This is one of the Lamaze Healthy Birth Practices.

Download a print-friendly PDF.

A pregnant woman in a Lamaze class asks about the way to push during birth: “The hospital where I plan to give birth has a birthing bed, but I still see lots of pictures that show women giving birth lying down with their legs up. Is there an advantage of one position over another? Also, I heard that holding your breath to push isn’t safe for the baby, so how can I push my baby out safely?”

Throughout history, images depicted in art show that women have used many positions to give birth to their babies, including standing, sitting, hands-and-knees, and side-lying. Until doctors began using forceps in the 17th century, women rarely were shown giving birth lying on their back. With the support and encouragement of family members and community midwives, laboring women used objects such as posts and ropes to gain leverage during pushing. They often used birthing supports or stools to help them squat, crouch, or kneel (Gupta & Nikodem, 2000). More recently, research has helped us understand how laboring women push when no one is telling them to push a certain way. Women following their own urge to push usually will wait for each contraction to build and then push for about five seconds, take a few short breaths, and then push again (Roberts & Hanson, 2007).

In contrast, a recent survey of women who gave birth in the United States in 2005 reported that 57% gave birth lying on their back, and an additional 35% gave birth propped up in a semisitting position (Declercq, Sakala, Corry, & Applebaum, 2006). Only 21% of women in the survey followed their own urge to push. The rest of the women reported that nurses or other health-care providers told them to push a certain way.

Positions for Pushing
Lamaze can help you feel more prepared for childbirth and more satisfied with your childbirth experience by providing you with information about various labor positions. By choosing the positions that feel most comfortable, you can create an overall more positive birth experience. Just as importantly, doing this enhances the progress of labor.

Using several positions during the bearing-down or pushing part of labor helps you work with your baby as she turns and comes down through your pelvis. The positions that you choose often will make you more comfortable and help your baby’s progress. There is no one position that is best for every woman and every baby. Each position has advantages and disadvantages and can be helpful in different situations (Simkin & Ancheta, 2005; Simkin & O’Hara, 2002).

Upright Positions
Upright positions—such as standing, kneeling, or squatting—take advantage of gravity to help your baby move down into the pelvis. Squatting increases the size of the pelvis, providing more room for the baby to move down (N. Johnson, V. Johnson, & Gupta, 1991; Simkin & Ancheta, 2005). Squatting is the most tiring position, so you may want to rest between contractions in a position that does not use gravity, such as side-lying, semisitting, or kneeling on all fours.

Some women have used a “standing supported squat” or “dangle” position, as described by Penny Simkin, a well-respected childbirth educator. In this position, you are supported under your arms, putting very little weight on your legs or feet. This position is most useful for someone with a long pushing stage and also makes the trunk on your body longer. It makes more space for the baby to move, which enables the pelvis to work more freely (Simkin & Ancheta, 2005).

Positions That Do Not Use Gravity
Positions that do not use gravity to help move the baby down—such as hands-and-knees, side-lying and semisitting—are relaxing and help if you are tired. Lying on your side will help slow down a labor that is progressing too fast and may help avoid tearing of the area between the vagina and anus as the baby comes out (A. Shorten, Donsante, & B. Shorten, 2002). Research shows that the hands-and-knees position helps ease back pain in labor (Stremler et al., 2005).

Types of Pushing
When you push in response to the natural urge to push, it is called “spontaneous pushing,” meaning you are doing what your body tells you to do. This natural urge comes and goes several times during each contraction. Each of these bearing-down efforts or urges usually lasts from five to seven seconds. However, when you are directed by your caregiver and those around you to hold your breath and push to a count of 10 seconds, repeating this two to three times during a contraction, you are using directed pushing.

Responding to the urge to push with short periods of holding your breath in a calm, unrushed environment has many advantages. Your baby will get more oxygen through the placenta, you will be less likely to become physically exhausted, and there is less chance of damage to the perineum and the muscles of the pelvic floor in the vagina (Albers, Sedler, Bedrick, Teaf, & Peralta, 2006; Roberts & Hanson, 2007). If you are having a very difficult time pushing the baby out, directed pushing might help. However, pushing spontaneously will usually be easiest and safest for both you and your baby.

