirth “wisdom” has been shown to be false. That’s not surprising since there was never any data to support it in the first place. Natural childbirth advocates simply made it up as part of their reflexive demonization of modern obstetrical practice.

  • Brooke Broersma

    I really do think hospitals and doctors will only post studies that keep them in business and flatter them. I believe a woman should give birth in what ever position she chooses. In my last painless and precipitous labor, I desired to give birth lying on my side. I will follow my instinct with this birth as well. I don’t believe the myth that giving birth requires labor or activity. I shall relax at home, and maybe give birth lying on my side. Why would I not give birth on my back? Lying on my back is too uncomfortable in late pregnancy.

    • Who?

      Do exactly as you please, no one here would suggest you do anything else. Don’t, however, assume that your experience is the same as everyone else’s and should therefore be extrapolated to everyone else.

      • Brooke Broersma

        I didn’t suggest anyone give birth in any particular position. The study posted extrapolates. I have given birth in many positions.

  • It is much more difficult to control the birth of the head, and avoid perineal laceration when the patient is upright. I personally, as a midwife, favored the left lateral position as being more comfortable for both the mother and the person delivering the baby.

  • Roadstergal

    OT – I had been enjoying the Adam Ruins Everything show when it would pop up now and then on my Facebook feed – but I recently heard they had a podcast, and downloaded a few episodes. The podcast is way better, IMO – he has a lot more time to get into a much more involved discussion, and he brings experts on and gives them time to get into the weeds.

    Which is all to say – there’s a lengthy episode where he gives Dr Jung (of Lactivism) a chance to go over the history of the pendulum swings of formula and breastmilk. I found it to be a really good listen, and it laid out the foundations of contemporary lactivism very well.

    He asks her for the ‘elevator pitch’ at the end, and it’s very nicely done. I recommend that as an external resource.

    Oh, and the WHO doesn’t come off looking great. :/

    • CSN0116

      I had no idea. Thanks so much!

    • Mattie

      LOVE Adam Ruins Everything! His episode on having babies after 35 really helped with my anxiety about ‘missing my chance’ at having babies.

  • Cat

    OT, but does anyone have any advice for a member of my family who suffers from endometriosis and is pregnant with her first child? We’re based in the UK and, if her pregnancy is likely to need extra monitoring, I want her to get it and not to get shuffled into the low-risk, midwife-led track because she’s young and inexperienced.

    • attitude devant

      She should do fine. As long as she doesn’t miscarry in the first trimester, pregnancy is very salutary for endometriosis.

      • Cat

        Thank you – that’s very reassuring. She’s out of the first trimester now so fingers crossed that’s the worst over.

        • Dr Kitty

          That hard part with endometriosis is getting pregnant.
          After that, unless you have lots of scar tissue and adhesions, it’s usually plain sailing.

          One thing that breastfeeding can do for women with endometriosis is to keep the disease quiescent for longer by keeping the ovaries inactive. No ovulation and no periods often equals significant improvement in endometriosis symptoms, and exclusive breastfeeding is a natural way to achieve that.

          If breastfeeding isn’t desirable, achievable or doesn’t result in amenorrhoea, it’s not going to be particularly helpful, but it is something to be aware of.

          Personally, I found breastfeeding easy, I don’t ovulate or menstruate even when I only feed once or twice a day and my endometriosis is never better than when I’m pregnant or nursing, but my experience is not universal and I still wasn’t tempted to BF much beyond a year.

          • Cat

            Thank you. I don’t know how much scar tissue she has (her endometriosis is pretty severe and she’s had a couple of operations this year), but it’s good to hear that she’s already done the hard part!

  • Cat

    This actually makes me very angry. During my recent pregnancy, the midwives consistently fed me the line that labouring on your back was a dangerous, archaic practice, roughly equivalent to using leeches, which had now been totally discredited by modern science. Didn’t mean much to me seeing as I went for an elective c-section, but my mother came out of my antenatal classes crippled with guilt because she now believed that her stillborn baby had died in the 70s because she’d laboured in the wrong position. How many other women have been burdened with the extra guilt and regret of thinking that they killed their babies by “doing labour wrong”? Excuse me while I go and find something to kick.

    • MaineJen

      It makes me angry too. I’m always angry when a vulnerable person is targeted, and who could be more vulnerable than a woman in labor? The pain is horrific, let’s let the lady deal with it the way she wants to!

    • KeeperOfTheBooks

      I hear and sympathize with you. On a similar note, I have a family member who is the warmest, kindest, most generous person you can imagine. She is and was a wonderful mother to her now-grown kids; she’s the glue that holds the family together, and that her many kids all, as adults, have fantastic relationships with her says a lot about her accomplishments as a mom.
      Nonetheless, she is convinced that her oldest kid’s bipolar disorder is due to the fact that she was unable to breastfeed her, and feels terrible guilt some thirty years on for not breastfeeding her, despite having tried quite hard, because “she’s the only one with a mental illness, and the only one who wasn’t breastfed, so Kid’s struggles are my fault.”
      I wish there was some way to reassure her that two facts aren’t connected, that who knows what the heck causes bipolar disorder, and that Kid is incredibly lucky to have a mom who loves her and supports her through such difficult times.
      (Do note this same person would excoriate anyone who *dared* to say something so nasty to another woman, but the NCB types did a number on her.)

