It happens. Poo in labour, that is. Poo can be a feature of labour and birth, just as it is a feature of everyday life.
Whether we like to admit it or not, it comes out of each of us on a regular (or, in some cases, semi-regular) basis. Whether we talk about it openly, crudely, in euphemisms, medical terminology, local slang or not at all if we can help it, it is a fact of life. Birds do it, bees do it, obstetricians do it, and it is also a feature of birth for many women. Despite being a universal activity, however, the art of releasing solid waste matter from one’s body is (at least in my experience), a topic which is generally discussed among those who give and attend birth only after a couple of glasses of wine.
And therein lies the problem. Our discussions about poo in birth and midwifery are really rather limited. We don’t mind talking about meconium in babies at all. We seek funding to research constipation in pregnancy and continence after birth. Midwives happily tell new mums what colour poo they can expect in each day’s nappies and we explain how the different colours tell us things about the way their baby is feeding. However, despite the fact that the act of pooing is a common feature of birth, we don’t really discuss how we feel about that, how we physically deal with poo when it appears or whether and how we talk about it.
This article is offered as a small stepping stone towards further discussion on this topic, in that it seeks to raise a number of questions for consideration. Having long observed that midwives seem to feel more able to talk about poo in bars during midwifery conferences, I invited a few to huddle around a bottle of wine with me in order to anonymously discuss this area so that I could gather and then discuss their thoughts. Experiences were shared not just from a midwifery perspective but also as women who have given birth. This is not intended to be a research report, but hopefully this brief description of the way our conversation began should give you a good mental picture of the kind of focus group that led to the following insights:
“We’re rather anal about poo, aren’t we?!”
“I once heard Ina May Gaskin tell a story about an obstetrician who said to her, ‘I don’t know what all the fuss is about; giving birth is just like having a shit’, to which Ina May replied, ‘Well I’ve never had to resuscitate a turd…!’”
Somehow, our culture has come to view pooing as hilarious in some contexts and as a source of intense embarrassment in others. But what can we learn from listening to ourselves talk about this?
The Language of Poo
Several of the midwives suggested that being comfortable with the issue and listening to the terms that women use is of fundamental importance.
“I listen to what words women use, and try to follow their language. I’ve tried to become comfortable with the whole range – having a shit, crap, bowels open, but poo is nice safe language.”
Indeed. Hence its use in the title of this article which needed something which was non-clinical and interesting enough to reinforce the point being made but also harmless enough to ensure that the reference will get found via online search facilities that ban stronger language. There’s clearly a line to be trodden with language and while we should remember that some folk alter their usual language in an attempt to not offend, the language that a woman uses can give us clues as to how she feels about herself, her body and her bodily functions. Which brings me on to how midwives treat women in relation to this particular bodily function…
Pushing and Pooing…
The midwives I talked to noted how common it is to be worried about pooing while pushing a baby out, and considered whether we could better prepare women to cope with this ahead of time. There was a consensus from the midwives who are able to get to know the women whose births they will attend ahead of time (e.g. those in independent and some team and community practices) that knowing each other can make it easier to discuss and deal with this kind of topic, providing one more reason to look for ways of enabling women and midwives to build relationships and trust over time.
We identified a tension between the needs of women and the needs of the system, in that it is not always easy (especially for more newly qualified midwives who may feel they are being watched closely) to ‘allow’ women lengthy periods of privacy on the toilet, yet this kind of privacy may be exactly what they need most.
“I mean, when you’re in the hospital and women want to go to the toilet, then leaving women alone may be the best thing to do, but are we [midwives] comfortable with that?”
The next question to arise was whether – when women are in places other than the toilet – wiping away any poo that emerges during the pushing part of labour is actually the best thing to do:
“What do midwives do when women poo? We don’t talk about it, we often just wipe it away, but do women want that? Many women haven’t had that happen since they were a baby…”
“A lot of women are grateful to have it removed, though – it’s one less thing to worry about…”
Perhaps this is one more thing that needs to be discussed ahead of time? Maybe different women will want different things? Some women poo before the baby’s head is even visible, while others poo as the head emerges. And some, in case you’re wondering, never poo at all. These can be very different scenarios, especially for women who poo near the beginning of a long pushing session.
We may also offer different things for different women depending on their position and location; the issues will vary between, for example, women who are birthing on the toilet, women who are sitting on the bed and women who are on all fours. Actually, although I said “offer” in that last sentence it is important to realise that midwives don’t tend to “offer” poo-related care in labour; they tend to just “give” poo-related care, perhaps because it is deemed kinder or more appropriate to wipe away and avoid drawing attention to the poo. As above, maybe that is also something we should discuss, and/or maybe think about why pooing embarrasses some people so much when it is, after all, something that we all do.
