Wait a Minute…I Don’t Have to Push on My Back??

Many parents arrive to the delivery room with the expectation that their baby will be born via the traditional lithotomy position (back-lying, legs up in stirrups). However, this is not the only birthing position, nor is it necessarily the best one for every woman. A multitude of positions exist and current research suggests that utilizing a variety of positions during the active phase of labor (i.e. pushing) may be beneficial. Not only are you able to try different positions while you push, you should be encouraged to do so whenever possible!

Why is a non-upright or back-lying position usually used?

Most vaginal deliveries in the U.S. occur via a non-upright position. Historically, physicians were trained to deliver mothers while lying on their backs.1 This is the easiest position for visibility and for continuous fetal heart monitoring. However, prolonged positioning on your back may present the same risk as sleeping on your back while pregnant: compressing major blood vessels and reducing blood flow to both mother and baby.2

What are the benefits of upright positions?

Gravity creates a major difference here. It can aid in moving the baby downward through the pelvis. In addition, some women report feeling less pain when they are upright during contractions and for pushing.3 Other potential benefits include:

• Decreased risk of abnormal fetal heart rate patterns as you might see in positions that could compromise blood flow3
• Decreased chances of receiving an episiotomy3
• You might not need forceps or a vacuum to augment your delivery3,4

What are my positioning options?

There are many birthing positions to try, and you may find that you come up with your own combination as you navigate pushing in the second stage of labor. Popular options include:

• Hands and knees with or without a birthing ball underneath your torso for extra support
• Kneeling – If needed, you can hold onto something for balance, whether that’s the bed or a support person.
• Squatting – This can be turned into a partner position by having someone support you from behind and underneath your arms as you lean back on them. You can also squat at the foot of the bed while holding onto a birthing bar.
• Sitting on a birthing stool which allows you to push in the same way you would have a bowel movement
• Standing – Again, hold onto whatever/whoever you need to balance.
• Elevated on your side – Prop yourself up on as many pillows as you would like. A support person can hold and lift your upper leg for you, or you can balance it on a birthing bar.

What if I have an epidural?

When you receive an epidural, you may lose a great deal of sensation in the lower half of your body or feel as though your lower half is heavy. Because of this, you might not have full control of your legs and are at risk for falling. Your L&D team will have you remain in bed, but you still have many positioning options! You can try a side-lying or sitting position with the head elevated at different heights. It can also be helpful to elevate the head of the bed and get into a kneeling position while facing the mattress, using the top of the bed to rest your forearms. This position might feel similar to kneeling and praying at a pew. Added tools such as a birthing bar can be used to balance hands, feet, and legs. You can even tie a sheet around it to tug on while you hunker down and push! A delivery bed has many moving and attachable parts that can all be adjusted to help you find supportive positions. Please feel empowered to explore your options! You can also ask your labor and delivery nurse as they often have tried many different positions with their patients over the years.

I’m nervous about trying these upright positions, how do I know this is safe?

Current practice guidelines from professional organizations encourage position changes during the second phase of labor, including upright positions, as long as they are not contraindicated or interfere with fetal monitoring2. This is not a new concept! In 1996, the World Health Organization advised against remaining in a back-lying birthing position for long periods of time due to the risk for disruption in maternal and fetal blood flow.5 Utilizing a variety of birthing positions during labor and delivery is widely encouraged in efforts to promote safety, comfort, and autonomy.

What can I do in preparation?

• Talk to your provider about plans for fetal heart monitoring. Alternatives such as mobile monitors might be viable options that allow you to move around more freely.
• Practice positions beforehand… but remember not to actually push while practicing!
• If you are planning to have a support person in the delivery room with you, try out partner positions in advance to increase your comfort level with these position changes during delivery.
• If you are planning to receive an epidural, remember that you can still explore many different positions in bed! Listen to your body and get creative.
• Consider incorporating a doula into your birthing plan. Part of what doulas can help you with during delivery is finding the positions that are best for you. Doulas are highly knowledgeable on this practice and a wonderful resource to have!

Overall, positioning choices are completely individual. Some women find that they actually prefer back-lying positions and periodically take breaks to roll to their side. The point is that you have the autonomy to explore positions that help you feel powerful and supported throughout your delivery. Your team is there to help you accomplish this within your safety parameters, do what feels right!

For visual examples of birthing positions and more information visit:

https://www.takingcharge.csh.umn.edu/birthing-positions

https://www.lamaze.org/labor-positions

References:

1. Dekker, R. The Evidence on: Birthing Positions. com. https://evidencebasedbirth.com/evidence-birthing-positions/. Updated February 2, 2018. Accessed June 21, 2020.
2. Approaches to Limit Intervention During Labor and Birth. acog.org. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth. Published December 20, 2018. Accessed June 21, 2020.
3. Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;5(5):CD002006. Published 2017 May 25. doi:10.1002/14651858.CD002006.pub4
4. Deliktas A, Kukulu K. A meta-analysis of the effect on maternal health of upright positions during the second stage of labour, without routine epidural analgesia. J Adv Nurs. 2018;74(2):263-278. doi:10.1111/jan.13447
5. Care in Normal Birth: A Practical Guide (1996). World Health Organization.