Pushing Positions (and Directed vs Spontaneous Pushing)
When it comes time to push, two choices are yours to make: the position you push in, and how you push. Both matter more than most people realize, and both are choices you get to make rather than defaults you have to accept. Your position can change the diameter of your pelvic outlet by up to 28 to 30%, and upright positions are linked to shorter, easier pushing. Yet most women end up flat on their backs, the position that makes pushing hardest.
No one can make these calls but you. Here is the honest picture: the full range of positions with their real trade-offs, why the hospital default is often about convenience rather than evidence, how an epidural changes your options, and the difference between coached and body-led pushing.
Why Informed Parents Choose Differently
Before the details, here is the heart of it. There is no single right way to push. Thoughtful, well-read parents land in different places because they are weighing different priorities, and because the position that feels right in the moment is often the best one.
Why an informed parent might choose upright, mobile pushing
Upright positions use gravity to help bring baby down instead of pushing uphill, and squatting can open the pelvic outlet by up to 28 to 30% compared with lying down. A Cochrane review links upright positions to fewer assisted deliveries, shorter pushing time (about 6 minutes shorter on average), fewer episiotomies, and fewer abnormal fetal heart rate patterns. A parent choosing this path values working with the body’s design and is usually planning an unmedicated or low-intervention birth where full movement is possible.
Why an informed parent might use a semi-reclined or side-lying position
Not every birth allows full mobility, and rest matters too. Side-lying lets your pelvis open without compressing major blood vessels, so it is gentler on baby’s oxygen flow than lying flat, and it lets you relax between pushes. It is the go-to when you have an epidural, when pushing is taking a long time, or when you simply need to conserve energy. A parent choosing this path is prioritizing a sustainable, restful, epidural-compatible option that is still meaningfully better than flat on the back.
Why an informed parent might follow their body over coaching
Spontaneous pushing means waiting for the urge and following your body’s cues rather than pushing hard on a count. Research links it to better oxygen for baby between pushes, less pelvic floor damage, and less exhaustion, with no consistent increase in total pushing time. A parent choosing this path trusts the body’s built-in reflex and wants a body-led experience. Others reasonably prefer the structure of coaching, especially with an epidural, and both are legitimate.
These are not the choices of parents who did not do their homework. Reasonable, equally informed women weigh gravity, rest, pain relief, and control differently, and many births blend several positions and both pushing styles. The best position is the one that feels right to your body in the moment.
Why Your Position Matters
Your pelvis is not a fixed, rigid ring of bone. It is designed to move and open during birth. Different positions can change the diameter of your pelvic outlet by up to 28 to 30%, which is a significant difference when you are trying to fit a baby through. Squatting opens the outlet to its widest point. Lying flat on your back actually narrows it.
Gravity is the other half of the story. When you are upright, gravity helps pull your baby down and out. When you are on your back, you are essentially pushing your baby uphill. It is like rolling a ball up a slope versus letting it roll down.
This is not just theory. Upright positions during pushing are associated with shorter pushing stages, fewer interventions, less severe tearing, and better blood flow to baby. Lying flat, by contrast, puts your pelvis at its narrowest, keeps your sacrum (tailbone) from moving out of the way, and can compress major blood vessels, which reduces oxygen to your baby. It is worth understanding both sides so the position you end up in is a choice, not an accident.
The Range of Positions, and What Each Trades Off
There is no single right answer here. Each position trades something for something else: gravity for rest, a wide pelvis for effort, mobility for compatibility with an epidural. Here is the honest picture of the main options.
| Position | Pelvis opening | Uses gravity | Works with epidural | Effort / rest |
|---|---|---|---|---|
| Squatting | Maximum | Yes | No | High effort |
| Standing | Good | Yes | No | Moderate |
| Hands and knees | Good | Partial | Sometimes | Moderate |
| Kneeling | Good | Partial | Sometimes | Moderate |
| Side-lying | Good | No | Yes | Restful |
| Throne / sitting | Moderate | Partial | Yes | Moderate |
| Semi-reclined | Limited | No | Yes | Restful |
| Flat on back (lithotomy) | Minimum | Against you | Yes | Restful |
Upright positions (best for unmedicated birth)
Squatting opens the pelvic outlet the most and uses gravity fully. The trade-off: most women in Western cultures do not squat regularly, so your legs may tire quickly. A squat bar, the bed rail, or a partner supporting under your arms all help. Standing uses gravity and lets you lean on support to rest between contractions.