      • Cat

        That’s absolutely heart-breaking, not to mention rage-inducing. She sounds like an exceptional mother and human being, and those NCB types aren’t worth her spit, quite frankly.

  • fiftyfifty1

    I can hear how the natural birth types will try to spin this: …but the epidurals!…but it must be important for the first stage…but the hospital is unnatural so the results are unnatural…but GRAVITY, but SPHINCTERS!!!!

    • Juana

      The anti-“on your back”-crowd’s argument that you have to work against gravity to push the baby out always seemed silly to me. Well, yes, the lowest point of the baby in the birth canal is not at the exit, but what difference in height are we talking about? We’re talking about pushing forces that can dilate or tear all that soft tissues (or even break a bone?), but the same forces are supposed to not be able to push the baby up a few centimetres? Sounds odd to me…

  • CSN0116

    Both times I gave birth vaginally, my body “forced” me to lie down and bear. It was almost instinctual. Once was with an epidural and the other time without (the without version was kind of side lying and bearing down, but I was mostly on my back). My body could not – refused – to give birth another way. Were my instincts unnatural? lol

    • Heidi_storage

      Maybe you are too white and civilized to have natural instincts. (I dislike pointing out when I’m being sarcastic, but I’m being sarcastic here–that’s a really ugly statement.)

      • CSN0116

        LOL

    • seenthelight

      Same here, also white. Theory confirmed.

  • MelJoRo

    So I am hoping you guys can help me out—so this study, among women who have previously given birth, showed and 5.3/6.7% chance of anal sphincter injuries….is that unusual? So I am currently pregnant, really waivering on a maternal request c-section. I previously read Choosing Cesearean, and my husband is reading it now. The problem I am having is that the data they reference in that book is hard to find through the index, and I am honestly too emotional about the whole process of birthing to handle reading that book again. Ultimately I need to have some big conversations with my doctor, but I would love some references for easy to find data. This is partially coming from my husband’s take on 3rd/4th degree tears as being “rare” having read Choosing Cesearean (I will note that he is voiced complete support of any safe birthing method I choose). These stats above do not make it look rare to me (I am also surprised by the high use of episiotomies). FWIW I am birthing with an OB group where a vaginal birth would be attended by the OB or CNM on call, plan to use an epidural and would be writing a “birth plan/preferences” list that indicates I am fine with a c section and would prefer a C section to any assisted delivery options. Would those things factor into reducing my risk of a serious tear/pelvic floor damage?

    I am 23 weeks, will be 29 at delivery, normal BMI and plan to only have 2 children (though I will not definitely rule out a third).

    • MaineJen

      Unfortunately, no one can really tell you ahead of time what is going to happen! Some women come through it with no tears at all, others are unlucky and get 3rd or 4th degree, although your husband is right, that severe is not common. It’s really luck of the draw. Episiotomies are NOT done routinely any more, my OB told me that she rarely does them, but if she sees that it’s necessary she’ll talk about it with me at the time.

      From my experience…I’m a fairly small woman, my first baby was 7 lbs, pushing stage was really fast (10 minutes) and I had a 2nd degree tear. It was stitched well, but it did take about 6 months to feel completely “normal” again. Second baby was only 6 lbs, only a first degree tear and I recovered much more quickly.

      You sound like you’re approaching it very logically, whatever you choose will be fine! I agree with you that a c section would be preferable to instrumental delivery, though.

    • mostlyclueless

      Maybe someone else can comment on this, but it looks like they had a particularly high rate of assisted vaginal delivery which might be linked to all the tearing.

    • jengerson

      I was really afraid of giving birth, too! Now that I’ve done it, honestly, I can tell you that it is not as bad as you fear. Good for you for getting the epidural — it was AWESOME. Made birth so much more comfortable. If you go the C-Section route, more power to you. But honestly, the epidural made that seem unnecessary for me.

      Now, on tearing. I was also terrified of a 3rd or 4th degree tear. There is good news and bad news. The good news is that a serious tear is rare. The bad news is that you will probably have some minor (1st or 2nd) tearing. Just about everybody does.

      The good news is this: Honestly, minor tearing not that big of a deal. Especially if you get the epidural. They just stitch it up when you’re paying attention to your baby and thanks to the epidural you don’t feel a thing. It sucks for a few weeks, but, like “Huh, I have to take an advil” kind of sucks. Really nothing unmanageable. Then everything pretty much goes back to normal. And there are things you can do if it doesn’t.

      I know that’s not every woman’s experience, but it was mine. And, I think, that’s the common one.

