The Evidence on: Birthing Positions
Have you ever thought about what position you would like to use to give birth? Most movies and television series depict birthing positions such as back-lying or semi-sitting in bed. But many people, if given the choice, instinctively choose a more upright position for birthing their baby—such as hands-and-knees, squatting, or kneeling.
What is the evidence on the different positions that can be used to help push your baby out? And why are the lying or semi-sitting positions so frequently recommended (or even required) in hospital settings?
We explore these topics, and more, in this Evidence Based Birth® Signature Article on Birthing Positions.
Before we get started with the evidence on birthing positions, let’s go over some definitions!
The second stage of labor begins when the cervix is completely dilated (10 cm) and ends with the birth of the baby.
In research, the second stage is sometimes divided into a passive phase, an active pushing phase, and the actual birth of the baby (sometimes called “delivery”) (Roberts, 2002).
- The passive phase of the second stage of labor is a period of rest or waiting (sometimes called “laboring down”), during which the baby rotates and descends toward the pelvic floor. The passive phase sometimes happens when you are fully dilated and you’re waiting for the urge to push. The passive phase does not occur if you begin pushing immediately after reaching complete cervical dilation.
- The active pushing phase is when the baby’s presenting part (head or bottom) is on the pelvic floor and you push spontaneously (after feeling an urge to push) or as coached by a care provider. If you have an epidural, you may feel pressure, an urge to push, or no sensation at all—depending on your situation and the strength of the medications in your epidural. In contrast, most people who give birth unmedicated (without an epidural) experience a strong urge to push.
- The delivery is when the baby’s head, shoulders, and body are emerging.
- In some un-medicated births, the active pushing phase and delivery may be more accurately described as the fetal ejection reflex—when your body expels the baby with little or no conscious effort (Newton, 1987). People who experience the fetal ejection reflex sometimes describe this as “I wasn’t pushing, my baby was just coming out!”
This Evidence Based Birth® Signature Article is specifically focused on birthing positions anytime during the second stage! In this article, we will not be covering the evidence for other pushing options—such as coached/directed pushing vs. spontaneous pushing, or immediate pushing vs. delayed pushing.
Whenever possible, we share if a study is looking at birthing positions in the passive phase, active phase, or during the actual birth of the baby.
How could upright positions benefit normal labor and birth?
(c) Illustration: Bigita Faber, courtesy of GynZone
Upright birthing positions include:
Standing/squatting, supported by a partner or prop:
Kneeling upright or on hand-and-knees:
Using a birth seat:
Researchers believe that giving birth in an upright position is beneficial for several physiologic reasons. Physiologic refers to your body’s normal function.
In an upright birthing position:
- Gravity can help bring the baby down and out
- There is less risk of compressing your aorta (the large blood vessel that carries oxygenated blood from your heart to the rest of your body):
- More blood flow through the aorta leads to a better oxygen supply to the baby
- Which leads to lowered risk of abnormal fetal heart tones
- Which leads to a lower risk of emergency Cesarean
- The uterus can contract more strongly and efficiently
- The fetus can get in a better position to pass through the pelvis
- It’s less painful than lying on your back!
Magnetic resonance imaging (MRI) studies have also shown that compared to the back-lying position, the measurements of the pelvic outlet become wider in the squatting and kneeling or hands-and-knees positions (Gupta et al., 2017). Also, research has shown that upright birthing positions may increase satisfaction and lead to more positive birth experiences (Thies-Lagergren, 2013).
However, despite these benefits of giving birth in an upright position, most people who give birth vaginally in U.S. hospitals describe pushing and delivering lying on their backs (68%) or in a semi-sitting/lying position with the head of the bed raised up (23%). A small portion of birthing people push and give birth in other positions such as side-lying (3%), squatting or sitting (4%), or hands-and-knees position (1%) (Declercq et al., 2014).
In contrast, research from home birth settings confirms that when birthing people are free to choose the position of their choice, they do not usually choose to lay on their backs or semi-sitting in bed. In Europe, a study of nearly 3,000 people who had planned home births between 2008 and 2013 found that the majority (65%) gave birth in upright or side-lying positions (Edqvist et al., 2016).
Before we move on any further, let’s go over terms that are used to describe birthing positions.
General terms that refer to lying on your back or side are called recumbent and semi-recumbent positions (http://bit.ly/2FBxdMQ). The side-lying position is often grouped with other nonupright positions by researchers, even though it may have different effects than lying on your back.
Recumbent and semi-recumbent positions include:
Supine position = lying on your back; if the head of the bed is elevated then this position might be called semi-sitting or semi-recumbent
Lithotomy position = lying on your back in a supine position with hips and knees flexed, thighs apart, and legs supported in raised stirrups or by people holding your legs in the air
Lateral position = side-lying
Another possible way to classify birthing positions is whether your body weight is on or off the sacrum, or the large flat bone at the base of the spine, and the coccyx or tailbone, which makes up the bottom tip of the sacrum.
A computer simulation of the birthing process found that when the coccyx is allowed to move freely, then it can move nearly 16 degrees (making more space for the baby’s head to come down and out through the pelvis). In contrast, when non-flexible sacrum positions are used, the coccyx can only move about 4 degrees (Borges et al., 2021).