Kneeling and hands and knees take pressure off your back, open the pelvis, and are easier to sustain than squatting. Hands and knees is especially useful for back labor, because leaning forward encourages a baby who is facing your front to rotate, and it is associated with less perineal tearing.
Side-lying (great for almost everyone)
Side-lying is an underrated middle ground between upright and flat. Your pelvis can still open, you are not compressing major blood vessels (so oxygen flow to baby stays better), and you can fully relax between pushes. It is associated with less severe perineal tearing, and it works even with an epidural and limited leg control.
It is particularly good when you are tired, when pushing is taking a long time, when baby is showing signs of stress, or when you want to slow pushing down to protect the perineum. An "exaggerated" side-lying position, with the top leg drawn up and supported, opens the pelvis even more.
One honest note on the evidence: the main trade-off some studies noted for upright positions was a slight increase in blood loss and second-degree tears. Many experts believe this is related to how those studies were conducted rather than the positions themselves, but it is worth knowing rather than glossing over.
Why Hospitals Put You on Your Back
If lying on your back is one of the harder positions for pushing, why is it the default in most hospitals? The honest answer is mostly about the institution, not about what produces the best birth. The lithotomy position (on your back, often with legs in stirrups) became standard because it offers clear visibility, straightforward access if an intervention is needed, and consistency with how most providers were trained.
Monitoring plays a role too. Continuous electronic fetal monitoring is standard in most hospitals, and those monitors tend to work best when you are relatively still. When you move around, they can lose the signal. That said, intermittent monitoring is an option for low-risk births, wireless (telemetry) monitors allow more movement, and many position changes can be accommodated even with continuous monitoring if the team is willing.
None of this makes your nurse or doctor the villain. The pressure is systemic: liability culture, defaults that feel safer to the institution, and less familiarity with catching babies in other positions. But it does mean the position is often chosen for the hospital’s convenience, not because the evidence says it is best for you. You have the right to choose your position unless there is a genuine medical emergency. A fair question to ask is: "Is there a medical reason for this, or is it preference?"
How an Epidural Changes Your Options
An epidural is a completely reasonable choice, and it does not sentence you to lying flat. It does limit which positions are possible, because you cannot support your own weight or move your legs freely. The good news is that you still have real choices, and using them makes a difference. (For the bigger picture on pain relief, see our pain management guide.)
Positions that still work with an epidural
- Side-lying is your best friend with an epidural. You may need help holding your top leg up during pushes, and a peanut ball keeps your pelvis open while you rest.
- The "throne" position, with the head of the bed raised as high as it goes, lets you use some gravity while staying fully supported.
- Semi-reclined with your legs supported (head of bed at 30 to 45 degrees) is better than flat on your back, even if it is not ideal.
- Hands and knees is sometimes possible with a lighter epidural or as it wears off, but it takes a lot of support. Ask your nurse whether it is safe for you.
Two things worth asking for
A peanut ball (a peanut-shaped exercise ball placed between your knees and ankles while you lie on your side) keeps your pelvis open even while lying down. It is one of the most useful tools for an epidural birth: using one is associated with a shorter first stage of labor (about 29 minutes shorter on average), shorter pushing (about 11 minutes shorter), and fewer cesareans. Many hospitals have them, but you can bring your own to be sure.
