Birth Positions

Part of Midwifery and Childbirth

Upright, squatting, and kneeling positions that use gravity to assist delivery and reduce complications.

Why This Matters

For most of human history, women gave birth upright — squatting, kneeling, or supported in a standing position. The horizontal lithotomy position (lying on the back, legs raised) was introduced in 17th century France to make delivery more convenient for the attending physician. It is not the optimal position for the mother or baby.

Upright positions use gravity to assist descent, enlarge the pelvic outlet, allow the sacrum to move freely, reduce the duration of labor, decrease the need for assisted delivery, and result in fewer perineal tears. A systematic review of dozens of studies confirms that upright positions reduce labor duration by an average of 1.4 hours and reduce episiotomy (surgical cutting of the perineum) rates.

In a resource-scarce environment without epidurals, surgical capability, or hospital beds, position is one of the most powerful tools a birth attendant has. Understanding which positions help what situation — and how to support a woman in each — is essential midwifery knowledge.

The Mechanics of Position

How Upright Positions Help

Gravity: When upright, gravitational force acts directly down the axis of the birth canal. The baby’s weight, the weight of the uterus, and the force of contractions all work with gravity rather than against it.

Pelvic dimensions: The pelvic outlet is approximately 28% larger in a squatting position than in a supine (lying on back) position, as measured by the distance between ischial spines. This additional space directly benefits descent of the baby.

Sacral mobility: The sacrum (the triangular bone at the base of the spine) can flex backward when the woman is upright or on hands-and-knees, creating more room. When lying on the back, body weight presses on the sacrum and limits this movement.

Maternal effort: A woman can bear down more effectively when upright — her abdominal muscles work with gravity rather than having to push the baby upward.

Positions for Labor (Before Full Dilation)

Upright Walking and Standing

Simply moving and remaining upright during early and active labor is beneficial. Walking during contractions encourages engagement of the baby’s head in the pelvis and keeps labor progressing.

Support: Birth attendant or support person stands beside, offering arm or shoulder to lean on during contractions.

Slow Dancing Position

Woman wraps her arms around the support person’s neck. Support person places hands on her lower back. They sway gently through contractions.

Benefits: Weight-sharing, counter-pressure on lower back, emotional closeness.

Leaning Forward

Woman leans forward onto a surface — a table, chair back, wall, or support person — during contractions, allowing the uterus to hang forward.

Benefits: Particularly useful for back labor (when the baby is positioned facing forward, putting pressure on the maternal spine). The forward lean shifts the baby’s weight away from the back.

Hands and Knees

Woman is on all fours. Particularly effective for back labor and for rotating a posterior baby.

Benefits: Allows gravity to encourage the baby to rotate to the anterior position. Relieves back pressure. Allows sacral movement.

Side-Lying

Useful for resting during a long labor. The left side is preferred (avoids compression of the inferior vena cava by the heavy uterus, maintaining blood return to the heart).

Benefits: Rest, recovery, useful if the woman is exhausted or if the baby needs to slow descent.

Positions for Pushing and Delivery

Squatting

The traditional universal delivery position. The pelvic outlet is maximally opened. Gravity fully assists. The woman can bear down with her whole body.

Implementation: The woman squats — feet flat on the ground if possible, heels together or hip-width apart. Support persons or a partner stand or kneel beside her, offering hands or arms to grip. A low squatting bar or something similar can be rigged from a doorframe or beam.

Challenge: Maintaining a squat for extended periods is exhausting. Many women need support — a birth stool (low wooden seat with a gap in the center) distributes weight while maintaining the open-pelvis position.

Semi-Recumbent (Elevated Head)

Compromise position — head of the bed or support elevated at 45-60 degrees. Not as good as full upright but better than flat on back.

Advantages: Easier for birth attendant to manage delivery. Acceptable compromise when other positions are not possible.

Kneeling on All Fours (for Delivery)

The baby is delivered from behind the mother, between her knees. Birth attendant kneels or sits behind.

Benefits: Maximizes sacral mobility. Good for large babies or tight perineum. Reduces perineal tears (reduced pressure on perineum). Very effective for shoulder dystocia management.

Lateral (Side-Lying) Delivery

Woman lies on her left side, her right leg lifted and supported by an attendant or herself.

Benefits: Reduces perineal trauma, useful for very fast deliveries where descent cannot be controlled, good for exhausted women.

Supported Standing

Woman stands with hands gripping something overhead or arm draped over support person’s neck. Baby delivered between her legs.

Traditional in many cultures. Effective gravity use. Requires birth attendant to be on knees or low position for delivery.

Changing Positions During Labor

One of the most important skills in labor support is recognizing when to encourage a position change:

Stalled progress: Change position. A 30-minute stall often resolves with a change to hands-and-knees or a supported squat.

Back labor: Move to hands-and-knees or leaning forward.

Maternal exhaustion: Move to side-lying for rest, then return to upright.

Fetal heart rate decelerations: Move to left side-lying (takes pressure off vena cava, improves placental blood flow).

Slow descent in pushing: Move to squatting or hands-and-knees.

Fast uncontrolled descent: Move to side-lying or semi-recumbent to slow delivery and allow perineum to stretch gradually.

Position Support Equipment

Simple items that assist birth positions:

Birth stool: Low wooden stool with a horseshoe-shaped cutout in the seat. The woman sits with her weight on her thighs, not her perineum, while remaining in an open, downward-facing position.

Rebozo (support cloth): A long cloth (traditional Mexican midwifery tool, but applicable universally). Used to support the woman’s weight, apply counter-pressure to the abdomen, and assist in baby repositioning through gentle rocking movements.

Pool or water: Warm water immersion reduces pain perception, allows easier movement between positions, and reduces perineal trauma. A clean tub, large container, or improvised pool serves this purpose.

Kneeling pad: A folded blanket or pad protects knees during extended time on the floor.

The Position Default

When uncertain which position to use, follow the woman’s instinct. A laboring woman who is not restricted will naturally move into positions that help her — rocking, swaying, squatting, leaning. Birth attendants should facilitate this movement rather than direct it. The best position is the one the woman chooses.