What is the Evidence for Pushing Positions?

Pushing in a squatting position

© 2012 Rebecca Dekker, PhD, RN, APRN

Researchers hypothesize that pushing in an upright position is beneficial for multiple reasons. In an upright position, gravity can assist in bringing the baby down and out. Also, when a woman is upright, there is less risk of compressing the mother’s aorta and thus a better oxygen supply to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. Finally, X-ray evidence has shown that the actual dimensions of the pelvic outlet become wider in the squatting and kneeling/hands-knees positions (Gupta et al. 2012).

However, despite these proposed benefits of pushing in an upright position, most women in the U.S. give birth either lying on their backs (57%) or in a semi-sitting/lying position with the head of the bed raised up (35%). A small minority of women give birth in alternative positions such as side lying (4%), squatting or sitting (3%), or hands-knees position (1%) (Declercq, Sakala et al. 2007).

A mom pushes her baby out lying on her back, with her feet up in stirrups. More than half of U.S. women give birth this way.
Source: koadmunkee

It is thought that most women are encouraged to push in a lying or semi-sitting positions because it is more convenient for the care provider. When women are lying or semi-lying in bed, it is easier to access the woman’s abdomen to monitor the fetal heart rate. Care providers are also more comfortable with the lying or semi-sitting position because this is how many of them are trained to attend births (Gupta et al. 2012). This caregiver preference for non-upright positions has persisted, despite the fact that current major obstetric textbooks state that it is beneficial for women to push in upright positions, especially for first-time moms (Kilpatrick and Garrison 2012)

For a woman who does not have an epidural, which pushing positions are best supported by evidence?

In a 2012 Cochrane review, Gupta et al. pooled the results of 22 randomized, controlled studies that included more than 7,200 women. In these studies, women were randomly assigned to either upright or non-upright positions during pushing. Researchers defined upright positions as sitting (on a birthing stool or cushion), kneeling, and squatting. They defined non-upright positions as side-lying, semi-sitting/lying (in bed with the head of the bed raised up) and lithotomy (back-lying with feet up in stirrups or feet supported by care providers’ hands).

The overall quality of these studies was mixed with some poor-quality studies included. The researchers state that this weakness makes their conclusions tentative. However, the researchers controlled for the quality of the study by running “sensitivity analyses,” which means that they re-ran the statistics using only good-quality studies. When they did so, the results stayed the same.

In comparison with non-upright positions, women who were randomly assigned to upright positions were:

• 23% less likely to have a forceps or vacuum-assisted delivery
• 21% less likely to have an episiotomy
• 35% more likely to have a second-degree tear*, except when a “birth cushion” is used, in which case there was no additional risk of tearing
• 54% less likely to have abnormal fetal heart rate patterns
• 65% more likely to have blood loss greater than 500 mL**

There were no differences between groups with duration of pushing, Cesarean section rates, third or fourth degree perineal tears, need for blood transfusion, admission to neonatal intensive care units, or perinatal deaths.

*The lower risk of episiotomies in women who give birth in upright positions was offset by a higher risk of second degree tear. However, since other researchers have found strong evidence that tears heal easier and are less traumatic to tissue than episiotomies (Carroli and Mignini 2009), a higher second degree tear rate in exchange for a lower episiotomy rate is a good trade-off. This may be particularly true with care providers who have high episiotomy rates. On the other hand, there are many care providers and settings with very low episiotomy rates, so this finding about the lower risk of episiotomy might not be applicable to women in those settings.

**Researchers found that women in the upright group were 65% more likely to have an estimated blood loss greater than 500 mL. The researchers questioned the accuracy of this finding because the blood loss was based on care provider estimates, which is not an accurate way of measuring blood loss. As mentioned earlier, there were no differences in the need for blood transfusion between groups.

Researchers were not able to compare the side-lying position by itself to other upright and non-upright positions. So we cannot assess the effects of the side-lying position from this Cochrane review.

In summary, researchers concluded that upright positions were more efficient than non-upright positions, as evidenced by the decreased risk of vacuum-assisted delivery, forceps use, and episiotomy. The bottom line was that women without an epidural should be encouraged to push in whatever position is most comfortable for them.