You can also ask your anesthesiologist for a lower-dose or "walking" epidural, which may give you more position options and let you keep some feeling of pressure and the urge to push. Something like: "Can we keep the dose low enough that I have some movement, and can still feel the urge to push?"
Directed vs Spontaneous Pushing
How you push matters as much as the position you push in. There are two main approaches, and they have different effects. This is a genuine decision with real trade-offs, and the right answer depends on your circumstances.
Directed pushing (coached)
This is the version you see in movies: take a deep breath, hold it, and push hard for a count of ten, usually about three times per contraction, often starting as soon as you are fully dilated whether or not you feel the urge. It is sometimes called "purple pushing," because many women’s faces turn purple from the strain of holding their breath. It is standard in most US hospitals.
The case against: holding your breath reduces oxygen to your baby, it is more exhausting, and it is associated with more pelvic floor damage.
The case for: it gives real structure to first-time mothers who feel genuinely lost during pushing, it helps when an epidural has dulled the urge to push, and it can help coordinate effort during a difficult or prolonged delivery. Some women simply find the coaching reassuring.
Spontaneous pushing (body-led)
Here you wait for the urge to push, then follow your body’s cues: push when it tells you to, usually for shorter bursts of a few seconds, breathe when you need to, vocalize if it helps, and rest between contractions. It is more common in birth centers and home births.
What the research shows: better oxygen to baby between pushes, less pelvic floor trauma, less maternal exhaustion, and no consistent difference in total pushing time. For an unmedicated birth, your body’s built-in pushing reflex is a powerful guide.
The honest caveat: with an epidural you may not feel the urge to push, so some guidance about when contractions are happening can help.
Where the evidence lands: ACOG acknowledges that both approaches are acceptable, and many midwifery organizations prefer spontaneous pushing. In other words, this is not a case where one path is clearly right and the other is a mistake. Many births use a blend of the two.
If you have an epidural, "laboring down" (waiting 1 to 2 hours after full dilation to let baby descend on their own before active pushing) can reduce the need for intense directed pushing. Ask your team to tell you when a contraction is happening so you can push with it, and try to avoid prolonged breath-holding by pushing in shorter bursts.
Our Take
The position that works best is the one that feels right to your body in the moment. That might be squatting, or side-lying, or something you invent on the spot. The evidence leans toward upright, mobile positions and body-led pushing for many women, but a semi-reclined position with an epidural and some gentle coaching is a completely respectable birth too. None of these choices is a failure, and there is no crunchy hierarchy of "better" births here.
What we would gently push back on is defaulting to flat on your back and hard-counted pushing simply because that is what the room expects. Know your options, put your preferences in your birth plan, tell your team ahead of time, and stay willing to change your mind mid-labor. Your body was designed to do this. Give it the best chance by choosing positions that open your pelvis, use gravity where you can, and let you feel strong and supported.
Make it an informed choice, not a default. Your birth. Your body. Your baby. Your choice.
Questions to Ask Your Provider
- What positions do you support during pushing, and how often do your patients push somewhere other than on their back?
- If I want to try upright or side-lying pushing, will you help me get positioned and catch the baby that way?
- Do you have a squat bar and a peanut ball available, or should I bring my own?
- If I have an epidural, can it be dosed low enough to keep some movement and the urge to push?
- Would you support "laboring down" before active pushing if I have an epidural?
- Do you coach pushing by counting, or will you let me push when I feel the urge?
- If I am told to be on my back during labor, will you tell me whether it is a medical reason or routine?
Want the Full Research Behind This Decision?
The Birth Decisions Research Guide covers pushing positions and 40+ other choices in depth: the pros and cons, the medical evidence and real citations behind every number, what hospitals tell you versus the full picture, and scripts to advocate for yourself.
Get the Research Guide - $39Includes lifetime updates and citations from medical journals
Ready to Create Your Birth Plan?
Document your pushing position preferences and 20+ other birth decisions in a beautiful, professional PDF to share with your care team.
