i 
[Reprinted from The American Journal of Obstetrics and Diseases of Women and 
Children, Vol. XIX., June, 1886.] 
POSTURE DURING LABOR. 
BY 
H. B. HEMENWAY, A.M., M.D., 
Kalamazoo, Michigan. 
With four woodcuts. 
Eakly in the course of my professional service, my attention 
was directed to the influence of posture upon the progress of 
labor. 
The English text-books advised the left lateral decubitus. 
American teachers seemed to favor the dorsal position. A pa- 
tient, whose other children had all been born upon the conti- 
nent of Europe, sought the inclined position. Seeing these 
varieties in practice and precept, the question naturally arose, 
" Is it true, as many practitioners affirm, that all positions are 
equally favorable for safe and speedy delivery ?" Within the 
past year, I have been aided and greatly interested in the study 
of this subject by reading Dr. George Engelmann's "Labor 
among Primitive People." As a summing up, Dr. Engelmann 
found that the reclining posture during labor is very rare, ex- 
cept among the more refined inhabitants of Europe and Amer- 
ica, where it seems to have been adopted on account of the 
ease with which the body may be protected from sight by the 
bed-clothes. Does it not seem a little strange, if that really is 
the best position for the mother undergoing her ordeal, that 
the children of nature carefully avoid the decubitus? Is it 
true that civilized man knows better what is good for the hu- 
man race than the Creator does Himself ? After a careful study 
of the case, the writer must agree with the author above refer- 
red to, that " the thinking obstetrician will soon confirm the 
statement not infrequently made by the ignorant but observing 
savage, by negro and Indian, that the recumbent position retards 
labor and is inimical to easy, safe, and rapid delivery." 
The chief duty of the accoucheur is not as an operator, but as 
a guardian. Until an abnormality presents itself, or danger 
threatens, he must be content to sit still and watch. When he 
1 Opus cit. 2 
Hemenway: Posture during Labor. 
does act, however, it should be to aid nature, not to operate in 
spite of nature. Frequently an obstetrician in his haste, or 
magnifying his importance and responsibilities, has applied in- 
struments, much to the injury of the patients, when, with a 
change of position, Dame Nature would have conducted the 
case with safety to mother and child. Such an obstetrician 
would, of course, choose a position most convenient for his ope- 
rations. 
The books and professors generally agree that during the 
first stage of labor we should encourage the patient to sit up 
or walk around the room. In the American practice, however, 
the patient is generally kept in bed. The reasons given for this 
advice are, that it is less tiresome to the patient, and that the 
first stage is thereby shortened. It is hard for the puerperal 
patient to lie quietly in the bed. It is tiresome. Whatever 
tires or worries tends to decrease the patient's strength. It is 
therefore evident to all that the patient should be encouraged 
to keep up as long as is consistent with safety. 
Why the first stage of labor is shortened by the erect or semi- 
erect posture, few have stopped to inquire, and I do not re- 
member to have seen any reason given. Partly from empiri- 
cism, and partly from observation, we all keep a patient who is 
threatened with an abortion quietly upon her back. Why, 
when we wish the uterus to discharge its burden, do we care- 
fully use the same position ? It seems to the writer that the 
explanation of the shortened first stage is fourfold. 
First. If we adopt the reflex theory of uterine contraction, we 
can clearly see that, since in the erect position of the body grav- 
ity brings the head of the child more firmly upon the os, the 
uterine contractions will thereby be increased. 
Secondly. Nature intends that the liquor amnii within its 
sac shall dilate the parturient canal.1 It is almost always a 
misfortune if the bag is ruptured before it reaches the vulva.2 
1 The Chicago Medical Journal and Examiner for March, 1885, contains 
an excellent article, by Dr. Henry T. By ford, upon " The Functions of 
the Membranes in Labor." The paper was read before the Chicago Gyn- 
ecological Society, February 20th, 1885. 
•2 In a discussion of this subject before the Kalamazoo Academy of 
Medicine, Dr. H. O. Hitchcock reported a case of placenta previa cen- 
tralis, in which he carefully preserved the membranes, but detached the 
placenta, so that -at one time the placenta and child were born. Both 
mother and child made a good recovery. Hemenway : Posture during Labor. 
