The following article first appeared on the sister Lamaze blog for childbirth educators, Connecting the Dots.
For as long as I can remember, as a childbirth educator I have been encouraging birthing people to adopt upright, forward, and open positions ("UFO positions") in labor in order to make as much space in the pelvis as possible. “Open the inlet” has always been my mantra along with many other educators, midwives, and L&D nurses.
Around five years ago, peanut balls (like a yoga/exercise ball, but shaped like a peanut) began appearing in labor rooms with great success in helping encourage dilation and baby's descent (moving down). After all, holding the peanut ball between the thighs keeps the knees apart, can be used with or without an epidural, and allows baby to descend into a welcoming, wide pelvis. Pushing baby out in those same kinds of positions has always been the norm.
So imagine my surprise when I read about the success of pushing positions with "knees together" (KT) on the Facebook groups to which I belong. I read things like: “Mom had been pushing for 2 hours and it was starting to look doubtful… so when the doc briefly left the room we tried three KT pushes and the baby flew out,” and “I’ve been so successful with this that our MDs are now on board!” and “Today we used the knees together, feet out pushing position with a suspected OP [face up baby] and it worked amazingly.” Of course, this is all anecdotal information, so I wanted to know more about this theory, which throws out everything I knew about the standard 90° angle, legs apart pushing positions – especially since there are currently no evidence-based studies to support the knees together technique.
To find the answer, I first went back to the anatomy of the pelvis. Despite four distinct female pelvis shapes, they have a lot in common. Generally, the entrance or inlet (aka "brim") of the pelvis is wider side to side, averaging 13 cm transversely and 11 cm front to back. The middle of the pelvis is slightly more round but begins to narrow, much like a funnel. Finally, the pelvic outlet is oval but widest (averaging 12.5 cm) from front to back and 10.5 cm transversely. Traditional pushing positions with the knees apart increase (open) the diameter of the inlet. But the outlet can also be made larger depending on the movement of the thighs (femur bones). Let’s say baby is comfortably deep in the mid-pelvis sitting at a fetal station of +1 and you've been pushing with little progress, even after laboring down (a period of waiting to push after reaching full dilation, 10 cm. Although we teach and encourage alternative pushing positions, we know that a large majority of people end up pushing while lying on their back or sacrum, which reduces the front-to-back space of the outlet. Is there a way to make more room in the pelvic outlet from side to side in any position? Enter "knees together" (KT) pushing.
To further explore the knees together concept, I spoke with midwife Gail Tully of Spinning Babies. According to Gail, if your care provider has sight of the baby’s head but the baby just isn’t moving down, “..in any position, put your knees together! Yes! Knees together and heels apart. Point your toes at each other. If on your side, it will basically be turning one thigh and foot into this position.” Putting the knees together opens the pelvic outlet across the more narrow part of the oval. However, Gail cautions that there is an optimal time to push this way: “If they say baby is still high and we’re waiting for baby to come around the bend or under the bone, then opening your knees is [more] suitable”.
©Krislyn Griffin. Used with permission.
With stories of knees together pushing continuing to spread across social media, I have to wonder if a study is not far off. As I stood in the shower a few weeks ago with my hands on my ischial tuberosities ("sitz bones") rotating my femurs in my own knees together in order to personally experiment, I could easily feel the expansion. For a better visual of the rotation and useful ways to use knees together pushing using the peanut ball, take a look at the photos on the Mamastefit.
I have now incorporated knees together pushing into my Lamaze classes. Have you heard about or seen knees together pushing? Have you tried it with a prior birth? Would you consider it for your upcoming birth? Share thoughts, questions, and stories below!
Illustrated drawing courtesy of the Royal College of Midwives Normal Birth Campaign, 2011.
Mamastefit. Feb 2019. The Pelvic Outlet: Anatomy and Movement Support. www.mamastefit.com/blog/2019/2/14/the-pelvic-outlet-anatomy-amp-movement-support. Accessed Dec 2019.
Paterson-Brown Sara. 2010. Basic Science in Obstetrics and Gynaecology (Fourth Edition). Chapter 5 Applied Anatomy. Pg 66-68.
Tully, Gail. (undated) Walcher’s: Open the Brim. www.spinningbabies.com. Accessed Dec 2019.
Tully, Gail. July, 2019. Prevent Tearing During Childbirth. www.spinningbabies.com. Accessed Dec 2019.
Tully, Gail. Feb, 2016. Maternal Positioning Needs Better Understanding. www.spinningbabies.com. Accessed Dec 2019.
About Mindy Cockeram
Mindy Cockeram is a certified Lamaze Educator working with a large hospital chain in Southern California where she's been teaching childbirth & lactation since 2011. She trained initially through the UK's National Childbirth Trust in Wimbledon, England in 2006 after a career in the financial markets in London. She graduated from Villanova University in 1986 with a bachelor's degree in Communications and a minor in Business Studies. She is also the author of two books: Breastfeeding Doesn't Have to Suck: Tips, Tricks and Knowledge for a Great Experience and Cut Your Labor in Half: 19 Secrets to a Faster and Easier Labor.