How Doctors (and Allegedly Louis XIV) Ruined Childbirth
Or, Women Shouldn’t Take This Lying Down!
It is currently most common in Western medicine for women in labour to be positioned in a prone posture, lying on their backs with legs spread (supine position) or with their legs in stirrups (lithotomy position, a term which derives from its use in the removal of urinary tract blockages) (Dundes, 1987; Mosby, Inc., 2013). However, this practice is both a global and a historical outlier. In most other cultures, as well as in Europe itself prior to the 17th century, women give birth in a wide variety of positions, including sitting, squatting, kneeling, and even standing (Dundes, 1987). Birthing chairs or birthing stools, which had a convenient hole cut in the front of the seat, were developed as early as ancient Babylon, and were frequently used in medieval and early modern Europe and America (Dundes, 1987).
This practice began to change due to a complex interplay of economic and gender dynamics in the practice of medicine. In France in the mid-1500s, midwives, previously the sole attendants at childbirth, were increasingly forced to compete with male barber-surgeons, who were generally regarded as lower-class trade workers. (Formally educated, higher-class physicians at first did not intrude on this area due to the perceived indecency of dealing with female reproductive organs). As surgeons began to become more common as birth attendants, first only in medically complex or dangerous cases, and then increasingly as a matter of course, they began to suggest a reclining birth posture, with the woman leaning backwards at an angle, that would enable them to see and manage the process better (Dundes, 1987).
In 1668, prominent French physician François Mauriceau recommended a reclining position in his book The Diseases of Women with Child and in Child-Bed (Dundes, 1987). He also held to an increasingly common idea among doctors that pregnancy was itself an illness, terming it “a Tumour caused by the Infant’s Situation in the Womb.” (Mauriceau, 1668). This shift in the view of pregnancy from normal biological process to abnormal disease state walled it off from the traditional training and knowledge of midwives, placing it firmly within the purview of the (male) medical establishment. It has also been reported (although the story may be apocryphal) that the then-monarch of France, King Louis XIV, ordered his mistresses and/or wives to give birth in a reclined posture so that he could see better, or even that he gained some fetishistic enjoyment from watching childbirth (Stark et al., 2023). Regardless of the reality of Louis’s supposed proclivities, he did give royal favor to lithotomic surgeon Jacques Beaulieu (also known as Frères Jacques, although he likely has no connection to the nursery rhyme), who practiced lithotomy at the Paris hospital Hôtel Dieu, which had a large maternity ward (Dundes, 1987; Ganem & Carson, 1999).
The United States seems to have taken this trend a step or two further in the 1800s. While the French used a reclined position and English bed deliveries were generally done with the woman lying on her side, American doctors began to recommend a flat horizontal prone position, as attested in the writings of University of Pennsylvania chairman of obstetrics William Potts Dewees circa 1834. The reasons for this deviation from both British and continental medical practices remain unclear. An overlap in 19th century American physicians who practiced lithotomy and obstetrics may have also contributed to the use of the lithotomy position during childbirth (Dundes, 1987).
This somewhat convoluted history raises the question of whether any birth posture is supported by scientific evidence as producing better health outcomes for mothers (or babies). As with many areas of women’s health, this question has not been studied as extensively or rigorously as it should be. Nevertheless, there have been various studies exploring this issue, even if they have not always been done systematically enough to allow easy comparison.
The most obvious disadvantage of the flat horizontal supine and lithotomy positions is that it points the birth canal upwards, forcing the parturient (woman in labour) to fight gravity; indeed, the baby often slips backwards between contractions (Stark et al., 2023). These positions also increase the chance that the medical team will perform an episiotomy, an incision into the perineum (the area between the anus and the genitals) that widens the vaginal opening to make delivery or manual extraction of the baby easier (Satone & Tayade, 2023). Furthermore, there is a somewhat increased risk of abnormal fetal heartbeat patterns (Gupta et al., 2017).