Researchers have found consistent evidence that positions that take the weight off the sacrum/coccyx and allow the pelvis to expand can make spontaneous birth (birth without the use of surgery, vacuum, or forceps assistance) more likely (Edqvist et al., 2016).
For a video showing how flexible sacrum positions can make birth easier, watch this video (http://bit.ly/2FB1I8D).
So, flexible sacrum positions take the weight off the tailbone:
- Using a U-shaped birth seat
While non-flexible sacrum positions put weight on the tailbone:
- Supine (back-lying) with or without the head of the bed raised up
- Semi-sitting in bed
- Lithotomy position
Non-upright positions may be beneficial in some cases. For example, the McRoberts’ position (http:// bit.ly/2FBxY8E)—when you lay back with your legs flexed and pulled tightly toward your abdomen— can help correct a shoulder dystocia (when the baby’s shoulders get stuck after the head has already emerged).
Why do most people give birth on their backs?
Many health care workers prefer patients to use non-upright birthing positions. This practice occurs even though current obstetric textbooks teach the benefits of pushing in upright positions (especially for first-time birthing people) (Kilpatrick & Garrison, 2012).
Convenience for Healthcare Workers
It is thought that healthcare workers encourage people to birth in back lying or semi-sitting positions—positions that put weight on the birthing person’s tailbone—because it’s more convenient for the care provider.
In one study that took place in India, 92% of labor and delivery nurses were aware of upright birthing positions, and 83% believed that women should have a choice of upright birthing positions– but 100% of the nurses said that lithotomy was the most common birthing position. “Ease and convenience” and “overcrowding in the labor room” were the most common reasons for not allowing patients to use the birthing position of their choice (Yadav et al., 2021).
Easier to do Non-Evidence Based Fetal Monitoring
If you are lying or semi-sitting in bed, it is easier for caregivers to access your abdomen to monitor the fetal heart rate electronically. Among people who experienced labor in the U.S. in 2012 and 2013, most had electronic fetal monitoring (EFM) either continuously (60%) or for most of the time during labor (20%) (Declercq et al., 2014).
Despite its widespread use, continuous electronic fetal heart rate monitoring is not evidence-based in many cases. When continuous EFM has been compared with intermittent auscultation (listening to the baby’s heart rate at regular intervals with a handheld device), continuous EFM has been linked to lower rates of newborn seizures but has not improved rates of cerebral palsy or infant death. Also, birthing people who are attached to continuous EFM during labor have higher rates of Cesareans and forceps/vacuum-assisted births (Alfirevic et al., 2017).
To learn more about the evidence on EFM, visit our Signature Article here: https://evidencebasedbirth.com/fetalmonitoring
Health Care Training
Care providers are also more comfortable with the lying or semi-sitting position because this is how most are trained to attend births (Gupta et al., 2017).
As the presenter explains in this video (http://bit.ly/2FyUcb4), while back-lying positions are harmful for birthing people and babies, they are the easiest way to position Noelle, a popular birthing mannequin (http://bit.ly/2FByIdW), for birth simulations.
The focus on back-lying birthing positions in training is a big reason why many health care workers are uncomfortable with attending upright births. One of our reviewers spoke with a care provider who asked a room full of medical students in the Southeastern U.S. if any of them had ever seen an upright birth on their OB rotation. Not a single medical student raised their hand.
If a physician or midwife has only been trained in back-lying positions, they may not feel that they can handle unexpected emergencies when the birthing person is in an upright position. This may explain why some doctors and midwives are so focused on getting their patients to lay back or assume the semi-sitting or lithotomy position for birth, even when the birth has been going smoothly.
As one nurse-midwife stated during a study interview in Tanzania, “…women are not allowed to choose the birthing position when they are at the hospital. If the woman chooses a position and at last, she ends up with the problem, the midwife will be responsible. Why should the midwife allow the woman to choose the position? It is wrong and not the right decision.” (Mselle & Eustace, 2020).
In this same study of nurse-midwives in Tanzania, if a mother insisted on pushing or birthing in an upright position, the mother was labeled as “uncooperative,” and the midwives would continue to pressure them to get into the lying down position.
Use of Epidurals
A high rate of epidural use can also lead to a higher use of back lying positions. Care providers may perceive that upright birthing positions are not possible with an epidural, and patients with epidurals—especially those with high-dose, or “heavy” epidurals—may be unable to get themselves into upright positions without trained help.
Some high-dose epidurals can block your feeling to such an extent that the care provider might use their hands to apply strong pressure to the inner part of the vagina to help with pushing efforts—a procedure that is usually done with the patient in the lithotomy position (Personal communication, S. Voogt, January 2018).
Myths about Protecting the Perineum
Some providers believe that they need to use special techniques during the delivery, such as perineal “massage” (using their hands to rub/stretch the vagina), episiotomy (a surgical cut with scissors to widen the vagina), or the modified Ritgen maneuver (using hands to press outside the birthing person’s rectum and manipulate the baby’s head into a tucked chin position). These techniques are most easily performed with the patient in a lithotomy, semi-sitting, or lying back position, with the health care provider sitting at the foot of the bed.
