What Position Is Best for Pushing?

There's more than one way to push out a baby -- in fact, there are several ways! But what about the "best" way? Is there even such a thing? When asking this question, people are often trying to understand the most effective (read: quick, more comfortable) way to position their body for pushing during a vaginal birth. That said, there are so many variables to consider when it comes to choosing a position for pushing, including:

• Hospital, home, or birth center
• In or out of bed, or in the water
• Use of epidural
• Any complications/risk factors
• Choice of care provider (may or may not encourage different positions)
• Support for pushing in different positions (from people and with different tools)
• Your knowledge and comfort with different positions

Each of the choices above can either expand or limit your pushing position choices, so it's important to become educated (including by taking a quality childbirth class) about your options and know how different choices and care providers can improve or reduce those options. 

Before talking about optimal positions for pushing, it's important to note the most common position seen in hospitals, which also happens not to be an ideal position for pushing: laying in a semi-reclined or fully reclined position on your back. This position may be useful in certain situations, but in general, because it does not take advantage of gravity like other upright positions and because it compresses the tailbone, it can cause increased difficulty when pushing, and may require interventions like vacuum extraction or forceps for birth. 

Ideal positions for pushing, in most cases during vaginal birth, include two components: being upright and taking the weight/compression off of the tailbone. For example, sitting up in bed is upright, but places weight on and compresses the tailbone, making the opening for baby to move down and out smaller. Upright positions that meet both requirements include:

• Sitting on a specially designed birthing stool/chair 
• Kneeling 
• On all fours/hands-and-knees 
• Squatting
• Standing

Side-lying positions take weight off of the tailbone, but do not have the benefit of gravity. Side-lying positions can be very helpful when a person needs to push in a more restful position or with an epidural as it allows for a widened pelvic outlet. 

For people who give birth without an epidural, upright positions have been shown to reduce the need for forceps or vacuum-assisted birth and episiotomy, and are less likely to produce abnormal fetal heart rate patterns. (Source) Upright positions can be associated with an increase in second degree tears (though this can be reduced when spontaneous pushing vs. directed pushing is used) and increased blood loss (though the accuracy of this finding is questionable, and in people who are well nourished, this blood loss is not harmful).  

For people who give birth with an epidural, the evidence shows that upright positions vs. supine (lying down) positions do not make a significant difference in the rate of cesarean or use of forceps or vacuum, nor did it impact the length of pushing time, incidence of tears, fetal heart rates, or blood loss. Based on the current evidence, there is not an "ideal" recommended position for pushing with an epidural. 

Ultimately, the ideal position for pushing and giving birth is the position that you choose, which means you are encouraged by your care provider and support team to try different positions that feel/work best to/for you. The best ways to try out different positions is to be sure you learn about the many options available to you (take a childbirth class!) and have a good continuous support team to help and encourage you when the time comes. A doula is an excellent choice to help suggest and support you in different positions throughout labor, including during the pushing stage.