Enf.º Alain Delgado

Nurse Specialist
in Maternal Health
Gynecology
and Obstetrics Service

My birth, my position!

HPA Magazine 24 // 2025

One of the issues that generates many doubts among pregnant women and deserves exploration is the position during the expulsion period that the woman, as a labouring woman, can choose. This includes which position is most effective, which she will tolerate best, and which is the most comfortable.

The World Health Organization (WHO) emphasizes that childbirth should be conducted in a humanized manner, avoiding unnecessary interventions and respecting the woman's autonomy. It also recommends freedom of choice regarding the birthing position.
Scientific evidence points to clear advantages in promoting vertical or lateral positions, which allow anatomical advantages, a more active participation of the labouring woman with psychological benefits in labour and in the partnership with professionals.
It is up to the professionals to advise and analyse the events of the birth, knowing that the final choice is the woman's, always safeguarding the foetal well-being together.
We will explore here some alternatives that labouring women can choose, clarifying advantages or disadvantages according to some published studies.
Different types of positions to be adopted during the expulsive period:
The birth positions can be divided into upright positions in which the angle between the lower limbs and the trunk is greater than 45º, which include variants such as standing, sitting, squatting, kneeling (supported by a bar or against the headboard of the bed), cat position (four-point position), sideways position with support from a peanut ball, versus the traditional horizontal lithotomy position (lying on the back or semi-reclining).
Several studies have sought to compare the advantages and disadvantages of each position, addressing the differences between each choice and which can help the woman decide her position for her birth.
We will present here in a succinct and generic way the differences and the most likely expected results associated with the different positions.

Lithotomy position - Lying on the back
Historically, it is described that the French King Louis XIV in the 16th century. In the 17th century, the first person to make his wife lie on her back to give birth was because he liked to watch the birth. This position became widespread in France and Europe and was later adopted by medicine throughout the Western world, becoming one of the most widely used positions to this day.
Anatomically, the sacrum and the narrow birth canal of women in labour are more immobile. This position can result in greater compression of the aorta, which can hinder proper foetal oxygenation.
The woman in labour may feel a greater sensation of pain, with a consequent greater demand for analgesia. Expulsive efforts may be less effective, which can slow down the descent of the presentation and the expulsive period.
There may be a greater possibility of 3rd or 4th degree lacerations and a lower occurrence of an intact perineum.
It allows the professional to easily view the perineum, and perineal protection measures can be adopted.
Upright positions
When using these positions, there is less compression of the central vessels such as the aorta and vena cava, which allows for better uterine and placental circulation.
The larger diameters of the maternal pelvis, together with gravity, aid foetal progression through the birth canal.
The position improves the effectiveness of uterine contractions and expulsive efforts, shortening the duration of the expulsive period.
These positions allow for more dynamic participation by the parturient, with anatomical and psychological advantages for the woman in controlling her labour.
The parturient can easily change to other complementary and reversible positions.
Expulsive efforts tend to be less demanding, parturient may feel less discomfort, and there is greater tolerance to pain.
There is a greater possibility of more perineal lacerations occurring, but this is generally associated with a lower rate of episiotomy.
There may be an overestimation of haemorrhage during labour.

Squatting position
The squatting position allows the lower limbs to be abducted and increases pelvic diameters. This position takes advantage of gravity, and the expulsive efforts are more effective, and can be useful in shoulder dystocia.
It allows professionals to have less visual access to the development of perineal tissues and less control of perineal protection, which increases the possibility of lacerations.
This position is associated with a greater possibility of postpartum haemorrhage.
Parturient do not usually physically hold this position for a long time, as they report fatigue and numbness in their legs, which is why it is advantageous to explore complementary positions.

Lateral position
This position promotes asymmetry of the lower abdomen and sacral mobility, which can facilitate the descent of the foetal presentation.
The lateral position associated with the peanut ball allows greater pelvic comfort for the parturient and better management of fatigue. Parturient report some relief from pain during pushing by hugging the peanut ball with their legs, facilitating the expulsive efforts.
This lateral position allows professionals good visual access to the conditions of the perineum during the expulsive period, facilitating the control and implementation of perineal protection measures.
Expulsive efforts involve a lower risk of laceration and less use of episiotomy with a higher rate of intact perineums.
This position minimizes fatigue from positions that require more effort due to pressure on the lower limbs.

Four-support position
The four-support position or support with a bar allows better oxygenation of the foetus because its weight is “suspended” over the mother's womb.
In this position, the woman's pelvis is "loose" for greater freedom of movement for the woman in labour.
In a high posterior presentation, it can favour rotation to the anterior position of the foetus, facilitating its progression through the birth canal.
Women in labour may experience less pain and more rest between contractions.
In short, the best position for childbirth is the one in which the woman feels comfortable. This is a personal decision, not a decision made by the professional who is assisting the birth. The professional is responsible for offering guidance if the position she is in is not contributing to the evolution of the labour. In these cases, their role is to offer more favourable alternatives, taking into account the progression and fit of the baby in the mother's pelvis.
However, the decision on whether to use it is up to the woman in labour, as long as there are no risks to the foetus. Informed consent is of special value in professional practice and demonstrates the importance and respect for women's rights.