      Don’t worry about the birth. What’s going to happen will happen. You will manage. It will be OK. Focus on the things you can control: notably, what’s going to happen AFTER the baby. Who is going to help you? How are you going to get yourself time to rest and recover? Birth is really not a big deal at the end of the day. Everything after birth is where the hard part starts.

      • MaineJen

        2nd on everything!

    • Jen

      Hi, I think it’s good to think of this in terms of how risk averse are you. I’m making this statistic up, but think I read somewhere that 85-90% of vaginal (meaning vaginal was the end method) deliveries go well and have few complications for the mother. For those that go wrong, they can go really really wrong and result in some serious damage. Planned Cesarean complications are very very rare (less than 1%). However, we know that Cesarean has a slightly longer and more significant recovery period than a low complication successful vaginal delivery. I personally decided I would rather go for the known somewhat lengthier recovery than risk being in that relatively small, but serious complications group. I’m very risk adverse and prefer being able minimize the worst possible outcome. Of course I’m also an economics major and fond of game theory 😉 I think it’s worth asking yourself this question as part of your decision making. I will say I absolutely loved both of my C-Section experiences. I never experienced any contractions and showed up on my scheduled date ready to go. The most discomfort I felt the entire time was the spinal anesthetic (you get that during vaginal too). I was up and walking the same day and within a couple of weeks pretty much pain free and feeling pretty normal. Just wanted to put a plug out for how awesome C-Sections are from my perspective. You’ll find plenty of scare stories implying the opposite.

      • MelJoRo

        Thanks for sharing your experience. The reality is that I am super risk adverse…and I already deal with a lot of baggage around sex and painful intercourse, and I feel that any damage to that area will set me back a lot. I was once dead set on a MRCS, but have had a few friends now have really easy recoveries from vaginal deliveries that have made it harder to jump in for a big surgery. My OB also made an off hand comment during a pelvic exam about how sometimes the unexplained pain I have during intercourse is lessened after pregnancy/birth. (My OB has really tried to help me find a treatable cause and has performed repeat exams, ultrasounds and referred me to PT). It has all suddenly left me feeling very unsure, which is a hard place to be when 6 months pregnant.

        • Jen

          It’s a hard decision for sure. It sounds like your OB is wonderful. I came to my decision after consulting with a urogynecologist. Similar to you, I had a reason to mitigate any damage to my pelvic floor. I’ve suffered from urinary incontinence since I was a child. I was worried that childbirth would render me completely incontinent. My urgogynecologist helped me decide that Cesarean was the best method to mitigate my risk. Obviously you have a different condition than I had so the recommendation is likely different. Good luck and I wish you the best possible outcome whichever delivery method you choose!

          • Jen

            Also, forgot to add that I really had a super easy recovery from both C-Sections as well. I was pain free with no issues after 2 weeks. Not everyone is quite that fast, but just wanted you to know that either method can result in an easy swift recovery.

        • Mel

          Hello!

          I have vaginismus as a rather unexpected side-effect of cerebral palsy. Physical therapy helped me so that vaginal intercourse is alright to mildly pleasurable.

          My understanding is that most women with vaginismus do not have a noticeable reduction in symptoms after vaginal birth.

          • MelJoRo

            So the pseudo diagnosis I was able to get is secondary vaginismis caused by a mismatch in my anatomy and my husband, which causes mild to moderate pain. I have dealt with the vaginismis, but there is ongoing pain that is specific to intercourse (I swear I might be one of the only women who even finds pelvic exams and cervical checks to be painless, since I have had so much practice relaxing those muscles!). So there is some possibility that “stretching” from a vaginal birth might result in alleviating the primary pain, but I also see there being a possibility that the additional pain from a tear/recovery could undo the work I have worked towards. Even with an understanding husband, this has been a big battle in our marriage where desire and ability to have sex don’t always line up….something I suspect you understand. There seems to be very little quality information about pain and intercourse, and especially related to how to changes with a pregnancy birth.

        • Dr Kitty

          If you haven’t already looked into it- psychodynamic psychosexual therapy can help a lot for vaginismus.

          CBT is for couples and focuses a lot on sensate focus and that kind of thing- that’s not what I mean. Psychodynamic psychosexual therapy is for the person with the vaginismus and is more about how you experience sex, why you experience it the way you do and what can help you to have a better experience.

          It is not for everyone (if you don’t buy the basis of classical psychotherapy; transference, counter-transference, denial, displacement etc, it’s not going to be for you), but it *can* be really helpful once you’ve worked on physical causes if you still feel stuck.

          I’m afraid that in my experience childbirth is no more a fix for painful intercourse than it is for painful periods- sure it can help for some people, but not everyone and it can make things worse.

        • guest

          I went through the same decision making process with my second delivery. I was still undecided at 36 weeks when I suddenly went into labor, so ended up with a vaginal delivery. I had a small tear with each of my 2 deliveries and while for most people that would be no big deal, I still have pain in those locations 3 and 6 years later. On the plus side, some of the pain I had previous to giving birth has gone away. So it was pretty much a trade off. My husband and I did have to learn all over again the positions and types of touch that would feel good to me, since pain locations had changed. I tease him that it’s like getting a new wife. Good luck with your decision!

