Top 5 Labor Positions for Vaginal Birth

What Are Some of the Best Labor Positions For Vaginal Birth?

Read on to find out why not all labor positions are created equal

If you have been pregnant for many months now, it is most likely time to get ready for the upcoming birth! Similar to a marathon, we need to train for childbirth to prepare the muscles and body for the upcoming event. For this reason, it is a good idea to start practicing being in different positions either with movement or holding a position for a long time. The first stage of labor involves contractions to dilate and open the cervix. Once the c

ervix is fully dilated, the second stage includes the passive and active phases of the baby crowning and coming out of the vaginal canal. The third stage involves the delivery of the placenta. We will go over each stage and how to best support our bodies throughout the childbirth journey.

Labor Positions during the First Stage of Childbirth

Practicing and knowing different positions during this first stage can be helpful when pain may escalate. Upright positioning such as: walking, standing, rocking back and forth, kneeling over birthing ball, leaning against wall, holding onto partner are just some of the many, many positions that can be helpful. The key in the first stage of labor is to incorporate your preferred but various upright positions to help decrease pain and promote dilation of the cervix. Women who are in more upright positioning during the first stage of labor have been found to have a shortened second stage labor and are less likely to have a cesarean section. 

Labor Positions for Second Stage of Childbirth

It is also important to find your optimal positions for the second stage of labor. During vaginal childbirth, the pubococcygeus muscle (the “kegel” muscle of the pelvic floor) stretches 3.26 times more than its normal length! So although it is a common assumption to think we need to be strong and strengthen the pelvic floor, it is equally, if not more important, to also be able to lengthen and relax the pelvic floor (think reverse kegels). Around 34-35 weeks pregnancy is a good time to start practicing releasing and bearing down without straining the pelvic floor muscles. Incorporating perineal massage techniques around this time can also help improve the ability of the pelvic floor to expand/lengthen and thus decrease the risk of perineal trauma. As the uterus contracts, we want the pelvic floor muscles to lengthen and get out of the way as the baby makes its way in and out of the vaginal canal.

For positions during the second stage of labor, it is important to: 

1. Find which positions make you feel relaxed and easy for pelvic floor muscles to lengthen.  Then...  
2. Practice in those positions that allow for maximal space in the pelvis! 
   1. Have an already prepared paper that lists different positions that you like so when you’re in labor, you won’t have to think- but partner/doula/nurse can look at the document quickly and get you in position. 

It is no longer recommended to be lying flat on your back for a few reasons. We want to allow the sacrum to move freely, as the coccyx (or tailbone) naturally extends backwards to allow for the baby to come through the vaginal canal. The dimensions of our pelvic outlet increases in upright positions, specifically in squatting, kneeling or in the hands and knees positions. Gravity is helpful in upright positions, and works against us when we are lying on our backs, sometimes making it harder for labor to progress. There are many benefits to upright positioning during labor, such as decreased likelihood of sustaining episiotomies, decreased use of forceps or vacuum assisted births, and decreased instances of fetal distress. However there is an increased risk of second degree tearing and possibly extra blood loss (although there are mixed results). While there is an increased chance of second degree tears, natural tearing is known to heal more effectively than episiotomies. There is no one position that is best for everyone and having many options is best.

There is a passive second stage (when there is no urge to bear down), and an active second stage of labor (when you feel the urge to bear down). If you have difficulty feeling that instinctual urge to bear down, because of an epidural for example, have the nurse or midwife help let you know when. When you have breaks in between the contractions, you want to try to change positions (preferably upright positions). Try and practice these 5 positions to see how you and your pelvic floor feel:  