However, research does not support these methods for protecting the perineum, and in fact, the most protective method for preventing tears involves not touching the patient’s genitals at all during the delivery. Furthermore, episiotomies are extremely harmful and can have negative long-term health impacts. So, upright birthing positions have an advantage in that they make it more difficult for care providers to manipulate your genital area during the birth.
We cover these myths and discuss why the hands-off method is more effective in our EBB Podcast series on “Protecting the Perineum.” For the research summaries and references on this topic, visit EBB Podcast episodes 206 (episiotomy), 210 (hands-on vs. hands-off), 218 (perineal massage), and 221 (birthing positions and more data on the hands-off method).
There are many pressures in hospitals that limit caregivers from truly supporting birthing people. Too few nurses and increased charting duties limit nurses’ ability to perform intermittent auscultation or to provide hands-on support for different birthing positions—especially for patients with epidurals who require extra assistance.
If you have an epidural, you may need two assistants to help you move into certain positions, which is not possible if a hospital is short-staffed on nurses, or if the nurse is supposed to be charting on the computer every five to ten minutes for medical, legal, and insurance reasons.
If hospitals were willing to invest in more hands-on care to support birthing families, we would likely see more auscultation (instead of continuous EFM) and more staff support for position changes during labor, pushing, and birth.
Many birthing people find that one of the benefits of hiring an independent doula is that the doula can team up with other family members (such as the partner) to help you push and give birth in upright positions (whether you have an epidural or not). To read the evidence on doulas, visit https://evidencebasedbirth.com/doulas
Symbolic Importance of the Hospital Bed
Hospitals often invest tens of thousands of dollars in specialized birthing beds that can be broken down to support a range of positions (from lithotomy to hands and knees to squatting). The hospital bed takes a central location and importance in the typical hospital birthing room (almost throne-like in its placement), and each bed can cost anywhere between $4,000 and $10,000 USD.
The hospital bed itself is a potent symbol of the rite of passage of having a technologically driven birth. Anthropologist Robbie Davis-Floyd, PhD, writes that “Rituals transmit their meaning through symbols. A symbol is an object, idea, or action that is loaded with cultural meaning. Instead of being analyzed intellectually, a symbol’s message will be felt through the body and the emotions… Routine obstetric procedures are highly symbolic.” (Davis-Floyd, p. 49).
When a birthing person puts on a hospital gown and gets into the hospital bed, this symbol conveys that they are sick and need the technology and skills of the hospital staff. Then, when the hospital bed is combined with the lithotomy position (in which the birthing person is positioned with their legs up in the air and genitals exposed for everyone to see, with the practitioner standing over them), this can be seen as a symbol of powerlessness (for the birthing person) and status/authority (for the practitioner).
The significant financial, ritual, and symbolic meaning of hospital beds may help explain why hospital staff are so insistent that deliveries (whether upright or lying down) should always take place in bed.
In contrast, births that take place at home and in freestanding birth centers provide access to a variety of props, furniture, and tools. These environments encourage upright birthing, with the purpose of facilitating physiological birth and empowering the birthing person.
In the first randomized controlled trial of its kind (still ongoing at the time we updated this article) researchers in Germany are studying changes to hospital birthing rooms that encourage upright positions and enhance relaxation and comfort (Ayerle et al. 2018). In the “intervention group,” birthing people have access to a room that includes:
- Bed that is absent or hidden from sight
- Mattress and foam mat on the floor
- Bean bag or easy chair
- Foam element shaped like a birthing stool
- Snack bar with table and chairs
- Posters showing upright positions
- Monitor showing natural sounds/music
- Sign on the door requesting privacy
In the “control” group, the delivery bed has a central place in the room and is accessible from three sides. A birthing stool, birth ball, and length of fabric suspended from the ceiling (to use for support while standing/squatting) remain available as is usual in some hospitals in Germany.
The results from this study, known as the “BE-UP” trial, have not yet been published. The researchers plan to examine the effects of the birthing rooms on Cesarean rates, episiotomy rates, perineal tears, epidural use, newborn health, and maternal feelings of self-determination.
A similar study, known as the “Room4Birth” trial, is also taking place in Sweden (Berg et al. 2019).
Evidence on Birthing Positions
So, what’s the actual research evidence on birthing positions?
Because most researchers study birthing positions only in people without epidurals, or only in those with epidurals, we will divide the research up based on epidural use.
Without epidurals, which birthing positions are best supported by evidence?
In a systematic review and meta-analysis published by Zang et al. (2020), researchers combined 12 randomized, controlled trials with 4,314 participants who were randomly assigned to upright vs. recumbent birth.
The researchers excluded any studies that used the lithotomy position because of its known harms and increased risks. They stated, “these horizontal positions can have serious negative effects on maternal health and are not recommended by many international organizations.” As a result, this review is smaller than the Cochrane review and meta-analysis by Gupta et al. (2017), which included the lithotomy position and thus had a larger number of participants.
The Zang et al. team followed the PRISMA guidelines for reviews (https://prisma-statement.org/ ), and they included studies that had participants with low-risk pregnancies at 37-42 weeks. Participants had to be pregnant with a single baby in spontaneous labor, and they could not have an epidural.
