Which Birthing Positions are Best: What the Evidence Tells Us

As doulas with 10+ years of experience, one of the questions we get the most from our clients is “what are the best birthing positions?” Understandably, they want to know which birthing positions will be the most comfortable and help create the most positive birth experience.

Which Birthing Positions are Best?

Every pregnancy and birth is different. We’ve seen what’s comfortable for one birthing individual feels like torture for another. And even the baby has a preference of positions as indicated by their intolerance of certain positions signalled by heart rate decelerations!

As an Evidence Based Birth® Instructor, I see birthing positions are one of the biggest hot topics right now and for very good reason. We find birthing individuals find themselves in a conundrum when it comes to pushing positions and we want to share strategies for navigating this vital issue! This is also an important ethical issue as being able to give birth in your position of choice is seen as a human right. However, it’s also one that’s not allowed in many cases here in the U.S. and around the globe.

The Two Most Popular Hospital Birthing Positions

Two pushing positions make up 91% of all hospital based birthing positions in the U.S. And, surprisingly, they are NOT evidence based!

They are:

  1. Lying on the back with feet in stirrups or legs being held (lithotomy position) 
  2. Lying on the back with the head of the bed raised (semi-sitting). 

The Benefits of Upright Birthing Positions

Evidence has clearly shown that upright positions such as kneeling, hands and knees or squatting offer many benefits.

This is because they:

  • Take advantage of gravity
  • Help open the pelvis
  • Allow the uterus to contract more efficiently

They also allow for more oxygen to flow to the baby as pressure is taken off the aorta, the body’s main blood vessel. Less pressure on the aorta leads to better oxygen supply to the baby. It also comes with a lowered risk of abnormal fetal heart tones leading to lower risk of emergency cesarean.

Any position, even side lying, that takes the body weight off the sacrum is beneficial. This is because the coccyx or tailbone at the bottom tip of the sacrum is flexible! Being on your back puts it in a fixed closed position. Allowing it to move freely? This actually allows it to flex an additional 16 degrees. This makes more room for the baby’s head to come down!

Lying on the back simply doesn’t make physiological sense. You would never see large mammals like the elephants of our beloved logo lying down to give birth! 

Benefits of Upright Birthing Positions

There is resounding evidence that for those without epidurals, upright birthing positions result in:

  • Less forceps or vacuum use
  • Shorter pushing times
  • Reduction in severe perineal tears
  • No increased risk of postpartum hemorrhage

In addition there are lower pain levels, fewer emergency cesareans, and more positive birth experiences reported! For those with epidurals, the lithotomy position with feet in stirrups has actually proven to be quite harmful with higher rates of cesarean, use of vacuum or forceps delivery, perineal tears, episiotomies and longer pushing phase.

The conundrum

One would think it would be simple to choose an upright pushing position. But unfortunately, it’s much more likely than not that you will most likely face opposition to this when it’s time to push. So, if your choice of position is important to you, it’s vital to do some advance planning to make it more likely for you to experience what you want. 

Understanding Why There’s Pushback About Upright Birth in Hospitals 

There’s been lots of talk lately about the possible origin of women birthing on their back. Interestingly, ancient history has shown that dating back to the bible, birth stools and sitting upright was the norm. It’s been said that King Louis XIV had a particular kink of watching women give birth. So, he instituted laying on the bed for a better view. Ewww. 

In modern days, women birthing on their backs in bed has more to do with convenience of the delivering physician. In one study, 92% of labor and delivery nurses were aware of the evidence on upright birthing position and believed that women should have their choice of positions. Yet, 100% of nurses said that the laying on the back position was the most common.

It also allows easier access to the abdomen for nurses to carry out their responsibility for continuous electronic fetal monitoring. However, in many cases, continuous fetal monitoring is also not evidence based! This continuous monitoring has not improved rates of cerebral palsy or infant death. Instead, it actually results in higher cesarean and forceps deliveries.

Instead, intermittent listening of the baby’s heartbeat with a handheld device has proven to be evidence based. However, it has not been adopted in hospitals due to the training and additional time with the patient that would be needed. 

Perhaps the largest reason for sticking to this lying down position? Health care training.

Most have not been trained to deliver in any other position than lying down. One of the reasons for this is the industry mannequin used in training, “Noelle” is easiest to position lying down!

Since they have not been trained in upright birth, it’s understandable why delivering physicians may be uncomfortable delivering any other way. They are trained to manage any unforeseen emergencies during delivery from this position. They are unsure they would know how to manage an emergency from any other position. They’ve learned how to handle shoulder dystocia, when one shoulder gets stuck – only with the patient on her back. Yet there is less incidence of shoulder dystocia in upright birth! 

