Re-Thinking Deep Squats During The Last Weeks of Pregnancy

by Christine Kent on September 26, 2012

In their landmark book, The Labor Progress Handbook, Penny Simkin and Ruth Ancheta describe six steps in the progression of labor1:

  1. The cervix moves from a posterior to an anterior position
  2. The cervix ripens or softens
  3. The cervix effaces
  4. The cervix dilates
  5. The fetal head rotates, flexes, and molds
  6. The fetus descends and is born.
fetus within pelvis
Figure 1 – Fetus within pelvic inlet

They explain that when the cervix has not undergone the first three steps of anterior movement, ripening, and effacement, significant dilation rarely occurs. “If this progress is ignored, an incorrect diagnosis of dysfunctional labor may be made before the woman is even in labor!”

Cesarean section for the indication of “obstructed labor” has steadily increased over the past 40 years. Simkin and Ancheta illustrate that failure to progress is often a result of fetal malposition, such as persistent asynclitism or occiput posterior.

“If early contractions are painful and irregular with little or no progress in dilation, it makes sense to consider persistent asynclitism or another unfavorable fetal position, such as occiput posterior. Labor normally begins with the fetal head in asynclitism, (the head is angled so that one of the parietal bones, rather than the vertex, presents at the pelvic inlet). This facilitates passage of the fetal head through the pelvic inlet, and then the head usually shifts into synclitism so that the vertex presents as the head descends further. Sometimes the asynclitism persists and, if so, it can keep the fetus from rotating and descending. Without descent, the head may not be well applied to the cervix and contractions often become irregular and ineffective.”

Maternal positions alter the forces of gravity, and midwives have long known that “having the woman lean forward moves the fetus’s center of gravity forward, which encourages its head to pivot into a more favorable position, leading to more regular, more effective contractions.”

While the major cause of failure to progress is well described, it remains unknown how non-progression ocurrs. How does the fetus get stuck? The anatomic reason for persistent asynclitism has not been fully described by either midwifery or obstetrics. However, biomechanical data from orthopedics and observations by gynecologic surgeons fill gaps in understanding of this very common phenomenon.

In their classic text, Vaginal Surgery2, Nichols and Randall describe how gradual the early stages of labor progression really are:

“Normally, and certainly in the labor of the primipara, at full dilation of the cervix the presenting part does not at that time emerge from the cervix and, for the first time, begin to descend into and through the vagina. Rather, the fully engaged presenting part, almost completely covered by thinned, beginning to dilate cervix, has in all probability occupied the upper third to half of the vagina for 2 weeks or more. As a result, distention of the upper vagina, with accommodation of the engaging vertex or breech, has occurred very gradually, so gradually in fact that the patient may not be aware of the descent taking place until she notices a new awareness of heaviness, low backache, and at times rectal pressure, while at the same time breathing becomes somewhat easier, for ‘lightening’ has occurred.”

Figure 2 – The pelvic “floor”

For the fetal head to enter the pelvic inlet, the top of the sacrum must move up and out of the pelvic interior, into a position known as “counter-nutation”. When the pelvis is in this position, the lumbar spine is flattened. As described above, the fetus moves very slowly through this early progression. This means the maternal pelvis stays in a counternutated position from the time the fetus enters the pelvis, until it is born. While it is often assumed that maternal lumbar curvature increases throughout pregnancy, it was proven in 1976 that the spine actually flattens during the final weeks before birth3. Even if a fully gravid woman is trying to maintain a full lumbar curvature, her spine remains in counternutation.

Figure 2 shows the correct orientation of the pelvis in the standing body, the entrance into the pelvis, and the pelvic diaphragm with anal opening at the back. Toward the end of pregnancy, the cervix, which has been pointing toward the back all these months, must now rotate anteriorly toward the vaginal opening before labor can progress.

Figure 3 – Improper sitting position
in late pregnancy

The most likely reason anterior rotation of the cervix becomes stalled is because the fetal head has moved too deeply into the back of the pelvis. In order for the cervix to rotate forward, the fetal head must move forward and into a more favorable position. This is supported by Simkin and Ancheta, who show that forward-leaning maternal positions help labor to progress after persistent asynclitism.

