Upright Birth Positions and Why They Help

Written by Igel Cudiera

If you are preparing for birth, you have probably heard advice to "stay upright" or "keep moving." That advice has real research behind it, but the evidence is more nuanced than it is often made to sound. What upright positions can do depends on the stage of labor, whether you have an epidural, and what matters most to you.

This guide explains what counts as an upright position, what the research does and does not show, which positions you might try, and how movement fits into a planned home birth.

What Counts as an Upright Birth Position

In research, "upright" usually means positions where your torso is more vertical than horizontal. A Cochrane review of the first stage of labor grouped walking, sitting, standing, and kneeling as upright. A Cochrane review of the pushing stage described sitting, birthing stools and chairs, squatting, and kneeling as upright, and lying on your side, semi-reclining, and lying on your back with legs raised as lying-down positions.

Hands and knees is not neatly upright or lying down, and it has mostly been studied separately, for comfort and for babies facing up. Side-lying is a lying-down position, but it is not the same as lying flat on your back, and it has a useful role for rest and with an epidural.

What the Research Shows

The evidence is different for each stage of labor, and it changes if you have an epidural. It also comes mostly from hospital studies of people with low-risk pregnancies, and many of the trials have limitations.

During early and active labor

A 2013 Cochrane review of 25 trials compared upright and mobile positions with lying in bed during the first stage of labor. On average, the first stage was about an hour and 22 minutes shorter for people who were upright, and they were less likely to have a cesarean birth or an epidural. The reviewers found no clear negative effects for mothers or babies. They also cautioned that trial quality varied, results differed widely between trials, and better-quality trials are still needed.

For people who already had an epidural, the same review found no clear differences between upright and lying-down positions.

Major guidelines support movement in labor. The World Health Organization (WHO) recommends encouraging mobility and an upright position during labor for women at low risk. The National Institute for Health and Care Excellence (NICE) in the UK advises helping women move and use whatever positions they find most comfortable throughout labor, except lying flat on their back. The American College of Obstetricians and Gynecologists (ACOG) notes that there is little evidence that any one position is best, and that for most women, no one position needs to be required or ruled out.

When you're pushing without an epidural

A 2017 Cochrane review of 30 trials compared upright positions with lying on the back during the second (pushing) stage for women without an epidural. It found both possible benefits and possible risks.

Upright positions were linked with:

• Fewer assisted births with forceps or vacuum
• Fewer episiotomies
• Fewer abnormal fetal heart rate patterns, based on two trials
• A very small reduction in the length of the pushing stage, though this was no longer clear when only higher-quality trials were included

They were also linked with:

• A possible increase in second-degree tears, though the reviewers could not be certain
• More blood loss of over 500 mL

There was no clear difference in cesarean births, third- or fourth-degree tears, or newborn intensive care admissions. A later overview of systematic reviews reached similar conclusions and noted that the overall quality of the evidence is relatively low.

If you have an epidural

This is where the evidence points in a different direction. In the BUMPES trial, more than 3,000 first-time mothers with a low-dose epidural were randomly assigned to an upright position or to lying down on their left or right side during the pushing stage. Spontaneous vaginal births were more common in the lying-down group (41.1%) than in the upright group (35.2%), with no apparent disadvantages for mothers or babies.

A 2018 Cochrane review that included BUMPES found little or no overall difference in operative births between upright and lying-down positions with an epidural. When only the most reliable trials were analyzed, lying down on the side or semi-reclining was linked with fewer operative births and cesareans.

Guidelines reflect this somewhat differently. NICE advises that, with an epidural, lying on your side may increase the chance of a spontaneous vaginal birth, but that you can use any other position you find comfortable, including upright positions. WHO recommends encouraging a birth position of the woman's choice, including upright positions, both with and without an epidural.

Why Lying Flat on Your Back Is Usually Avoided

When people ask why women give birth on their back, it helps to separate lying flat on your back from other lying-down positions. NICE advises that lying flat on your back can lead to a drop in blood pressure and may reduce blood flow to the placenta. ACOG notes that the traditional supine position has known adverse effects, including supine hypotension and more frequent fetal heart rate decelerations.

That is one reason the "lying-down" positions used in modern trials, like BUMPES, were on the side rather than flat on the back.

Positions to Try and What Each May Offer

Most people change positions many times during labor. There is no right order. These are options to explore with your midwife, based on how you feel.

Standing and walking

Walking, swaying, or standing and leaning on a partner, counter, or wall are common choices in early and active labor. They are part of the upright and mobile positions studied in the first-stage Cochrane review.

Sitting, on a birth ball or stool

Sitting upright on a birth ball, chair, or toilet lets you rest your legs while staying upright. Birthing stools and chairs were among the upright positions studied for the pushing stage, with the benefits and trade-offs described above.

