Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

The Lithotomy Position is NOT a Form of Squatting! February 18, 2009

The other day while at work, I heard an obstetrician utter a phrase that both confused and outraged me.  I had spent the last eight hours caring for a couple in their late thirties who were in labor and expecting their first baby (let’s call them Laura & Matt).  Laura had broken her water at 4 o’clock in the morning and after talking to her doctor on the phone, came into the hospital around 8:00 am.  Dr. Q, the couple’s obstetrician, followed in soon afterwards to check her…2 centimeters, 50% effaced, -3 station.  She was contracting about every 6-7 minutes and in true obstetrical fashion, was promptly started on the pitocin augmentation protocol for “dysfunctional labor” (a term I feel is often thrown around willy-nilly and almost always “diagnosed” improperly.) 


I should probably digress for a moment to explain the “like-dislike” relationship I have with Dr. Q and many of the other obstetricians I work with.  Dr. Q and the other two OBGYNs in his practice are fairly new to my hospital.  They used to practice at a community hospital that has their own in-hospital birth center and no in-house residency staff.  Due to their history, I have generally found this practice to be less aggressive than others when it comes to managing labor as well as personally more involved with their own patients (e.g. regularly checking on their own patients when they are on call, as opposed to requesting that the residents manage their patients until delivery).  So it is traits like these that I am supportive of (*like*).  However, it is becoming more and more frequent for this group, as they become assimilated to the “high risk hospital culture,” to do things like order pitocin augmentation on a primip* for “dysfunctional labor” after only “allowing” her 4 hours “show progress” (*dislike*)!  See what I mean?  Now back to my story…


When I took over Laura & Matt’s care from the day-shift nurse, Laura was 5 centimeters dilated, sitting up in the rocking chair, and breathing through every contraction like a pro!  Her husband was very supportive and they both worked well together as a team, which is super important since they had been planning and preparing for a natural birth.  I was excited to be a part of their experience and spent the next several hours offering my assistance as a labor companion with position changes, comfort measures, brainstorming, personal hygiene, etc., on top of performing my nursing responsibilities like monitoring the fetal heart rate, assisting with vaginal exams, charting and so on. 


At 10:00pm it was finally time to push!  Dr. Q was pleased to inform Laura that not only was she fully dilated, but all that intense rectal pressure she had been experiencing was for a good reason…the baby was at a +2 station!  And here is where the infamous comment was made.  Since Dr. Q prefers to catch babies while sitting on a stool, I was instructed to “break the bed**” and position the patient in a modified lithotomy position.  Since the patient was not under the influence of any pain medications or anesthesia, I tactfully broached the subject of trying any other position, but my suggestions were promptly dismissed by the doctor.  “The baby is small,” he said, “she won’t be pushing for very long.”  What kind of a reason is that!?  Anyways, so there she was, lying on her back with her head at about a 30 degree angle as her husband and I supported the bottom of her feet, awaiting the “okay” from Dr. Q to begin pushing.


And here is where the infamous comment was made…


As the patient began pushing, Dr. Q turns to me and says (and I quote), “Do you know who invented this position?”  Puzzled by why he would bring this up at this particular moment I responded hesitantly, “Who?”  “The Mayans,” he stated confidently and with a smile on his face, “all it is really is a squatting position!”  Shocked at his blatant disregard for historical fact I confidently, but quietly, stated back “No it isn’t!  This is nothing like squatting!” but of course, I did not think this was the appropriate time or place to have such a discussion and so I quickly turned my attention back to my patient (where it belonged!) and boiled a little bit inside until I could say more to him after the delivery outside of the room.  When I did finally get a chance to confront him, he smiled and said, “Well, you know what I mean…”


Actually Doctor…I DON’T know what you mean because you comment borders on delusional!  Is this how obstetricians think?!  Is this why so many women I talk to tell me that their OBGYN, as they put it, “acted totally different in the office than in the hospital during labor.”  Is this what they mean when they tell patients that they are willing to let you try “alternative” positions for delivery!?  YIKES!


For the record, lying on your back with your legs in the air is NOT squatting and ANYONE who has EVER done an actual squat will tell you that!  According to the Merriam-Webster dictionary, to “squat” is to “assume or maintain a position in which the body is supported on the feet and the knees are bent so that the buttocks rest on or near the heels; to cause oneself to crouch.”  When you assume the squatting position for delivery (or any other upright position for that matter) gravity is working with you not against you!  This is why every culture around the globe for thousands of years developed their own upright positions for birth.  And, for that matter, it is why toilets are designed the way they are!


