There is overwhelming evidence to show that upright labor and birthing positions provide many physiologic benefits for mother and baby. Birthing upright widens the pelvis, allowing it to expand and move more freely, especially in the pushing stage of labor.
Despite this evidence, most women still end up giving birth while lying on their backs and even labor on their backs for most active labor.
Changing positions during labor and following your body’s cues for more natural birth positions will help your body and baby work together, as intended, to create space for your baby to move down, through the pelvis, and out.
There are many upright birthing positions to labor and deliver in, which can help labor progress and encourage a smoother delivery, even if you are birthing with an epidural.
When delivering in a hospital setting, you might be restricted in how you can move and what positions you can use. This may be due to hospital policy, provider preference, or the need for continuous fetal monitoring. If you know what options are available to you ahead of time, it will be easier to adapt to your environment in the moment and find an optimal birth position for pushing.
Let’s get into why most women end up birthing on their backs and some other positions that you can use instead.
Why do women usually give birth on their backs?
It is common in pop culture to show women giving birth semi-reclined, red in the face, on a hospital bed with her legs held up or on the stirrups. I bet that’s the image most people see in their minds when they picture someone having a baby. But it wasn’t always this way.
Some of the earliest historical art (like Cleopatra in ancient Egypt, circa 69-ish BC) have images and sculptures of women giving birth in a squatting position, on all fours, standing up, and even kneeling.
When women are allowed to birth intuitively, it is rarely on their back. So, how did we get to this standard practice of care in modern-day hospitals?
It turns out, it doesn’t have anything to do with women at all or even the average person, but rather King Louis XIV, who was France’s ruler from 1643 to 1715. According to some medical scholars, King Louis XIV, who had 22 kids with multiple women, enjoyed watching women give birth, but the upright birth position blocked his view.
“Since Louis XIV reportedly enjoyed watching women giving birth, he became frustrated by the obscured view of birth when it occurred on birthing stool, and promoted the new reclining position. The influence of the King’s policy is unknown, although the behavior of royalty must have affected the populace to some degree.”
So, if giving birth on your back is how the royals do it, the common people started adopting the practice as well.
Just because this position’s popularity originated in an odd way doesn’t make it inherently bad. However, being upright provides many benefits, including:
- A shorter second stage of labor (the pushing stage)
- The reduced need for assisted delivery
- A reduction in the need for an episiotomy
- Fewer abnormal fetal heart rate readings
The main reason that women deliver on their backs is that most caregivers prefer it that way. It is also easier to teach students how to deliver babies when a mother is on her back because it provides a better view of what is happening.
Interestingly enough, current obstetric textbooks tout the benefits of upright birth.
Another reason providers like to have women on their back is due to continuous fetal heart rate monitoring. Being still and lying down makes it easier to constantly read the baby’s heart tones.
When a provider sees signs that a baby may be in distress, they are quick to rush to a C-section. However, continuous fetal monitoring has not made any impact on improving birth outcomes since it was introduced in the 1970s.
As a doula, most of my clients want to give birth in whatever position they find helpful at the time. They prefer to be free to move around during the pushing stage, and push instinctively.
At our prenatal visits, I encourage clients to ask their provider what position they want for the birth. I suggest leaving the question open-ended, rather than asking yes or no questions, to encourage conversation around the topic.
My clients always happily report that their provider said they could labor and push in whatever position is most comfortable for them. Yet somehow, my clients almost always end up pushing on their backs, even when they don’t have an epidural.
I see it nearly every time in a hospital setting. It’s time to push, excitement fills the room, and mom is laid down on the bed, stirrups pulled out, and coached how to push.
Coached pushing and pushing on your back is a lot less likely to happen with a provider that attends a birth center or home birth, where birth is less medicalized and systematic. In these settings, freedom of movement occurs naturally.
Out of hospital providers, usually midwives, are with you during the entirety of labor. They are more likely to rely on how the labor is progressing rather than data from a monitor (although they do monitor fetal heart tones intermittently with handheld dopplers).
Recent studies show that home birth, when attended by a provider trained in and skilled at home birth, is just as safe or safer than birthing in a hospital.