Kneeling and leaning forward

Kneeling while leaning forward on a ball, the bed, or a stack of pillows is a position many people find comfortable, and it gives a partner easy access to your back for counterpressure or massage.

Squatting

Squatting, either supported by a partner or holding onto something sturdy, is one of the upright positions studied for pushing. Some people find it tiring to hold for a long time.

Hands and knees

In one trial of women in labor whose babies were facing up, spending time on hands and knees was linked with less back pain. In another trial, women on hands and knees reported more comfort. It may be worth trying if you feel contractions strongly in your back.

Side-lying

Lying on your side, often with a pillow or peanut ball between your knees, can let you rest without lying flat on your back. It is also the lying-down position that was linked with more spontaneous births for first-time mothers with an epidural in the BUMPES trial.

Can Positions Turn a Posterior Baby?

Many people hear that certain positions will turn a baby who is facing up (an occiput posterior or "sunny-side up" position). The research has not shown this.

• A randomized trial of 439 women in labor with a baby in the posterior position found that hands and knees did not lead to a statistically significant difference in the baby rotating to face down, but women did report more comfort.
• A Cochrane review found that hands and knees in labor was linked with less back pain, but the reduction in posterior positions at birth was not statistically significant. Hands and knees for 10 minutes twice a day in late pregnancy did not change the baby's position at birth.
• A 2024 Cochrane review found no evidence to guide the use of maternal positions in late pregnancy to correct a baby's position.

So hands and knees may help you feel better if you have back pain, even though research has not shown that it turns the baby.

Upright Positions and Tearing

No birth position has been shown to prevent tearing. In the research on pushing without an epidural, upright positions were linked with fewer episiotomies but possibly more second-degree tears, with no clear difference in more serious tears. For more on what can lower the risk, see our article on how midwives reduce the risk of perineal tearing.

Moving Freely at a Home Birth

At Holistic Midwifery New York, movement, position changes, and upright birth are encouraged. At a planned home birth, you can use your own furniture, a birth ball, the shower, or a birth pool, and change positions as often as you like.

ACOG notes that frequent position changes can be supported as long as the positions allow appropriate monitoring of you and your baby and are not ruled out by a medical or pregnancy complication. During a home birth, your midwife listens to your baby's heartbeat at intervals and may ask you to shift briefly so they can hear clearly.

Epidurals are not available at home. If you decide you want one, that means a transfer to the hospital, and the evidence on positions with an epidural becomes relevant. Read more about what happens if a home birth needs to transfer to a hospital, or compare settings in our guide to home birth and hospital birth.

When a Different Position May Be Needed

Choosing your own positions is the usual starting point, but it is not the only consideration. Your midwife may suggest a change in position to listen to your baby's heartbeat, to check on labor, or because of a medical or pregnancy complication. Rest matters too. Being upright does not mean staying on your feet for hours, and alternating with side-lying or supported positions can help you conserve energy.

If your midwife recommends a different position, it is reasonable to ask why. Your care team can explain what they are seeing and the reasons for their suggestion.

Practicing Positions Before Labor

Trying positions before labor can help you and your support people know what feels good. You might practice leaning on a ball, kneeling over pillows, or supported squats, and talk with your partner or doula about how they can help. Our comparison of a midwife and a doula explains the different roles on your birth team.

Your prenatal visits are a good time to ask about positions. If you are still choosing a provider, our list of questions to ask when choosing a midwife includes questions about labor and birth.

This article is general information and is not medical advice. It does not replace individualized care from your midwife or other healthcare provider. Talk with your care team about which positions are right for you and your pregnancy.

Sources

• Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews. 2013.
• Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews. 2017.
• Walker KF, Kibuka M, Thornton JG, Jones NW. Maternal position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. 2018.
• Epidural and Position Trial Collaborative Group. Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial. BMJ. 2017.
• Zang Y, Lu H, Zhang H, et al. Benefits and risks of upright positions during the second stage of labour: an overview of systematic reviews. International Journal of Nursing Studies. 2021.
• Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database of Systematic Reviews. 2007.
• Guittier MJ, Othenin-Girard V, de Gasquet B, et al. Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial. BJOG. 2016.
• Hofmeyr GJ, Moreri-Ntshabele B. Maternal postures for fetal malposition in late pregnancy for improving the health of mothers and their infants. Cochrane Database of Systematic Reviews. 2024.
• World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. 2018.
• National Institute for Health and Care Excellence. Intrapartum care (NG235): Recommendations. 2023.
• American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth (Committee Opinion No. 766). 2019, reaffirmed 2025.