The researchers compared upright versus recumbent positions.
- They defined “upright” as walking, standing, leaning, using a birth chair, semi-sitting, squatting, and kneeling.
- However, none of the included studies used semi-sitting as an upright position.
- Upright birthing positions were used only in the passive pushing phase in 4 studies, only in the active pushing phase in 3 studies, and in the entire second stage in 7 studies.
- The reviewers defined recumbent as lateral (side-lying), supine (lying), or semi-recumbent (lying with the head of the bed raised up).
The studies in the Zang et al. review took place in the United Kingdom (U.K.), Finland, Brazil, China, Ireland, Turkey, and South Africa, and the publication dates ranged from 1983 to 2017. Unfortunately, the risk of bias was unclear in 8 studies, and the risk of bias was high in 4 studies. Most of the studies had problems with randomization (selection bias), blinding (detection bias), and a few studies had problems with attrition (people dropping out of the study). As such, we need to take this review’s findings with caution.
Zang et al. found that upright birthing positions led to:
- Lower rate of instrumental delivery (forceps/vacuum use)
- Shorter length of the active pushing phase (by 8 minutes on average)
- A much shorter length of the active pushing phase when squatting was used (by 16 minutes on average)
- Substantial decrease in the risk of severe perineal trauma (75% relative risk reduction; only 2 of the 12 studies reported on severe perineal trauma)
- Higher risk of 2nd degree tears with the positions of squatting and sitting on a birth seat
- No difference in blood loss of >500 mL between groups (in contrast to earlier reviews that found a higher risk of blood loss in upright groups)
- No difference in the length of the entire second stage
The effect of birthing positions on episiotomy rates was unclear because the studies had a wide range of episiotomy rates. For example, some studies had episiotomy rates closer to 0% in both groups, while some studies had episiotomy rates of close to 90%. Because all the studies were so different, it wasn’t possible to combine the results on episiotomy.
Some people may be surprised to see the higher risk of 2nd degree tears with squatting or using a birth seat. But this can be explained by the fact that in these studies, the higher rate of 2nd degree tears with upright births was exchanged for a lower rate of episiotomies. Since other researchers have found strong evidence that natural tears heal easier and are less traumatic to tissue than episiotomies (Jiang et al., 2017), a higher risk of second-degree tear in exchange for a lower risk of episiotomy is considered a good trade-off.
Previous researchers (Gupta et al., 2017) have noticed a higher risk of blood loss with upright birth, but this was not seen in the Zang et al. (2020) meta-analysis.
Other outcomes, such as pain, satisfaction, or use of Pitocin® to augment labor, were not examined in the Zang meta-analysis. However, results from individual randomized, controlled trials, have found additional benefits to upright birth.
For example, in 2017, Moraloglu et al. published a study with 102 people giving birth without epidurals in Turkey. Participants in this study were randomly assigned to push and give birth in a standing/squatting position holding onto a bar, or the lithotomy position with the head of the bed raised 45 degrees. The study showed that those who stood, then squatted down with a bar to push during contractions, had shorter second stages of labor by about 34 minutes. They also experienced less pain, were less likely to receive Pitocin® to augment labor, and had higher satisfaction with the birth experience, compared with the group that pushed and gave birth while back-lying with the head of the bed raised.
Other individual randomized trials have found that in people without epidurals, upright birthing positions lead to:
- Significantly lower rates of pain (de Jong et al. 1997; Purnama et al. 2018)
- Lower rates of shoulder dystocia (Zhang et al. 2017)
- Lower rates of abnormal fetal heart tones (Crowley et al. 1991; de Jong et al. 1997)
- Lower rates of emergency Cesarean (Zhang et al. 2017).
For people with epidurals, which birthing positions are best supported by evidence?
Epidural analgesia is common in many countries; for example, more than 60% of those giving birth to a single baby in the U.S. use epidural or spinal analgesia (ACOG, Practice Bulletin No. 177, 2017).
In 2018, Walker et al. published a Cochrane review that examined the evidence for upright vs. non-upright birthing positions among people with epidurals. However, since this review was dominated by BUMPES randomized trial (more than three-fourths of the Cochrane review participants came from this trial), I chose to write about the BUMPES trial instead of the Walker et al. Cochrane review.
The BUMPES trial on side-lying with an epidural vs. upright with an epidural
The BUMPES trial was a very large randomized, controlled trial on birthing positions carried out by a group of researchers in the U.K. called the Epidural and Position Trial Collaborative Group (2017). The researchers compared upright vs. side-lying birthing positions in first-time birthing people, all of whom had a low-dose epidural.
Between 2010 and 2014, a total of 3,236 people were enrolled in the study from 41 centers in the U.K. To be included in the study, participants had to be over the age of 16, pregnant with a single, head-down baby at 37 weeks or greater, planning to give birth vaginally, and in the second stage of labor with a low-dose epidural.
Since participants weren’t randomized to upright or side-lying positions until the second stage of labor, this research doesn’t apply to positioning with epidurals in the first stage of labor. It also doesn’t tell us anything about the back-lying, semi-sitting, or lithotomy positions with an epidural.
The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position.
