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Where is the pelvis? The Importance of an Upright Pelvis in Birth

We often ask, “Where is the baby?” in a pregnant woman, but even more important is the question “Where is the pelvis?”  A new vision is urgently needed in birth.  Anatomically, babies are supposed to be born “out the back.”  In the diagram here of a woman on a bike, note that even in an upright position, small movements in posture affect the angles between the spine and the pelvis.  The arrows depict the direction in which the baby will be born. Today, most women are lying on their backs birthing their babies “out the front” which makes birth more difficult.  Anatomically, babies are supposed to be born “out the back.”

Even though we are not always aware of it, our bodies are always in constant motion with the heart beating, lungs breathing, and blood vessels carrying precious nutrients throughout the body and excreting what is not needed.  Gravity plays an important role in these processes.  Even a newborn needs to start learning anti-gravity positions to start the process of being upright and eventually creeping and walking.  The human body wants to be upright and active to function efficiently.  This includes birthing a baby.

We have gravity because of the dynamic equilibrium of the Earth moving around the sun. The speed with which this happens creates a centrifugal force that balances the gravitational force between the Sun and the Earth.  Gravity is so important to our very existence that astronauts in space need to exercise at least two and a half hours each day to give the body a sense of weight-bearing.

It is much easier and more comfortable to defecate in upright positions.  In the same way, it is easier and more comfortable to birth our babies when the pelvis and the organs within it are in upright positions.  Just picture a section of a water hose held upward at either end.  If this was the birth canal, imagine how much more difficult it would be to have to push the baby up against gravity to be born – yet this is exactly what most women do!  They are lying on their backs with knees pulled up and out making birth much more difficult.  How much easier it would be to turn around onto hands and knees or on knees leaning over a birthing ball or pillows on a chair, or lying sideways with the pelvis shifted forward, or even standing, allowing gravity to be their friend!

Standing, holding onto a rope and taking weight off the feet offers a very important aspect of giving birth not much talked about.  This is the effect of stretch receptors feeling the stretch upward on the upper body.  It is helpful in labor to have the forces going up balancing the forces going down.  It is believed that stretch receptors actually play a part in signaling a woman’s body to go into labor. Gravity plays a role when giving birth as well.

The way in which a woman in labor postures herself, is likely to affect the way the entire birth may go.  This is because the baby has more space in which to move when the pelvis is tipped forward in upright positions.  This allows the baby to move into advantageous positions to move and rotate through the pelvis and helps to prevent dysfunctional labors.

The pelvis lying down appears very different than the upright pelvis.  Even slight angles forward make a huge difference in terms of how the baby comes out as can be seen in the diagram.   Lying down flat on the back, a woman is lying on her sacrum.  The sacrum needs to move forward and backward which actually changes the available space in the superior and middle inlets.  In an upright position, the pelvis is already, normally in an oblique position, tipped forward.  Add to that the help of gravity assisting the baby in coming down, and a laboring woman moving her body, changing positions, all of which can make labor easier. At the same time, the uterine muscle, itself, is working hard to contract down to help the baby move into the pelvis.  If a woman allows gravity to assist this process  by keeping herself upright or at least with her pelvis forward, she is likely to have a shorter and easier labor.  Of course, add to that the presence of a doula or birth companion so she feels safe, and the experience can be much more positive.

If you have seen women in labor lying down, you may notice something interesting.  This has to do with the Rhombus of Michaelis.  These are a bundle of nerves by the low sacrum that have a role to play in labor.  The baby in an OA or Occiput Anterior position, will flex or bend his head to put pressure on these nerves just before the moment of birth.  The mother will reflexively respond by lifting up her left hip and knee with a slight puffing out in her low back. This opens up the birth canal for birth so the baby can be born “out the back.”  With an epidural, you can see women trying to lift up this part of the back with none or limited ability to do so.

So which way do you want to birth your baby? With gravity or without gravity?  It is as simple as that!  Become familiar with upright, forward leaning positions for labor.  Try them out while pregnant so they become familiar to you.  Then know that these are optimal positions for your labor.  But if you need a rest, sidelying with an anterior or forward pelvis is also a good option.

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WHO recommendations: non-clinical interventions to reduce unnecessary caesarean sections1

Just 40 years ago when I first gave birth, a cesarean was still considered an operation done only for specific life-threatening conditions as well as when having had a prior cesarean.   Today, it has become an accepted, if not almost routine, way of giving birth.  What has caused this significant and disturbing trend?  Concerns about the sustained and unprecedented world-wide rise of cesarean section has prompted the World Health Organization to issue this report.  In the “WHO Recommendations Non-clinical Interventions to Reduce Unnecessary Caesarean Sections, they stated, “This is a major public health concern. There is an urgent need for evidence-based guidance to address the trend.” Their report was based on evidence of the effectiveness of interventions from an updated Cochrane review of 29 studies.