          • MelJoRo

            yeah…I would like to avoid that. Obviously serious incontinence or major pelvic floor damage would her horrible, but even these more minor things are are just one more thing, and it feel like too much to handle. Honestly in the last few days everything about labor just sounds a bit like too much and I am feeling more confident in asking for a MRCS for my mental health in addition to the physical aspects. I am afraid of the judgement, and I am a bit afraid of the longer recover time, but it doesn’t give me the extreme anxiety that thinking about some of these other things does. Thank you all for helping to have a place to get some realistic information!

          • KeeperOfTheBooks

            One thing on the recovery time: I was not in especially good physical shape prior to either CS, though I was in much better shape with the second. I was out walking a couple of miles at a time at a gentle pace by 10-14 days PP with baby #2. Many of my friends who had even fairly uneventful vaginal births couldn’t say the same thing. Several report it hurting to sit down for a couple of months postpartum. Me? With the first, I lagged on my pain meds two nights in, and it was BAD, but then I didn’t take narcotics after day 3 or 4. Didn’t need them by then. Second kid, same thing, and I am not one to suffer post-op pain for the heck of it. Believe me, any pain was totally under control with ibuprofen at that point. Getting in/out of bed wasn’t hard or painful at all by day 2 with kid 2, either.

          • MelJoRo

            that is super helpful! My pubic bone is already aching just from carrying this baby around inside me, so I can’t image how much pain some folks must be in from birth (never mind the trauma to soft tissues). Any my bedroom/bathrooms are all upstairs in my house, but going up stairs post-op sounds not much worse than going up stairs post surgery. I find myself becoming more nervous about narcotics with all the media coverage about opiate addiction, so it is kind of nice to have a gauge for how long I might actually need to take them.

            I will say that I am in pretty excellent shape–I regularly do pilates and cardio, and have been able to maintain that so far in pregnancy (which I freely admit is mostly luck–no judgement to those who can’t do it). I am hoping that a strong core and pelvic floor will help me recover either way, but who knows.

          • Heidi

            I got hydrocodone for my pain from 2nd degree tears. I honestly felt it was about worthless. It made me tired (yet post partum I was restless for months) but not much more. I certainly wasn’t high. I took my 600 mg ibuprofen instead. I still have those hydrocodone in my cabinet almost 2 years later. I’m not trying to down play opiate addiction but I don’t know if it’s a huge concern if you don’t currently battle addiction. Now if you already suffer from alcoholism or another addiction, it might be something to think about.

          • Heidi_storage

            For what it’s worth, I’ve never needed more than ibuprofen after my vaginal births (one second-degree tear, two first-degree tears); 8 days after delivery 2 I was shoveling snow, and 3 days after delivery 3 I grocery shopped (got help out, though). So you might have a very easy recovery…or not. You can’t really know in advance.

          • BeatriceC

            My experiences were slightly different that KotB, but I had some rather more intense complications. Nonetheless, my second CS, which was done under “smash and grab” circumstances, was the easiest part of my postpartum recovery. (I was also dealing with pre-eclampsia that had been progressing quickly towards full blown eclampsia and HELLP syndrome, among other issues). It was about two weeks before I was really out and about after my second. With my first CS, which didn’t have those sorts of added complications I was up and about by day three or four with very little discomfort, which is a lot better than I can say for my vaginal delivery, where I couldn’t sit down comfortably for a couple weeks.

            And, the real test here; 18, 16, and 15 years later: I have no long term consequences from the two c-section deliveries. Even the scars are extremely difficult to locate. However, my gyn and I are talking about the risks and benefits surgery to correct my anatomy to fix the worsening incontinence issues I’ve been having over the last several years, due almost entirely to the damage done by the vaginal delivery of the child who’s 18 now.

          • Roadstergal

            “I find myself becoming more nervous about narcotics with all the media coverage about opiate addiction”

            I wouldn’t let that deter you. I’ll let doctors weigh in more, but from what I’ve read and heard, the issue is with people who take them for chronic pain, not acute post-op pain. I’ve had about a week on opioids after each surgery I’ve had, and was done with them when the pain eased.

          • Heidi_storage

            I remember my brother saying nervously to me, “Now, are you going to start weaning yourself off of the pain meds?” This was 2 days after elbow surgery. Really, the hysteria reminds me of those inaccurate DARE programs where just one whiff of a toke doomed you to a life of hopeless addiction. The opioid crisis is real and problematic, but this DOES NOT translate to, “Avoid pain medication after surgery or it will RUIN you!”

          • KeeperOfTheBooks

            Put it this way: based on the vastly different experiences I had in days 1-4 postop with each kid, you will absolutely NOT regret being in good shape for delivery, however that delivery happens. Keep up the good work!
            With the narcotics, I suggest taking what you need, and then by day 3-4 (if you have a CS or tear or what-have-you) try postponing your narcotic pill but KEEP UP THAT IBUPROFEN. Pain gets bad, take the narcotic; if it doesn’t show up or is mild enough you don’t want the narcotic, don’t take it. Basically, use common sense. 🙂 Being pain-free will help a lot with your recovery because the sooner you’re out of bed and moving gently about, showering, etc, the sooner you’ll start feeling much better and more like you, and pain will inhibit that. Just my experience, of course, and mileage may vary–again, my CS were scheduled, I didn’t go through labor first, etc.

