Better Birthing Through Alignment: Optimal Labor Positioning

The best birthing positions for labor and delivery.

The position of a woman’s body when pushing and giving birth can greatly effect the experience, outcome, and success of a healthy delivery. When women are supported to move naturally into the positions that feel best for them in labor, the forces of gravity, movement, and alignment will assist the labor and birth to be less painful, shorter, and easier for mom and baby. The majority of women today are instructed into the worst positions for labor to progress physiologically, thus contributing to the high rates of intervention, pain, and fetal distress that may occur in birth.

Know what positions can help you to have the best labor so you can have the best birth possible for you and your baby! Pregnant women also need to make sure that their doctors and midwives will support them to move as they freely wish in labor and birth in the positions they choose. If your care provider refuses to allow you to birth how you want, you have the ability to choose a new care provider. Know your options and choices before labor for the best birth!

The pelvis consists of three bones, the sacrum and the two iliac bones. The iliac bones come together in one joint at the pubis symphysis in the front anterior pelvis. The sacrum holds together the posterior part of the pelvic bowl with two joints on the left and right connecting with the iliums. The pelvic bones from a bowl shape which expands when the woman is in forward leaning, squatting, and side-lying position, and compresses when in lithotomy or semi-sitting positions. The position a woman takes in labor, pushing, and birth can create more space in her pelvis for her baby to be born with greater ease, comfort, less chance of tearing, and less strain on the mother’s pelvic floor. 

When in the lithotomy position, which is lying supine on her back with her legs apart and feet supported, a woman is in a compromised position for a natural biodynamic birth. When a woman is flat on her back in labor, her sacrum and sacral joints are compressed and restricted and the pelvic capacity of the woman is reduced up to 30%. The vagina naturally slopes anteriorly, so when a woman is in the lithotomy position she actually has to push against gravity. This is the worst position to birth in, as it reduces space for mother and baby, increases pain for mother, increases chances of tearing and need for assisted delivery. This position also increases the pressure of the baby on the mother’s vena cava and aorta potentially reducing oxygenation of the baby, increasing chances of fetal distress, as well as aggravate a women’s sciatic nerve through compression as well. Some doctors still utilize and encourage the lithotomy position because it is easiest for the attending practitioner to see the perineum. 

Many people are now aware that the lithotomy position is undesirable for birthing and that it is more convenient for doctors than mothers and babies. Unfortunately, many women are instead encouraged to be in a recumbent or semi-sitting position, in which their upper back is raised, but the sacrum is still flattened against the bed, creating restricted space in the pelvis. This is an attempt to change the historical use of the lithotomy position in obstetrics, however fails to create maximum mobility and opening of the pelvic bones. If a woman is in a semi-sitting position during pushing and having a prolonged time, rolling onto her side may increase the pelvic bowl circumference, freeing the sacrum, and creating more space for the birth. The recumbent position in labor still decreases the pelvic outlet by up to 30%. 

In a lithotomy or recumbent position, the mother has increased chances of prolonged pushing, shoulder dystocia, assisted delivery via forceps or vacuum, as well as c-section. The McRoberts maneuver is commonly used in hospitals and with some midwives for attempting to resolve shoulder dystocia. In the McRoberts maneuver, the mother is guided to pull her knees back and her thighs far apart as much as possible, while on her back or recumbent, and push as hard as she can. This may work for some births, but not all as this still continues to compress the sacrum and keep the space of the pelvic reduced. Obstetricians and midwives will often employ this maneuver along with applied pressure above the pubic symphysis and pulling on the baby. 

A better alternative for resolving shoulder dystocia is the Gaskin maneuver, developed by Midwife Ina May Gaskin. If a woman is experiencing shoulder dystocia in labor and is on her back, semi-sitting, or side-lying, roll her onto her hands-and-knees. The movement and turning onto all- fours, as well as the increased space in the pelvis will usually and quickly resolve a shoulder dystocia.  