The importance of this WHO report is that it represents the first global guidelines of a clinical encounter between a health-care provider and pregnant woman in the context of patient care. The purpose of the study is to “provide evidence-based recommendations on non-clinical interventions that are designed to reduce cesarean section rates.” Their report acknowledges that a cesarean is a surgical procedure that when necessary can prevent maternal and newborn mortality when medically indicated.  However, beyond a certain threshold at risk, may result in increased maternal and perinatal morbidity along with both short and long-term health risks that may extend for decades beyond.  This in turn results in substantial increases in health-care costs, morbidity, and mortality for mothers and babies.

In the USA, about one in three births result in a cesarean, having increased dramatically from 5% in 1970 to over 32% in 2016. Today.  it seems to matter what country you are born in and in the USA, which state you live in. In the USA it is better to be born in Utah (22.3%), Idaho (21.9%), New Mexico (24.8%),  Alaska (23%) or Hawaii (25.2%) versus Mississippi topping the list at 38.2% or Louisiana (37.5%), Florida (37.4%), West Virginia (34.9%), NJ (36.2%) or Connecticut (35.4%).

Internationally, Finland has a low cesarean rate of about 16% of births and the UK’s rate is about 24%. Brazil tops the list at more than 50% with even higher rates in private sectors.  Latin America and the Caribbean follow with high cesarean birth rates at 40.5% and North America (32.3%) ranging down to Asia (19.2%) and the lowest in Africa (7.3%).

When cesarean rates vary to this degree, it must be due in part to how birth is managed rather than birth itself. The international health-care community has considered the ideal rate for caesarean section to be between 10% and 15%.  WHO concluded that “at the (global) population level, cesarean rates above 10% were not associated with reductions in rates of maternal and newborn mortality.”

The WHO report acknowledges that although societal changes such as increases in obesity, multiple pregnancies and older pregnant women have contributed to the increased cesarean rate, these are unlikely to explain the variance  of cesarean section rates between various countries or states.  Other non-clinical factors such as women wanting to plan their birth dates, physician factors, malpractice fears, and other economic and social factors are also implicated in the high variability of cesarean rates.

We know today that there are many non-clinical interventions that have proven to be successful in labor and birth but which are underutilized by most women, birth professionals, and facilitators.  These include warm water, optimal pelvic positioning,  the presence of a birth companion or doula, massage, speaking encouraging words, and keeping a positive and private environment.   On the contrary, medical intervention rates are very high with for example a 75% rate of epidural anesthesia and other obstetrical drugs to control pain.

In the WHO report, recommendations to reduce cesarean targeted women, health care professionals, and health organizations, facilities, or systems.

For women

  • Education that addresses fear of pain, advantages and disadvantages of cesarean sections and vaginal birth, risks and benefits of pain relief techniques and obstetrical drugs, and guidelines for indications and contraindications of cesarean sections.
  • Relaxation training and stress reduction programs conducted by nurses
  • Couple-based prevention programs that are inclusive and provide problem solving suggestions, mutual support strategies, and conflict management.
  • Psycho-education for women who fear childbirth itself and that address topics such as normalization of individual reactions, stages of labor, hospital routines, birth process, and pain relief.

For Health-Care Professionals

  • Implement “evidence-based clinical practice guidelines combined with structured, mandatory second opinion for cesarean section” in settings with adequate resources and senior clinicians.
  • Implement “evidence-based clinical practice guidelines, cesarean section audits and timely feedback to health-care professionals.”

Health Organizations, Facilities or Systems

  • Establish a collaborative midwifery-obstetrician model of care where the model of staffing is based on care provided primarily by midwives with 24-hour back-up from an obstetrician who provides in-house labor and delivery coverage.
  • Establish financial strategies such equalizing physician fees for cesarean and vaginal births.

The highest level of certainty evidence was the recommendations for health-care professionals where accountability was required.  Interventions in labor and birth need to be guided by the basic premise that if the harms clearly outweigh the benefits for valued outcomes, they should not be used.

The WHO report stated that women find learning new information about birth to be empowering  but it should not provoke anxiety.  Women want emotional support alongside the communication of facts and figures about birth. But interestingly, there seemed to be no differences in cesarean rates based on computer-based decision aids, booklets, role play vs lecture for women with fear of childbirth, or educational brochures in spite of the fact that women seemed to want such things.

They did not see differences among various ways to present the childbirth information, but none of the discussed formats for learning included an experiential and emotional preparation for birth that is based on basic human values as is available in BirthWorks.