        • Daleth

          I was once dead set on a MRCS, but have had a few friends now have
          really easy recoveries from vaginal deliveries that have made it harder
          to jump in for a big surgery.

          Look at it this way: I have a few friends who came through car accidents just fine despite not wearing seat belts. That’s absolutely meaningless information when it comes to figuring out whether I am likely to come through a car crash just fine without a seat belt.

          Obviously the risk is different (statistically one is way more likely to have a complication-free childbirth than a no-injury car crash without a seatbelt), but the point remains: what happened to your friends is in no way indicative of what’s going to happen to you.

          Also, it’s actually hard for me to think of any type of surgery that’s less “big” than a c-section. It takes 20-30 minutes and you’re wide awake the whole time because it’s simple enough that they only need regional anesthesia.* Most women are able to go home 2 days later.

          If you want to talk about “big” surgeries, ask someone who’s had a hip replacement or bowel surgery or something. The kind of surgery where you’re knocked out with general anesthesia, you spend 3 or 6 or 10 hours in the operating room, and afterwards you spend weeks in the hospital or a step-down unit or rehab center, recovering to the point where it’s even possible to go home. THOSE are big surgeries. C-section is not. Literally the only reason it is classified as “major surgery” is because it penetrates the abdomen–major surgery is defined as any surgical procedure that penetrates the abdomen, chest or skull.

          * Crash c-sections are often done under general, because you can knock a patient out with general in under a minute while regional anesthesia takes ~20 min to start working; in a life-threatening emergency you don’t have time for regional, so general it is. But we’re talking about maternal request CS, not crash CS.

      • Roadstergal

        “Of course I’m also an economics major and fond of game theory”

        I sometimes think a game theory course would be more useful for pregnant women than a Lamaze class. 😀

        • Jen

          OMG, With my first I had gone through consultation and planning with my OB for a Csection. I had to a see CNM for one of my routine prenatal appts late in pregnancy. She asked me if I would be interested in attending a birthing class and proceeded to explain how wonderful they are. I said “umm no, planned csection here”. I kid you not, she looked at me and said “I still recommend them because you never know”. I couldn’t wait to get out of that appointment. A birthing class? really?

          • Roadstergal

            You’re familiar with this one?
            https://www.youtube.com/watch?v=khfJ-HB12Z0

          • Jen

            That was hilarious! So glad I dodged that bullet. I can’t imagine sitting through that nonsense without making a scene.

          • Hannah

            I may have made a few small scenes in my NCT class… needless to say the midwives were just happy to see the back of me, and if anyone still gets together from it, I don’t know them 😛

          • Empress of the Iguana People

            During our childbirth classes, my husband was the one who got on the floor and huffed and puffed. (partly because I was 8 months along and really quite tired of getting up and down, and partly because all this still seems silly to me)

          • Lilly de Lure

            I made the mistake of going to a birth class after seeing this sketch. When our teacher actually did come out with “A tear heals faster than a cut” I didn’t dare look at my husband for fear of us both bursting into hysterical laughter on the spot. Of course he then went and spoiled my good intentions by murmuring “paging Dr Bear” just loud enough for me to hear.

            Dodged the bullet is right – if I had my pregnancy to do over again avoiding NCT classes like the plague would be top of my list.

          • Kim

            It may seem nonsensical, but it’s not hard to find support for the belief that tears heal faster than cuts. From MedLine Plus: “Episiotomies don’t heal better than tears. They often take longer to heal since the cut is often deeper than a natural tear.” https://medlineplus.gov/ency/patientinstructions/000482.htm

          • Roadstergal

            I wish they had citations that weren’t just two textbooks, though. 🙁

            They’re not done routinely in the US or the UK, to my understanding.

          • Kim

            Definitely not done routinely in the UK any more, though they used to be.

          • Wren

            Doesn’t that assume that the tear would have been smaller than the cut in all cases? You can have huge tears in bad directions, can’t you?

          • Kim

            That’s certainly true. A third or fourth degree tear is never going to be good news. I think my objection to the Dara O’Briain routine is that he makes it seem simple and clear-cut when it’s not. In the UK, every woman who gave birth vaginally was routinely given an episiotomy and it was people like the NCT who campaigned to change that.

          • Kelly

            It’s true though that you never know. I think she was trying to get you to change your mind but I wish I had prepared for a non medicated birth in case I couldn’t get the epidural in time. My second child decided to come in less than three hours and I did get the epidural but only for twenty minutes of pushing. I would have like to been prepared for dealing with the pain a bit better.

          • MaineJen

            I really don’t think there’s any way to prepare for the pain. Even when you think you’re prepared…sometimes you’re not!

