BACK OFF: Why Lying Flat On The Back Is Bad For Birth
(Originally published May 2021)
I thought the days of being told to lie down while birthing a baby were long over, but just recently one of our clients revealed that her doctor insisted she lie on her back to push. I was very surprised that this happened here, at a local lower-mainland hospital, this very year. I had naively thought we had completely moved on from the archaic lie-flat-on-your-back approach to birthing.
When we encounter birth on TV or in the movies, or indeed in memes, books, cartoons or virtually any form of representation, the birthing person is always supine, on her back, with or without her feet in stirrups. This image of birthing flat on the back is so entrenched and pervasive that we even see it in movies about prehistoric cave-people, space aliens, post-apocalyptic futures--societies where there would be no justification for such a historically-inaccurate, unlikely, and dysfunctional birthing position.
To be clear, the justification we have now is grossly insufficient, but at least we know how it came to be: a merging of doctor-preference, with a harmful social construct of birth that continues to taint our paradigm.
When birth first moved from homes into hospitals, our understanding of the process suffered a monumental shift, or rather, we lost a colossal amount of knowledge about how birth works. Hitherto understood as a normal physiological process, a healthy and ordinary life event, attended by skilled midwives with extensive training and apprenticing, the brand new field of obstetrics declared itself the latest innovation in medicine, and ripped the scope of birth out of the homes. First luring women into hospitals with promises of superior hygiene and modern technology, followed by slanderous campaigns against midwives and their dangerous, dirty, witchy ways, and finally enacting laws against traditional birth attendants for ‘practicing medicine without a license’, centuries worth of birth knowledge was practically eradicated within one or two generations. No longer a normal, healthy life process, birth became a surgical problem to solve.
Obstetrics is a surgical specialty. When hospitals took over birth, moving it from the realm of the healthy to the realm of the sick for the first time ever, there was no understanding of the mother or baby as participants in the process. There was no understanding of the role of hormones, or movement, or indeed any of the complex physiology. Instead, the baby was now seen as an object that required removal from a host body. In other words, birth was no longer an experience in which women actively engaged, it was now merely a surgical issue: how to skillfully extract the baby from the mother’s body.
The doctor thus positioned himself as the saviour, expertly performing the act of delivering the baby from the mother’s body. The mother was reduced to a vessel--a harmful one, at that--and the baby was reduced to something between a tumour and a captive. Neither has any agency or active role in the process, both are being saved by the doctor.
If birth is reduced to a question of extraction within a surgical model, one can see how lying the inert body flat on a table raised to the doctor’s convenient height makes sense. How efficient! The mother is immobilized, and can’t interfere in the delicate medical procedure. This is clearly easier for the doctors than if she were upright: swaying, squatting, or swearing at them.
So what’s the problem with birthing flat on the back? Why doesn’t it work?
Let’s start with the obvious: gravity. If we’re trying to get a pillow out of a pillowcase, we wouldn’t lie it flat. We would hold it upright, because that way gravity does half the work for us. Likewise, gravity will help the baby descend and emerge if the birthing person is upright, but will work against the process if said person is lying flat. It’s worse than neutral, because the pelvis is shaped so that the baby actually has to travel uphill if the woman is supine.
Pushing a baby uphill is harder for both the birther and the baby. It requires more force, obviously, more blood-vessel-bursting effort. It takes longer. It’s more exhausting. It’s harder on the mother’s pelvic floor muscles, increasing the risk of pelvic floor muscle strain and lingering incontinence. And it is more likely to result in tearing and stitches, which is something all birthers dearly hope to avoid.
Lying on one’s back also compresses the size of the pelvic outlet, so that the tailbone blocks the baby’s exit. In an upright position, the tailbone simply gets gently pushed out of the way by the baby’s head, but when you’re lying on it, it has nowhere to go. The pelvic outlet loses up to 2cm from being in the supine position, which is a lot of potential space for an emerging baby. This can cause damage to the tailbone, resulting in pain, bruising, and sometimes even fractures, all of which can be avoided by not lying on it.
It used to be believed that the size of the baby’s head and the size of the mother’s pelvis could be incompatible, that some mothers would grow babies who were just too big to come out. Since both pelvis and skull are made of bone, it was assumed they are both fixed and unyielding entities. However, this is not true. Hormones throughout pregnancy cause so much softening and loosening in our bodies that we become flexible and accommodating. Pelvises can stretch around babies’ heads, and babies’ heads can likewise compress to fit through tight pelvises. All those soft spots on a baby’s head serve a purpose, which is to allow skull plates to squish together, even to overlap when required.