1. Hands and knees: This position is a great way to ease low back pain during labor and opens up the pelvis to help with dilation.  Gravity in this position is also a plus. You can put your arms on the birthing ball or at the head of the bed as other modified options in this position. With the support of your team and adequate muscle strength, it is possible to get into this position with an epidural. 
2. Lying on your side: Try this with a peanut ball in between legs, or supported by your partner. This is a great position for when you need a break in between contractions but still opening up that pelvis and allowing coccyx to move freely. This is also what many people with epidural prefer.
3. Kneeling: This can be done with a birthing ball, rail and/or supported by a partner, etc. Gravity is also a plus in this position and helps open up the pelvis. If you have pubic symphysis pain, this position may not be ideal for you
4. Squatting: There are many versions of squatting with and without tools. You can bring your body over the birthing ball or put your hands around your partner’s neck or chair, and or on a birthing rail.  Gravity is helping, but this position does carry an increased risk of tearing. Squatting can be a great position, but it is recommended to start training in this position to improve flexibility and learn how to relax the pelvic floor in this position. 
5. Sitting/birthing chair/toilet- Women often feel perineal relief in this position, but sometimes experience some irritation from the toilet seat. This can be another good position for those with epidurals. However, this position can sometimes increase blood loss and it is not an ideal position for those with high blood pressure.

If having an epidural, it is possible to get into a squatting or hands and knees position with arms holding onto something strong and sturdy. But it does depend on the strength/stability of your legs and your support/birth team to ensure it is done safely.

Labor Positions for Third Stage of Childbirth

Last, but not least, the third stage of childbirth involves the delivery of the placenta. Now, at this point you have delivered your baby, your body’s hormones have shifted tremendously! You may feel overwhelming emotions of joy and exhaustion at the same time. You may find yourself shivering, and this is normal immediately post giving birth and can last up to one hour. Oxytocin, the bonding hormone, rises sharply to compensate for the drastic drop in estrogen. Oxytocin also helps with the delivery of the placenta, as it helps separate from the uterus. Depending on your birth plan, your team may help you deliver the placenta with medications, gentle fundal massage, and gentle tugging of the cord. This will likely be in a position with you lying on your back. Or, you may continue to spontaneously deliver in any position that you feel comfortable, whether that is an upright position, hands and knees position, or even lying on your back. Placenta may come out on its own, or you may feel the urge to push again. The key is to choose a comfortable, yet appropriate position for you. 

Take-aways

 Labor positions and results

Overall, there is a higher satisfaction among maternal women who were able to move freely during both first and second stages of labor. Upright positions also decreased low back pain, decreased the duration of the second stage of labor, decreased the likelihood of resorting to emergency cesarean section, decreased the need of assisted childbirths (forceps, vacuum) and decreased the need for episiotomy procedures. However, there is an increase in second degree perineal tearing and possibly blood loss. Regardless of where your labor journey takes you, with or without epidural, listen to your body as you take it through different positions frequently, use tools to help conserve energy (partner, birth rail, birthing ball, seat, etc.), and move around when you can. After giving childbirth, give yourself the space to process the overwhelming emotions you may experience, and prepare for the delivery of the placenta. Pelvic floor physical therapists can help teach you how to lengthen the pelvic floor muscles, perform perineal massage techniques, find some of your favorite positions based on your ability to relax and lengthen the pelvic floor muscles, and overall improve endurance and stamina for your upcoming joyous childbirth journey.  

Please check out our other blogs on other pregnancy topics, as well as our postpartum health blogs for the fourth trimester.

References:

Hofmeyr GJ, Singata-Madliki M. The second stage of labor. Best Practice & Research Clinical Obstetrics and Gynaecology: 2020, 67; 53-64. https://doi.org/10.1016/j.bpobgyn.2020.03.012 

Abdelhaim AM, Eldesouky E, Elmagd IA, et al. Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials. Intl Urogynecol J 31, 1735-1745 (2020). https://doi.org/10.1007/s00192-020-04302-8 

Dekker, Rebecca. The Evidence on: Birthing Positions. Evidence Based Birth. February 2, 2018. https://evidencebasedbirth.com/evidence-birthing-positions/