How Maternal Positioning Influences Labor Progress and Birth Outcomes

By Birth & Baby University · Last updated: October 2026 · 3 min read

“Get her upright” and “get her off her back” are among the most repeated lines in birth work. The research behind them is real but more mixed than the slogans suggest. This article walks through the main Cochrane reviews so you can describe positioning accurately and offer options that suit the person in front of you.

Key takeaways

• In the first stage of labor, upright positions were associated with a shorter first stage and fewer cesareans in trials of variable quality.
• In the second stage without an epidural, upright positions were associated with fewer assisted births and episiotomies, but also with more second-degree tears and more estimated blood loss over 500 mL.
• With an epidural in the second stage, upright and recumbent positions may make little or no difference to operative birth.
• Position is a choice to support, not a technique to prescribe. Medical conditions, monitoring and anesthesia can limit options.

What the research says

First stage

A Cochrane review of 25 trials with 5,218 women compared upright and ambulant positions with recumbent positions and bed care. The first stage was about 1 hour 22 minutes shorter with upright positions (mean difference -1.36 hours, 95% CI -2.22 to -0.51), and upright women were less likely to have a cesarean (RR 0.71, 95% CI 0.54 to 0.94) or an epidural (RR 0.81, 95% CI 0.66 to 0.99). The authors cautioned that trial quality was variable, and heterogeneity for the labor duration result was very high (I2 93%). The review found no significant differences for second stage duration or other outcomes for mothers and babies, and, among women with epidurals, no significant differences between groups.

Second stage without an epidural

The 2017 Cochrane update analyzed 30 trials involving 9,015 women. Compared with supine positions, upright positions were associated with a second stage about 6 minutes shorter (very low-quality evidence), fewer assisted births (RR 0.75, 95% CI 0.66 to 0.86, moderate quality) and fewer episiotomies. They were also associated with a possible increase in second-degree tears (RR 1.20, 95% CI 1.00 to 1.44, low quality) and with more estimated blood loss over 500 mL (RR 1.48, 95% CI 1.10 to 1.98, moderate quality). There was no clear difference in cesarean rates or in third and fourth-degree tears. The review warns that results should be read cautiously because risk of bias was variable.

Second stage with an epidural

The 2018 Cochrane review for women with epidurals included eight trials with 4,464 women, three-quarters of them in one large UK trial. Overall there may be little or no difference between upright and recumbent positions for operative birth (average RR 0.86, 95% CI 0.70 to 1.07, low-quality evidence), and the effect on cesarean alone was uncertain.

Putting the reviews side by side

A 2021 overview of Cochrane reviews concluded that the body of evidence is limited for clearly judging the benefits and risks of upright positions during childbirth, rated the evidence very low to moderate in quality, and called for better research, including on squatting.

What this means for doulas

• Offer, do not insist. The evidence supports giving people the freedom to move and choose, not requiring a position.
• Be honest about trade-offs. If a client asks about pushing upright, you can say trials associate it with fewer assisted births and episiotomies but also with more estimated blood loss and perhaps more second-degree tears.
• Match positions to the situation. Continuous monitoring, an epidural, an induction or a medical condition can change what is practical. Ask the nurse or midwife what is possible rather than assuming.
• Do not manage the birth. You can suggest options and help with comfort. Decisions about positioning for fetal heart rate concerns, bleeding or perineal protection are clinical.

Putting the evidence into practice

• Teach a short menu of positions in prenatal visits (standing, leaning forward, hands and knees, side-lying, sitting, supported squat) and make clear that comfort guides the choice.
• Ask the team early in labor which positions are compatible with the monitoring and any anesthesia in use.
• Rotate positions when labor slows, for comfort and variety, and describe this as an option, not a fix.
• After birth, avoid attributing an outcome to a position. The evidence does not allow that kind of cause and effect for individual births.

The bottom line

Positioning is worth supporting because it is low risk for many people and can aid comfort and autonomy. The outcome benefits, though, vary by stage, anesthesia and the quality of trials. Describe the research in measured terms, and let your client’s comfort and clinical advice guide the choice.

This article is for professional education. It is not medical, legal or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• Lawrence A, et al. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2013. Read the source
• Gupta JK, et al. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2017. Read the source
• Walker KF, et al. Maternal position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews 2018. Read the source
• Kibuka M, et al. Evaluating the effects of maternal positions in childbirth: An overview of Cochrane Systematic Reviews. European Journal of Midwifery 2021. Read the source

Position support is one of many hands-on skills covered in birth doula education. See the training and mentorship options on the For Doulas page.

More for professionals: the Professionals Blog.