What is the Evidence for Pushing Positions?

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?

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.

Side-lying – at my midwife’s direction. I was too beyond anything to direct my own positions by then. I do remember a blast of pain when I had to lie on my back for even a second. Makes me shudder to even imagine having to be immobile during the later stages of labor! (Never mind immobile on my back)

Marcia
October 2, 2012 at 8:10 PM

I put “would like to be allowed to labor in any positions I choose” on my birth requests. Got the prior OK from the doc and nurses upon admission. Still ended up sitting on my tailbone!

For my second birth, I put “I don’t want to push while sitting on my tailbone” on my birth requests. Got prior OK and the OK from the nurses upon admission. STILL ended up pushing while sitting on my tailbone, because I was kneeling on the bed and they MADE me turn around.

Hi Marcia, I just don’t get how that happens– how a woman’s wishes could be ignored like that. It would be one thing if you were with it enough to advocate for yourself, but when you are pushing out a baby can be one of the most vulnerable moments of your life. So it is really up to your care providers (and your support persons) to encourage you to push however you are most comfortable. You might like this quote from the Cochrane research study referenced above:

“The influence of medical personnel and institutions over the positions adopted by women during labour and birth has been viewed as inconsiderate… disempowering, abusive and humiliating. In view of indirect evidence that a positive, supportive labour environment promotes a sense of competence and personal achievement experienced by women during childbirth, and their subsequent confidence as mothers and risk of postnatal depression (Wolman 1993), serious attention should be given to medical practices which may undermine or humiliate women during labour.”

Wow! If researchers call forced laying down during second stage abusive… wow. That’s pretty strong. Similarly, if a woman was forced to stay upright when she wanted to lay down, that could also be considered abusive. When it comes to pushing positions, as long as baby is okay and mom is okay, then pretty much mom should be not only allowed– but encouraged– to push however she is most comfortable.

sara r.
October 10, 2012 at 8:17 PM

This same thing happened at my first birth, and also at the past birth that I observed as a doula. Both times the mother (I and my client) insisted on NOT being on the back for pushing, and both times the mother was forced by the staff into a position of their choosing. I noticed at the last birth that even the light in the ceiling is positioned exactly where the mother’s vagina will be when on her back or semi-reclining on the bed. Both times there was no epidural involved, so that wasn’t the issue.
I wonder if tearing rate is affected more by the encouragement of the staff to PUSH PUSH PUSH than the position?
With my second I was at home and chose to be on my side. Anything else would have been TOO fast!

Liz
October 2, 2012 at 9:01 PM

I pushed on my back with my feet in stirrups with my first (full epidural, couldn’t even feel my legs). He was out in 15 minutes. My second was a 2 hour active labor and was so fast that the doctor barely got in the room and scrubbed up before he was out. I was sitting on the bed when I got the urge to push and there’s no way I could have switched positions if my life depended on it. He was out in less than 2 minutes. Apparently I’m a power pusher I had second degree tears both times.

Shannon
October 2, 2012 at 11:24 PM

Hi laboured on my back with my first son and pushed for 3 hours!! I knelt in a tub with my second and pushed three times!! My midwife encouraged me to turn onto my hands and knees with the first but I was so tired and in so much pain I felt like I couldn’t do it, looking back I wish I’d listened

[…] extraction and episiotomy. The precise increase of these other procedures is hard to determine from the research we do have–here’s a very thorough look at the data on this topic– but it’s significant […]

Bibi
October 3, 2012 at 3:18 PM

I had two kids natural birth and pushed the first one for 15 min, and the second for 9 minutes. No tears, it was great. I think pushing should be done in the position that the labouring woman finds approriate/less painful/desirable for her at the moment.
For centuries nomadic women of Central Asia delivered babies standing (I mean really standing up) and holding to a pole/ long stable stick or some sort. My grandmother gave birth tow 13 healthy children that way and never had any complications. Whereas I would probably be scared to fall down and hurt the baby or myself, I think the upright position is the closest to that method of birthing and one of the most beneficial in my view.

Liesal
October 3, 2012 at 6:50 PM

The majority of my pushing was done side-lying. I did not have an epidural, but that position was just how I ended up. I think it was because my dr gave me the ok to push after checking me (stupid me shouldn’t have waited, but just went with my body-I probably would’ve pushed standing if I had listned to my body), so I was on my back, and just rolled over when she was done. They did suggest that I get on all fours to push for a bit to help me make progress, but it was not as comfortable for me and my son’s vitals went down in that position too. I don’t exactly remember what position I was in when I actually delivered him. I think it was half side half back. Since I didn’t have an epidural, so they pretty much let me do whatever I wanted.

cat
October 4, 2012 at 1:04 AM

I pushed lying on my left side. My body began to push while I was in a squat and my legs would shoot up straight during contractions and I could feel the baby descending… I was so shaky from hormones and getting tired that I was scared of my legs holding up. kneeling and leaning against the back of the bed was suggested- but I really wanted to lay down.

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Joanna miller c
October 10, 2012 at 5:43 PM

I love to hav Pts get on their hands and knees. Sometimes the circulation to their legs isn’t too good after a bit but otherwise they often make significant progress in this position. I also love the toilet for pushing (I wish we had a birthing chair/stool). I hav seen it all– moms delivering while standing, laying in the cold labor room floor, sitting on the toilet … Just whatever felt right. If they have an epidural we often have them play tug of war with a knotted bed sheet! If helps them pull upright and really does the trick for moms who seem stuck!

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