The lithotomy position was actually first used in ancient times to remove kidney stones, gall stones and bladder stones via the perineum (a.k.a. the region between the “who who” and the “poo poo” J).  In fact, the word “lithotomy” is derived from the Greek words for stone (“lithos”) and cut (“tomos”).  The lithotomy position came to be used in childbirth when doctors began attending deliveries, as they found it easiest for performing obstetric interventions including: maintaining sterility, monitoring fetal heart rate, administering anesthetics, performing and repairing episiotomies, and using forceps.  Notice how NONE of those reasons includes “because it was best for mother and baby” (and in fact, the research shows it isn’t!)


So to all the providers out there who might feel the same way as Dr. Q, I have one thing to say to you.  If it looks like a duck, swims like a duck, and quacks like a duck, THEN IT’S A DUCK DAMMIT!





* “Primp” is a term used to describe a primiparous woman, that is, a woman who has given birth only once or is about to give birth for the first time, regardless of how many times they have been pregnant.


** Many hospital beds that are designed for labor and delivery allow you to remove the foot of the bed to reveal stirrups and foot holders and the term for putting the bed in this position is called “breaking the bed.”


7 Responses to “The Lithotomy Position is NOT a Form of Squatting!”

  1. talkbirth Says:

    Wow! That is unbelievable. I guess then he can feel like he is “giving the patient what they want!” and go about his merry way. 😦


  2. nursingbirth Says:

    Isn’t that the truth! It is so misleading. Thanks for the comment Molly!

  3. Joy Says:

    This is how I gave birth twice and I have to admit that it was VERY uncomfortable. My instinct was to squat but of course I had an epidural and couldn’t do that.

  4. Marissa Says:

    my Physical Therapist and I were talking about this birthing position the other day. She sees a lot of women who had no problems until they were forced to deliver in this position, at which point they end up with shearing of the pubic symphysis because it doesn’t allow flexation of the sacrum, so there’s a lot of extra pressure put on the pubic bone.

  5. Anne Says:

    Adding on to what Marissa wrote – YES. It’s not just about gravity, which is enough of a problem in itself; it’s about closing off the pelvic outlet. Squatting increases the pelvic outlet by a whopping 15-20%, and also shortens the birth canal. Not to mention that in lithotomy, all that pressure goes right to the perineum.

    Boy, don’t get me started. It seems like that doctor thought, “Gee, the angle of the femur to the pelvis is somewhat similar in both . . . therefore it’s the same thing.” GAH! Not on this planet it’s not.

  6. contortingmom Says:

    Help please. My OB insists that although I can push in any position, I need to be on my back with knees in the air to deliver. She doesn’t insist on me being FLAT on my back (like my last OB – who I fired for this reason as it was the last straw), but I am dismayed. She knows that I left the last OB for this reason and when we first spoke, all she said is that she can’t “contort” anymore because of a bad back. I agreed that of course I want her to have a good view & access to the baby, but I thought this just meant what she said, that she needed a good view – still plenty of options for positions. When I asked her about perineal support last week, she insisted that this nonsense “squat” was best position to prevent tearing and the only option. She won’t even “let” me try a side-lying position. I am concerned that she’s making declarative statements not based in fact and it’s making me worry about everything else now. Having the a mother-chosen position makes a lot more sense to me and is backed by the research.

    Additionally, I had spinal surgery last year and a tailbone fracture that never healed right, so this “squat” position feels very painful to me and I can’t imagine doing it while delivering my baby. The pressure will almost certainly break my tailbone again. I told her this and it’s like she didn’t hear it – I have to instead worry about her back. Anyway, sorry this is long – but she’s also the best OB I can get for many reasons and there’s no changing now (I’m 40 weeks and 1 day). She also said that even if she’s not on call, she will be there for my delivery. I’m afraid to push this any further beforehand, because then maybe she won’t show and I’ll get a far worse alternative. I have a supportive husband and a doula.

    So, my question is – how do I stay in the position I want without going to war in the middle of my child’s birth? Do you have any tips from your experience on a mother successfully delivering in the position she wants?

    Thank you. Your blog has been very helpful and I’m spreading the word.

  7. Wilbert Says:

    nAd this is why I love Killer post.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s