“When I was nursing, we would use this 12 activities of daily living thing and ask people about their pooing habits, and I sometimes think we should do the same thing with pregnant women…”
The discussions that led to this article included the suggestion that maybe there are issues of informed choice here, which might mean that this area should perhaps be covered in childbirth preparation sessions and included in suggested birth plans, although this led to another discussion about whether we should also talk to women more about the involvement of others during birth. Some midwives suggest that, if you’re not comfortable pooing in front of someone, you shouldn’t have them in the room when you give birth. And that’s not just a literal thing, either. It’s a good illustration of how you need to be able to relax in labour, so need to be surrounded by those you feel safe and comfortable with.
Partners and Poo
For some women, anxiety around pooing in labour may be linked less to the presence of a (known or unknown) midwife and more to the presence of their partner. Our discussion uncovered a great deal of variation between midwives in relation to what we were happy to do on the toilet in front of our partners, friends or strangers, and there is no reason to believe that this variation doesn’t also exist in the population at large.
“How does this thing about pooing in front of a partner affect the dynamic of birth, and is it something we should ask women about antenatally? And how do women’s partners feel as well?”
“I do actually say to women, ‘how do you think that’s going to be?’ i.e. who will you feel comfortable having around you?”
Given the importance of privacy and feelings of safety in labour, we went on to discuss the issue of being comfortable more widely.
“Women who have experienced constipation may have learned not to push, which can then have an impact upon how they feel about pushing during second stage, and how effective their pushing actually is.”
Gosh. I had started out with a desire to explore an area that isn’t talked about much, and now we’re wondering whether this was an issue that could actually inhibit labour. Despite the almost complete lack of attention it receives in textbooks, perhaps pooing in labour is a far bigger issue that we have thus far acknowledged? Even just among a group of about eight female midwives and their close family, we discovered the existence of people who can’t poo when they go on holiday, people who can poo only on their home toilet, and one midwife who has a spontaneous urge to poo every time she enters a library; a trait which she has apparently passed on to her daughter. Clearly, this kind of variation will exist among birthing women as well, and we were fast concluding that, despite our cultural reluctance to talk about such things, this kind of discussion was long overdue.
Pooing in the Pool…
Another issue concerns women who give birth underwater. I must admit I hadn’t really questioned the use of sieves and strainers as helpful pool-poo-removal tools, until one of the midwives raised this.
“The problem I have with the fishing net in the birth pool thing is that it reinforces the idea that pooing is nasty, when it’s clearly normal. I don’t know if I’m saying we shouldn’t use it, but, to me, the net sort of says, ‘this is offensive, let’s get rid of it…’”
Interesting. Mary Douglas (1966) defined dirt as “matter out of place” and perhaps our culture views water pools and birthing beds as the ‘wrong’ places for poo, which partly explains our attempts to wipe away or cover up the mess or scoop out the flotsam. But, as the quote above shows, this may signal to women that we feel them to be dirty for producing such dirt. The level of embarrassment and self-consciousness which this could cause has no place in the kind of midwifing which seeks to enable women to express their true selves, to go inside themselves and to birth their babies unselfconsciously and with power. The flip side of this, however, was alluded to above. Toilets, which are seen as the ‘correct’ place for poo, are not always seen as the correct place in which to give birth, especially in the hospital setting, and this creates a situation which women can’t easily win. Clearly, this needs more debate and Mavis Kirkham’s (2007) book exploring the concept of pollution in relation to women’s health carries the important message that debate and exploration can lead to positive change.
Redressing the Balance
There was absolutely nothing systematic about this exploration at all, and it only scrapes the surface of the issues. I believe, however, that it does raise some important questions that are worth further consideration.
- Why doesn’t this subject get even a column inch in most midwifery textbooks, especially given the important links that the midwives here have drawn between this issue and women’s ability to relax, release and give birth?
- Given the attention that has been paid to similarly difficult and potentially embarrassing topics such as urinary incontinence and sexually-transmitted disease, what makes pooing in labour such an apparently taboo topic for midwives?
- Are there links between how women feel about pooing and their ability to give birth normally, safely and / or enjoyably?
- With many women (anecdotally) feeling scared of the idea of pooing while they are in labour, what can we do to help? Would women prefer that midwives or other attendants clean their poo away, or to allow it to “be”? Does it depend on position, location and / or medium (i.e. air or water)? Given that everybody is different, are there ways of raising this question that would be OK for all women? Should we talk to women about this issue in relation to the presence of their partners in labour?
Finally, as one midwife noted as she raised her wine glass in a toast,
“Here’s to pooing, which is central to life and can teach us a lot!”
Here’s hoping that we can open this debate up a bit more, talk further to women about how they feel – both on a one-to-one basis and through more research – and find out how we can help women to have birthing experiences that honour the totality of their being, which includes their need to poo.
You might also find this discussion interesting:
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With grateful thanks to the midwives who shared their thoughts with me for this article, all of whom chose to remain anonymous!
Douglas, Mary (1966). Purity and Danger. Routledge, London.
Kirkham, Mavis (Ed) (2007). Exploring the Dirty Side of Women’s Health. Routledge, Oxford.
A version of this article was originally published as Wickham S (2008). The Poo Taboo. TPM 11(4):16-18.