          • Kelly

            I agree but it took me completely by surprise and I think I would have been able to make better decisions if I had thought about it before being out of my mind with pain.

    • Dell

      You really cant predict birth sadly. Both c section and vaginal have pros and cons. My sons birth happened at 37 weeks and with only 3hours of labour. He was only 5lbs 13oz but even with the small baby, I tore a lot. The worse was the tear towards my urethra, ouch! None of the tears were greater than second degree, but I had a few of them. But because of the speed of the labour, even if I had an c-section booked for 38 weeks, and because there was no stress on baby, i had no other option but a med free, vaginal delivery.

      So my advice is plan for the birth you want to have, whatever that may be. But still prepare yourself for all possible paths that your birth can take so if it doesnt go to plan you will still be okay.

    • TheArtistFormerlyKnownAsYoya

      I recall Choosing Caesarian quoting 20% of women suffering 3rd/4th degree tears…that didn’t seem rare enough to me so I opted for elective c section.

      • MelJoRo

        are you in the US? I am curious if anything here has had any issues with insurance coverage. I think, in addition to talking with my doctor, I will call my insurance provider and ask if there are any reasons that they don’t pay for a C section

        • TheArtistFormerlyKnownAsYoya

          I’m not in the US, I am somewhere with socialized medicine. My OB did fudge things by noting fibroids as the reason for the c section. I’m not sure why he felt that was necessary; maybe just to avoid too many questions.

          Looked through my copy of Choosing Caesarian and I can’t find that 20% so not sure where I got that number. I found a RCOG document online that said 5.9% which still seems quite high to me.

    • CSN0116

      I had two cesareans followed by two vaginal births. I suffered a 2nd/3rd degree tear with my first vaginal birth and hands-down the recovery was more painful, and longer, than my two cesareans *combined. My second vaginal birth, upon things literally being “stretched out” and, quite frankly, *permanently altered, was far easier and I sustained no tearing whatsoever. My recovery from that birth was a breeze. I credit that solely to fucking my vagina up royally on Round I. My vagina is now “looser” / wider and my vaginal opening is literally in a totally new position than where it used to be (surgically done when repairing the tearing), but sex is much less painful now.

      If I had it all to do again, I would still endure the first vaginal birth to get to the second one, ONLY because I wanted several children and no more than three cesareans. If I was OK with a family of three or less children, HANDS-FUCKING-DOWN it would have been MRC every time. I much prefer cesareans and their recoveries to vaginal births.

      Moral of story: it’s a total crap shoot, but the super rare, potential long-term effects of CS are dwarfed by the much more common long-term effects of VB. IMO.

    • KeeperOfTheBooks

      Two planned C-sections here, planned in the sense of first baby was transverse, second refused to show up, C-section after his due date found a short, tight cord around his neck.
      Recovery? Fairly easy with the first kid, an annoying-but-non-dangerous infection aside, much easier with the second kid (same annoying-but-not-dangerous infection aside) due to being in better physical shape.
      I will say–and this will, of course, be highly specific to each woman–that I do have regrets about having the kids via CS. Not that I feel that they were in any way “unnecessary,” you understand; they were decidedly necessary and I’m very grateful to have been able to have them in a safe, clean, first-world hospital! I do wish I could have had the experience of vaginal birth for a number of reasons, though, as I had placed a (probably much too high) personal value on the experience, and now that’s not a possibility. YMMV, of course; it’s simply something to consider. Needless to say, if you decide you want a C-section for any reason, I fully support your having one! And while I might be sad about having had the sections, I consider not hurting during sex post-babies to be a VERY strong plus of the CS route, and ditto not worrying about incontinence of any kind.

      • Allie

        Have you ever had an incredibly hard, big poo that scrapes on the way out so much that you’re convinced you must have swallowed a 6-pack of straight razors that is now exiting your body the hard way? Well, multiply that by about a thousand and that’s basically what you missed out on : )
        Plus, yes, there was the poop incontinence, which thankfully lasted only about 6 weeks post-birth, as well as the ongoing pee incontinence and painful intercourse (some positions are okay some of the time, but hit that episiotomy scar tissue the wrong way and it’s like those razor blades are trying to come out all over again). It’s almost 5 years later, btw.
        Plus, perhaps for some people it is some big mystical, magical, empowering thing. But the reality is, even if that’s true, once it’s over, no one, and I mean no one, wants to hear about it. Not your kid, not your hubs, well, maybe the amazing people on skepticaob.com will let you go on a bit : )

        • EmbraceYourInnerCrone

          What Allie said…all of it.

        • MelJoRo

          So after being with a friend who gave birth and seeing/feeling how special it was, I had some thoughts about missing out a bit on an experience. Thank you for reminding me what it is likely to actually be, haha.