With this understanding, it becomes obvious that the very worst position a woman in the last weeks of pregnancy can spend time in is a full squat with her knees higher than her hips. The pelvic inlet is fully open at this stage and the fetal head has entered the pelvis. Therefore, gravity simply moves the asynclitic head further into the back of the pelvis where it prevents anterior rotation of the cervix and stalls the progression of labor.

Deep squatting is being advised as preparation of the pelvic “floor” for birth. However, no scientific data exists that the pelvic floor needs special preparation outside of normal physical activity. If the pelvic diaphragm were anything but fully supportive, the sharp angle that it makes as it wraps around the anus would widen, and fecal incontinence would ensue.

The pelvis and pelvic diaphragm have a range of motion that is utilized in many functions, including vaginal childbirth. While pelvic nutation and full lumbar curvature represent the position of pelvic, pelvic organ, and spinal stability, during the last weeks of pregnancy the pelvis takes advantage of its full range of motion by remaining in counternutation as the cervix is prepared for birth. Support the subtle and lengthy early stages of labor progression by keeping sitting positions where the knees are lower than the hips.


Notes:
1 Simkin P Ancheta R The Labor Progress Handbook Wiley-Blackwell 2000

2Nichols D Randall C Vaginal Surgery Williams and Wilkins 1989

3Snijders C et al Change in form of the spine as a consequence of pregnancy. Digest of the 11th International Conference on Medical and Biological Engineering August 1976

{ 12 comments… read them below or add one }

Susan McPhee January 17, 2014 at 4:15 pm

Thank you Christine for this article. It set me on the right track with a primiparous client whose baby wasn’t engaged at 40+5. The doctors were anxious to induce but thankfully, she was not. On reading this I recall that she had mentioned doing squats daily and asked her to stop them. We used everything suggested on spinning babies. As well, I told baby at the start we were going to do some things to help her get into her mother’s pelvis to be born. Mom had already floated in a warm bath and felt baby move upwards. At the end of rebozo, myofascial releases, etc, I told baby to move down in the pelvis while her mother was at the movies. Mom had instructions to avoid arching her back and closing the pelvic brim. The next day baby was well engaged and two days later labour started spontaneously, progressing well. We successfully outran the doctors breathing down our necks.
yesterday I showed mom to give baby tummy time. I picked up baby and held her when she was getting to her overload state. She settled and I told her that I need to do that too to make my back and tummy strong. She turned her head to look up at me and I imagined from her facial expression her thought might have been, ‘Oh, yah, you’re the one with all the moves that make me work!’
Ivy, if you were my client I would talk over the idea of doing the dance, because you would enjoy it, and adding some additional work, perhaps with a chiro, to ensure balance in your pelvic area. Hope you find someone who you are confident to work with.

Marianne Littlejohn August 12, 2013 at 4:00 pm

I have found in my practice that when a baby is malpresenting and labour progress is delayed that squatting or trying to use forces of gravity is contra-indicated. I use a technique called ‘roasting the chicken’, where the mother adopts a side lying position and she rests on each side for 20 minutes at a time for as long as it takes for the shift to occur. This may be several hours even up to 24 hrs, sometimes longer. Most of all, the tired mother gets a chance for her body to relax, rest and soften as the baby burrows slowly, stretching the hip joints and rotating correctly. I combine this with a maximising breath technique that gives the mother a tool to minimize sensation of pain. Waiting patiently is the key.

Jessica August 2, 2013 at 1:14 pm

And yes OF COURSE! Bee you hit the nail on the head! We do not even squat – we rest seated on the toilet for elimination!

Jessica August 2, 2013 at 1:12 pm

Great article. I think its interesting though, to hear that we need not do anything special above and beyond regular activities to prepare the pelvic floor.
In our country ‘regular’ activities include a lot of sitting, driving reclining…. Unlike our ancestors we DO NOT squat to work rather than sit, we do not naturally walk (run, climb, lift) several miles a day.
I feel it IS important for moms, moms to be and all healthy women to be active and YES squat while playing with kids on the floor or stacking shelves or folding laundry etc.. and if you are not doing so then add some of it to your exercise routine! It does not need to be the sustained deep squat late in pregnancy (although I have yet to see it contribute to asynclitic presentation in my experience- I will do more research…) But squats and lunges are great natural movements!

