You've done it. You've been laboring for hours now and your cervix is fully dilated, softened, and thinned. Baby is also nice and engaged in at least a -2 station in the pelvis. It's time to start pushing! If you've done this before you may opt to try the position you pushed in last time. If that doesn't work, or if this is your first time around, you may want to try several different positions until you find what works.
To optimize your pushes, you'll want to be in a position that A) works with gravity to bring baby down and out, B) creates and encourages an overwhelming urge to push, and C) generally feels right. Here are a few positions to consider.
In a seated position, with the bed (or partner, as seen in the picture below) leaned back as much as is comfortable, you will bring your ankles together and let her knees fall to either side. The semi-reclined position is probably the most common position for delivery. This is a good option if you have been laboring for a long time and need a break from being on your feet. When your contraction reaches it's peak, curl your chin into your chest, place your hands behind your knees, pull your legs towards your ears, and push with your pelvic floor. You can also pull on the bed rails if you'd rather not add extra pressure to your perineum.
This position may cause some tearing (although a little is common for first time moms), but not nearly as much as lying flat on your back. To avoid a bad tear, remember to take your time and follow your body's lead. Push when you feel the urge, rest when you don't. This position can also be taken in a birth pool or tub.
While lying on one side, with your top leg pulled up towards your armpit, you will curl your chin to your chest, and push into your bottom area at the peak of your contraction. Same idea as semi-reclined, just on your side. Side-lying is also a good position if your legs are tired or you have an epidural.
This position can be done on the bed, floor, in the tub, or on a birth stool. If you're doing this on a hospital bed, you'll want to incline the back as far as it can go. Get your body in the squatting position, hold onto the back of the bed, engage your pelvic floor muscles, and push like you're having a bowel movement. You can also use a squatting bar that goes across the hospital bed to hold onto. If you're squatting on the floor you can hold onto the couch, bed, or chair for stabilization.
Pushing in this position really works with gravity and allows you to have full control over your pushes. However, this position may not be optimal if you've been laboring for a long time and are tired. Sitting on a birth stool or squatting in a birth pool can alleviate some of the work.
Some providers may feel uncomfortable with this position as they have a harder time seeing the progress you are making. It's always a good idea to discuss pushing positions with your care provider before labor, and choose providers who are willing to (safely) listen to your intuition. It's also important to remember that YOU need to be comfortable in whatever position you choose for pushing. If you can't feel the urge to push or the progress you're making, you risk extendeding the second stage. Choosing the position that works best for you can also minimize the risk for tearing as well as an instrumental delivery (with forceps or a vacuum).
Hands and Knees
If you are wanting to really allow your body to do the work for you, hands and knees is a great position to consider. This is often the position taken during fast deliveries. Could be the natural-ness women feel here, or it could be that it's the quickest position to get it when climbing onto a bed. Who really knows.
For women with back labor, this is a good position as it is easier for doulas, partners, or care providers to give counter pressure or hip squeezes while you push. This position can also encourage optimal fetal positioning to make labor and delivery easier.
Other Tips and Tricks for Second Stage
If you are struggling to find or maintain the urge to push, consider laboring down a little longer. Laboring down allows the baby to gently move further down the pelvis. It also allows for the fetal ejection reflex to naturally kick in and move baby down and out with much less effort. For some women, a large mirror to visually see the progress they've made is enough to push through the second stage (pardon the pun). You can also use a small hand mirror, if a large one (as pictured) is not available.
If you have labored down, or need to get through the second stage quickly, and you're still having a hard time pushing properly, try playing tug-o-war with your partner, doula, or nurse. This trick works just fine for most positions. It can even be used if you've gotten an epidural. Your partner/doula/nurse will hold onto one side of a towel, rebozo, or bed sheet, with their feet firmly planted, and as you push with your contraction, you will pull the other end with all your strength. This push/pull will help you engage the proper muscles, moving baby down the birth canal, and protecting your vagina and bottom from unnecessary damage.
Remember that this is YOUR body, YOUR birth, YOUR baby! Allow your body to lead and guide you. You might not know what to do, but I assure you, your body does.
For more evidence for pushing positions, check out this post by Evidence Based Birth ---> https://evidencebasedbirth.com/what-is-the-evidence-for-pushing-positions/.