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Best positions to “push” baby out

Pregnant and getting ready to deliver? Confused on what the best pushing positions are? We got you! Your main two pushing options during labor are positions that promote internal rotation of the hips vs external rotation of the hips. The most common position people think of during delivery is the lithotomy position, which is commonly shown in movies and TV shows. But is this the most optimal way to deliver your baby?

Based on pelvic mechanics, the lithotomy position may not be best to deliver baby. Why not? Because when you are in the lithotomy position, you are laying on your back with your hips externally rotated (knees apart, feet together). When your hips are externally rotated, it narrows the bottom of the pelvis (pelvic outlet), making it harder for baby’s head to exit the birth canal. Your sacrum (base of your spine) and tailbone are also pushed into the table and unable to move away from you to make more space at the base of the pelvis.

So what positions best encourage the baby’s exit?  Getting into a position where your hips are internally rotated (knees together, and feet out) is going to open the base of the pelvis so the baby has the most room to pass through the birth canal. Positions promoting internal rotation also allow your tailbone and sacrum to move freely without being blocked by the delivery table. You can get more internal rotation of your hips by choosing positions like: laying on your side, getting on your hands and knees, or propping yourself up on an exercise ball or delivery bed. Just make sure your knees are closer together and your feet are further apart in these positions.

Pushing in positions where your hips are internally rotated can help stretch and lengthen your pelvic floor, which reduces the likelihood of perineal trauma. Even with an epidural, you should still be able to get into most of these positions with assistance. So make sure to advocate for yourself!! It might be helpful to attend a childbirth course run by a doula or pelvic floor physical therapist to go over pelvic mechanics during labor and learn optimal pushing strategies and positions.

So why are so many women encouraged to deliver on their backs? The lithotomy position (hips externally rotated) is easier for healthcare providers to monitor baby’s vitals and determine labor progress. This position also allows quicker access to medical interventions, such as the use of forceps or vacuum extraction to get baby out quickly. So what if you end up in the lithotomy position for one of these reasons? No need to worry, there are modifications we can make and pushing strategies we can implement to improve mechanics and reduce stress of your pelvic floor!

While both internal and external rotation pushing have their advantages, the best approach depends on various factors, including a mother's comfort, the baby's position, and any medical considerations. Becoming informed on all your options and sharing birth preferences can help your delivery team find positions that make you feel the most comfortable and empowered!

*All photos used in this blog are credited to and are not owned by LPPT.

Alex Warden-Michl, PT, DPT, MSCS, LSVT-BIG

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