Upright positions in labour – the benefits

The Cochrane Review

The authors of a Cochrane Review on Maternal positions and mobility during first stage labour found that:

“There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers’ and babies’ well being. Given the great heterogeneity and high performance bias of study situations, better quality trials are still required to confirm with any confidence the true risks and benefits of upright and mobile positions compared with recumbent positions for all women. Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever positions they choose.” (Lawrence et al 2013).

My recent research suggested that being active and off the bed can be even more useful for women who are larger than average. This may also be the case for other groups of women who are deemed to be ‘at higher risk’. Which is one reason why we need to question the illogical guidelines that keep larger or so-called ‘at risk’ women from accessing beneficial options such as midwifery-led units and birth pools.

Why research on this is problematic

However, doing research trials on upright positions in labour has always been problematic, and will probably always be problematic.

It’s ethically questionable to randomise women and tell them what sort of position to adopt. Especially as so many of us see the benefits of encouraging women to follow their own instincts. One size doesn’t fit all when it comes to positioning.

It’s also difficult to research the benefits of a more physiological approach when the vast majority of women are giving birth in hospitals and experiencing numerous intervention which can inhibit or limit movement and activity.

So this area is a tricky one. Nadine Edwards explains more about the difficulty of researching labour in this book.

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Advantages of upright positions in labour

But we do have some research into this area, and the authors of a 2025 paper have summarised these.

“Evidence is sparse on using various positions during the first stage of labour. However, a few studies have found advantages such as shorter duration of labour, less use of epidural analgesia (EDA), and a lower risk of caesarean section in women without EDA adopting upright positions compared to recumbent positions in the first stage of labour.

“Further, it has been found that women may experience less pain, have a greater sense of control, and higher reported satisfaction with childbirth when giving birth in an upright position.” (Kjeldsen et al 2025).

But there’s a problem…

Many of those who support birth will tell you that there’s a problem though.

As in so many areas of maternity care, having evidence about the benefits of active birth and upright positions in labour isn’t doing anything to change practice.

There are a number of related reasons for this.

The first is that almost every depiction of labour and birth in mainstream western culture shows women on beds. So people assume that this is a good thing, or what they are expected to do. Even though the research shows the absolute opposite: that upright positions and being off the bed is beneficial.

This idea is reinforced by the fact that, when you walk into most labour rooms, the bed is the most prominent feature. This reinforces the idea that the bed is the most important piece of furniture, and that one is expected to get on it.

Which isn’t ideal, because sitting or laying on a bed is exactly the opposite of the kind of position that helps labour progress and brings all the benefits I’ve listed above.

A depressing statistic

In fact, the authors of the paper I mentioned above carried out a small but important study on maternal positioning.

This research was carried out in Denmark, but other studies have found that far more women give birth in a supine position than in a sacrum-flexible position. For example, an Italian study found that, in “…2240 nulliparous, at-term pregnancies … 76.9% gave birth in a supine position and 23.1% gave birth in alternative positions.” (Familiari et al 2023). 

The figures will be no lower in the US, UK, Australia or many other countries. In fact, they may be higher.

One of the reasons for this, as Kjeldsen et al (2025) discuss, is the high rate of induction of labour. In Denmark, this is over 30%. In some areas, it is now higher than this.

So what can we do?

So what can we do about this?

Well, if you’re the person who is about to labour or give birth, the answer is fairly simple.

Don’t get on the bed if you don’t want to.

If you’re asked to get on it, ask why. Then you can decide if you want to get on the bed or not. You don’t have to do anything that you don’t want to do. If you do decide that there is good reason to get on the bed, for example if you want a test or examination, you can opt to get off again as soon as it’s over.

Remember that you do not need permission to move your own body, and you can say no to anything that doesn’t feel right to you.

Your body, your baby, your decisions. (Lots more on this here.)

And get informed about interventions like induction, epidural, and fetal monitoring, so that you can weigh up the pros and cons and decide whether any possible benefits are worth the downsides.

Ideas for midwives and birth workers

I also have a list of ideas for midwives and birth workers, from my own practice, and from conversations in my workshops and courses about how we can help more women feel that they can be free to do things other then get on the bed the second they enter a delivery room.

These ideas are particularly helpful when we’ve not met the woman/family before. They offer a chance to interrupt the cultural conditioning that we have experienced around beds and birth, and create a space to have a conversation about this, or just to make it clear that there are other options.