The non-upright group was assigned to side-lying with the head of the hospital bed raised up 30 degrees. Because they were all supposed to use the side-lying position, we will call this group the side-lying group.
About 80% of participants assigned to both the upright and side-lying groups were able to move around, meaning that they had true low-dose epidurals. For the most part, people used their assigned pushing positions.
The researchers found that fewer people assigned to upright birthing positions experienced spontaneous vaginal birth compared to people in the side-lying group (35% vs. 41%). Most participants in this study gave birth either with Cesarean or with vacuum/forceps. We were surprised to see such high rates of intervention in this study—the rate of vacuum/forceps births was 51%-55% and more than half (55%-59%) of people received an episiotomy—a procedure that is known to increase harms. These numbers are very high. In the U.S., for example, the overall rate of vacuum/forceps births is only around 3% (Martin et al., 2017).
It’s not clear why people assigned to upright birthing positions were less likely to have spontaneous vaginal births in this study. The researchers did not find a difference between groups in rates of failure to progress or fetal distress leading to vacuum or forceps. They also did not find differences in any other health outcomes. It could be that people with low-dose epidurals have a greater chance of giving birth spontaneously when they use a side-lying position for the second stage of labor rather than an upright position. However, the findings from this study should be taken with extreme caution—the results may not apply to settings with more support for spontaneous vaginal birth (where there is less use of vacuum or forceps).
In two other randomized trials, researchers found evidence that the lithotomy position is harmful if you have an epidural.
In the first study on the lithotomy position with epidurals:
- Researchers randomly assigned 199 participants giving birth at a hospital in Spain to a “traditional model of birth” or an “alternative model of birth” (Walker et al., 2012).
- People assigned to the traditional model began pushing in the lithotomy position immediately after they reached ten centimeters and gave birth in the lithotomy position.
- People assigned to the alternative model delayed pushing and gave birth in a specific type of side-lying position:
- The alternative model group was instructed to change position every 20-30 minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push.
- Hospital staff assisted them in moving into different positions like sitting, kneeling, side-lying, or hand-and-knees.
- If, after 2 hours in the passive phase, the epidural prevented people from feeling an urge to push, they were asked to start pushing with each contraction.
- When people in the delayed pushing group were ready to begin pushing efforts, staff assisted them into a specific side-lying position. In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. The birthing person’s upper body was placed in a neutral position and supported with pillows, if necessary.
- Those who delayed pushing and gave birth in a side-lying position were less likely to need forceps, vacuum, or fundal pressure (20% vs. 42%) and had a higher rate of intact perineum (40% vs. 12%) compared to people who pushed immediately and delivered in a lithotomy position.
- There was no difference between groups in the rate of first-, second-, or third-degree perineal tears, so the lower rate of episiotomy (21% vs. 51%) in the side-lying group accounts for the higher rate of intact perineum in that group.
In the second study on lithotomy positions with epidurals:
- Researchers randomly assigned 150 birthing people in Spain to position changes every five to 30 minutes in the passive phase of the second stage of labor or to a lying down position for the entire second stage (Simarro et al., 2017).
- Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position.
- The people assigned to position changes during the passive phase of the second stage of labor had better outcomes than the group that was lying down for the entire second stage, even though everyone gave birth in the same back-lying position.
- The group that changed positions had fewer Cesareans (1% vs. 10%) and fewer cases of vacuum/forceps (24% vs. 39%). They also experienced shorter second stages of labor (95 minutes vs. 124 minutes) and fewer episiotomies (18% vs. 31%).
In other words, evidence continues to show today that the lithotomy position is harmful and should not be used for pushing or delivery, even in with people with epidurals.
Evidence on Birth Seats (for people with and without epidurals)
Birth seats or stools have been used for thousands of years. For example, they are mentioned in the book of Exodus 1:16:
“When you serve as midwife to the Hebrew women and see them on the birthstool…”
Recently, researchers have begun exploring the effectiveness of different types of birth stools.
The Swedish Birth Seat Trial was carried out at two hospitals in Sweden between 2006 and 2009
(Thies-Lagergren, 2013). The study included 1,020 participants giving birth vaginally for the first time between 37 weeks and 41 weeks 6 days. Nearly half (45%) used epidurals for pain relief during labor. Participants were randomly assigned to either give birth on a special birthing seat called the BirthRite seat (http://bit.ly/2FBk5a8) or in any other position.
The researcher found:
- The birth seat resulted in a shorter second stage of labor by an average of 6-13 minutes, as well as less use of Pitocin® for augmentation of labor.
- No difference in the rate of forceps or vacuum assistance.
- People who gave birth on the birth seat were at increased risk of postpartum blood loss; however, the blood loss did not influence hemoglobin levels 2-3 months postpartum.
- There was no difference between the groups as far as perineal tears, but the birth seat was linked to fewer episiotomies—2% of those who gave birth on the birth seat had an episiotomy compared to 14% of those who gave birth in other positions.
The study did not find a difference in health outcomes for mothers or infants other than the increase in postpartum blood loss. However, the participants who were assigned to give birth on the birth seat were more likely to report that they felt “powerful, protected and self-confident”—which led to greater satisfaction with childbirth.