3 
Every observing midwife knows that the dilatation of the soft 
parts by the fetal head is more painful to the patient and more 
likely to be accompanied by ruptures. A physician has no 
right to rupture the membranes in order to shorten labor, un- 
less either the mother or the child is in danger. Now, in the 
production of this bag of waters the fetal head acts as a ball 
valve. During a pain, the head is pressed down, and the bag 
of waters finds its least resistance in the cervical canal. With 
the cessation of the uterine contraction the head rises and 
allows more fluid to flow in towards the os. As the operation 
is repeated the bag of waters is increased, and the cervix is 
dilated by constant radial pressure, equal in all directions, 
though varying in degree from moment to moment, and not 
by the less regular axial pressure, unequal upon different por- 
tions of the circumference, as is the case when the membranes 
are ruptured. What is true of the cervix is also true of the en- 
tire parturient canal. It is very evident that, with the body in 
a horizontal position, on account of its low specific gravity com- 
pared with the amniotic fluid, the child's head does not rise 
from the os after a pain, so that the water does not so readily 
flow in front of the head, and it is not kept there so perfectly, 
and consequently the progress of the case must be slower. 
Thirdly. Since the water does not flow so readily, the mem- 
branes are not sufficiently pressed down. According to the nat- 
ural method, the membranes serve as a covering for the mater- 
nal parts to protect them from friction. If pressure is long 
kept up upon any one portion of the membranes (as it will be if 
the water does not flow in), a rupture will probably occur, and, 
as a result, the child's head must be the cervical dilator, and the 
child's body must rub upon the mother's parts. This result- 
ing friction must, of necessity, tend to retard the dilatation, and 
also produce unnecessary local irritation and inflammation. The 
writer could not but think that an early change of position 
might have prevented the troublesome delay in the first three 
cases mentioned by Dr. Elliott Richardson in his recent article 
upon " Tardy First Stage of Labor," published in the Journal 
of the American Aledical Association (Jan. 9th, 1886). 
Fourthly. Since the first stage of labor is accomplished by uter- 
ine contractions alone, the mother simply uses up her strength 
when she tries to assist nature by voluntary muscular effort. If 
she is lying upon the bed, she has less to divert her attention, 4 
Hemenway : Posture during Labor. 
and is more inclined to assist each pain than she is while she is 
around the room. She thererefore gets impatient over her 
slow progress, and her impatience is likely to result in irregular 
pains, rapidly recurring, exhausting the patient's strength, but 
producing no advancement. 
While it is true that an erect or semi-erect posture of the 
body shortens the first stage of labor, its influence upon the 
second stage is fully as apparent. Take three cases, for example. 
The first I must give from memory, not having exact data 
by me. 
Case I.-Mrs. C. G., American, aged 38, rather short and 
quite fleshy. Pelvis large in proportion to her* size. Had four 
children. Labors normal, but not especially rapid. At the time 
of her fifth confinement she woke early in the morning with 
slight pains. She got up to urinate, and while sitting upon the 
chamber had another pain, with which a well-formed female child, 
weighing six pounds or more, came into the world of light. Since 
that the mother has had at least two other children, and in 
neither case was the labor very rapid. 
Case II.-Mrs. F. G., American, aged 26, good figure, but not 
very strong, woke up about 2:30 A.M.one April morning, with slight 
pains indicating the approach of her confinement. I was sum- 
moned as soon as possible, and arrived at the house, four miles 
from my residence, about four o'clock. I found that after a lady 
friend had been called in, and her husband had started to sum- 
mon me, the patient got up and sat in a chair. After her bed 
had been prepared she still persisted in sitting up, because, as 
she said, she did not want to have the child before the doctor got 
there, but chiefly because in her other confinements the pains had 
lasted about six hours, and she wished to stay up as long as pos- 
sible, thinking the chair less tiresome than the bed. Soon after 
she got into the chair the pains increased in force, and the child, 
a girl weighing five and a half pounds, was born at 3:30. She 
was then put to bed, and the after-birth came almost immediately. 
I could discover no rupture, and the patient recovered without 
any drawback. 
Case III.-Mrs. M., American, weighing about one hundred 
pounds, aged 25, was delivered of her second child, January 24th, 
1886. When I reached the house at 2 a.m. I was informed that 
after two or three pains the membranes ruptured at 12:45. I 
found the patient reclining upon her right side. Upon examina- 
tion I found the os widely dilated. Vertex presentation, third 
position. The head was pressing upon the symphysis. After 
each pain the head receded more than is usual. Not much pro- 
gress being made, about 2:50 I inverted a common chair and put 
it upon the bed; Upon this I placed a good-sized pillow and 
fold her to recline backwards against it, thus bringing th® body Hemenway: Posture during Labor. 
5 
to an inclination of about 40° (Fig. 1). Very soon I noticed a 
difference in the results of the pains. With each uterine contrac- 
tion the head made progress, and though receding in the intervals 
of pain, it did not go back as far as before. At 3:30 a well- 
formed boy appeared, weighing about seven pounds. The patient 
said that the change in position was a great help. She did not 
suffer so much when propped up. Recovery rapid and without 
the slightest drawback. Her first labor took about six hours. 