For a woman who has an epidural, which pushing positions are best supported by evidence?

Almost three-quarters of women in the U.S. (71%) receive an epidural during childbirth (Declercq et al. 2007). There have been only two randomized, controlled trials that compared upright versus non-upright pushing positions in women with epidurals.  Results from both studies show that being upright during the second stage of labor shortens labor in women with epidurals.

Karraz et al. (2003) randomly assigned 221 women with walking epidurals into either an upright group (walking, sit in a chair, or semi-lying) or a non-upright group (not allowed to sit or get out of bed). The upright group was encouraged to mobilize throughout labor (not just during pushing), and had a significantly shorter overall time from epidural insertion to delivery (173 minutes versus 236 minutes). There were no other differences in outcomes between the two groups.

In a smaller study, Golara et al. (2002) randomized 66 first-time mothers with walking epidurals to be upright (walk or stand at least 30 minutes) or remain lying down during the second stage of labor. They found that women who were upright during pushing had a significantly shorter pushing time—51 minutes versus 73 minutes. There were no significant differences between groups with any other outcomes that were measured (Golara, Plaat et al. 2002).

Overall, evidence suggests that women with walking epidurals are capable of mobilizing during the second stage of labor, and that women who are upright are more likely to have a shorter labor and pushing phase. However, the research for pushing positions with epidurals is quite limited. The two studies that discussed above only focused on women with walking epidurals—these are women who are able to actually get up and move around with support. No studies have compared upright positions (such as a supported squat), side-lying positions, or back-lying and semi-lying positions in women with traditional epidurals.

However, as the video below shows, it is possible for women to push in many different positions with an epidural. Also, many hospital beds can form and shape to different positions, making it easier for a woman with an epidural to push in positions other than lying down. For example, one manufacturer makes a maternity bed that can be used for upright sitting, squatting, McRobert’s maneuver, lithotomy, side-lying, knee/chest, kneeling, and leaning forward positions.   

Summary of the Evidence:

• For women without an epidural, pushing in an upright position is associated with a decrease in the risk of episiotomies, vacuum and forceps-assisted deliveries, and fetal heart rate abnormalities, an increase in the risk of second-degree tears, and a possible increase in the risk of having blood loss more than 500 mL
• Women with walking epidurals who push in upright positions may experience a shortened labor and pushing phase
• More evidence is needed to evaluate pushing positions in women with traditional (non-walking) epidurals
• The take home message is that women should  push in any position they find comfortable– it is not necessary to be continuously upright or continuously lying down during the pushing phase

The following videos are presented only to demonstrate some of the different pushing positions that are possible– not to advocate for one type of position over the other (see final take home message above).

Here is a nice video with examples of how a woman with an epidural can be assisted into different pushing positions

This video by Lamaze International demonstrates how women without an epidural can push in upright positions

If you are a consumer: What position did you push in? Were you encouraged to push in whatever position was most comfortable for you? If you had an epidural, did anyone offer to assist you into different positions?

If you are an educator or care provider: What positions do you routinely encourage your clients to push in? Why?

References 

1. Carroli, G. and L. Mignini (2009). “Episiotomy for vaginal birth.” Cochrane Database Syst Rev(1): CD000081.
2. Declercq, E. R., C. Sakala, et al. (2007). “Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International.” J Perinat Educ 16(4): 15-17.
3. Golara, M., F. Plaat, et al. (2002). “Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia.” Int J Obstet Anesth 11(1): 19-22.
4. Gupta, J. K., G. J. Hofmeyr, et al. (2012). “Position in the second stage of labour for women without epidural anaesthesia.” Cochrane Database Syst Rev 5: CD002006.
5. Karraz, M. A. (2003). “Ambulatory epidural anesthesia and the duration of labor.” International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 80(2): 117-122.
6. Kilpatrick, S. and E. Garrison (2012). Normal labor and delivery. Obstetrics: Normal and Problem Pregnancies. S. G. Gabbe. Philadelphia, PA, Saunders Elsevier: 267-281.