To watch a video from Evidence Based Birth® that shows different types of birthing stools, visit here: https://www.youtube.com/watch?v=gbHujklthyo
What evidence do we have on birthing positions from observational studies?
We found three observational studies on birthing positions in the second stage of labor that have been published in the last ten years—two from Sweden and one from Italy.
Swedish Study compared “women-centered” care to standard care
The first study from Sweden looked at strategies care providers can use in the second stage of labor to improve health outcomes (Edqvist et al., 2017). Midwives treated 296 first-time birthing people with a three-part protocol called “woman-centered care,” and the other 301 first-time birthing people received standard care. The use of epidurals in the study was 61%.
The group that received woman-centered care had:
- Spontaneous pushing (pushing efforts were not coached or directed),
- Flexible sacrum birthing positions (kneeling, standing, hands-and-knees, side-lying, birth seat)
- Birth of the baby’s head and shoulders in two separate contractions (for more about this evidence-based method, called the “two-step delivery method,” listen to EBB Podcast Episode 168)
In contrast, the midwives who practiced standard care did not receive any special instructions.
The researchers determined that the odds of second-degree tears were less likely in those who received woman-centered care compared to those who received standard care. However, we do not know which part of the 3-part protocol contributed to the lower rate of second-degree tears.
Swedish study looks at birthing positions and severe tears
Another study also from Sweden looked at the effect of delivery position on the rate of obstetric anal sphincter injury (OASIS) (Elvander et al., 2015). These severe tears, also called third- and fourth-degree perineal tears, are related to long-term complications, such as anal incontinence, sexual dysfunction, pain, and a reduced quality of life.
The researchers included more than 100,000 people from a birth record database in the study. The database included midwives’ records of which position the birthing person used during the actual birth. More than half (57%) of the first-time birthing people used epidurals and 26% of those who had given birth before used epidurals. Everyone included gave birth vaginally to a single baby, and no episiotomies were used.
The researchers found that the lowest rates of severe perineal tears occurred among people who delivered in a standing position, and the highest rates of severe tears occurred among those who delivered in the lithotomy position.
Italian study looks at birthing position and urinary incontinence
In another study, researchers in Italy explored what effect birthing positions may have on urinary incontinence (Serati et al., 2016). They conducted phone interviews 12 weeks after the birth with 296 people who used an upright position to deliver and 360 people who used a back-lying or side-lying position. To assess urinary function, participants were asked questions like: How often do you leak? How much urine do you usually leak? When does the urine leak?
The survey data showed that delivering in upright positions was related to a lower episiotomy rate (30% vs. 41%) but a slightly higher rate of third- and fourth-degree perineal tears compared to delivering in the lying down position (1.35% vs. 0%). The episiotomy rate in this study was very high, so these results may not apply to low-episiotomy settings.
Importantly, these Italian researchers found that lying down delivery positions increase the risk for postpartum urinary incontinence and of stress urinary incontinence, defined as involuntary leakage on effort or exertion or sneezing or coughing. It’s possible that this increase in the risk of urinary incontinence may be related to the higher rates of episiotomies with lying down positions.
Positions during Pushing vs. Actual Delivery
In my discussions with professionals and parents around the world, I have heard that some providers may be willing to support pushing in upright positions (passive or active second stage), but few obstetricians will attend an actual birth or “delivery” in an upright position.
For example, health care workers may support someone pushing in a squatting position, but when the baby is about to emerge, they may insist the birthing person sit back in a semi-sitting or lying back position for the delivery. They may say something like, “I need you to get onto your back right now for safety reasons” or “You don’t want to tear, do you? Then get on your back right now,” or “Your baby is going to get stuck under your pubic bone, unless you move right now!”
In other words, it’s common to be given a vague threat combined with an urgent direction. This situation can be confusing, because parents may think it is a true emergency (which is a possibility, of course), so they almost always comply… but many times it is not an emergency, and there is nothing wrong with the birth or baby.
The coercion that some providers use to get patients to lay on their back may be due to general anxiety and fear of upright birth. Since most health care workers are not trained in true upright birth, and rarely (if ever) see one, an upright birth may make them feel nervous and uncomfortable. The easiest way to relieve these feelings of discomfort is to pressure the patient to lay on their back.
The desire for some medical staff to have the delivery happen in a “controlled” manner (non-upright position) is so strong that many birthing people have shared stories with us of either being coerced or forcibly put into non-upright positions during childbirth.
In 2016, Caroline Malatesta won a landmark court case in Alabama in which she sued her hospital for malpractice and fraud. At Ms. Malatesta’s birth, the hospital nurses forcibly turned her onto her back (she was in a hands-and-knees position) during the delivery and held the baby’s head in for 6 minutes until the doctor could arrive, causing a severe, lifelong, maternal nerve injury. The jury awarded a $16 million verdict in Ms. Malatesta’s favor, finding that forcing a birthing person into a delivery position against their will violates the nursing standard of care, especially for un-medicated or “natural” births.