Another reason is the high rate of epidural use. This can make it difficult to get into an upright position. But it CAN be done—it just takes extra personnel and training.

Delivering physicians relying on non evidence based belief that hands on methods of protecting the perineum is beneficial. This means they will want the patient in a position that they can have access to this area. Yet, evidence clearly shows a hands off approach is best to prevent tears!

How Do YOU Feel About Birthing Positions?

With all birth plan items, it’s important to prioritize your goals and desires. Perhaps this isn’t an issue that you have much of a preference on and that’s okay. It’s challenging to fight this particular fight. So, if it’s not particularly important to you, by all means that’s okay. Put your focus and energy on other things that matter most to you! 

What we know

Also despite all the benefits of upright birth, it’s rare to actually deliver in any other position than lying down in the hospital for SO many reasons. So, don’t set yourself up for feeling badly about it if in the end you are one of the 91% of individuals who does end up delivering this way. It’s okay!

It’s impossible to know how you’ll feel in the moment

We’ve had clients who thought this was an issue of the highest priority to them. But only in the moment, they wanted want to stay on their backs as it was either the most comfortable for them or they simply weren’t up to moving the mountain they would need to move to make anything different happen in the moment. After you’ve been through an entire labor and are at the finish line you may not be in the same mental state or the physical shape who originally walked into your labor room. And that’s okay too!

Something to be aware of…

Even in cases where you are “allowed” to push in various positions, the delivering health care provider will often direct you to get on your back for the actual delivery. This can either be done as a suggestion, a directive, or a threat of what’s best for the baby and this is hard to argue with in the heat of the moment. If a provider says “I need you to get on your back now so I can safely deliver the baby,” this is hard to not comply with.  

Before specializing only in hospital births, we saw that when women move freely in labor, they almost always come into an upright position for pushing. That’s because they found it the least painful and instinctively more efficient using gravity and creating the most room for the baby to come down and out. Finding themselves on hands and knees was perhaps the most common and comfortable position.

What You Can Do

  • Become familiar with alternative birthing positions and birthing tools!
  • Gather Evidence Based Information to support your goals and conversations with your healthcare provider
  • If the birthing position is important to you, include this priority in your birth plan 
  • Discuss birthing positions with your healthcare provider in a prenatal appointment

Be on the lookout for red flags that don’t make sense to you, condescending answers, or fear mongering about safety to the baby. If necessary, consider changing your provider. However, with large practices it’s impossible to know who will be on call when you’re ready to deliver. This discussion ahead of time can only get you so far.

Discuss Your Goals with Your Nurse!

Your best bet is to concentrate on discussing your goals when you are actually in labor with your nurse!

Your best ally would be your nurse on duty during the final stages of your labor. They know the preferences, methods, and style of the delivering physician on call most likely to be doing your delivery! Bring this up with your nurse to see what you might be up against and ask for their assistance in increasing the odds that you can at least push in alternate positions if not actually deliver the baby in them. Their knowledge of the healthcare provider’s attitude and methods will help you prepare for how to deal with him or her in the moment. There’s lots of things your nurse can say and do to increase the odds of getting to push in your desired position. It’s imperative to invite their cooperation with words of gratitude…and bringing some yummy treats doesn’t hurt either! 

If you find your nurse to be particularly not helpful or working against you, you have every right to request a different nurse who supports your birth goals.

This doesn’t have to be a confrontation and usually the nurse is just as happy to not have you as a patient if you’ve been butting heads!!

Simply contact the charge nurse (their number is usually posted in your hospital room) and request a different nurse stating you don’t believe you’re a good match. 

Get prepared! Get educated about your hospital birth! 

Last but not least – remember, it’s why we (The Hospital Doulas!) exist!

We believe it’s VITAL to be prepared for the routine care that is awaiting you in your hospital birth. Proper preparation is KEY! Knowing the ins and outs of the hospital birthing system and learning simple strategies for navigating the system without confrontation or stress. And we have all of the tools and information you need. Consider enrolling in our prenatal masterclass and you’ll come away feeling more prepared and empowered for birth!

Who We Are: Online Childbirth Class Instructors and Hospital Doulas

  • Lisa Collins, MA., CD(DONA), ProDoula, Evidence Based Birth® Instructor
  • Marnie Lea, RDH., CD(ProDoula)

Co-Founders of The Hospital Doulas & Associates LLC