Choice of birth location makes a significant impact on your freedom to choose labor and birth positions, helping you have a more empowering birth experience. If it is important to you to move freely, especially during the pushing stage, it is crucial to talk to your provider about it frequently. I have had clients talk about it at every single appointment, so their providers know that this is something very important to them.
Best birthing positions & different positions for labor
Phew! That was a lot of information to digest. Now that you are more informed on why women usually labor and birth on their backs, let’s get into the alternative options, when they might be a good choice, and how to modify them for use with an epidural.
Even better? There are things that you can do before labor even begins to encourage flexibility and create more room in the pelvis to make these positions even more effective. Doing optimal fetal position exercises daily will help your labor and delivery go even smoother.
How to do it: This one is pretty straightforward. There is nothing special about it, just walk. You can walk in circles, try curb walking, or even walk back and forth in your delivery room.
When to use it: An upright walking position is usually great for early labor when things are not as intense, and it is still easy for you to cope through contractions.
Pros: Walking keeps your pelvis moving, helping your baby and your contractions move together to get the baby lower into the pelvis.
Cons: This can be pretty boring to do for long periods, especially if you are hooked up to a monitor or confined to a small space.
Epidural modifications: Walking with an epidural is impossible, but you can keep your pelvis moving by changing positions every five contractions. Minor changes will do, such as lifting one leg up and down, and then switching to the other leg. Small changes in your position can make a big difference in how the pelvis sits.
Lying on your side
How to do it: Technically, this isn’t an upright position, but it is a great alternative to being upright when you need a rest. Lie on your side and prop something between your knees to open the pelvis as your labor.
When to use it: This is an excellent position to use when you just need a break. Labor is hard work, and rest is sometimes needed, especially for more prolonged labor.
Pros: This is an excellent position that encourages your baby to move down while you take a nap between contractions (or have the epidural).
Cons: Lying on one side for too long can encourage the baby’s head to move into an awkward position, so make sure to switch sides every 20-30 minutes.
Epidural Modifications: This is an excellent alternative to laboring on your back with an epidural. Switch sides every 20-30 minutes, and add in sitting up by putting the back of the bed up and dropping the legs down to sit upright.
Sitting on a birth ball
How to do it: Grab a birth ball or a CUB and just sit or move your hips.
When to use it: This is a great way to change things up and can be great in any labor stage. You can even push your baby out on the CUB, which also doubles as a birth stool.
Pros: Sitting on a birth ball creates great alignment in the pelvic area and makes it easy to move around with little effort. Think hip circles, figure eights, and pelvic tilts.
Cons: While most hospitals have a couple of birth balls available for use, you might not be able to find one. For home birth, you will likely need to get your own. Sometimes, it can be hard to keep steady on a ball and requires more lower back engagement which can get tiring after a while.
Epidural Modifications: Put the head of your bed straight up and drop the feet of the bed all the way down; this is called the throne position and is a great way to be upright with an epidural. Roll up a towel and put it behind your lower back to free up your sacrum to move. You can even hunch your upper body over a birth ball and rest, and lots of times even get a little wiggle in with your hips.
Squatting bar birthing position
How to do it: The squat bar is probably the most underutilized birth tool in a hospital, and all hospitals have them. I have been at births where nurses have never seen them used. They simply slide into connectors on the side of the bed. Get up into a squat position and bear down.
When to use it: This one is great for the pushing stage. Squatting is a great way to open the pelvic outlet and make space for the rest of your baby’s journey.
Pros: A squat bar can be a good compromise between a provider that wants their patient to birth on their back and a mother who wants to birth upright. It is virtually the same point of view and gives the doctor a clear look at what is happening as the baby descends and is born.
Cons: This position requires a lot of leg strength and can wear you out if pushing takes a while.
Epidural Modifications: While it is much harder to squat with an epidural, it is not impossible with the proper support. You can request the epidural be turned down and make sure you have two support people, one on each side, holding you up as you are squatting.
Birth in the squatting position
How to do it: No squat bar required. You can squat unassisted or tie a knot in a sheet or long scarf, shutting the knot securely on the other side of a door. Then you can pull on the sheet or scarf for support.
Make sure your feet are flat and pointed forward (or toes pointed slightly towards each other) to keep the pelvic outlet nice and open. Make sure your bum is tucked under like in the image below.