Susan Alexander August 2, 2013 at 9:12 am

Fascinating… And a little reassuring. My SPD has been SO bad this time around that I pretty much cannot squat without causing myself tons of pain. I was afraid I was at a disadvantage, but it sounds like my body just knows what to do. Guess I should trust it more, huh? FWIW, I’ve never been great about doing kegels or squatting and have had pretty fast (I would argue almost too fast) labors in the past… I do think that chiro is VERY effective in good baby positioning – my only pregnancy I didn’t do chiro, baby was persistent breech. In my other 3, baby has been persistently LOA from about 30 weeks on. :)

Ivy Murphy July 17, 2013 at 8:44 pm

I have been checking back over the months to see if you had answered my question. I am still interested in a response.

Bee February 7, 2013 at 2:18 am

Interesting! You say no deep squatting is necessary for pelvic floor health. Even for going to the bathroom? Isn’t that the natural way to have a bowel movement?

Ivy Murphy January 6, 2013 at 12:32 am

Thank you for your great article. I gave birth last year by Cesarean birth after a labor that stalled due to asynclitism. I actually gve birth a year ago today. I was fully dialated and then pushed on and off for fourteen hours. I was the squatting queen and I did tons of Kegels. Since my birth I have been trying to figure out what I could do to prevent this condition from happening again in a VBAC. What exercise do you recommend for pregnancy? I would like to take an aerobic dance class but I read on Spinning Babies that dancing can cause unevenness in muscle strength and cause asynclitism. Thank you again.

admin October 2, 2012 at 9:58 pm

Thanks, Nicole, and frankly, deep squats are not a panacea for pelvic health in general. Are they more problematic in a breech birth? My guess is probably so, since the head is more mobile than the bottom and therefore could reposition more easily.

Squatting up on metatarsals with full lumbar curve in place is wonderful exercise for both the spine and arches of the feet. As I pointed out to Katy, however, it is impossible to keep the lumbar curve while flattening feet to the ground. She responded, “Biomechanical evaluation will show that the geometry of the joints, muscles, tendons, and ligaments will allow a lumbar curve with the heels on the ground.” At Whole Woman, we insist our “proof” be self-evident.

Squatting with knees higher than hips presents the same sort of problems pointed out in the article. However, instead of a fetus becoming stuck at the back of the pelvis, sometimes it is the bowel, or even a retroflexed uterus. Additionally, this position is the endpoint of hip joint flexion, and the epidemic numbers of femoroacetabular impingement happening across age groups give pause to the thought of spending much time with the femur jammed against the acetabulum in this way. Humans are flexible creatures, but we should be aware of common limitations – and hip joint hyperflexion is numero uno. If you raise your feet on a stool to have a bowel movement, as many people do because they’ve heard it replicates deep squatting and that squatting to have a bowel movement is healthy, you run the risk of blowing out your pelvic organs.

A little bit of deep squatting is fine. A lot is detrimental, and none is necessary for pelvic floor health.

Nicole C. October 2, 2012 at 9:07 pm

Wow, this is really interesting! I did an interview with Katy Bowman of the Restorative Exercise Institute a few months back about the benefits of squatting during pregnancy, but I think a lot of people read it as “deep squats are always good during pregnancy.” This is great clarification on the issue – will share!!

I’ve also had two breech pregnancies and did deep squats later in pregnancy when I was pregnant with my first. During my second pregnancy, I did a lot of research that seemed to suggest that was a really bad idea. Would you emphasize this especially for women whose babies are in the breech position?

Rebecca October 2, 2012 at 12:51 pm

Wow! This is really fascinating!! Great article.

Louise September 28, 2012 at 10:44 pm

This reminds me of my third pregnancy, my first spontaneous labour. I had the urge to go on a long walk as labour started. Several hours later, post walk and a 45 minute car journey, I arrived at the hospital with labour well-established. I cannot explain why, but I felt that I needed to be well forward, either sitting upright, or later, pacing the halls, or on all fours, during contractions, even during contractions in the car. The baby was posterior. There wasn’t a lot of amniotic fluid. They thought the membranes had been ‘leaking slowly’ for some days. He eventually flipped at Transition and came out in normal presentation.

It was such a weird sensation, needing to be quadrupedal. I had no desire to lie down or squat at all, which was quite unexpected.

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