You don’t have to give birth on your back

Picture the birth of a child. Do you see a woman sweating under fluorescent lights, on her back with her legs in stirrups, screaming? Informed by first-hand experience and depictions of birth in pop culture, this is what we know. 

But it doesn’t have to be.

Many mothers are unaware of their choice in the matter of birthing positions, but that choice is a human right and may have major health implications for the mother and child. 

Know your options

Recumbent and semi-recumbent birthing positions are horizontal positions assumed in the majority of hospital births in the U.S. and include: 

  • Supine position: Lying flat on the back, sometimes with the head elevated, and the knees spread. 
  • Lithotomy position: Supine position with the addition of stirrups to keep the hips and knees flexed and thighs apart. 
  • Lateral position: lying on the side.

Upright birthing positions include: 

  • Standing or squatting, supported by a partner or prop
  • Asymmetrical upright kneeling (one knee on the ground)
  • Kneeling against support
  • Hands and knees (think cat pose)
  • Sitting upright or slightly reclined using a birth seat

The risks of recumbent birthing positions

Despite the benefits of birthing in an upright position, 68% of people who give birth in U.S. hospitals report they give birth on their backs and 23% report they give birth lying down with the head of the bed raised. Here are some risks to giving birth in recumbent positions that may compel you to reconsider:

Occiput posterior presentations (OP)
OP is the most common fetal malposition. The birth canal is restricted when weight is placed on the mother’s sacrum, which can cause the baby’s spine to roll downward into occiput posterior presentation (meaning the back of the baby’s head is against the mother’s back). Persistent occiput posterior presentations are associated with increased operative interventions like episiotomies, severe perineal tears and forcep injuries to babies. 

Prolonged second-stage labor
The supine position is associated with prolonged second stage labor, which begins when the cervix is fully dilated and ends with the birth of the baby, because the horizontal position works against gravity while pushing. 

Increased risk of fetal hypoxia and maternal hypotension
In recumbent positions, the baby lies on top of the inferior vena cava and aorta, decreasing the return of blood to the mother’s heart and increasing the risk of developing fetal hypoxia (deprivation of oxygen) and maternal hypotension (low blood pressure) which is associated with stillbirth, preterm birth and postpartum hemorrhage.

Psychological trauma
In layman’s terms… lying on your back with your genitals exposed and your legs held in place with stirrups can be degrading and humiliating. Stirrup use during birth and gynecologic exams causes women to feel less comfortable, more vulnerable and more exposed.

Why do hospitals encourage recumbent birthing positions?

Allegedly, it all started with one esteemed voyeur. King Louis XIV of France reportedly enjoyed watching women give birth and was frustrated by traditional positions that obscured his view of the “show.” Louis desired to watch the birth of his son and Ambroise Paré, official surgeon to the royal family, obliged. Thus, according to some scholars, recumbent and semi-recumbent positions came into fashion and stayed there.

With the advent of the modern hospital system, forcep-assisted birth, surgical birth intervention and anesthetics, recumbent birthing positions continued to grow in popularity until they became what we now understand to be the norm, if not necessary to a healthy birth.

Epidural drugs are used to block nerve impulses from the lower spinal segments, resulting in decreased sensation in the lower body. Over 50% of women in the U.S. opt to receive an epidural during labor, which can make birth in upright positions dangerous without proper assistance. High-dose epidurals can reduce the mother’s muscle control to such an extent that providers must apply manual pressure to her abdomen to move the baby through the vaginal canal.

Electronic Fetal Monitoring (EFM) is a technique used to monitor fetal oxygenation during labor. Despite its popularity, EFM is not without risk and offers little benefit to women with low-risk pregnancies. The EFM technique can be used externally via a sensor placed around the mother’s abdomen or internally using a wire that runs through the dilated cervix and attaches to the baby’s head. Both methods are limiting to the mother’s mobility. Intermittent auscultation (the use of a fetal stethoscope and handheld Doppler) is a safe alternative to EFM which allows mothers to move freely and with more control. 

Convenience for the provider largely contributes to the use of recumbent positions. Horizontal birthing positions allow providers to remain seated for the duration of labor while maintaining easy access to the perineum as the baby makes its debut. 

As for hospital operations, it’s no secret that hospitals in the U.S. are understaffed (in a survey conducted by RNnetwork, 91% of nurses believed their hospital was understaffed) which means inadequate support for mothers in labor. In 2014, Alabama couple Caroline and J.T. Malatesta sued their hospital for a traumatic birth and won. The couple alleges that one nurse used physical force to coerce Caroline into the supine position, resulting in a rare nerve injury, while a second nurse physically held the fetal vertex (head) into the perineum for six minutes because the doctor was late to the delivery. 

Support for the right to choose

The World Health Organization (WHO) concludes that women should assume any birthing position that feels comfortable and avoid lying in the supine position for long periods of time. The American College of Nurse Midwives (ACNM) Midwives Alliance of North America (MANA) and the National Association of Certified Professional Midwives (NACPM) released a consensus statement in support of healthy physiologic birth, concluding that freedom of movement and choice of position are critical to this goal. The American College of Obstetricians and Gynecologists (ACOG) recommends that no one position be mandated or proscribed and cite the fact that many providers encourage a supine position during labor even though it has known adverse effects, including low maternal blood pressure and more frequent abnormal fetal heart rates.

As a society, we’ve evolved to respect women’s right to informed consent, bodily autonomy, dignity and safety. It’s time to hold hospital systems accountable to do the same. If you’re pregnant or plan to become pregnant in the future, know your rights. If possible, do your research when selecting a physician or midwife before your delivery date, make sure you feel comfortable with their approach and ask the hard-hitting questions. Remember you have the right to choose the birthing position that’s best for you and to refuse drugs or procedures that you aren’t comfortable with. If your provider disagrees, on to the next.


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