An erect posture during the first stage will shorten the second 
stage if it increases the size of the bag of waters. Clearly, if the 
parturient canal is well dilated, there will be less obstruction in 
the passage of the child through this canal. Moreover, as was 
hinted in the remarks on the first stage, nature intends the 
Fig. 1. 
amniotic membrane to protect the mother's parts. If that is in 
its place, the child's body is less likely to catch upon such tissues 
of the mother as may tend to retard labor. There is less fric- 
tion between the head of the child and the inner surface of the 
amniotic membrane than between either the child's head or the 
outer surface of the membrane and the mother's parts. The 
inner surface of the membrane is firm and smooth, while the 
other structures are softer and not so smooth. It therefore fol- 
lows that, with the amniotic membrane lining the parturient 
canal, the child will pass through more easily, and with less 
danger of producing ruptures in the maternal parts. Lastly, if 
an erect position during the first stage shortens that stage, the 
patient's strength is thereby saved, and she is better able to 
complete the second stage quickly and safely. 6 
Hemenway: Posture during Labor. 
By the erect or inclined positions during the second stage we 
gain the assistance of gravity in the expulsion of tlie child. 
Since the uterus is most nearly erect when the body of the 
mother is inclined at an angle of 50°, we gain the greatest 
assistance from gravity in that posture. My explanation of the 
great recession in case III. is that the fundus of the womb was 
lower than its mouth. When the uterine contractions ceased, 
therefore, gravity took the fetus back to the fundus. By this 
means the muscle of the fundus gained little strength from rest, 
while the cervical fibres were not tired out, as nature intended. 
The inclined position lends support to the perineum, aiding 
it to throw the child's head forward as soon as it passes the 
symphysis. In this position, therefore, a rupture of the perineum 
would be less likely to occur. As soon as the child's head is 
born, to prevent undue flexion of the infant's body, or the re- 
tarding of labor by its pressure upon the bed, the mother should 
be immediately placed upon her back or side. 
Without doubt, the left lateral decubitus is most advantageous 
for many of the obstetric operations, but the foregoing consid- 
erations show that it is hardly the best for natural expulsion. 
In that position, with the patient drawn to the right side of the 
bed, the physician can make examinations with his right hand, 
without being hindered by the patient's limbs. Since her back 
is turned, the patient will not see, and hence be made nervous 
by the preparations which are being made for her confinement. 
Opposed to the position we find that labor is hindered rather 
than aided by gravity. Moreover, the weight of the body tends 
to prevent the separation of the symphysis. 
In the dorsal decubitus, the axis of the womb declines towards 
the os, thus aiding the formation of the bag of waters. On the 
other hand, the weight of the body tends to press the sacrum 
up, thus shortening the shortest diameter of the superior strait. 
In that position also the limbs of the patient are often in the 
way of obstetric operations. 
In the inclined dorsal position, the weight of the body 
is upon the ischia, so that there is no limitation thereby of 
pelvic diameters. Gravity gives its greatest assistance in the 
formation of the bag of waters and in the natural birth of the 
child. The position is inconvenient for most obstetric operations. 
Thinking that there is something further than has before 
been hinted at, to explain the difference of posture taken by Hemenway : Posture during Labor. 
7 
uncivilized parturients, as compared with the more refined 
patients we are called upon to treat, I continued to study the posi- 
tions taken, and came to the conclusion that the lumbar curve of 
the vertebral column is a prominent element in the conduct of 
labor. I notice that, in the pictures given of savage parturients 
and in the descriptions of the semi-civilized confinements, the 
natural lumbar curve is prominent. In the positions advised for 
very fat women in Italian publications of the fifteenth and six- 
teenth centuries, the lumbar curve is made as great as possible. 
In case III., above mentioned, more progress was made while in 
the inclined posture, when the patient pushed with her hands 
than when she pulled. Now, in the inclined position, pulling 
tends to reverse the lumbar curve, and pushing has little effect 
upon it. The effect of the lumbar curve was also shown by 
Case IV.-Mrs. B., born in Holland. Four children. In the 
fifth confinement the membranes ruptured at 6:15 A.M., February 
4th, 1882. I reached the house at eight o'clock. I found the os 
fairly dilated. Contractions regular. The patient was reclining 
Fig. 2. 
at an angle of 45°, but with the lumbar curve reversed. Progress 
was slow until at about 9:25. I removed some of the pillows from 
the head and shoulders of the patient, so that the lumbar curve 
would be corrected. From that time the case progressed rapidly, 
and a nine-pound girl was born at 9:57. 
These are only two of the many cases that might be men- 
tioned to illustrate the influence of the lumbar curve. 8 
Hemenway : Posture during Labor. 