What Research Tells Us
According to the Cochrane Pregnancy and Childbirth Group, a respected international organization that defines best practices based on research, the use of any upright or side-lying position compared with lying on your back with your legs in stirrups is associated with the following results:

• shorter second (pushing) stage of labor;
• a small decrease in the use of vacuum or forceps;
• fewer episiotomies;
• less chance of experiencing severe pain;
• fewer abnormal fetal heart tracings;
• a small increase in second-degree tears (in the upright group only); and
• an increase in estimated blood loss, although there was no evidence of serious or long-term problems from the extra blood loss (Gupta, Hofmeyr, & Smyth, 2004).

Lying on your back may cause lower blood pressure and less blood flow to your baby due to the weight of the uterus on major blood vessels (Roberts & Hanson, 2007). When you lie on your back with your legs up in stirrups, you are actually pushing your baby out against gravity.

Research does not support the routine use of directed pushing, and some researchers suggest it is harmful. Holding your breath for a long time naturally decreases the flow of oxygen to your baby. Research suggests that this is stressful and may even be harmful for your baby (Roberts & Hanson, 2007). Also, the excess force of directed pushing can be harmful to your perineum, resulting in more tears and weaker pelvic floor muscles several months after the birth (Schaffer et al., 2006). Weakness in these muscles is associated with incontinence (involuntary loss of urine or feces). Listening to your body, working with the pushing urges, and birthing your baby between contractions reduce the risk of tears (Albers et al., 2006).

One study showed that the average length of the pushing part of labor is 13 minutes shorter in women who use directed pushing (Bloom, Casey, Schaffer, McIntire, & Leveno, 2006). However, there is no medical benefit to a shorter second stage of labor as long as you and your baby are doing well (Janni et al., 2002). Because there are no important benefits to directed pushing and there is the possibility of harm when it is used, it is best for you and your baby if you push how and when it feels right to you.

Recommendations from Nurses
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) recommends that all pregnant women receive information about the benefits of upright positions for the second stage of labor (Mayberry et al., 2000). The association also recommends that nurses discourage lying on your back and, instead, encourage squatting, semisitting, standing, and upright-kneeling positions. In addition, AWHONN recommends that laboring women do not begin pushing until they feel the urge to do so and that, when they do push, they push according to their body’s natural urges. AWHONN also proposes that the nurse should encourage grunting, groaning, or exhaling during the push and holding your breath for less than six seconds as you push in response to your contractions.

Recommendations from Lamaze International
Lamaze International recommends upright, hands-and-knees, or side-lying positions for birth.. During labor, you should push when and how your body tells you to and choose the positions for birth that are the most comfortable for you. You should be confident that by responding to what you are feeling, you will make birth easier and safer for yourself and your baby.

To learn more about safe, healthy birth, read The Official Lamaze Guide: Giving Birth with Confidence (Lothian & DeVries, 2005), visit the Lamaze Web site (www.lamaze.org), and sign up to receive the Lamaze…Building Confidence Week by Week e-mails.

Most recent update: July 2009

References
Albers, L. A., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2006). Factors related to genital tract trauma in normal spontaneous vaginal births. Birth, 33(2), 94–100.

Bloom, S., Casey, B., Schaffer, J., McIntire, D., & Leveno, K. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13

Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth Connection.

Gupta, J. K., Hofmeyr, G. J., & Smyth, R. (2004). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002006.

Gupta, J. K., & Nikodem, C. (2000). Maternal posture in labour. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 92(2), 273–277.

Janni, W., Schiessl, B., Peschers, U., Huber, S., Strobl, B., Hantschmann, P., et al. (2002). The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome. Acta Obstetricia et Gynecologica Scandinavica, 81(3), 214–221.

Johnson, N., Johnson, V., & Gupta, J. (1991). Maternal positions during labor. Obstetrical and Gynecological Survey, 46(7), 428–434.

Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Nielsen-Smith, K. (2000). Second-stage management: Promotion of evidence-based practice and a collaborative approach to patient care. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).

Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.

Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M., & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192(5), 1692–1696.

Shorten, A., Donsante, J., & Shorten, B. (2002). Birth position, accoucheur, and perineal outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 18–27.

Simkin, P., & Ancheta, R. (2005). The labor progress handbook (2nd ed.). Malden, MA: Blackwell Science.

Simkin, P., & O’Hara, M. (2002). Nonpharmacological relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S131–S159.

Stremler, R., Hodnett, E., Petryshen, P., Stevens, B., Weston, J., & Willan, A. R. (2005). Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth, 32(4), 243–251.

Acknowledgements
This healthy birth practice paper was revised and updated by Joyce DiFranco, RN, BSN, LCCE, FACCE.

The six healthy birth practice papers were originally written in 2003 by Lamaze International as the 6 Care Practice papers.