​We know that giving birth is more complicated for humans than it is for other mammals. To understand why, it is important to understand the differences in pelvis shapes and sizes. There are distinct differences between human female and male pelvi (pelvi: plural of pelvis) and pelvi of the great Apes.

​For the human baby to be born it must make a series of turns and movements through the mothers pelvis. These movements are known as the Cardinal movements (CMs). CMs are in response to the baby being pushed down through the pelvis by the contraction of the uterus.

​As pressure increases on parts of its head and shoulders, the baby must turn to fit through the mother’s pelvis. The baby’s own reflexes, coupled with the downward force from contractions help to steer it through the available space following the ‘path of least resistance’.

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• Engagement: When the top of baby’s head moves down into the pelvis. This can happen in late pregnancy with first babies but often not until labor begins with second or subsequent babies.
• Descent: When the baby’s head moves deeper into the pelvis as it is pushed down by the strength of contractions. This moving down happens throughout labor.
• Flexion: The baby’s head tips forward, and the chin touches it’s chest. This happens in early labor.
• Internal Rotation: This allows the longest part of the baby’s head to match the longest part of the mothers pelvis
• Extension: The baby’s chin comes off its chest and the neck arches as the head is born. The baby’s face is now looking towards the mothers anus.
• Restitution/External rotation: After the head is born, there is generally a short pause, particularly in 1st births. This allows the baby to now turn again to fit it’s shoulders through the widest part of the mothers pelvis. Once this happens the baby’s face will move from looking down to now facing either of the inner thighs. This movement allows the shoulders to fit through and under the pubic arch at the front of the mothers pelvis.
• Expulsion: after the shoulder closest to the pubic arch moves out from under the it, the opposite shoulder follows shortly. The rest of the baby’s body is then born. Occasionally this process happens all in one apparent movement relatively quickly once the head is born.

​Another adaptation that takes place is the moulding of the baby’s head to make it smaller. It is very common for newborn’s to have what appears to be an oblong head shape immediately following birth. This allows the baby to fit through the maternal pelvis and happens during labor as baby is pushed down through the birth canal.

​Head moulding during labor is caused by the movement of the bones of the baby’s scull in response to downward pressure from contractions and resistance from below from the mothers tissues and pelvis shape. These forces make the bones of the baby’s scull move to change the shape and size of the baby’s head to make it easier for it to be born. The bones of the baby’s scull can easily move and even overlap because they are not yet fused together. The ability of the baby to adapt the size and shape of its head to fit through the maternal pelvis is more noticeable in some babies than in others. It usually changes back to the more expected round shape within 24 hours following birth.

​However, in other mammals, the size and shape of their pelvis, compared to the size and shape of their babies head is very different to humans. Specifically in the great apes that are genetically the closest to humans; these cardinal movements don’t, and do not need to happen.

As we have seen there is much less space for human babies to be born through their moms pelvis than there is for baby apes! This is why it is really important for women to maximise every little bit of space within their pelvis when they are giving birth by moving freely and instinctively and more upright birthing positions.
Upright positions for labor include standing, kneeling, squatting, all fours, lunging or sitting upright.

Upright Positions for Labor, Upright Positions for Birth

According to the United Nations About 385,000 babies are born every day, that’s an incredible 140 million a year. So, it is safe to say that for millions of mothers around the world knowing as much as they can and making labor and giving birth as safe and as easy as possible is a top priority!
Using a variety of birth positions and having an active labor where upright positions are included can have many benefits for birthing women and their babies when they are giving birth and being born.
Throughout history an upright birthing position and the use of a birthing stool or birthing chair was common in many cultures from the ancient Egyptians, the Aztecs, Medieval Europeans and in many African cultures! As far back as written records, carvings and paintings go, women have given birth in an upright position – whether it was using stacked bricks to create a type of birthing stool, a wooden seat or holding onto leaves and ropes hung from trees. There is even a famous drawing from Egypt that shows Cleopatra (69-30 BC) kneeling to give birth.

Historical documents show that laying down to give birth is a relatively modern practice as childbirth has become more medicalised. Giving birth laying down may have been encouraged to make it easier for midwives and obstetricians to assist during labor and birth and for others present to have an easier view of the birth!  It is widely reported that King Louis the XIV of France is believed to have enjoyed watching women give birth and was likely present in the room when his wife gave birth. However, it was the famed 17th-century French doctor François Mariceau who is generally credited with the practice of having women lie flat on their backs during birth. This has developed into the modern expectation that laying on your back or semi sitting with legs in the air is the ‘correct’ position for women to labor and give birth in.

Upright positions for labor include standing, sitting upright on a CUB birth stool or ball, squatting, kneeling and variations of kneeling, lunge position and all fours. Any one of these positions can also be used to give birth. It is important that your care providers and the people you choose to support you during childbirth know that you want to be upright, active, and mobile during labor as opposed to be confined to a hospital bed.                         
 
