When Carolyn Lau was delivering her first child, Ng Senja, her instinct was to sit up during the contractions. But she wasn’t allowed to despite her protests about having to lie on the bed.

“The pain was too much. My back was killing me and I didn’t have the strength to push hard enough. In the end, Senja was vacuumed out because I wasn’t pushing enough,” Lau remembers of her first childbirth five years ago.

Her second child was delivered at a hospital which allowed her to choose the most comfortable position during delivery. “I squatted, leaning over a chair for support. The delivery was fast,” she says. Unfortunately, there were complications with the pregnancy and her baby was delivered stillborn.

By her third pregnancy, Lau, a landscape architect, was convinced that lying on her back during labour would not work for her. When the midwife started preparing the bed and stirrups for her, she told them she needed to squat. To her doctor’s credit, she was allowed to find her own comfortable position until she delivered her twins, Sutri and Sujan.

According to the US-based Coalition for Improving Maternity Services (CIMS), mother-friendly maternity services should be promoted in accordance with the principle that birth is a normal, natural and healthy process, and women and babies have the inherent wisdom necessary for it.

Such mother-friendly initiatives, CIMS adds, must provide the birthing woman with the freedom to walk, move about and assume positions of her choice during labour and birth unless there are complications, and discourages lying flat on the back with legs elevated (known as the lithotomy position).

Still, very few hospitals or doctors in Malaysia allow women to practise active birthing that includes choosing upright positions, instead of supine positions on a bed, that allow gravity to naturally help a woman deliver.

“Standing up helped me manage my labour pains better than when I was lying down,” Silvana Montoni, 40, testifies about her daughter’s birth eight years ago. Montoni, who is married to a Malaysian, says she also stood under a warm shower to help her manage the pain. “I was not terrified about [my first] childbirth because I was actively working through my 20-hour labour,” she adds.

Mother of two An Juat Lan says using active birthing for her second delivery made the labour pains more bearable than during her first delivery when she employed conventional birthing methods.

“With active birthing, my labour was shorter and I healed much faster,” she says, adding that she naturally found leaning on the bed in an upright position as the most comfortable way to deliver.

Medicalisation of birth

Consultant obstetrician and gynaecologist Dr Choong Kuo Hsiang says that traditionally, women of all cultures worldwide have delivered in upright positions. He explains that the French king Louis XIV was believed to have started the trend towards delivering in the supine position in the 17th century. “It is rumoured that he asked for his mistress to lie on the bed for delivery in order to give him a better view of the birth,” Choong tells theSun.

While it was a Frenchman who invented the forceps, Choong adds, it was a Scottish physician who pioneered the use of forceps in the 18th century. The use of anaesthesia for birth began in the following century.

“As birthing was gradually taken under the control of obstetricians rather than midwives, and as use of technology and analgesia increased, the majority of women began to have hospitalised births under the control of the medical profession rather than traditional birth attendants or midwives,” Choong says.

When this happened, he adds, doctors began treating birthing mothers as patients and placed them flat on beds and in lithotomy positions so that they could have a better view.

Another consultant obstetrician and gynaecologist, Dr Ashar Abdullah, admits that placing a woman on the conventional labour bed is more for the medical staff’s convenience than for the mother’s comfort.

Choong says the practice of delivering in a supine or semi-sitting position spread worldwide as more and more doctors and midwives trained in the West. “Eventually, the natural event of birth became medicalised. We think all childbirth has the potential to be dangerous when the majority are very normal events,” Choong observes.

“As a medical student, I wasn’t trained in active birthing,” says Ashar, a doctor of 20 years. “I was only exposed to it in private practice.” He adds that his wife Datuk Dr Jemilah Mahmood, who is also Mercy Malaysia president, was instrumental in his increased awareness.

Choong, who has been a doctor for 32 years, admits that he, too, didn’t become a proponent of active birthing until his wife, Christine Choong, a lactation consultant and childbirth educator at Mamalink, began to learn more about active birthing herself, as a result of her own birthing experiences.

“My first two childbirths were very painful. But for my third child, I spent most of my labour at home and found myself naturally adopting more upright positions. It was easier and more comfortable to be upright than on the bed,” Christine remembers.

