Babies are not spanked at birth in modern hospitals, and the practice has been abandoned by mainstream medicine for decades. The image of a doctor holding a newborn upside down and delivering a sharp slap to get that first cry is deeply embedded in popular culture, reinforced by old movies and television, but it does not reflect how delivery rooms actually work today. What replaced it is a sequence of far gentler steps, and the science behind how newborns start breathing turns out to be more interesting than the old slap-on-the-bottom story suggests.
Where the Idea Came From
The spanking-at-birth image is not entirely fictional. For much of the twentieth century, a brisk slap to the buttocks or the soles of the feet was a standard way to provoke a newborn’s first breath. The logic was straightforward: a sudden, sharp sensation would startle the baby into gasping, which would inflate the lungs and get respiration going. Doctors were trained to do it, parents expected to hear a cry, and the practice became so iconic that it entered the cultural shorthand for what birth looks like. If you have ever seen a mid-century film depict a delivery, the slap is almost always there.
The problem is that it was based on a crude understanding of what actually triggers breathing. And as neonatal medicine advanced, clinicians realized the slap was not only unnecessary for most babies but could be actively harmful to some. By the 1970s and 1980s, professional guidelines in wealthy countries had largely moved away from it. The shift was not dramatic or sudden; it happened as evidence accumulated about gentler and more effective alternatives.
How Newborns Actually Start Breathing
During pregnancy, a baby’s lungs are filled with fluid. One of the critical transitions at birth is clearing that fluid so air can move in. For a long time, people assumed the squeeze of passing through the birth canal physically pushed the fluid out, but research has shown that the process is mostly chemical, not mechanical. The bulk of lung fluid clearance is driven by sodium channels in the cells lining the tiny air sacs of the lungs, which actively absorb the fluid in the hours around birth, with only a limited contribution from physical compression or pressure changes.1PubMed. Physiology of fetal lung fluid clearance and the effect of labor Labor itself triggers hormonal signals that switch these channels on, which is one reason babies born by scheduled cesarean section before labor begins sometimes have slightly more trouble clearing their lungs.
The vast majority of newborns begin breathing on their own within the first minute of life. About 90% need nothing more than basic care: warmth, drying, and perhaps a gentle rub. Roughly 10% need some help getting started, and fewer than 1% require extensive resuscitation measures like chest compressions or medication.2Europe PMC / BJA Education. Neonatal resuscitation: current evidence and guidelines The first cry, which parents and movies fixate on, is really just one sign that the lungs are inflating. Many healthy babies do not cry loudly right away, and that is perfectly normal.
What Replaced the Slap
Modern delivery rooms use what is called tactile stimulation, which sounds clinical but is really just gentle, purposeful touch. When a baby does not start breathing immediately, the standard approach is to dry the baby briskly with a warm towel and rub the back or flick the soles of the feet. These are mild sensory inputs, nothing like a slap. The drying itself serves double duty: it prevents heat loss, which is a serious risk for newborns, and the friction provides enough stimulation to prompt breathing in most cases.
A retrospective study of preterm infants found that the most common forms of stimulation were rubbing the soles of the feet (68% of cases) and rubbing the back (12%), with flicking the feet used only about 2% of the time. An observable effect on breathing or heart rate was seen in about 18% of the stimulation episodes that had a clear clinical reason, such as a drop in heart rate or a pause in breathing.3Frontiers in Pediatrics. Tactile Stimulation to Stimulate Spontaneous Breathing during Stabilization of Preterm Infants at Birth: A Retrospective Analysis That 18% figure might sound low, but the study also found that babies who did not receive stimulation were more than twice as likely to need a breathing tube placed in the delivery room (18% versus 7%).3Frontiers in Pediatrics. Tactile Stimulation to Stimulate Spontaneous Breathing during Stabilization of Preterm Infants at Birth: A Retrospective Analysis
A systematic review by the American Academy of Pediatrics looked more broadly at the evidence for tactile stimulation in newborns who were not breathing adequately. It found a reduction in the need for intubation among infants who received stimulation compared with those who did not, though the certainty of the evidence was rated very low.4American Academy of Pediatrics (Pediatrics). Tactile Stimulation in Newborn Infants With Inadequate Respiration at Birth: A Systematic Review The takeaway is that gentle rubbing and drying appear to help, but research on exactly how much they help, and what technique works best, is still surprisingly thin. If the baby does not respond to these gentle measures within the first thirty seconds or so, clinicians move quickly to positive-pressure ventilation, which means using a mask and bag to push air into the lungs. Spanking does not appear anywhere in the modern resuscitation sequence.