Side-lying position is an excellent choice for birthing, it can be done by women in any location - home, birth center, and in hospital beds. This is a position that allows free mobility of all three of the pelvic joints, as well as giving the mother the opportunity to rest deeply between contractions. A doula can be helpful in assisting to hold up the mother’s leg when in side-lying position. In between contractions, the knee and leg can be supported to rest upon a small birth ball to keep the pelvis wide. Side-lying position can also reduces tearing of the mother’s perineum, and still provides optimal view for the attending obstetrician or midwife. 

An optimal position for birth that laboring women have instinctively taken on throughout time is the hands-and-knees or all-fours position. When a women is upright and forward-leaning, the pelvis is able to open 1 to 2 cm and facilitate the birthing process. The upright or hands-and-knees position in labor compared the the lithotomy position results in less pain, shorter labors, less shoulder dystocia, more healthy moms and babies, shorter pushing times, fewer perineal tears, and facilitates the rotation of posterior babies. All of the pelvic joints are free to open and expand in the upright position, as well as the mother is able to be mobile, moving, rocking, and adjusting her hips to facilitate the baby’s cardinal movements. 

Upright and leaning-forward are the best positions for labor. These positions are great both in early labor to facilitate the baby entering the pelvic inlet in the best way possible, as well as for second stage to ensure maximum space in the pelvic bowl for the baby to turn and move through. A woman in labor can be walking, leaning-forward on a counter or high furniture, on her knees leaning on a birth ball, or another variation. Being upright allows gravity to work with the birth and leaning-forward creates more room between the pubic bone and sacrum. These positions also give mother a feeling of more control in labor. 

Sitting can be a relaxing and upright position for a mother in labor who needs to rest. Sitting on a birth ball is ideal for this allows wide spacing of the knees and opening of the pelvis, as well as mobility for the mother to sway, rock, and circle her hips. A woman may like sitting in a rocking chair too. Most all hospitals and birth centers have glider rocking chairs now, as they are comfortable for early labor as well as rocking babies postpartum. If a woman is sitting on a birth ball, she can also lean forward and rest between contractions on a pile of pillows on a bed or table before her. She could also lean forward and rest  with her arms around her partner or support person. 

Squatting is a great position for second stage through pushing and delivery of the baby. Squatting with feet wide and soles flat on the floor, opens the pelvic outlet by up to 2 cms. Squatting is great for pushing to open the pelvic outlet but not during early labor as it can make the pelvic inlet smaller. Once the baby is fully in the pelvis, then squatting can be a great position for delivery. This is a natural position that women have used in labor for millennia. Squatting bars are used in many hospitals and birthing centers to support women in a squatting position in labor.    

However, be aware that many times, when in a hospital setting and the mother requests the squatting bar, it should be used for actual squatting and not for putting the feet on. In my experience as a doula, numerous times I have requested the squatting bar for mothers, only to find the nurses encouraging recumbent and modified lithotomy positions with the bar. Putting the bar in place in the hospital bed, nurses may encourage a woman to lean back and put her feet up on either side of the bar. The appropriate way to use the squatting bar is for the mother to come up flat on the soles of her feet, with knees and hips flexed, and hang on the bar with her hands or under her arms. This creates an upright position is which gravity works with the mother and all the joints of the pelvis are free and flexible. 

Squatting down on one-knee is a position that women who are birthing instinctively, without guidance from care providers, may take to birth their babies with optimal control. On one-knee a woman can open her hips, and also catch her own baby, working with gravity to birth gently. Whapio Diane Bartlett, founder of La Matrona Midwifery School, says this is the position she sees women usually take when they catch their own babies.    

Through natural instinct mothers can find their optimal position for birth.

Choosing the right position for labor and birth can significantly increase the mother’s comfort and ease of birthing, and reduce the chances of intervention or trauma.

Ideally the mother should be able to move freely into what position she wants and be in a supportive environment that encourages upright, leaning-forward positions.