The use of forcing birthing people into the care provider’s preferred position is a form of obstetric violence. In their paper describing Ms. Malatesta’s case in the Journal of Perinatal and Neonatal Nursing, Pascucci and Adams (2017) state:
Obstetric violence is, in its simplest form, a form of violence against women that occurs in the childbirth setting. It is an attempt to control a woman’s body and decisions and may involve coercion, bullying, threats, and withdrawal of support, as well as other violations of informed consent and physical force. Obstetric violence might manifest as forcing a woman supine because that is the doctor’s preferred position for birth… Forcing someone into a particular delivery position could be viewed by the courts as negligence or battery (Pascucci and Adams, 2017).
It is best practice for hospitals, obstetric providers, and nurses to support birthing people in their right to choose positions for pushing and delivery. This does not mean that providers cannot encourage certain positions (or frequent switching of positions) if they feel that they would be helpful in specific situations—but it is unethical for a provider to use coercion or force to achieve a delivery position.
Listen to Evidence Based Birth® Podcast Episode 225 with Mandy Irby, RN, about how the lithotomy position can also be considered an unethical “restraint.”
What are some of the practice guidelines on birthing positions?
In a publication by the World Health Organization (WHO) called “Care in Normal Birth,” the WHO concludes that women in labor should adopt any position they like, while preferably avoiding long periods lying down (WHO, 1996). They recommend that birth attendants get training in supporting upright births, since much of the positive effect of upright birthing positions depends on the birth attendant’s experience with the position and willingness to support the patient’s choice of position.
In 2017, the World Health Organization also published a document called “Managing Complications in Pregnancy and Childbirth,” in which they stated the health care provider should “support the woman’s choice of position during labor and birth.”
In the U.S., the American College of Obstetricians and Gynecologists (ACOG) has a Committee Opinion called “Approaches to Limit Intervention During Labor and Birth.” In this opinion, ACOG states that for most people, “no one position needs to be mandated nor proscribed.”
ACOG also states that it is normal for people in labor to assume many different positions, and that no one position has been proven best. They cite the fact that many care providers encourage a supine position during labor even though it has known adverse effects, including low maternal blood pressure and more frequent abnormal fetal heart rates. They go on to say that continuous EFM has not improved outcomes in low risk pregnancies, and that care providers should “consider training staff to monitor using a hand-held Doppler device (intermittent auscultation)…which can facilitate freedom of movement and which some women find more comfortable.”
The statement concludes with a general recommendation that care providers can support frequent position changes during labor to enhance maternal comfort and promote optimal positioning of the baby if they do not hinder monitoring and there are no complications.
In 2012, three U.S. midwifery organizations –American College of Nurse Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives—created a consensus statement on supporting healthy, physiologic childbirth (U.S. Midwives, 2012). They stated that freedom of movement in labor and the woman’s choice of birth position are essential to this goal.
The Royal College of Midwives (RCM) in the U.K. recommends the use of active and upright positions to assist with labor and delivery. In their guidelines, they urge midwives to be proactive in demonstrating and encouraging different positions in labor, since birthing people often “choose” to do what is expected of them, and the most common image of the laboring person is “on the bed.”
Since the environment is key to freedom of movement, RCM suggests that there should be a variety of furniture and props available in the room to encourage people to try different positions: bean bags, mattresses, chairs, and birth balls. They recommend that midwives support clients with suggestions on how to remain upright even if they’re in a situation that might limit mobility—such as with traditional EFM, intravenous (IV) fluids, and different medications for pain relief.
Summary of the Benefits and Risks
In summary, evidence from randomized trials suggests that for people without epidurals, upright positions during the second stage of labor provide several benefits: a lower risk of abnormal fetal heart rate patterns, less pain, and less use of vacuum/forceps and episiotomy. Upright birthing positions may also shorten the second stage of labor and lessen the use of augmentation with synthetic oxytocin.
In terms of risks of upright birthing positions, some studies have found an increase in second-degree tears from upright birthing positions, but this risk is considered a good trade-off in exchange for a lower rate of episiotomies.
Also, it may be possible to reduce the rate of tears by using the evidence-based “hands off” method in the second stage of labor. You can find our “Protecting the Perineum” Series in Episodes 206, 210, 218, and 221 of the Evidence Based Birth® Podcast.
The evidence on birthing positions for people with epidurals is less conclusive. So far, researchers have not identified clear benefits or risks with different positions when you have an epidural. However, there is some evidence that giving birth in a supported side-lying position may reduce the length of the active pushing phase, and lessen the use of episiotomy, forceps, vacuum, and fundal pressure. Those benefits are more likely when the side-lying position is combined with position changes in the passive phase of the second stage of labor.
Whether or not you have an epidural, researchers have consistently found that the lithotomy position has many harms. One randomized trial found that the use of a special “birth seat may” shorten the length of the second stage of labor, result in less Pitocin® for labor augmentation, and lead to fewer episiotomies and greater satisfaction with childbirth.
Since most of the research on birthing positions is restricted to healthy, low-risk people, these findings may not apply to people with more complicated pregnancies. Future research should avoid grouping the side-lying position with the other non-upright positions, since side-lying allows for more flexibility in the sacrum area, so it shouldn’t be classified alongside the lithotomy or recumbent position.
The Bottom Line
The bottom line is that people giving birth have the right to push and give birth in whatever position is most comfortable for them.
Evidence and ethical guidelines support this bottom line!