BirthWorks childbirth preparation is designed to build confidence for birth.  We offer a broader systems approach to childbirth that is based on a foundation of human values where optimal pelvic positioning is key.  Women learn how to work with their bodies in labor, knowing that the knowledge about how to give birth is already born within every woman.  Included are also identifying beliefs and releasing fears thus re-framing them to a positive experience,  the role of hormones and the value of the microbiome as well as the importance of mother-baby skin-to-skin contact, mother-daughter relationships, the value of doulas, and grieving and healing.  Classes are interactive and a place of joy and learning which is what the experience of birth can be.  BirthWorks childbirth preparation builds confidence and decreases fear through the integration of mind, body, and spirit.


  1. World Health Organization 2018. This report is available under the Creative Commons Attribution –NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO,
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The Sounds of Silence During Labor

Written by Sarah Baker CCE(BWI)

I recently listened to an On Being podcast entitled “Silence and The Present of Everything.” The guest, Gordon Teppitt, was an audio ecologist, a career which I’d never heard of and found utterly fascinating. His gentle and calm voice spoke in a poetic way about his experiences and the insights gained from them, a subtle lulling lilt in his energy that soothed me.  His insights on silence, or lack thereof, spoke deeply to me. He defined silence not as an absence of sound, but an absence of noise – an important distinction that is often misunderstood.

Teppitt’s observations were a catalyst to me reflecting on my own experiences with silence. Naturally, being a birth worker, I couldn’t help but immediately think about one of the many skills I’ve had the privilege of refining as a result of my doula work: being comfortable with silence during labor, and more importantly, willingly remaining present during the silent space of labor. In that space is something sacred, something that can’t be easily quantified, and it’s something that is easily missed by those who aren’t paying attention. In all fairness, it’s not  their fault they miss out on the sacred: the interventions and energy and hustling/bustling of the hospital environment drown out the sacred sounds of silence during birth. It dulls the senses and mutes some of the most beautiful aspects of birth by putting such staunch focus on the clinical, the medical, the mechanical. Women and partners often find comfort in the sound of their baby’s heartbeat galloping away on the fetal monitor. The blips and beeps of IV and epidural pumps become white noise or aggravating interruptions. The atmosphere becomes casual and party-like as a revolving door of family members and friends visit the laboring woman. The irritating sounds of nursing station gossip blurts in every time the door is opened. All of it interrupts and disrupts the sacred silence of birth, so much so that many people often cannot distinguish the normal sounds of birth from the man-made noise so common in modern birth.

Just like Teppitt defines silence as an absence of noise rather than an absence of sound, so it is with the experience of silence during labor.  During labor, women instinctually release primal, guttural moans and groans, often referred to as “vocalizing.” When I discuss the concept of vocalizing during my BirthWorks classes, one of my go-to phrases is this: “It’s not a matter of forcing yourself to make these sounds, but rather, giving yourself permission to do so.” The sacred space of silence during labor is often not an absence of noise, for the normal sounds of labor can even be quite loud as they resonate outward from a woman’s vocal cords. But it’s the absence of modern, technological birth noises.

For some women, it takes a conscious effort to let go of their inhibitions, which result from a number of influences (society, family, her personality and temperament). Such influences can create cognitive dissonance within her body. Her instinctual, “old” brain is gradually taking over as she shifts into active labor and is creating the perfect environment internally for the delicate hormonal dance that’s necessary to achieve a healthy labor.

As she begins vocalizing, she naturally starts filling the silent spaces with sounds that may feel very foreign to her. And yet when inhibitions are present, her frontal cortex, or “new brain” is fighting for attention, sending a loop of unproductive messages:

“Listen to yourself, you sound weird!”

“What will they think of you with these crazy noises you’re making?”

“Control yourself, it’s too risky to let go of control.”

Teppitt described why people feel uneasy and uncomfortable with an absence of noise: sitting in silence leaves us feeling vulnerable. Vulnerability invites us go deeper, to allow our truest selves to be seen. Vulnerability is simulataneously exhilarating and terrifying. And so it is with labor and birth. When a woman allows herself to turn off the noise, both the “noisy chatter” of her frontal brain and the literal noise of modern birth, what’s left is an uncomfortable silence and a part of herself she’s never experienced before.

A curious phenomenon begins to occur once she becomes comfortable with the uncomfortable newness of her primal self and primal sounds. Her guttural sounds begin to fill the laboring space. The sounds wash over her with each contraction and create a palpable tension felt by every person present. In between each contraction, she sits in true silence. Time begins to stand still, not only for the woman, but for us, too. All of us become keenly aware of every subtle sound we make, keeping quiet, only speaking when absolutely necessary and in low, hushed voices.