Start My Free Birth PlanCommon questions
Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. We are not doctors. Every birth is unique, and the best position is often whatever works in the moment. Always discuss your specific situation with your healthcare provider before making decisions about your care.
Last reviewed July 23, 2026.
Sources
This article is drawn from our research guide. The sources below are the peer-reviewed studies and clinical guidance behind the key facts on this page.
- Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub4 doi.org/10.1002/14651858.CD002006.pub4
- Russell, J. G. B. (1969). Moulding of the pelvic outlet. Journal of Obstetrics and Gynaecology of the British Commonwealth, 76(9), 817-820. DOI: 10.1111/j.1471-0528.1969.tb06185.x doi.org/10.1111/j.1471-0528.1969.tb06185.x
- Humphrey, M. D., Hounslow, D., Morgan, S., & Wood, C. (1973). The influence of maternal posture at birth on the fetus. Journal of Obstetrics and Gynaecology of the British Commonwealth, 80(12), 1075-1080. DOI: 10.1111/j.1471-0528.1973.tb02982.x doi.org/10.1111/j.1471-0528.1973.tb02982.x
- Soong, B., & Barnes, M. (2005). Maternal position at midwife-attended birth and perineal trauma: Is there an association? Birth, 32(3), 164-169. DOI: 10.1111/j.0730-7659.2005.00365.x doi.org/10.1111/j.0730-7659.2005.00365.x
- Tussey, C. M., Botsios, E., Gerkin, R. D., Kelly, L. A., Gamez, J., & Mensik, J. (2015). Reducing length of labor and cesarean surgery rate using a peanut ball for women laboring with an epidural. Journal of Perinatal Education, 24(1), 16-24. DOI: 10.1891/1058-1243.24.1.16 doi.org/10.1891/1058-1243.24.1.16
- Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. (2001). Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: A randomised controlled trial. The Lancet, 358(9275), 19-23. DOI: 10.1016/S0140-6736(00)05251-X doi.org/10.1016/S0140-6736(00)05251-X
- Prins, M., Boxem, J., Lucas, C., & Hutton, E. (2011). Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: A systematic review of randomised trials. BJOG, 118(6), 662-670. DOI: 10.1111/j.1471-0528.2011.02910.x doi.org/10.1111/j.1471-0528.2011.02910.x
- Schaffer, J. I., Bloom, S. L., Casey, B. M., McIntire, D. D., Nihira, M. A., & Leveno, K. J. (2005). 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. DOI: 10.1016/j.ajog.2004.11.043 doi.org/10.1016/j.ajog.2004.11.043
- Roberts, J. E. (2002). The "push" for evidence: Management of the second stage. Journal of Midwifery & Women’s Health, 47(1), 2-15. DOI: 10.1016/S1526-9523(01)00233-1 doi.org/10.1016/S1526-9523(01)00233-1
- Fraser, W. D., Marcoux, S., Krauss, I., Douglas, J., Goulet, C., & Boulvain, M. (2000). Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. American Journal of Obstetrics and Gynecology, 182(5), 1165-1172. DOI: 10.1067/mob.2000.105197 doi.org/10.1067/mob.2000.105197
- Roberts, C. L., Torvaldsen, S., Cameron, C. A., & Olive, E. (2004). Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG, 111(12), 1333-1340. DOI: 10.1111/j.1471-0528.2004.00282.x doi.org/10.1111/j.1471-0528.2004.00282.x
- American College of Obstetricians and Gynecologists. (2024). First and Second Stage Labor Management. Clinical Practice Guideline No. 8. Obstet Gynecol, 143(1), e1-e18.
- American College of Nurse-Midwives. (2020). Physiologic Second Stage Labor Care: Supporting Women’s Innate Capacity. Clinical Bulletin No. 18. J Midwifery Womens Health.
- Simkin, P., Hanson, L., & Ancheta, R. (2017). The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia (4th ed.). Wiley-Blackwell. ISBN: 9781119170464