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What is it
Using upright, squatting, side-lying, hands-and-knees, or supported positions during the second (pushing) stage rather than the classic semi-reclined or lithotomy (feet in stirrups) position.
How your body works here
The pelvic outlet is not a fixed shape. Squatting and hands-and-knees increase the outlet's front-to-back diameter by up to 30% by letting the sacrum move backward — a movement that's blocked when you lie on your back. Side-lying takes weight off the sacrum, unloads the pelvic floor, and often reduces perineal tearing. Upright positions add gravity assist. The 'best' position is usually the one that changes across pushes; the pelvis benefits from motion, not a single pose.
Benefits (B)
- For births without an epidural: shorter second stage, fewer episiotomies, and fewer instrumental deliveries.Review sources ↓
- For births with an epidural: still benefit from position changes (side-to-side, hands-and-knees with support, throne) — evidence is smaller but present.Review sources ↓
- Side-lying pushing is associated with lower rates of severe perineal tearing than lithotomy.Review sources ↓
Risks (R)
- Upright and squatting positions may increase blood loss slightly in trials — usually not clinically meaningful.Review sources ↓
- With an epidural, upright positions need physical support from the bed, partner, or peanut ball.Review sources ↓
- Some providers are more familiar with supine catches; a conversation ahead of time helps.Review sources ↓
Alternatives (A)
- Semi-reclined pushing (common default).Review sources ↓
- Lithotomy (feet in stirrups) — usually reserved for instrumental delivery or specific clinical situations.Review sources ↓
Evidence summary
Cochrane review of pushing positions without epidural (30+ trials) shows shorter second stage, fewer episiotomies, and fewer assisted deliveries with upright/lateral positions vs supine. WHO recommends supporting the birthing person's chosen position.
Sources
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Questions to ask your provider
- What positions are you comfortable catching in?
- Can we plan for side-lying or hands-and-knees if I want them?
- If I have an epidural, what's your plan for rotating positions during pushing?
Intuition & Nothing/Wait (the I and N in BRAIN)
What is your gut telling you? What happens if you do nothing or wait?
Add to my birth plan
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This is a personal preference, not a decision. Final choices happen in conversation with your care team.
After you talk it through
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