For people present with her who are unexperienced with birth or unexperienced with the normal sounds of birth, this gentle tension created by the birth sounds and the literal silence often leads to feelings of discomfort. Tippett says, “True listening requires vulnerability.” And so it is for the people present, with no external noise to distract them and drown out the primal sounds of birth or to fill the silence in between contractions, it leaves them vulnerable.

Even as an experienced birth professional, I am not immune to such feelings of vulnerability. Over the years, I have learned to embrace this vulnerability. I have learned (and am continuing to learn) to let go of my own inhibitions, quiet the empty chatter of my own mind, and enter into this vulnerable, sacred space with her. I push through the uncomfortable and find my own strength because I know what she is doing in those sacred moments is much greater than my discomfort. I let her primal sounds wash over me, I tune into my own energy and make sure it’s in alignment with the sacred, I encourage her with simple phrases if needed, and resist the urge the fill the silence with unnecessary words. I let go and open myself up fully as she surrenders to the ebb and flow of waves and birth sounds.

Birth has changed me and continues to change me. How could I possibly be left unchanged by such sacred vulnerability, one of the most vulnerable experiences that a woman will ever face, and one in which I willingly remaining present with her? Wisdom, that has only come with experience as I’ve learned to embrace silence and the sacred sounds of birth, is truly a gift that has carried over into every other area of my life. Birth has taught me to welcome my own vulnerability, to sit with myself in the absence of noise, and to embrace the silence of my own heart.

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Interview with the Global Health and Travel Magazine in Singapore

answers by Cathy Daub – President of BirthWorks International

Question – The World Health Organisation (WHO) now advises medical staff and midwives to stop speeding up birth unless there are real risks of complication. This contradicts their previous advice stating that labour progressing at a slower rate than one centimetre of cervical dilation per hour in the first stage is considered risky. Can you explain why certain cervical dilations take longer and why is it considered risky in the first place?

It is essential that the baby’s head is positioned on the cervix so it presses in all directions to dilate equally. Malposition may occur with babies in an occiput posterior position where they can’t tuck their chins well and the head may present forward on the cervix.  Or, if the baby is in an asynclitic position with the head tilted to either side, the cervix will take longer to dilate. There may also be tight ligaments holding the baby back.  The good news is that with movement and relaxation exercises for the pelvic floor, many of these situations can be alleviated and the baby can have a normal birth. Unless the cervix is fully dilated to allow the baby’s head to pass through, the baby will need surgical delivery.

Question –Do you believe their current advice is the correct thing to do and why?

Absolutely!  This is a good and wise change of advice by WHO.  We sometimes say that babies are like cakes- some need 25 minutes to bake and some 45minutes.  Women labor in many different ways and can dilate slowly or quickly.  This new advice gives women freedom to feel safe to labor without the pressure of restrictive timeframes. Women give birth in their own special way.  But giving birth in upright positions or left sidelying with the pelvis tipped forward will most always result in a quicker birth.

The key word here is MOVE! There are ways that women can shorten their labors and dilate more quickly. Currently most women in the USA give birth lying on their backs with epidurals in place.  Rather, they need to be up moving around and changing positions frequently.  This helps them to use gravity and allows their babies to move into optimal pelvic positions for birth.  The more space the baby has in which to move, the more optimally he/she will enter the inlet of the pelvis and make the two rotations necessary for birth.  Movement of the sacrum is essential as this helps to open the inlet and outlet of the pelvis for birth whereas lying on the back with an epidural does not allow this movement and slows labor.


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BirthWorks Int. Pre-Conference 2016 Event October 12th presents Nils Bergman, MD from Africa!

Nils Bergman MD


BirthWorks Interntional Pre-Conference 2016 Event – Mark your calendar. Full Day Workshop 10-12-16 featuring Nils Bergman, MD from Africa.

Pre-Conference 10-12-16 and Full Conference 10-13,14,15 &16 events are being held at The Hotel ML, 915 Route 73, Mt. Laurel, NJ. The ML Hotel also features an Indoor Water Park.

Keynote Title: “Turning Ancient Truths Into Modern Science”

Description: There is at times a gap, even a chasm, between the truths about birth that all women instinctively know inside themselves, and the real world of the health services providing obstetric care based on evidence based medicine. Perhaps the reality is that we do not know enough about “instinctive truth”, nor do we have enough evidence to address the whole picture. This workshop will seek to provide a broad and holistic conceptual framework for understanding birth. It will be based on the current knowledge of “truth” that we now have from life sciences theory, the broad scope of reproductive biology, developmental neuroscience along with Epigenetics, brain based reproductive behavior and the role of milk and the Microbiome. Such a big picture is necessary for holistic care, but also for formulating future research questions, so that we can create the necessary evidence base that will make what is “ancient and instinctive” also “modern and standard”.


Press Here For more information on BirthWorks International Go To Conference 2016