Why does an Upright Birthing Position Matter?

Many women report that giving birth when laying on their backs feels more painful, difficult, and uncomfortable than if they are free to move around and find positions that are more instinctive.
Studies have also shown that those that give birth in an upright position feel more in control of their birth and express greater satisfaction with their birthing experience. There is extensive research that shows the physical benefits for mothers and their babies when upright and active positions for birth are used and just some of these include:

• Less risk of emergency Caesarean section,
• Less rates of baby becoming distressed during labor
• More available space within your pelvis making it easier for baby to be born
• The time taken to become fully dilated can be shorter
• The time taken to push baby out to birth is shorter
• Contractions are more effective
• Less need for medical intervention such as Ventous (suction)
• Less need for a cut to your perineum (episiotomy)

 
 “The central principle of an active birth, is for the woman to be free to move spontaneously and be led by her body, adopting upright positions during labour and birth. This practice is universal and cross-cultural and makes birth easier, safer, more efficient, and less painful.”
Janet Balaskas Pioneer of the Active Birth Movement
 
   Next steps?    

• Find out what resources are available to you for pregnancy, labor and birth from your care provider.
• Consider buying a CUB as this is the most versatile and useful product to support you through all stages of pregnancy, labor, and birth if you are planning an active birth using upright positions

By Sarah Geo Walton, Birth and Postpartum Doula and Childbirth Educator from Reno, Nevada

I am so excited about this new birth tool called the CUB. It can be taken ANYWHERE so it is suitable for home, birth center or hospital births! I’ve written two posts about how this innovative device can be used wherever you choose to birth for a possibly quicker, easier and safer experience.

A bit about the CUB (Comfortable Upright Birth support)

The CUB is an inflatable, versatile support stool that can be sat on or leaned over like a birth ball or used during pushing to give birth on, much like a traditional birth stool.

It was created to help birthing people labor in positions that are upright and out of the bed. These positions allow more space in the pelvis, utilize gravity and have shown in research to make labor shorter, smoother and safer for the parent and their baby by lowering complications during the birth process.

Research on birthing in upright positions suggests that being upright throughout labor and birth can increase the space within your pelvis by 28-30% so first stage can be shortened by up to 50% and pushing can be more effective. This can lead to a significantly shorter labor. It also shows that your baby is 54% less likely to have distressed fetal heart rate abnormalities.

With labor being shorter with a happier baby, less intervention may be needed, decreasing the need for a medically assisted birth by 23%, episiotomy by 21% and emergency cesarean sections by up to 29%! (Source: https://www.cub-support.com/research-on-upright-birth/)

How CUB Can Help In The Hospital

Being in an upright position can be pretty important throughout labor in order to take advantage of gravity, encourage mobility and movement and help with optimal positioning of both the birthing person as well as their baby.
It is wonderful to see that birth balls have become an acceptable and approved tool for labor in most hospitals, but many patients complain of feeling incredibly unstable on them. If we are trying to encourage positions where the person in labor feels safe, supported and can easily rest, the instability of the ball can be a deal breaker. This means that patients will often choose to get back into the hospital bed. The flat base of the CUB is the cure for this wobbly and unsteady seat!

The CUB has multiple inflatable sections, granting it several size options depending on the height of the person and which position they are most comfortable laboring it. It is also made of a nonporous material and can be easily cleaned, making it a sustainable option for Labor and Delivery floors to offer to laboring people again and again.

By Sarah Geo Walton, Birth and Postpartum Doula and Childbirth Educator from Reno, Nevada

I am so excited about this new birth tool called the CUB. It can be taken ANYWHERE so it is suitable for home, birth center or hospital births! I’ve written two posts about how this innovative device can be used wherever you choose to birth for a possibly quicker, easier and safer experience.

A bit about the CUB (Comfortable Upright Birth support)

The CUB is an inflatable, versatile support stool that can be sat on or leaned over like a birth ball or used during pushing to give birth on, much like a traditional birth stool.

It was created to help birthing people labor in positions that are upright and out of the bed. These positions allow more space in the pelvis, utilize gravity and have shown in research to make labor shorter, smoother and safer for the parent and their baby by lowering complications during the birth process.

Research on birthing in upright positions suggests that being upright throughout labor and birth can increase the space within your pelvis by 28-30% so first stage can be shortened by up to 50% and pushing can be more effective. This can lead to a significantly shorter labor. It also shows that your baby is 54% less likely to have distressed fetal heart rate abnormalities.
With labor being shorter with a happier baby, less intervention may be needed, decreasing the need for a medically assisted birth by 23%, episiotomy by 21% and emergency cesarean sections by up to 29%! (Source: https://www.cub-support.com/research-on-upright-birth/)

How CUB can help at home

I’m really looking forward to the CUB becoming a part of many midwives and doulas toolkits for the simple option of a birth stool that is not the toilet! This could be a game changer!