Places Where Spanking Persists
While high-income countries moved away from spanking newborns decades ago, the practice has not disappeared everywhere. A survey of birth facilities in Nigeria found that spanking the baby while holding it upside down by the legs was the primary method of resuscitation in over 90% of the facilities studied.5African Health Sciences. Newborn resuscitation practices and paucity of resuscitative devices in Nigeria; a call to action Other reported practices included massaging the body with hot compresses or salicylate-containing balms, inserting irritant substances into the nose or anus to provoke a pain response, and using local herbal preparations.5African Health Sciences. Newborn resuscitation practices and paucity of resuscitative devices in Nigeria; a call to action
These practices are not a matter of ignorance so much as a reflection of resource constraints. Bag-and-mask ventilation devices, pulse oximeters, and radiant warmers are standard equipment in hospitals across wealthier nations, but many birth facilities in low-resource settings simply do not have them. When the only tools available are your hands and whatever is in the room, clinicians and birth attendants fall back on older techniques. International organizations like Helping Babies Breathe have been working to train birth attendants in evidence-based resuscitation using low-cost equipment, but the gap between guidelines and reality remains wide in many parts of the world.
Why Aggressive Stimulation Can Be Harmful
The shift away from spanking was not just about finding something that works better. There are real risks to rough handling of a newborn. A baby’s skin is thin and fragile, and forceful slapping can cause bruising or petechiae, which are tiny broken blood vessels. Holding a baby upside down by the ankles, as the classic movie image depicts, puts stress on the joints and spine and risks dropping the infant. Perhaps most concerning is the neurological impact: a newborn’s brain is highly sensitive, and excessive or painful stimulation in those first moments can trigger a stress response that works against the very goal of getting breathing established.
Newborns already experience a surge of stress hormones during a normal vaginal birth. These catecholamines are at their highest levels in the first thirty minutes and actually serve a useful purpose, helping the baby stay alert and strengthening early memory and learning.6Wiley Online Library. Skin‐to‐skin contact the first hour after birth, underlying implications and clinical practice Adding painful stimulation on top of this natural stress response pushes the system into territory where the effects become harmful rather than helpful. The goal in modern neonatal care is to support the transition without adding unnecessary distress.
Suctioning Got Rethought Too
Spanking is not the only old delivery room routine that has been quietly retired. For decades, it was standard to suction a newborn’s mouth and nose immediately after birth, whether or not the baby seemed to need it. The reasoning was preventive: clear out any fluid or mucus before it could cause a problem. But the evidence has shifted dramatically on this point.
A systematic review found no evidence that routine suctioning of clear amniotic fluid at birth provides any benefit, and it turned up very low certainty evidence of a temporary drop in oxygen levels afterward.7Resuscitation Plus. Suctioning of clear amniotic fluid at birth: A systematic review Other research has shown that routine suctioning can trigger the vagus nerve, which paradoxically slows the heart rate and can cause pauses in breathing, the opposite of what you want. It can also cause pain and damage the delicate mucous membranes, raising the risk of infection.8PubMed Central. Delivery room handling of the newborn Current international guidelines recommend against routine suctioning and suggest that simply wiping the baby’s face, nose, and mouth with a towel is sufficient for most infants.9International Liaison Committee on Resuscitation. Suctioning clear amniotic fluid at birth: NLS 5120 Suctioning is still used when there is a clear airway obstruction, but as a targeted intervention, not as a default step for every baby.
The pattern across both spanking and suctioning is the same: interventions that were done routinely “just in case” turned out to be unnecessary for most babies and mildly harmful for some. Modern neonatal care has moved toward a philosophy of doing less by default and stepping up only when the baby signals that help is needed.
The First Minutes in a Modern Delivery Room
For a healthy, full-term baby born vaginally, the first minutes after birth look nothing like the movies. The baby is typically placed directly on the mother’s chest or abdomen, skin to skin, and covered with a warm blanket. A clinician dries the baby gently, assesses the breathing and color, and watches. That is it for most births. Skin-to-skin contact in that first hour reduces crying, helps the baby regulate its temperature, and supports the transition from womb to world.6Wiley Online Library. Skin‐to‐skin contact the first hour after birth, underlying implications and clinical practice
The baby is assessed using a scoring system that evaluates five signs: heart rate, breathing effort, muscle tone, reflexes, and skin color. This assessment happens at one minute and five minutes after birth.10PubMed. The Apgar score: evolution, limitations, and scoring guidelines It is done largely by observation, with minimal handling. If the score indicates a problem, the team escalates through a well-defined sequence: stimulation, then airway positioning, then ventilation with a mask and bag, then more advanced interventions if needed. The sequence is designed to match the level of intervention to what the baby actually requires, rather than applying a one-size-fits-all set of procedures to every newborn.
