GUEST BLOG by Lisa & Marnie from The Hospital Doulas

What’s the best position to give birth in - let’s see what the evidence recommends.

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 safest, 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 woman 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! How do we define best? ‘Best’ can mean - best for mom and baby - or best for staff…

Birthing positions are one of the biggest hot topics right now and for very good reason. Women are finding themselves in a conundrum when it comes to pushing positions and we want to share strategies for navigating this vital aspect. 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 facilitated in many areas in the U.S. and around the globe.

The Two Most Common Hospital Birthing Positions

Two pushing positions make up 91% of all hospital based birthing positions in the U.S. but surprisingly, they are NOT evidence based and may in fact create complications.

They are:

1. Lying on the back with feet in stirrups or legs being held (lithotomy position) see image below.

2. Lying on the back with the head of the bed raised (semi-sitting). 

What are the evidence based alternatives?
Enter: Upright Birthing Positions

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

Why is this?

• You’re taking advantage of gravity

• It helps open the pelvis even more

• It allows the uterus to contract more efficiently

Upright positions also allow for more oxygen to flow to 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 your 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 (for all the reasons above), it’s vital to do some advance planning to make it more likely for you to have a positive experience.

Understanding Why There’s Resistance to Upright Birth in Many 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 wanted to watch 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, if you’re a health well full term mom continuous fetal monitoring is not evidence based and comes with significant tradeoffs! Continuous monitoring does not improve birth outcomes and the research is overwhelming (fear of litigation drives this practice).

Healthy well women who opt for continuous monitoring instead of intermittent monitoring experience 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 fear of litigation and additional time with the patient that would be needed (it’s very unlikely you’ll have continuous 1:1 care with a nurse/midwife in labor).

Perhaps the largest reason for restricting your right to choose your position for birth is 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 many physicians have not been trained in upright birth, it’s understandable why they 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. However there are providers who facilitate birth in almost any position, respectful of mom’s preferences and the physiology of 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 (or an amazing doula and well informed partner). Be sure to read the GentleBirth Epidural Birth Preferences blog to get the most from an epidural while minimizing associated risks.

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 may be 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 very challenging to debate positions on the day. So, if it’s not particularly important to you, that’s okay. Put your focus and energy on other things that matter to you! 

What We Know

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 the reasons we’ve described here. Proactively finding a provider who will support you is key. Here are some questions to consider when discussing ways to avoid tearing in labor.

It’s impossible to know how you’ll feel in the moment so be somewhat flexible - you may hear of women who in that moment didn’t want to change positions and that’s ok too!

Something else to be aware of - even in some cases where you are “allowed” to push in various positions, the delivering health care provider MAY direct you to move onto your back for the actual delivery…Yup…and 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.  This is why finding a careprovider who is on the same page as you can make or break your birth experience. Then you can be reassured that changing your position is really needed and not just your provider’s preference for what’s easier for them.

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 explore with your provider.

If the birthing position is important to you, include this priority in your birth preferences .

Discuss birthing positions with your healthcare provider in a prenatal appointment.

Be on the lookout for red flags that feel ‘off’ to you, condescending answers, or fear mongering about safety to your 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.

As doulas specializing in hospital birth we believe a helpful strategy is to concentrate on discussing your preferences 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 (assuming they are supportive). They know the preferences, methods, and style of the delivering physician on call most likely to be doing your delivery. Your partner can bring this up with your nurse to see what you might be up against and ask for their assistance in increasing the odds of trying some different positions. 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 appreciation. If you find your nurse to be particularly unhelpful 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!! Have your partner 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.  It’s no big deal - having the right energy in the room so you feel supported and psychologically safe will contribute to a more positive experience no matter how your baby arrives.

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. Comprehensive preparation is KEY! Knowing the ins and outs of the hospital system and learning simple strategies for navigating the system without confrontation or stress. And we have all of the tools and information you need.

This post was brought to you in collaboration by The Hospital Doulas & Associates

Contact us for more details so you can prepare to 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.