When to use it: This is another great alternative for the pushing stage of labor or when you need to get the baby to move down. When trying to get the baby engaged, point the toes outward to open the brim of the pelvis.
Pros: It’s a great birthing position to bring the baby down and push the baby out.
Cons: As with a squat bar, it can be hard on the legs and knees and may not be possible for long periods.
Epidural Modifications: With an epidural, definitely pull out the squat bar and have people supporting you, so you don’t fall. It might not be possible, but it might be worth a try.
Hands and knees birthing position
How to do it: This is how I birthed my three VBAC babies. Just get on your hands and knees. You can even lean your arms or upper body against a birth pool, birth ball, or bed for support. It’s a very intuitive birth position for women.
When to use it: This is an excellent labor position for any stage. In early and active labor, you can sway your hips from side to side to encourage your baby to descend. During pushing, it is a great birthing position to bear down and push.
Pros: This position is easy to move in and out of. It’s great to rest when you are propped against something. There are also many variations you can use without moving off your hands and knees. You will be able to keep your pelvis moving, and it has lots of space to open and flex as it needs to.
Cons: It can be hard on the knees, so kneel on a pillow or a foam pad if you can.
Epidural Modifications: This may be possible with an epidural by raising the head of the bed all the way up and leaning your upper body against it. Male sure you have at least two people helping you get into this position and supporting you by your side, so you do not fall. You can also bend your knees and sit down backward to help stabilize yourself.
Giving birth standing up
How to do it: Standing is standing; it’s hard to mess this one up.
When to use it: Anytime during labor, it’s excellent to keep changing positions from sitting, to standing, to lying down, to hands and knees. Keep moving as much as possible.
Pros: Standing is simple and easy. Like with your hands and knees, you can sway and move with contractions and help the baby move down, through, and out.
Cons: Standing for too long can be tiring while you labor; changing positions will be your best friend to keep you from getting too exhausted.
Epidural Modifications: While there is such a thing as a “walking epidural,” it is hard to find an anesthesiologist that will give you a dose low enough to stand up and support yourself. It’s best to stick with some of the other positions we have covered.
Kneeling birthing position
How to do it: Get on your knees. It is very similar to laboring on your hands and knees; you just aren’t supporting your upper body.
When to use it: Use it when you feel like it. Anytime in labor is great! Keep it in your arsenal of positions to move into and out of.
Pros: Kneeling is a nice, straightforward upright birth position.
Cons: As with the hands and knees position, it can be hard to stay on your knees for an extended time, so switching positions is essential.
Epidural Modifications: This is another one that would likely be impossible with an epidural.
Here are answers to some frequently asked questions about birth and labor positions.
Which position is good for delivery?
The best position for delivery is whatever feels intuitive to you. Being upright and able to move will help your baby descend and be able to move as needed for birth. Upright birth positions are associated with fewer Cesarean births and the reduced need for assisted delivery.
What is the most painful way to give birth?
Giving birth is one of the most intense experiences you will have in your lifetime. While some women have calm, pain-free births using meditation or hypnosis, most people will experience some level of discomfort. Things that make childbirth more painful are fear, feeling unsafe, being forced to labor on your back, and not having a supportive environment.
What is the most pain-free way to give birth?
Giving birth with an epidural can take away most or all of your pain. If you choose to give birth without an epidural, there are options like Hypnobirthing that can teach you coping tools to reduce the amount of pain you feel. Being in a supportive environment will also make it easier to tolerate labor.
How birthing positions affect delivery
Laboring in an upright position can bring a better supply of oxygen to the baby and make the mom more comfortable. Moving intuitively as you labor and birth will reduce the chance of needing an episiotomy and a Cesarean. It is best to remain mobile as long as possible.
What birthing positions can you do with an epidural?
Having an epidural doesn’t mean you have to be flat on your back. Birth positions with an epidural include side-lying, exaggerated side-lying, throne position, sitting up, supported squat, supported hands and knees, kneeling on the bed, and leaning over the bed, to name a few.
What are some birthing positions where fathers can assist?
Fathers can support labor and birth in any position. Being a calm presence with the mother will make a significant impact. Let her lean against you as she labors, give her a massage, do counter-pressure, and speak positive and encouraging words. You can be her advocate and talk to the birth team for her, and help her move into different birth positions.
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