Across the world during labour and birth many women and birthing people are placed into the lithotomy position. In this article Florence Wilcock, Consultant obstetrician Kingston Hospital, London, and podcaster @TheObsPod, explains how she set up the lithotomy challenge to help understand the impact of being in that position. Are you ready to take this on?
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In 2022 had the privilege of giving a TEDxNHS talk: Birth should be special. I walked on stage in front of a live audience and shocked everyone by proceeding to lie down with my legs in the air. I started to speak. ‘Imagine lying like this, unable to feel your legs, surrounded by strangers, naked, how would it feel?’, the audience giggled uncomfortably. ‘This is lithotomy position, this is how more than a quarter of women in the country give birth, my name is Florence I am an obstetrician, a doctor who specialises in pregnancy and birth, this is a normal occurrence for me to see a woman in stirrups like this’. Some people have applauded my approach and seen it as courageous making people think, others have criticised saying I belittled women and trivialised their experiences and trauma. Whatever your view I believe there is value in thinking about what motivated me. Why did I choose to give possibly the most important speech of my life in this position? Birth should be special | Florence Wilcock | TEDxNHS – YouTube
Let’s look back at how it all began. In 2014 I started some work trying to improve women’s experience of maternity care. You may have come across #MatExp which quickly snowballed from a small pilot of Whose Shoes co production workshops in London to a large online community of people trying to improve maternity experience. In 2015 I was leading this work and came across NHS Change day, a day where anyone and everyone could take action to try and improve care in the NHS. I wanted to participate, to help build energy in our growing maternity community. I had personal experience of what it felt like to lie on the operating table having had two emergency caesarean births myself, but I had no idea what lithotomy position might be like. So, I hit upon the idea of the lithotomy challenge; I would spend an hour in lithotomy to mimic the duration a woman might experience if she birthed and needed suturing, to try and understand what it felt like from the woman’s perspective – literally. I put up posters in maternity and tweeted about it in the hope that other enthusiastic maternity staff elsewhere may follow suit. In fact one of them, Professor Jim Thornton, jumped right in and beat me to it tweeting a photo of himself trying it out with the words: ‘ not as happy as I look. Undignified & disempowered. Avoid if poss’.
On the day I wore a hospital gown and shorts underneath. To try and make it as realistic as possible I strapped a fetal heart monitor round my middle and stuck a drip to my arm as woman often complain they feel tied down by our equipment. I needed the help of a midwife to get into position as it’s impossible to do yourself. I felt exposed despite my clothes, and I felt uncomfortable. I couldn’t imagine what it would feel like with a baby bump too, my whole torso already felt compressed. Staff came out of curiosity to peer into the room. I noticed they talked to the midwife, not me, almost as if I wasn’t a person but an exhibit. Afterwards I wrote a blog reflecting on my experiences and what I learnt from undertaking the challenge, which was a personal first, unleashing a creative side I didn’t appreciate I had- The #MatExp Lithotomy Challenge – Maternity Experience.
Now and again, I repeat the lithotomy challenge with students and staff. They are often reluctant and embarrassed but for those that are willing they find it eye opening and appreciate just how vulnerable and exposed a mother to be can feel in this position.
The best bit was what happened next; maternity teams up and down the country started to undertake the #lithomomychallenge. Each team adapting it and incorporating their own ideas – some doing mood boards of staff reflections, some doing it as theme of the week, some doing it with students. The energy grew and it was wonderful to see the idea develop as people embraced it and made it their own. I started to be contacted by people who wanted to know more and incorporate it into their own quality improvement projects. One such person was Deepa Santosh, prior to her becoming a student midwife, who did a whole Upright Birth project at her NHS hospital as a result. You can listen to Deepa chatting to me about it here Episode 57 Upright Birth (buzzsprout.com) .
Nine years on the ripples are still spreading. Last year I heard of a perinatal mental health team that had done the lithotomy challenge for maternal mental health week. At my own trust one of our practice development midwives Helen Green has incorporated the challenge into her suturing workshop for new staff. She feels it’s an obvious extension of what she was already doing demonstrating how our labour beds work and where the relevant equipment is.
So why nine years on did I feel the need to start my TEDxNHS talk in this way? Sadly, the Care Quality Commission (CQC) maternity survey 2022 still tells us that 27% of women with an unassisted vaginal birth give birth in lithotomy and 39% of women overall gave birth in lithotomy. Women that give birth in this position have worse than average experiences for care and involvement in labour than women that did not. Evidence tells us women dislike this position and NICE guidance says it use should be limited to procedures. The UK isn’t the only place this is an issue; lithotomy position is widely used around the world.
That is why I am still championing the #lithotomychallenge. If you have never been in this position, try it out, even for a brief moment and see how you feel. Think then what it would feel like naked, helpless, surrounded by strangers. I know we can’t do away with lithotomy all together- for some women who need assistance it is a necessity- but we can minimise the duration, we can think about how we try and preserve some dignity and privacy. We can appreciate how immobile and vulnerable it can make a woman feel. We can be kind and caring in our explanation as to why it is required when it is. This way hopefully we can change practice, use it the bare minimum and not cause stress to a woman at one of the most important events of her life and, as a result, try to avoid causing birth trauma. So to end with a zesty bit just like each of my podcast episodes: What are you waiting for, give it a try!
Florence Wilcock Consultant obstetrician, Kingston Hospital & podcaster @TheObsPod
February 2024