I can not even begin to tell you how many people in homebirth environments end up having their babies in the teeniest of tiny bathrooms because the toilet is such an amazing (and often extra effective) place to push. While we love recommending the toilet as a place to labor, the CUB would be a lot more comfortable on the sit bones than the hard toilet seat.

The CUB may also be preferable to many people who might worry that their baby will fall into the toilet. While this rarely happens, it is a common fear which can become a repeating thought. That fear can cause people to hold back and hold tension in their pelvic floor muscles instead of relaxing and allowing their body to do what it needs to while pushing.

Since the CUB has an generous opening, it allows the parents or midwife to easily reach down to help the birthing person receive their baby. This cuts out the awkward moment of trying to communicate with the pushing person to either stand up from the toilet or reach down to catch while their baby is emerging.

One of the other beauties of the CUB is that it is really light and portable! This means you can use it in ANY room. We often notice people who have chosen to have their babies at home strongly prefer to be, and stay in, a certain room or floor of their house. The portability of the CUB allows the birthing person to choose whichever room they feel most comfortable in and have as much or as little privacy as they would like. Since it can be really hard for them to maneuver very far when labor is at its most intense, it is an added perk that they do not have to move across the house because the CUB can be moved to them.

Wherever someone chooses to birth, the CUB allows for plenty of positions where the person in labor can be supported by their partner or other birth support person.

Feminist Birth Positions To Consider:
Get off your back and birth in a position that is most comfortable for you!

• Squatting: Birth in a squatting position can increase pelvic space by about 30%. It may be helpful to have your partner, a birth stool, or the CUB provide support and stability.
• Standing: Pushing in a standing position, with or without the support of your birth partner or doula, is helpful because gravity serves as a natural assistant to help baby be born. 
• Hands and Knees: Both your arms and legs support your body weight in this position. It also enables your belly to hang away from your body, potentially reducing pressure or pain on your lower back and providing more oxygen-rich blood to baby.

Feminist Birth Positions Resources:
Learn more about research that supports upright birth and resources to help you achieve a feminist birth!

• Evidence Based Birth has a ‘Signature Article’ all about the history of birth positions and research supporting upright birthing positions.
• Comfortable Upright Birth (CUB) is an inflatable labor and birth support support that you can use in a variety of ways during labor and birth. You can find helpful resources, information, and research that supports upright birth positions with the use of the CUB on their website.

You can also read this blog here

By Alayna Spratley, Certified Childbirth Educator and Doula from Cleveland, Ohio

As a certified Lamaze Childbirth Educator, Birth Boot Camp Instructor, and local community educator with Indie Birth, I serve Cleveland, Ohio families by providing independent childbirth education courses and early parenting workshops in my community. One of my favorite classes to teach is the Comfort Measures for Labor Workshop. This class is designed for expectant parents and we explore a myriad of evidence-based natural pain relief strategies, tips, tools, and techniques to help the birthing person stay calm, comfortable, and confident during labor and delivery. I often refer to this workshop my “Birth Show-and-Tell” class, because I bring a few birth tools with me and discuss their various uses and benefits. Couples enjoy learning how to use tangible tools that can support them throughout labor.
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One of my favorite “Show-and-Tell” tools is the CUB. The CUB, an acronym for Comfortable Upright Birth, is an award-winning inflatable support cushion that can be used throughout labor to facilitate an easier, shorter, and a more enjoyable birth experience. You are probably thinking, “Seriously!?!  How exactly can a giant, blow-up pillow make birth less painful and shorter?” The answer isn’t magic but science. The CUB’s innovative design and intended use are based on the best evidence-based birth practices including staying upright and mobile during labor. The CUB is a hybrid birth stool and birth ball all-in-one. Its simple, yet practical design combines both traditional birthing knowledge with modern technology, research, and convenience.

By Camille Nyman, Doula and Childbirth Educator from Maryland

If doulas were a tool you could purchase on the internet, you'd be hard pressed to find anything that fit the bill better than a CUB! 

For the uninitiated, a CUB (short for Comfortable Upright Birth) is a U-shaped, inflatable device intended for birthing people to use in a variety of ways.  It's completely portable, wipeable, and versatile.  Much like some of what doulas aim to do in the delivery room, the CUB encourages women to utilize a host of positions and pain relief techniques.  It invites users to find the place and position that they are most comfortable birthing in, then meets them where they're at.