        • KeeperOfTheBooks

          This also made me lol.
          I’m under no delusion that vaginal birth is all Magic Fairy Sparkles, and I also know that my CS experiences were quite good overall. My–regrets? If you can call them that?–center around a concatenation of factors: 1) from around puberty, natural birth was held up to me as a rite of passage, something painful, yes, but beautiful, that nearly all moms go through; (that, I think, was one of the harder things–I’ve always felt like an outsider, and now I don’t have this in common with a lot of moms or my female relatives, either–no sense of shared female experience)
          2) this was a luck-of-the-draw thing, but it seems my uterus doesn’t heal so well. After two CSs, it was very, very thin around the scar, meaning that it will be a lot less likely that DH and I will have the big family we wanted without resorting to adoption, something that is both expensive and intrusive in our state. That also ties into my having seen my body as bad/dysfunctional/inherently awful–sort of a “and now it can’t even reproduce well” kind of thing. (My family of origin is NUTS.)
          I do recognize that many of these feelings are illogical, which is why I have no intention whatsoever of acting on them, but they’re there, nonetheless.

      • Sarah

        Mate, I’ve done it and it’s not worth the fuss. I can always kick you in the vag for many hours if you like though. That should replicate it well enough.

        • KeeperOfTheBooks

          Ha! That made me chuckle. Thanks.

    • AnnaPDE

      So maybe I’m biased a bit, but I had a planned CS and thought it was brilliant. Not just on a relative scale for surgeries, but as an experience. Even though my recovery was at the crappy end of the spectrum.

      What I’m a bit concerned about is the focus on tears — which usually refers to tears at the point of exit, or an episiotomy. Sure, they’re not fun, but they mostly heal. What often doesn’t go away after a few weeks, and often can’t even be fixed with surgery, is damage to the pelvic floor, when the levator ani muscle is injured or just torn right off the bone. That’s the kind of injury that leads to incontinence, prolapse and the like. Injuries like this happen in 20-30% of vaginal births. They’re what the current class action lawsuit about those Johnson&Johnson transvaginal mesh implants are about (or rather, that the meshes, which were supposed to fix this kind of injury, often made an already bad situation even worse, and were still sold and used despite the frequent adverse outcomes).
      Anyhow, if you’re risk averse — which I personally find quite sensible in decisions that can result in life long health impacts –, the idea of an MRCS is a logical idea and nothing to be ashamed of.

      • MelJoRo

        So honestly my fear falls into 2 categories—the terror of this type of muscle damage that makes me nauseas, and the more private and hard to vocalize to my friends fear that any vaginal birth could damage my already kind of crummy sex life. You are right though that way too much attention sometimes goes to the tears themselves, which can often heal and at a minimum can be surgically closed. I happen to love my pelvic floor muscles where they are, and the fear of not being able to be active or having fecal incontinence is terrifying. My mom delivered me with forceps assistance, and even after a super easy second birth of my sister she recently told me she would have taken a c section any day. I think I have decided to tell me doctor a MRCS is what I want, knowing we have a few months to talk about if that is the best choice. And then when I feel guilty or shamed at all I know I can come over hear and be reminded that birth is tough and that people are judgy, and hopefully I will be blessed with a baby to remind me why I am doing this!

        • Daleth

          I happen to love my pelvic floor muscles where they are, and the fear of not being able to be active or having fecal incontinence is terrifying.

          That was exactly how I felt!!!!! I was like, wait, what if this destroys my sex life? Man, I would much MUCH rather have a scar on my belly than a destroyed vagina and, god forbid, prolapse! And fecal incontinence… I can’t even imagine how absolutely and awfully that changes your life. Your entire life, but also your sex life. Oh god. Those poor women.

          And I actually did have wound healing complications post-c-section, because I had gained so much water weight that the wound had trouble staying closed. I had to wear a wound vac on my belly for weeks. But the nurse who came by to put the wound vac on told me she had patients with wound vacs on their genitals! AAAAAAAAGH! I would much rather have ten c-sections requiring weeks of post-op wound vacs than a devastating genital injury and permanent pelvic floor damage.

          Also, my mom has prolapse even though she delivered smallish babies easily, without vacuum or forceps. I was like 6.5 pounds and my little brother right around 8 pounds, and her labors were both easy and pretty fast, and she was in her 20s, so it’s not like her tissues were older and less resilient. And yet it still damaged her, not in terms of tearing, but in the long run, in her pelvic floor.

    • Daleth

      This is partially coming from my husband’s take on 3rd/4th degree tears as being “rare”…. These stats above do not make it look rare to me

      The same numbers can look rare to other people. “Oh look! Only like 6% of women get those injuries–that means 94% don’t!” A 94% chance of not getting the injury makes the injury sound reasonably rare, until you remember that 6% is like 1 in every 17 women.

      I’m with you. I focus much more on the “1 in every X women” number than I do on the percentage. And I think if you translated percentages into “1 in every X,” a whole lot more women would suddenly realize, omg, that’s actually a huge number, and a much bigger risk than I’m willing to take.