Both the Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG) and the American Nurses Association (ANA) have issued statements affirming the importance of patient autonomy. Personal autonomy is defined as the belief that all people have inherent worth and dignity and, thus, the capacity for self-determination (for self-governance and freedom of choice) (ACOG, 2015).
The Code of Ethics for Nurses recognizes specific patient rights, especially the right to self-determination. The Code of Ethics also holds that nurses have an obligation to preserve, protect, and support the moral and legal right of patients (ANA, 2015).
It is an ethical violation for care providers to restrict a laboring person’s freedom of movement or coerce a patient into specific labor or delivery position. This is especially true with un-medicated or “natural” childbirth, since movement and positioning are proven pain management strategies that, for some, could mean the difference between coping vs. suffering.
But how do we put this bottom line into practice?
- Given the evidence and ethical guidelines, educational programs should begin training all students and residents on how to support deliveries in a variety of birthing positions, and teach about the harms of the supine and lithotomy positions. Our future health care workforce must be equipped to uphold the ethical and evidence-based standards of their profession.
- Physicians and midwives should strongly advocate for a birth environment that supports patient choice in birthing positions. If physicians feel that their training and experience have left them anxious about managing complications in an upright birth, they should reach out to midwifery colleagues for training and support on this matter, as many midwives (although not all) are experienced and confident with the concept of upright birth.
- Nurses should seek training/mentorship in upright birthing positions and encourage their patients to push and deliver in upright or side-lying positions. They can physically assist patients into a variety of positions, using all the props and tools available. They can ask, “What position would you like to be in when the baby comes out?” then let the provider know the patient’s preferred delivery position. Nurses can also advocate for upright birth to be taught to patients in hospital childbirth education classes.
- Doulas and childbirth educators can nurture a supportive environment for the birthing person to have the delivery position of their choice. They can physically rehearse different positions with their clients, role play what the patient can do if they experience pressure to get into a back-lying position, and teach advocacy skills. Doulas can support the birthing person’s wishes by asking their client, right before the pushing phase, to remind everyone what position they prefer for the delivery. After the client answers, the doula could tell the birthing person loud, in front of the health care team, “Okay, it sounds like you want to give birth in [blank] position. That’s great! We are all on a team to support you and to honor your wishes.”
Finally, birthing people and their partners should be up front and honest with their health care team about their birth plan. During a prenatal visit, have an honest discussion with your health care provider about your preferred positions for pushing AND delivery. If the health care provider and their practice partners do not seem 100% supportive with the concept of an upright birth, consider switching providers.
To listen to stories from parents who switched providers after learning the evidence, visit EBB Podcast episodes #127, 186, 208, 223, and 231.
And if you are unable to switch providers, or you end up with a provider who is not supportive of your wishes, ensure that you have an advocate (or two!) by your side who can speak up and reaffirm your human right to give birth in the position of your choice.
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- American College of Obstetricians and Gynecologists (Reaffirmed 2015). Informed Consent. Practice Bulletin No. 439. Obstet Gynecol 2009; 114:401–8.
- American College of Obstetricians and Gynecologists (2017). Obstetric analgesia and anesthesia. Practice Bulletin No. 177. Obstet Gynecol; 129:e73 – 89.
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- American Nurses Association (2015). Code of Ethics for Nurses With Interpretive Statements. Accessed online December 10, 2017.
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- Yadav, A., Kamath, A., Mundle, S., et al. (2021). “Exploring the perspective of nursing staff or caregivers on birthing positions in Central India.” J Family Med Prim Care 10(3): 1149-1154.
- Zang, Y., Lu, H., Zhao, Y., et al. (2020). “Effects of flexible sacrum positions during the second stage of labour on maternal and neonatal outcomes: A systematic review and meta-analysis.” J Clin Nurs 29(17-18): 3154-3169.
- GynZone offers many resources, including apps about childbirth (App Store and Google Play)
- You can check out their Bundle of Birth apps– includes postpartum rehabilitation (App Store)
- We particularly love their Birth Positions app! (AppStore and Google Play)
- This video of birthing position options
- This video of birthing positions specifically for people with an epidural
- This poster with images of birthing positions from the Royal College of Midwives
- This video of a wireless, waterproof monitor, and these links to the Novii and GE monitoring products
- These links to the BirthRite Birthing Seat and the CUB (Comfortable Upright Birth) Seat
- Evidence Based Birth® Podcast Episodes:
We would like to extend our gratitude to our expert reviewers for their valuable feedback and critique of the 2018 update of this article: Li Thies-Lagergren, midwife, PhD, Adjunct Lecturer, Lund University; Shannon J. Voogt, MD, Board-Certified in Family Medicine; Hannah Ellis, HCHD, doula at Happy Helper Doula Services in Alabama; and Jesanna Cooper, MD, OBGYN at Simon-Williamson Clinic in Alabama. We would also like to acknowledge Anna Bertone, MPH, for writing the updates in the 2018 version, which has since been replaced by the 2022 update.
We are grateful to Katrine Jonasen and the company GynZone for providing the wonderful birthing position graphics in this article.
We would also like to thank Cristen Pascucci for medical editing assistance in the original version of this article.
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