No-one is suggesting that we stop women from getting on the bed if they really want to, of course. Some women really would prefer it, want interventions (such as induction, fetal monitoring, or an epidural) which may necessitate being on the bed, or would love to be active during their labour but are just exhausted.

However, given that many modern delivery rooms aren’t conducive to promoting active labour and physiological birth, it is important to consider how we can break the cycle of expectation that can lead to slower labours than would occur if women were nesting on the floor, sitting on birth balls, roaming around, adopting a range of positions and/or all of the other things that help babies out.

Make the bed less accessible

I know lots of people who feel that beds are far too prominent in many delivery rooms, and they are concerned that women entering the room think that they are supposed to get on the bed straight away.  So, when they’re getting the room ready for the woman, they make the bed a bit less accessible.

If they can get away with it, some people do a bit of furniture moving and push the bed against the wall when they’re preparing for the arrival of a woman and her family. It makes it less prominent than if it is there in the middle of the room.

Others pump the bed up so it is higher than normal, so that it would have to be pumped down again before anyone could get on it. This makes the act of getting on the bed a conscious one, rather than the default action. I sometimes joke that, because you need a working knowledge of advanced mechanics to figure out the remote control for some of these beds nowadays, by the time someone has worked out how to get the thing back down again, the baby might have been born.

Put something on it

Midwives in one research study described spreading the woman’s maternity notes out on the bed and using it as a writing surface, which again meant that the bed was less accessible as a bed. There are pros and cons to taking ownership of the bed in this way, and this might not be appropriate in every context, but like all of these it’s just an idea for the toolkit.

A midwife I worked with as a student used to offer to carry the woman’s hospital bag so that the woman’s partner could support her as they walked to the room together. She would then heave the hospital bag and their coats up onto the bed and encourage the couple to unpack anything they needed onto the bed, which also had the effect of turning it into a table. Ownership issue sorted and, because it’s the family’s stuff, they didn’t feel that they had to ask permission to move it.

Give verbal permission to be bedfree

I once heard a midwife say this, while she was plonking the woman’s bag or her and her partner’s coats onto the bed:

‘You can use this for its intended purpose anytime you want to, but your labour is likely to be faster and less painful if you hold off getting up there for as long as possible, so you might want to try to stay upright as long as you can. Let me know if you’d like to get into the pool for a bit of relief or just snuggle up on the beanbag if you need a rest.’

Another said:

‘I know that everyone in One Born Every Minute gets on the bed right away, but that’s partly why so many of them end up with problems. I’ve made you this nest [more on this below], so maybe try that first and see what you think?’

Offer alternatives

As above, some midwives and birth workers will offer an alternative, either by pushing the bed away and making a nest, or suggesting trying the pool. Other options include putting birth ball in the room ahead of time.

My own preference when working in a hospital setting was to offer a cosy nest in addition to whatever other furniture is there. I liked to build nests in a quiet corner of the room out of chairs (useful for making a ‘wall’ between the woman and the door for privacy – think blanket forts), floor mats, inco (chux, blue) pads, beanbags and spare hospital bedding. I would make them look as inviting as possible (which, yes, is hard with hospital bedding, but it’s a good chance to exercise creativity), and point them out to women upon arrival. I would let the woman/family know that it was all theirs, and that they were welcome to move it, and add their own things to it.

One note, though. My experience is that, if you do this beforehand, woman are much more likely to use such alternatives than if you offer them as an option later on. 

There’s a good analogy involving parties here. If you put snacks out before anyone arrives, people will just start eating them. If you haven’t already put them out and you say to a guest, ‘would you like me to put some snacks out?’, then (at least in the UK and unless they are really hungry) they might decline, because they don’t want to create extra work for you.

Changing the culture

Labour room beds are just one example of things that have become embedded in our culture as a ‘norm’, despite there being good evidence (not to mention common sense wisdom) that many women would be better off avoiding them.

There are many aspects of our culture that we have little control over.

But there are also things we can do that will make a difference.

The key is to look for those opportunities and to take them when we can.

For more information on birth decisions

What’s Right For Me?

In Your Own Time

Inducing Labour

Plus Size Pregnancy

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Books to help you become informed and make the decisions that are right for you…

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