      I would prefer a C section to any assisted delivery options

      In your shoes I would use much stronger language. I told my doctors, as part of arguing for a maternal request CS, “I will not consent to vacuum or forceps.” That was one of my reasons for getting a CS: I’m not going to consent to either of those, and since you can’t guarantee that things won’t go wrong in labor and require one of those, let’s just schedule the c-section instead. In a joking tone of voice, with a doctor who seemed amenable to humor, I said, “If anyone comes near me with forceps, I will kick them in the
      teeth.” He laughed and said no no, that won’t be necessary, don’t worry, you’ll get your CS.

      But for you, that same statement (I won’t consent to vacuum or forceps) could be the prelude to a detailed conversation. Look up what’s normal in labor and what indications suggest that it might not be proceeding normally. For instance, if it lasts longer than X hours, or if it’s been X hours and you still haven’t reached Y dilation, or if the baby is malpositioned (breech, face up, etc.), or if there is any concern whatsoever about the heart tracing… etc. etc. Get to know, from the web and from your OB, what those complications are that might start you down the road to needing vacuum or forceps.

      Then tell your OB that if any of those complications even, like, start to start, you want to go to a c-section immediately rather than waiting to see if things get better, because you already know you won’t consent to vacuum or forceps and you don’t want things to go wrong for long enough that the situation becomes critical or it’s too late for a CS and you need forceps, or whatever.

      If they try to tell you that vacuum and forceps are nothing to worry about, tell them the mother of a friend of yours was permanently handicapped by forceps use at her own birth. I am that friend of yours. My mother got a spinal cord injury from being delivered with forceps. It’s rare, but it happens. Also tell the doc that you’re aware that instrumental birth (vacuum or forceps) is exponentially more likely to cause serious pelvic floor injuries than vaginal birth alone. Long story short, that’s why you won’t consent to either, and therefore you want the doctor to be ready to go to a c-section at the first sign of trouble.

      • The Bofa on the Sofa

        I’m with you. I focus much more on the “1 in every X women” number than I do on the percentage. And I think if you translated percentages into “1 in every X,” a whole lot more women would suddenly realize, omg, that’s actually a huge number, and a much bigger risk than I’m willing to take.

        I would also add in that, even lots of small probabilities can combine into something bigger. So even if you think that a 6% chance of X is a small risk, there might be a 4% chance of Y (another small risk), and a 3% chance of Z (even smaller), and a 2% chance of A and a .5% chance of B, C, D and E. On their own, they all seem like pretty small risks. But given those odds, the chance of SOMETHING happening adds up 16%, or 1/6. Suddenly, it’s not quite a “small chance” of something happening, it is (literally) a roll of the die!

        Are you going to go in knowing the chance of something bad happening is the same as throwing a 7 on a pair of dice?

        • Daleth

          Yes, good point.

      • MelJoRo

        Thank you–this is definitely the type of advice I am looking for. And *if* I end up deciding to try to a vaginal delivery, a big part of that is finding out not only how supportive my OB is of this type of birth plan, but also the other providers in her practice. If I get the feeling that these wishes will not be respected, or that I would spend the time I am in labor having to argue for a C-section or against medical procedures I don’t want, then I am not interested. I have always liked having a large OB/GYN practice that can accommodate emergency appointments easily, but now the idea that someone I don’t know could be managing my care makes me nervous.

  • Roadstergal

    The numbers are small, but it’s certainly not showing that there’s any _harm_ to laboring on your back.

    • The Bofa on the Sofa

      This is my thought as well:

      The actual differences between the upright group and the lying down group were so small as to be trivial. It seems to me that a more accurate conclusion is that position in labor makes no difference to the likelihood of spontaneous birth, so women should be encouraged to adopt the position that they prefer.

      My take is that yes, the different is so small as to be trivial. Especially considering that the differences in outcomes themselves are trivial in the first place.

      Yeah, adopt whatever position is more comfortable for you. It doesn’t really matter. Most importantly, it shows that laboring standing up certainly doesn’t help with a spontaneous vaginal delivery, if that is your thing.

      • Steph858

        I was under the impression that crunchy types took the attitude of: “How dare those evil obstetricians force poor women to give birth lying on their backs? If the mother wants to stretch her legs a little and give birth while in the Downward Dog position, she should be allowed to. In fact, if a woman’s body is telling her to get into a certain position, there’s probably a reason for that; ignoring or suppressing those signals can only lead to trouble.”

        In other words, women should give birth in whichever position is the most comfortable, whether that be lying on her back or swinging from a trapeze. I actually agreed with them on this, to a point.

        So is their real position that women should give birth in any position so long as it’s NOT lying down?

        • The Bofa on the Sofa

          I quote Cat’s comment from yesterday:

          This actually makes me very angry. During my recent pregnancy, the midwives consistently fed me the line that labouring on your back was a dangerous, archaic practice, roughly equivalent to using leeches, which had now been totally discredited by modern science.

          So, apparently, yeah, that’s exactly they message they are sending.

  • Karen in SC

    Similar to that made-up benefit of letting the baby “choose its own birthday.”

  • attitude devant

    Funny how that evidence-based thing works…..