Both Choong and his wife began doing more research. Christine says active birthing gained momentum because women in the West started to rebel against the medical technology that took over the natural process of birthing.

Actively birthing

Rather than being confined to a bed during labour, Choong and Christine tell women who choose active birthing to walk about, lean forward, kneel, squat, sit astride a chair, lie sideways, rock or circle their hips during labour.

“They can use their partner, pillows, bean bags, chairs, stools, birth balls, a birthing wheel or the wall for support,” Christine explains. She adds that she tells women to bring in their favourite music and scents, massage oils, a hot pack, and extra pillows for the birthing.

The Ampang Putri Specialist Centre in Kuala Lumpur provides women with the option of using the Roma Birth Wheel (see pix above right) from Switzerland. The birth wheel’s position can be changed using a remote control to allow a woman greater comfort and flexibility in choosing a position during labour. It comes with a hot pack that can be heated up in a microwave to relieve pain.

“Many women find heat is helpful on the lower back or lower abdomen,” Choong says. Hence, sitting in a warm shower or bath and using hot water bottles or heat packs can help with pain management. “Massage can also be very helpful and many fathers are now assisting the mother in labour by massaging her back or thighs,” he adds.

The benefits of active birthing are well-documented. “If a mother is sitting on the bed, the movement of the coccyx or tail bone is restricted, thus narrowing the outlet of the pelvis. This makes it more difficult for a mother to push her baby out into this world and also increases the degree of pain she experiences while pushing,” Choong explains.

Ashar agrees, adding that labour is generally shorter when women are in an upright position because of the aid of gravity. “Women who choose the birth wheel also experience less pain and backache and hence do not request for painkillers or episiotomy (an incision to enlarge the vagina and assist in delivery) as much,” he observes.

Other benefits include the improved angle of the uterus, increased pressure between contractions, improved circulation, less pressure on pelvic nerves and less resistance to uterine effort, and less pressure on the baby’s neck.

Active birthing also facilitates spontaneous separation of the placenta, reduces the likelihood of infection, ensures more even expansion of perineal tissue, and increases a mother’s sense of control.

Choong explains that when a woman delivers without the aid of an epidural (a spine-administered anaesthetic), the body releases endorphins — natural painkillers — that ensures that the mother and baby are more alert and responsive to each other immediately after birth. “This may be an important link in mother-baby bonding and helps the baby take to breastfeeding faster,” Christine adds. It also ensures that women have more positive memories of giving birth.

Slow acceptance

Choong and Christine lament that despite their promoting active birthing from as early as 1993, it has not taken off significantly in part because not enough hospitals or doctors support it.

“When given a choice, more women are opting for these methods,” Choong says. There are also many women who would like to use more natural methods but who are not being allowed a choice, he adds.

For example, many countries now have free-standing birth centres where women are in very homely and comfortable surroundings, often with a bath or birth pool available. “Thus far, no hospital in Malaysia has been willing to accommodate a birth pool,” he says.

A Bangkok hospital has three birthing rooms equipped with birth pools, and at least three Singapore hospitals, including the National University Hospital, have them. “Some of the government hospitals in Bangkok also allow women to choose their own birthing positions,” says Choong, noting that active birthing is only done in private hospitals in Malaysia.

Ashar adds that less than 5% of his patients know about active birthing or want to draw up their own birth plan. It is estimated that less than 10% of pregnant women who go to the Ampang Puteri Specialist Hospital choose the birth wheel.

“Most of the women who want active birthing are expatriates or Malaysian women who have lived overseas or who have read about it,” observes Ashar.

Some medical staff are not supporters of active birthing because it is messier and they may have to get down on their hands and knees to observe the delivery.

Choong says that when he first started allowing active birthing, the nurses and midwives were not sympathetic. “But, gradually, they have become more supportive.”

Still, it is the woman who must make the choice and demand for it, note Choong, Christine and Ashar. “I do not promote active birthing above conventional methods. I let the woman decide which she will be more comfortable with,” Choong explains.

“It’s about empowering the woman,” Ashar adds, “so that she can make a choice about how she wants to deliver.”

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