I first encountered the CUB when I was training as a certified childbirth educator.  The concept amazed me- it was squishy like a birth ball, but more stable.  It was portable and adjustable for varying heights.  It functioned as something to sit on and something to lean over.  It left room for a support person to come behind a laboring woman without being awkward.  I was amazed!  I immediately began searching for where this fascinating tool might already be in use in my local community.  It was then that I discovered that almost no one in the USA was using the CUB yet.  Disappointed, I returned to my 'usual' bag of tricks when attending births and didn't think much more about it.

A few years went by, and I ended up attending a rather long and difficult birth.  Many tools and positions were attempted, and the CUB repeatedly kept coming to mind.  I just kept thinking to myself how incredibly useful it would be in that situation. 

One of the most frequent complaints I hear from my clients as they labor and/or push is that they feel unstable.  The desire to find their 'anchor' in labor is visceral and surprising to them.  Birth balls are fantastic, but don't fit the bill; for someone struggling to find their center of gravity, they can be unnerving.  They also don't readily adjust for women of marked height differences.  Who wants to purchase multiple balls for each room in a hospital?  (Read: no one.) Birth balls can roll away.  Peanut balls are amazing when you need to lean over something firm and comfy- but not so great for sitting on.  Birth stools are excellent for getting you into a better position to squat supported during pushing but often my clients complain they hurt if you sit on them for more than a few minutes.  The CUB answers every single one of these issues.

The CUB can be deflated and tucked in your trunk or birth bag, ready to go when you need it for your birth.  It can be inflated to a size that feels right to you.  It can be sat on, leaned over, shared with a partner.  It's a jack of all trades in labor.  If someone expresses a need for movement and flexibility but is anxious about not feeling 'stable' when doing so, the CUB is the solution. 

​The CUB is a tool that meets you where you're at; what's more quintessential 'doula' than that?

By Shalini Wiseman, Chartered Physiotherapist in Women’s Health & Continence, Cork University Maternity Hospital in Ireland

As a physiotherapist in women’s health, my introduction to the Comfortable Upright Birth- Support (CUB-Support) was in the labour ward. No, not for myself, but for the purpose of updating the hospital guidelines on the management of pelvic girdle pain in labour.
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This was during my trip to the down under (or labour ward, as the staff call it) with another colleague to review the new beds being used.  This is a bi-annual opportunity for us to examine the beds and evaluate the range of movement required for the labouring hips, especially for antenatal women suffering from debilitating pelvic girdle pain.

In a corner-we spotted a cosy looking blue inflatable seating. The midwives raved about how useful it was during labour,’ working as a gym ball during labour with the comfort of being seated with support and safety’.
As curios physios do, we proceeded to take turns, sitting on it and adopting different positions- gravity-assisted positions for the first phase of labour of course!

It was surprisingly comfortable and felt more secure than a gym ball. CUB-Support provided the safety of being supported while sitting, with the ability to rotate and tilt your pelvis to alleviate  any discomfort at the sacroiliac joints (SIJ). It also allows you to lean forward onto it in kneeling, or in a forward lean with the CUB-Support on a bed (Fig.1). From this position, you can rock back and forth with ease and safety, thereby easing any discomfort in the low back. This secure support is not felt with a gym ball unless a husband kindly obliges by holding it while you do different gravity-assisted dynamisms.

Small rocking movements at the lumbosacral joints have been utilised in many traditions to help ease labour pain, the Mexican Rebozza techniques being one such example. The CUB-Support allows for a bit more: working as a gym ball to alleviate restriction and aids movement at the SIJ and hips while allowing for the Rebozza techniques without the woman being restricted on a seat or her hands and knees. Additionally, the CUB-Support has a distinct sensation of while you rock your pelvis, a combination of mild vibrations, wobble and bounce with a definite sense of being supported and secure while doing so. 

I am really taken by this! I needed to take this out of the down under and move it to the first floor (Physio department). In order to aid women in their second and third trimester in the self-management of pelvic girdle pain with safety, I decided to modify some of their gym ball exercises for use on the CUB-Support. This approach proved very beneficial.

 Forward kneeling, upright positions and rocking have always been advised in the late trimester to allow the descent of the baby into the pelvis. CUB-Support allows 36 weekers to sit upright or adopt a supported kneeling position and leaning forward onto the CUB-Support to rock back and forth with secure support
The majority of the women loved the fact that with the CUB-Support they could experience the same benefits that the gym ball provided in the easing the SIJ discomfort while also experiencing the soothing affects of the wobbling motion that is peculiar to the CUB-Support. And all this with the added assurance of knowing they would not fall off it. The CUB-support is not just useful in labour. I have found it helpful in antenatal classes especially for women with debilitation pregnancy-related pelvic girdle pain who need the reassurance of safety while exercising.

The above information is a clinical opinion based on clinical experience. The CUB-Support has only been used with patients under supervision. There is no research supporting my claims, but this has been my anecdotal experience. However, there is the scope for utilising CUB-Support for pelvic girdle exercises in the third trimester by politely borrowing it from the labour ward.