Hips and feet should never meet

The emphasis that is currently placed on evidence based practice within maternity care raises many questions for women and midwives, one of which relates to the value we place upon different forms of knowledge. A midwife once asked me if I could help her find evidence to support her in raising an issue with her employer. She had become concerned that the local health and safety policy did not directly advise against the practice wherein women in a semi-recumbent position are encouraged to brace their feet against the hips of midwives, students and / or family members while pushing. This practice carries a number of potential risks, not only to the woman who is in a less than optimal birthing position, but also to those whom she is bracing against. The midwife – we’ll call her Kerrie – was particularly concerned about the impact of this practice on midwifery students, feeling that they might not realise the potential danger and thus risk injury before they even qualified.

Kerrie knew of a number of midwives and students who had been hurt or injured in one case, seriously after engaging in this practice. When she spoke with those who were responsible for updating the Trust health and safety advice, she learned that she needed to produce evidence in support of her concerns in order to have this considered by the relevant committee. After failing to find anything on her own, she contacted me and asked if I might be able to help.


Anecdotes and Mechanics

Together, we explored a range of different kinds of knowledge on this topic. We pooled our own stories which included my having known of further injuries stemming from this practice and those of other midwives. We felt that, whether or not we could find any published data on this area, the anecdotal evidence raised concerns in itself. We searched books and journals, finding plenty of advice about staying physically safe but nothing that specifically discusses this issue. Then we sought the opinion of an osteopath. He provided us with detailed mechanical explanation of how this practice could be risky to attendants, seeing the primary risk as the direct pressure that the woman’s feet would exert on the anterior superior iliac spine. This, he explained, could lead to a rotation of the pelvis which might go unnoticed at the time but which may go on to cause pain or injury in the lower back and / or sacrum.

He then went on to point out another couple of risks that existed in relation to the degree of pressure that a woman could exert while pushing in this position. Firstly, if the woman’s leg slips upwards at any point while she is putting significant pressure on the attendant’s hip, there is a risk of injury to soft tissue or internal organs. In addition, the degree of pressure that a woman is able to exert while pushing leads to the attendant needing to resist, or push back with counter pressure. However, if any one of the people involved in this kind of manoeuvre changes the degree of pressure they are exerting without warning (and, realistically, we can’t expect women who are pushing babies out to give warning any more than we can expect warning from a midwife, student or partner who is about to slip, sneeze or faint at the sight of their new baby), the other people involved are at risk of falling. Add into that mix the vulnerable position of the woman and baby, the presence of bodily fluids and the oddly-shaped lumps of metal that are attached to many of the beds on which women labour, and I believe we have good reason to consider advising against such practices whether or not published data are available. Indeed, given that we live in a society which sets out to reduce risk at every turn, I find it both astounding and ironic that Kerrie has not yet managed to get this practice red-flagged because she cannot provide data proving that it is harmful.


The Burden of Proof

This is not to suggest that the title of this article should be an absolute mantra: the creation of absolutes is rarely helpful and autonomy and individual judgement are wonderful concepts. There may be occasions where the risks of this activity are both accepted by all involved and overwhelmed by the potential benefits. Let’s not forget though, as above, that this practice also involves women themselves being in a semi-recumbent position which is less than physiologically ideal.

Perhaps most importantly, though, this issue concerns one of those important questions that is raised by the importance currently placed on evidence. Where we do not have published data to support or refute a practice which one or more midwives believes may be detrimental to women or themselves, who holds the burden of proof? Do we want to continue to participate in practices that may cause us injury until we can prove that they are harmful, or should we be demanding that our employers discourage them unless they can prove them safe?


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A version of this article was originally published as Wickham S (2009). Hips and feet should never meet. TPM 12(9):42.