This simultaneous stretching of the pelvis and squeezing of the skull is fueled by hormones, but accomplished through movement. Responding to sensations of discomfort, tightness, and an overwhelming need to rock and sway, birthers rotate and gyrate, rocking the pelvis back and forth, from side to side, in circles, and up and down. This relieves pressure and eases pain, but also helps the baby and pelvis respond to one another, reshape to their varying sizes and structures, so that one can squeeze through the other. The hormones create the potential but the movement provides the means. This responsive dynamic of yielding joints remains untapped when lying flat on the back.
When we remember that mothers give birth--that it is an active process performed by an active agent--it no longer seems reasonable to immobilize them in the most passive position imaginable. Adding stirrups takes the act of restraining to a whole other level. Flat-on-the-back allows for no leverage, no physical power to push. Imagine trying to expel a major bowel movement while lying on your back. The position is tortuously unsuited to harnessing your pushing muscles, your diaphragm, or sphincter. It is a position that renders a person passive rather than active, that debilitates and undermines any efforts to gain traction, to exert leverage, or to be effective. It’s a position that creates helplessness: it confines the mother as object rather than subject.
This is obvious physically, but it is even more poignant psychologically. In prenatal class, when we look at images of different birthing positions, women always notice that the lithotomy position (on back with stirrups) causes extreme vulnerability. The body is literally spread eagled, on display, trussed, and open, and horribly, traumatically, revealed to be helpless. I think I speak for everyone when I say that nobody wants their vagina forcibly displayed like that, especially on a table, in a bright room, with fully-dressed people staring. It is an extreme position, one which is reminiscent of violent bondage. It’s a position that can make women feel grievously victimized. It can be dangerously traumatic.
Many people report feeling traumatised by birth, and this usually boils down to two causes. Interestingly, pain is not one of them. They are (1) feeling like stuff was done to them without their understanding or consent, which is a whole other essay, and (2) being forced into this fully exposed and helpless position. This kind of negative experience obviously affects one’s pathway to parenting, colouring the postpartum and breastfeeding and the whole psychology of early parenthood, but also directly affects the immediate birth. Stress hormones cause instant sabotage to birthing hormones. We can’t contract and dilate and push when we feel unsafe. So the supine position leads to preventable problems in second stage labour, resulting in more frequent cases of forceps, vacuum extractor, caesarean birth, tearing, dystocia, and trauma.
I had an obstetrician in my prenatal classes a number of years ago. After she had her baby she said she wished she could write a letter of apology to all the hundreds of mothers she’d attended prior to this moment. She had told them all to lie on their backs to push, and now, having been through it herself, swore she would never, ever expect such a thing again. She had not known how much it would hurt, how everything in her body and soul would be shouting for her to get upright, how deep-down sure her body would feel that lying on her back was wrong, wrong, wrong. Luckily, her own doctor was fine with her kneeling, so that’s what she did, and she would never tell anyone not to, ever again. Her own experience of giving birth has no doubt saved countless people from enduring a harmful position, but unfortunately a lot of doctors will never have that level of personal participation or insight: they will never give birth themselves, and will never know the unique sensations of birth that demand we get off our backs. They will continue to think that they are performing this delivery, and that they know best.
Most people find lying flat to be very uncomfortable during first stage labour, and even more so during pushing. This is our body’s way of telling us not to. We have to get up, and we have to be able to move, rock, and sway. If we return to that pillow and pillowcase analogy, we would not only hold it upright to ease the pillow out, we would likely shake it gently, provide some movement to facilitate its egress. We do this in labour too. The movement dances our baby downward, creating tiny pockets of space in our pelvis to assist baby’s progress, stretching us this way and that way, and gently shaking baby down. We do this in response to the pain, but the ulterior purpose, or result, is that it helps birth the baby. Listening to our body is the most straightforward way to facilitate birth.
Since lying flat is more painful, doing so results in more frequent requests for pain medication. Anaesthetics themselves can undermine the pushing process, since dulling the sensation of contractions also dulls our sensation of pushing. Epidurals carry both the pro & con of reducing pain, since the newfound comfort of lying flat also means people feel less urgency to get up. We can’t listen to our bodies when we numb the language our bodies speak. One can still use an upright position with an epidural, but one has to consciously and deliberately decide to do so, since the internal cues will be muted.
The supine position is a corrosive vestige from an outdated birthing paradigm. It has iatrogenic effects that harm both birthers and babies, ranging from physical to psychological damage that can undermine bonding, breastfeeding, and postpartum adjustment. There are rare and extreme circumstances when it might be necessary, but generally speaking, the days of pushing flat-on-the-back should be well behind us. We have to stand up and insist on our right to birth in whatever position we want, and barring medical emergencies, tell our attendants that we, and not they, do the pushing. So back off.
Stephanie Ondrack has been with The Childbearing Society since 2003. She lives in East Van with one partner, four kids, four chickens, and five cats. You can read more of her rants on birth, parenting, and learning at www.thesmallsteph.com