A squatting position is sometimes considered one of the most natural positions for birth, as it is a fairly normal resting position in numerous cultures, as well as in other closely related species such as chimpanzees; it is also frequently adopted for purposes of defecation in areas without modern toilets (Gupta et al., 2017). However, it may be difficult for women to maintain a squat for a long time if they are unused to adopting it in other contexts. Some of this discomfort may be alleviated by devices such as birthing bars or ergonomic ankle supports (Satone & Tayade, 2023; Lin et al., 2018).
Another potential aid is the aforementioned birthing chair/stool, which allows the parturient to give birth in the sitting position common in the developed world. Women are reported to have an increased likelihood of significant (>500 mL) blood loss in any upright birth position, but blood loss may also be more accurately measured in these circumstances (Gupta et al., 2017); logically blood would tend to flow downwards out of the body in an upright posture, while in a supine or lithotomy position it may remain within the reproductive system. Upright postures in general seem to reduce labour time, pain, fetal heart rate abnormalities, and incidence of episiotomies (Gupta et al., 2017; Satone & Tayade, 2023).
There is an unfortunate dearth of systematic data on kneeling and standing birth postures.
Based on the available evidence, there seems little medical reason to recommend the supine and lithotomy birth positions. This is relatively unsurprising given that the adoption of these birth positions seems to have been driven by their convenience for male doctors (who may have been relatively unfamiliar with female anatomy, at least compared to midwives) and the overlap between the practices of obstetrics and lithotomy, rather than either sound medical reasoning or well-designed studies. More research in this area would undoubtedly prove beneficial for both pregnant women and babies, but with the generally low quality of currently available data, it seems reasonable to recommend that parturients be allowed freedom to give birth in whatever position seems most comfortable or least painful, at least in the absence of serious medical complications.
While there has been increased attention paid to alternative birth positions in recent years, the prevailing birth practices in developed countries’ formal health care settings seem resistant to change. The presence of a bed in most delivery rooms (and usual absence of other aids such as birthing chairs, bars, or ankle supports) nudges women into supine positions. The typical absence of portrayals of alternative birthing postures in mass media (especially both scripted and reality television) also plays a role in normalizing adoption of horizontal positions during labour. Much more research, strong messaging aimed at both doctors and patients, and possibly increased use of midwives would likely be necessary to alter these cultural norms.
Works Cited
Dundes, L. (1987). The evolution of maternal birthing position. American Journal of Public Health, 77(5), 636–641. https://doi.org/10.2105/ajph.77.5.636
Ganem, J. P., & Carson, C. C. (1999). Frère Jacques Beaulieu: From rogue lithotomist to nursery rhyme character. The Journal of Urology, 161, 1067-1069. https://urologichistory.museum/Documents/Histories/Biographies/Frere-Jacques-Beaulieu-From-Rogue-Lithotomist-to-Nursery-Rhyme-Character.pdf
Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel., J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia (Review). Cochrane Database of Systematic Reviews 2017, 5. https://doi.org/10.1002/14651858.CD002006.pub4
Lin, Y. C., Gau, M. L., Kao, G. H., & Lee, H. C. (2018). Efficacy of an ergonomic ankle support aid for squatting position in improving pushing skills and birth outcomes during the second stage of labor: A randomized controlled trial. Journal of Nursing Research 26(6), 376-384. https://doi.org/10.1097/jnr.0000000000000262
Mauriceau, F. (1736). The Diseases of Women with Child and in Child-Bed. (7th ed., Hugh Chamberlen, Trans.). London: T. Cox and J. Clarke. Original work published in French 1668. https://wellcomecollection.org/works/hqz9hx3j/items
Mosby, Inc. (2013). Lithotomy. In Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed., p. 1050). Elsevier.
Satone, P. D., & Tayade, S. A. (2023). Alternative birthing positions compared to the conventional position in the second stage of labor: A review. Cureus, 15(4), e37943. https://doi.org/10.7759/cureus.37943
Stark, M., Mynbaev, O., Malvasi, A., & Tinelli, A. (2023). Inviting Newton to Visit the Delivery Room. The Role of Gravity During Childbirth. International Journal of Women's Health, 15, 1059–1061. https://doi.org/10.2147/IJWH.S405077