There is no single “best” birth position for everyone. The American College of Obstetricians and Gynecologists states that no one position needs to be mandated or ruled out for most women, and recommends frequent position changes to enhance comfort and promote optimal fetal positioning. That said, different positions offer distinct advantages for pain, labor progress, perineal protection, and baby’s descent. Understanding what each one does can help you make an informed choice when the time comes.
Why Position Matters During Birth
The position you’re in during the pushing stage affects how much room your baby has to move through the pelvis, how efficiently your contractions work, and how much strain your perineum absorbs. In an upright position, gravity helps your baby descend naturally. In the classic on-your-back position (lithotomy), you’re working against gravity, pushing your baby upward and over the curve of your tailbone. Hospitals have traditionally favored the on-your-back position because it gives the care team easier access to monitor mother and baby, not because it’s physiologically ideal.
Upright Positions: Standing, Squatting, and Kneeling
Upright positions let gravity do some of the work for you. Standing, squatting, and kneeling all align the birth canal in a way that encourages your baby to move downward with each contraction. Squatting in particular opens the pelvic outlet wider, creating more space for the baby to pass through. Ultrasound research has confirmed that positions involving deep hip flexion slightly widen the pubic joint compared to lying flat on your back, though the difference is small (about 1 millimeter).
A Cochrane review of 19 randomized trials found that women in upright positions who were not using an epidural had a second stage of labor that was about 6 minutes shorter on average compared to women in horizontal positions. Six minutes may not sound dramatic, but during active pushing, every minute counts for energy and endurance.
Squatting does come with a tradeoff. Studies of first-time mothers found that squatting had one of the highest rates of severe perineal tears at 8.3%, likely because the baby can descend quickly and forcefully. If you choose to squat, having support (a partner, a bar, or a birth stool) can help you control the speed of delivery. Birth stools showed a similarly elevated tear rate of 7.1%.
Side-Lying: Strong Perineal Protection
Lying on your side during pushing is one of the gentlest options for your perineum. In this position, the pressure of the baby’s head spreads more gradually across the tissue, and rapid expulsion of the head is less likely. A large observational study found that first-time mothers who gave birth in a lateral position had a 21% reduction in episiotomy rates and a significantly lower risk of moderate perineal tears (roughly a 15 percentage point drop) compared to other positions.
The tradeoff is time. First-time mothers in lateral positions had a second stage that was about 10 minutes longer. For many women, that’s a worthwhile exchange for less tearing and a smoother recovery. Side-lying is also one of the most restful positions available during what can be an exhausting process, since your body weight is fully supported by the bed.
Hands and Knees
The all-fours position is often recommended when the baby is facing the wrong direction. Babies ideally face your spine during delivery (called occiput anterior), but some face your belly instead (occiput posterior), which can cause intense back labor and slow progress. One trial of 100 women found that after just 10 minutes on hands and knees, the baby was 74% less likely to still be in a lateral or posterior position compared to women who sat upright.
That said, larger studies paint a more complicated picture. A trial involving over 2,500 women who practiced hands-and-knees positioning twice daily in late pregnancy found no difference in the baby’s position at delivery. And a trial of 147 women who used the position during labor itself showed a trend toward fewer posterior babies at birth, but the result wasn’t statistically significant. The position seems most useful as a short-term tool during labor rather than a preventive strategy in pregnancy.
Hands and knees also takes pressure off your lower back, which can provide real relief if you’re experiencing back labor regardless of fetal position.
On Your Back: Lithotomy Position
Lying flat on your back with your legs in stirrups remains common in hospital settings. It gives your provider the clearest view and easiest access, which matters during complicated deliveries or when instruments are needed. The severe perineal tear rate in lithotomy is about 6.1% for first-time mothers.
The main downside is physiological. When you lie flat, the weight of your uterus compresses major blood vessels. MRI research has shown that even 20 to 30 minutes in the supine position acts as a stressor to the baby, reducing placental blood flow and oxygenation. One study found that fetal heart rate was higher when mothers lay on their backs (about 139 beats per minute) compared to lying on the left side (about 134 beats per minute), a sign the baby’s cardiovascular system is compensating for reduced oxygen. A semi-reclined position (tilted at least 45 degrees) avoids much of this compression while still giving providers reasonable access.
How an Epidural Changes Your Options
If you have an epidural, your lower body will be partially or fully numb, which limits the positions you can safely hold without support. You won’t be able to squat or stand independently, but side-lying, supported sitting, and semi-reclined positions are all feasible. Some hospitals offer “walking epidurals” with lower doses that preserve more leg strength and allow kneeling or supported upright positions.
A Cochrane review comparing upright and recumbent positions for women with epidurals found no clear difference in rates of cesarean delivery, instrumental delivery, or the length of the second stage. The confidence intervals were wide, meaning neither option proved clearly better. The reviewers concluded that women with an epidural should simply use whatever position feels most comfortable.
Choosing a Position That Works for You
Your ideal position may change as labor progresses. Many women start upright or on hands and knees during early pushing, then shift to side-lying or semi-reclined as they tire. Here’s a quick comparison of the main options:
- Squatting or standing: Opens the pelvis, uses gravity, may shorten pushing. Higher risk of perineal tears.
- Side-lying: Best perineal protection, restful, slightly longer pushing stage.
- Hands and knees: Relieves back pain, may help rotate a posterior baby.
- Semi-reclined (45+ degrees): Good compromise between provider access and avoiding blood vessel compression.
- Flat on back (lithotomy): Best provider access for complicated deliveries, but works against gravity and can reduce blood flow to the baby.
The strongest takeaway from the research is that mobility matters more than any single position. Changing positions throughout labor helps you respond to pain, encourages the baby to rotate and descend, and lets you find what feels right in the moment. If your birth plan allows it, discuss position flexibility with your care team before labor begins so you know what’s available to you in the delivery room.