A glance at Figure 2 shows that in the normal position the 
lumbar curve of the vertebral column throws the fundus uteri 
forward, so that the axis of the womb nearly coincides with 
that of the superior pelvic plane. In that position contrac- 
Fig. 3. 
tionsof the abdominal wall crowd down upon the fundus, aiding 
in the expulsion of the child. When the lumbar curve is re- 
versed (Fig. 3), or even obliterated, the fundus falls towards the 
Fig. 4. 
spinal column, so that its axis forms an angle with that of the 
superior strait. Abdominal contractions, instead of aiding its 
expulsion, tend to increase the axial angle. As a result, the head 
presses against the symphysis pubis. This pressure retards Hemenway : Posture during Labor. 
9 
labor, and tends to produce sloughing. Since in about seventy- 
seven per cent of vertex presentations the occiput is toward the 
front, it will be seen that the reversed lumbar curve tends to 
produce face presentations, by causing the occiput to be caught 
upon the pubic bones.1 
As may be seen from Figure 4, when the lumbar curve is 
greatly reversed, it may throw the fundus uteri forward of the 
pelvic axis. Tn that position the head of the child is pressed 
firmly against the posterior wall of the pelvis, and the perineum 
must be extended to its utmost. We should naturally expect 
perineal ruptures, and a recto-vaginal fistula would not be 
strange. If T am not mistaken, one or more cases have been 
reported in which a rupture took place involving the posterior 
part of the perineum, the recto-vaginal septum, and the sphincter 
ani, but leaving intact the anterior portion of the perineum. The 
child was born through the abnormal canal. A glance at Figure 
4 shows how this might easily occur, especially with a long 
perineum. 
He may be mistaken, but it seems to the writer that the fore- 
going fully explains facts often noticed by accoucheurs, and 
well described by his friend, Dr. II. B. Osborne, in an unpub- 
lished discussion before the Kalamazoo Academy of Medicine. 
Dr. Osborne said : " We sometimes see a pregnant woman who 
walks erect with her shoulders thrown back, and abdomen very 
prominent, as though to say to the world ' I am pregnant.' 
When she comes to be confined and the physician makes an 
examination, he finds the vulva pointed a little backward. Such 
a parturient usually gets through her ordeal with comparatively 
little trouble. If ruptures occur, they are but slight. 
" On the other hand we sometimes see a woman enceinte, 
who leans forward as she walks, as if to hide her condition. 
Often, as such a one lies upon her back, her vulva is found to 
be nearly horizontal, and her labor is likely to be slow, and 
attended with more or less ruptures." 
' Since the above was written, the author has noticed in the American 
Journal of the Medical Sciences (April, 1886, p. 658) a review of an 
article by Kiistner, published in the Zeitschrift fill' Geb. und Gyn., 
Heft, xi., p. 326. By an ingenious method, K. measured the angles 
made by the axis of the pregnant uterus with the axis of the superior 
plane. He found that when the patient was erect the two axes generally 
coincided. In the supine position (upon a table), the fundus generally 
fell back, giving an average angle between the axes of 19°. In one case 
the angle was as great as 24°, 10 
Hemenway : Posture during Labor. 
In such cases the abnormal curve is not generally of so recent 
formation that the midwife can entirely correct the deformity. 
The trouble is chronic, and the cartilages and bones of the 
spinal column have accustomed themselves to it. It would be 
well, therefore, if every man should hesitate for a longtime before 
inviting any girl, who does not walk erect, to marry him. Such 
a course would, in a forcible manner, cause women to correct 
their improper positions. It would tend to make them look care- 
fully for the causes of the abnormal curves. Among the causes 
may be mentioned : Fashion, which sometimes dictates that her 
devotees shall wear a " Grecian bend." The extra clothing which 
the women of to-day fasten upon their buttocks, which causes 
them to lean forward to keep the centre of gravity where it should 
be. The high-heeled French shoe, whose wearers instinctively 
lean forward to relax the anterior muscles of the lower extrem- 
ities, and preserve their equilibrium. Walking while the body 
is too weak, especially at the monthly periods in young girls. 
Among savage tribes, the parturient often aids herself by 
drawing herself up by means of a rope or stake. The advan- 
tages of this position are : 
1. It relieves the pelvis of external pressure, allowing it the 
greatest possible chance of expansion. 
2. The pelvis is allowed the greatest possible freedom of 
motion upon the vertebral column. The natural parturient, 
wherever found, is inclined to sway backwards and forwards. 
The vertex of the child rubs upon the mother's symphysis, and 
this swaying tends to aid the head in getting over the obstruc- 
tion. 
3. The anterior wall of the abdomen is made tense. 
To sum up, then, we conclude that the dorsal decubitus now 
so common should be discouraged, because : 
1st. It retards labor. 
2d. It exhausts strength. 
3d. It favors mal-positions. 
4th. It tends to produce tears and sloughing. 
5th. It tends to produce local inflammation. 
6th. Since the labor is retarded, it increases the length of time 
that the child's head is compressed and so endangers its life.