The Gentle Birth Movement
The move away from spanking and aggressive handling was part of a broader rethinking of how birth affects babies psychologically, not just physically. In the 1970s, French obstetrician Frédérick Leboyer popularized a method of “gentle birth” that aimed to reduce sensory overload for the newborn: dim lights, quiet voices, warm water baths, and minimal stimulation. The approach was controversial at first, dismissed by many as sentimental, but research provided some support for the underlying idea.
A study comparing babies delivered with a modified Leboyer method to those delivered in the conventional manner found measurable differences. Babies in the gentle-birth group spent more time with relaxed hand muscles during the first ten minutes and more time with their eyes open overall. The conventionally delivered group showed more trembling, shuddering, and blinking in the first fifteen minutes.11PubMed. Gentle birth: its safety and its effect on neonatal behavior The study also confirmed that the gentler approach was safe for both mother and baby, which was the main objection skeptics had raised.11PubMed. Gentle birth: its safety and its effect on neonatal behavior
Today’s delivery room practices have absorbed much of this philosophy without necessarily calling it Leboyer. Immediate skin-to-skin contact, delayed cord clamping, reduced suctioning, and a quieter environment are all standard recommendations in many hospitals. The spanking-at-birth image belongs to an era when the baby was treated primarily as a medical object to be processed rather than a person making a stressful transition.
Why the Myth Sticks Around
Even though spanking at birth has been gone from mainstream practice for a generation, the idea persists in public consciousness for a few reasons. Movies and television shows, especially older ones, cemented the image so thoroughly that many people assume it still happens. The dramatic arc of the scene is irresistible: tension during delivery, the doctor holds the baby up, a slap, a cry, and the room floods with relief. It is a powerful narrative beat, and accuracy has never been Hollywood’s priority in depicting medical procedures.
There is also a common-sense appeal to the idea. People hear that babies need to cry to start breathing and reason backward: if the baby is not crying, you must need to make it cry. The logic feels sound but misses a key point. Crying is a sign that the lungs are working, not the cause. Plenty of babies breathe well without crying loudly at all, and the first breaths can be quiet, shallow, and gradual rather than the dramatic wail that movies demand. When parents in the delivery room do not hear the expected loud cry immediately, they sometimes panic, but the clinical team knows to assess the actual signs of respiration rather than waiting for a sound effect.
Another factor is generational transmission. Grandparents and older relatives who gave birth in the era of spanking tell their stories, and those stories become family lore. When a first-time parent hears “the doctor will spank the baby to make it cry,” it sounds like authoritative insider knowledge. The practice was real; it just is not current.
When a Newborn Truly Does Not Breathe
For the small fraction of newborns who do not respond to drying and gentle stimulation, the resuscitation pathway escalates quickly and does not involve spanking at any step. If breathing has not started within about thirty seconds, clinicians begin positive-pressure ventilation, delivering air or a blend of air and oxygen through a small mask placed over the baby’s nose and mouth. If the heart rate remains below a hundred beats per minute despite ventilation, or if the baby is gasping or not breathing at all, the intervention intensifies.2Europe PMC / BJA Education. Neonatal resuscitation: current evidence and guidelines
The entire process is tightly protocolized and time-sensitive. Teams train with simulation drills to keep the steps smooth and fast, because every second counts when a newborn is not getting oxygen. In this context, spanking would be a waste of time even if it were effective. When a baby genuinely cannot breathe, the problem is usually something that touch alone cannot fix: the airway is blocked, the lungs are not inflating, or the heart is not pumping strongly enough. These situations call for ventilation, sometimes intubation, and occasionally medications or chest compressions. A slap to the bottom addresses none of these.
The evolution of delivery room care from reflexive spanking to evidence-based resuscitation is one of those quiet medical advances that most people never hear about. The dramatic version of birth makes for better stories, but the real version, where a baby is gently dried and placed on its mother’s chest while a team calmly watches and waits, is the one that produces the best outcomes.