Does Squatting live up to all the hype?
The easy answer based on research and personal clinical experience is – no, for most women in developed countries.
A study of almost 20,000 in Sweden found that squatting increased the risk of 4th degree perineal tears. The lithotomy position (laying on back with feet raised in stirrups) was the worst offender, closely followed by squatting.
Most women in developed countries don’t squat as part of their daily lives – so their perineums and pelvic floor muscles are not used to the significant stretch that squatting causes, likely increasing the risk of tearing with a squatting birth position.
As is almost always the case with pregnancy & birthing – there isn’t one *right* answer. Squatting may be a great tool for helping baby descend & engage in the pelvis, and even for birthing baby for some women. Many mothers will labor on the toilet as it can help with lengthening and opening up the pelvic floor, partly because we’re conditioned to release in this position when emptying our bladder and moving our bowels.
Here are a few things to consider before adding a squatting birth position to your birth plan. 
Squatting is a great preparatory exercise during pregnancy (and even before). Regular squatting ensures good flexibility in your lower back and pelvic floor muscles, which can make birthing easier.
However, trying to birth in a squat, with no prior experience in maintaining the position for long durations of time may not be a great idea. A supported squat using a birth stool or an upright positioning device such as the CUB may be kinder on your pelvic floor than attempting to maintain an unsupported squat. Listen to your body, and follow it’s instincts. Often your body will instinctively cue you to be in a certain position, or a wise birth attendant may. 😉
Anecdotal evidence shows that women experiencing undisturbed labor will adopt positions – asymmetrical kneeling (runner’s pose or Captain Morgan), hands & knees , or a kneeling squat – based on baby’s position in the birth canal.
While maintaining an upright birthing position is harder with epidural pain relief, the good news is that more and more hospitals are open to supporting mothers in various positions using birth beds and additional support through pillows, exercise and peanut balls. The kneeling squat (gravity-assisted), Hands & knees (Gravity assisted-neutral) and sidelying (gravity-neutral) maybe the best positions to push for an intact perineum. A German study found that space in the mid-pelvis increased by almost 2 centimeters (!!!) with a kneeling squat, when compared to the conventional lithotomy position (laying on back with legs up). The same study also found an average increase of 1 cm in pelvic outlet diameter – making it easier for baby to emerge – in women who birthed in a kneeling squat. Practice being in a few positions that you think you may want to use when birthing. Preparing your birth plan on paper is a step in the right direction, but practicing being in the positions you plan to labor & birth in is highly recommended. The lifestyle in most developed societies has few opportunities for women to be in positions that allow for good length and flexibility in our pelvic and pelvic floor muscles. Spending most our time sitting in chairs or couches, with legs crossed over each other, or moving through incomplete range of motion leaves us with tighter muscles than what our body was designed to have. This tightness increases risk of pelvic pain during pregnancy & postpartum, and the risk of injury to the perineum during birth. If you experience pelvic pain before or during pregnancy or suspect yourself of having a tight pelvic floor – consider working with a Pelvic Floor Therapist during pregnancy to gain confidence in your ability to birth as you hope in your birth plan. A Pelvic Floor Therapist is often able to use techniques that a conventional OT/PT may not be trained in using, helping you achieve a comfortable pregnancy and postpartum.
Please remember that no matter what position you birth in, sometime perineal tearing is part of the experience. Tearing does not mean a failure of your body or birth plan. The female body is designed to heal from the massive ebbs and flows that pregnancy & labor brings. Sometimes a little expert help with knowledge of nutrition, positioning & support, tissue protection and toileting habits may help your recovery be easier. We love working with Pregnant and Postpartum mothers to help them achieve their goal of pain-free and confident.
