The rule that applies to everyone

NICE's intrapartum care guideline makes one clear negative recommendation about position in the second stage, and it applies whether or not you have an epidural: advise a woman that "lying flat on her back can lead to a decrease in blood pressure and may reduce placental blood flow."

Everything after that is preference. For a woman without an epidural, NICE says "she can use any other position she finds comfortable to give birth", adding that "upright positions and keeping mobile may be beneficial (as they may reduce fetal heart rate abnormalities, episiotomy rates and improve her birthing experience)."

Note the verb. NICE says may, not will. Upright positions are worth trying and worth being offered. They are not a test you can fail.

If you have an epidural

The advice changes shape here. NICE tells teams to advise a woman with an epidural in place that "lying on her side may increase the chance of a spontaneous vaginal birth, but she can use any other position she finds comfortable to give birth, including upright positions."

That is a meaningfully different sentence from the one for women without an epidural. With modern low-dose epidurals many people can still shift position, kneel over a raised bed head, or be supported upright with help — but side-lying is the position the guideline singles out as potentially improving your odds of birthing without forceps or ventouse.

NICE also asks teams caring for women on continuous monitoring to "encourage and help women to be as mobile as possible, to find positions that are comfortable for them, and to change position as often as they wish." A monitor is not a reason to lie still.

Positions worth trying in labour

The HSE lists a practical set and recommends rehearsing them: "practice different positions during your pregnancy and see what feels comfortable."

Standing, "moving your hips from side to side or in a circular motion".
Kneeling.
Squatting.
Lying on your side, with a pillow between your knees.
Kneeling on all fours.

The NHS adds that in the second stage you may want to "sit, lie on your side, stand, kneel, or squat, although squatting may be difficult if you're not used to it", and offers one specific tip: "If you've had lots of backache while in labour, kneeling on all fours may help."

The HSE's reasoning for staying mobile earlier on is worth borrowing: being active "helps you to cope better during labour and helps to progress your labour." The NHS says something similar about the latent stage — stay upright and gently active, because it "helps your baby move down into your pelvis and helps your cervix to dilate."

Equipment that supports position

The HSE suggests asking your unit what it has, and lists floor mats, bean bags, birthing balls and peanut balls, birthing stools, ceiling slings, showers and baths, and birthing pools. It also notes you can bring your own if the hospital does not provide them — your own ball, an extra pillow, pool floats or a yoga mat.

The NHS puts the same question on its list of things to ask on a maternity unit tour: "What equipment is available — for example mats, a birthing chair or bean bags?" and "Can I move around in labour and find my own position for the birth?"

In the water

If you are labouring or giving birth in a pool, the HSE recommends changing position there too: kneeling and leaning over the side, squatting while holding the sides, using floats under your arms for support, floating on your back with your head supported, or floating on your front with your head turned to one side on a pillow.

Pushing: spontaneous or directed

Position and pushing technique are treated as separate questions by NICE, and the advice again splits on whether you have an epidural.

Without an epidural

NICE advises women without an epidural that "spontaneous pushing may shorten the second stage of labour compared with directed pushing", and that "if directed pushing is used, pushing while exhaling may shorten the active second stage of labour for multiparous women."

The HSE describes what directed pushing sounds like in the room: take a deep breath in; when you breathe out, "push down into your bottom as if you were trying to do a poo"; take a breath when you need to and push again; rest between contractions. It also notes that in a water birth "there will be no coached pushing. You will go with your own urge to push."

With an epidural

Here the guidance inverts. NICE advises first-time mothers with an epidural that "directed pushing rather than spontaneous pushing may reduce the likelihood of having an unplanned caesarean birth", and that "delayed directed pushing (up to 2 hours after full dilatation) may shorten the active second stage of labour."

For women who have given birth before and have an epidural, delaying directed pushing by an hour after full dilatation "may reduce the likelihood of needing birth with forceps or ventouse" and "may shorten the active second stage of labour."

RCOG makes the same point in plainer language: the need for an assisted birth "may be reduced by not starting to push too soon after your cervix is fully open. You may be advised to wait until you have a strong urge to push, or to try and delay pushing by 1-2 hours depending on your individual situation."

If pushing is not working

NICE's answer is not "push harder". It says that if pushing is ineffective, or if you ask, teams should "offer strategies to assist birth, such as support, change of position, emptying of the bladder and encouragement." A full bladder is a genuinely common and genuinely fixable obstacle.

Protecting the perineum

Two of NICE's recommendations here are about what happens around your position rather than the position itself. Once the baby's head is stretching the perineum, teams should "offer to apply a warm wet compress to the perineum and continue this until birth", checking the temperature is comfortable for you. Perineal massage with a water-soluble lubricant can be considered instead if you prefer it. Neither applies to births in water.

The NHS describes the moment itself: when the head is almost ready to come out, "your midwife will ask you to stop pushing and to pant or puff a couple of quick short breaths, blowing out through your mouth", so the head is born slowly and the perineum has time to stretch.

What to take from this

Rehearse a handful of positions in late pregnancy. Ask your unit what equipment it has. Expect to move. If you have an epidural, ask about side-lying and about delaying the start of pushing — both are in the guideline, and neither is automatic unless someone raises it.

Positions for Labour and Pushing