Many parents ask about the best position to give birth to avoid tearing. There is no single answer, and some tears cannot be avoided because of things like the baby’s size or head position. Still, research shows some birth positions can lower the chance and severity of perineal tears. The goal is to know how positions affect the pelvis and perineum and to choose what feels natural and supportive for your body.
A perineal tear is an injury to the area between the vagina and the anus that can happen as the baby is born. Tears range from small first-degree tears, which often do not need stitches, to third- and fourth-degree tears that involve the anal sphincter and can cause long-term problems. By using positions that open the pelvis and reduce pressure on the perineum, you can actively try to lower the risk of more serious tears.
How Does Birth Position Influence Tearing Risk?
The position you use in labor and birth matters a lot. It affects how the baby moves through the pelvis and how your tissues stretch. Some positions support a smoother, more natural birth. Others can increase strain on the perineum.
The pelvis can change shape during birth. The sacrum and coccyx (tailbone) can move to make more room. Positions that let this movement happen tend to help reduce tearing.
Why Upright and Side-Lying Positions Can Help
Upright and side-lying positions are often recommended for their natural benefits. When you are upright-standing, squatting, kneeling, or using a birth ball-gravity helps the baby move down. This can mean less hard pushing and less intense pressure on the perineum.
These positions also support better pelvic movement. MRI studies show that squatting and kneeling/hands-and-knees can widen the pelvic outlet more than lying on the back. Upright positions also help keep pressure off major blood vessels, which helps blood flow and oxygen to the baby. That can lower the chance of abnormal fetal heart tones and emergency Cesareans. They also let the tailbone move freely, increasing pelvic space by up to 16 degrees, which helps the baby’s head pass more easily. Side-lying is not upright, but it also takes weight off the sacrum and coccyx, allowing similar pelvic opening and less pressure.
| Position | Pelvic space | Pressure on perineum | Notes |
|---|---|---|---|
| Side-lying | Good | Lower | Slows birth of the head; good with epidural |
| Hands-and-knees | Good to very good | Lower | Helps baby rotate; eases back pain |
| Squatting | Very good | Higher if very fast birth | May switch to kneeling or side-lying at crowning |
| Kneeling/upright | Good | Moderate to lower | Can use pillows or birth ball for support |
| Back-lying/lithotomy | Poor | Higher | Limits tailbone movement; more strain |
Drawbacks of Lying on the Back or Lithotomy Position
Lying on the back (supine) or in lithotomy (on the back with legs in stirrups) has several downsides that can raise tearing risk. These positions put weight on the tailbone, blocking its movement and limiting pelvic opening. The birth canal becomes functionally smaller, which can lead to harder pushing and more tears.
Back-lying can also press on major blood vessels, lowering blood flow to you and the baby. This can cause lower blood pressure, weaker contractions, and fetal distress. These positions can be easier for staff because monitoring and procedures are simpler, but they are often not the best choice for your body. Many providers are most used to these positions, which can create a comfort bias that does not match current research.
Evidence from Clinical Studies
Studies repeatedly show benefits of upright and side-lying positions for lowering tearing. A review and meta-analysis by Zang et al. (2020) found that upright positions led to fewer instrument-assisted births and a large drop in severe perineal trauma (about 75% lower relative risk). Some studies in that review did find more second-degree tears with squatting and birth seats, but there were fewer episiotomies, and natural tears usually heal better than surgical cuts.
A 2015 Swedish study of over 100,000 births found the lowest rates of severe tears in standing positions, and the highest rates in lithotomy. Standing and side-lying had the lowest severe tear rates for both first-time and experienced parents. These results support avoiding positions that limit pelvic movement and using those that work with the body’s design.
Top Positions to Minimize Tearing During Birth
Picking helpful positions lets you work with your body and gravity, which can lower tearing risk. Every birth is different, and what feels right may change as labor goes on. Still, several positions are often suggested because they protect the perineum.
Side-Lying Position
Side-lying is a strong choice for lowering tearing. You lie on your side, often with a peanut ball or pillows between your knees. This helps open the pelvic outlet like upright positions do, but with less effort.
Side-lying takes pressure off the perineum and can slow the baby’s descent, giving tissues more time to stretch. That slow stretch helps prevent tears. It also works well if you are tired or have an epidural, because it is comfortable and keeps good hip and pelvic alignment. Many people also like that it allows face-to-face contact with a partner. Certified nurse midwife Michelle Stiltner calls it her favorite position for comfort and lower tearing risk.
Hands-and-Knees Position
Hands-and-knees (all fours) is another great option. Gravity helps the baby rotate into a head-down, face-down position. It can also ease back pain, especially if the baby is occipito-posterior (“sunny side up”).
This position takes pressure off the lower spine and lets the pelvis move more freely. Like side-lying, turning the legs inward a bit (ankles wider than knees) can create extra room at the pelvic outlet. Hands-and-knees is often gentler on the perineum than squatting, which many people prefer for a calm birth of the head.
Upright Positions: Squatting, Kneeling, Using a Birth Ball
Upright positions use gravity to help the process. Squatting, kneeling, and using a birth ball each have benefits.
- Squatting: Widens the pelvic outlet a lot, giving the baby more space to descend. It can be intense on the perineum if the birth is very fast. Many providers suggest moving from a squat to kneeling or side-lying as the head crowns to allow a slower stretch. Practicing squats during pregnancy can help pelvic floor strength and mobility.
- Kneeling: Kneeling upright or on hands and knees shares many of the benefits of squatting but may put less direct pressure on the perineum. You can add pillows, a birth ball, or a couch for support. It adapts well to different stages of labor.
- Using a Birth Ball: Sitting on a birth ball and moving your hips in circles or figure eights can help open the pelvis and encourage descent. Leaning over a birth ball while kneeling can be soothing and reduce back pressure. The ball allows gentle movement and easy changes in position throughout labor.
Birth Seat and Supported Standing
Birth seats or stools have been used for a long time and are popular again because they work well. They keep you in a semi-squat, upright position that uses gravity and opens the pelvis. The Swedish Birth Seat Trial found that birth seats can shorten the second stage, reduce the need for synthetic oxytocin, and lower episiotomy rates, while raising birth satisfaction.
Supported standing is another helpful choice. You can lean on a partner, a wall, or a fabric sling. Standing lets gravity help and keeps the pelvis free to move. Walking, especially on stairs or curbs, can create slight hip and pelvic shifts that help the baby drop. The main idea with all upright positions is to stay mobile and allow natural movement so the baby can find the best path.
Positions Compatible with Epidural Use
Many people wonder if an epidural limits position choices. A high-dose epidural can reduce feeling and movement, which can make some upright positions hard without help. But it does not mean you must lie flat. Low-dose epidurals, now common in many places, allow more movement and more position options.
Side-Lying (Lateral) Position with an Epidural
Side-lying is an excellent choice with an epidural. It takes weight off the sacrum and coccyx so the pelvis can open, which helps lower tearing risk. Even with less feeling, you can be well supported on your side with pillows or a peanut ball between your legs. This keeps good hip alignment and pelvic opening.
Studies show that supported side-lying with an epidural can shorten active pushing and reduce episiotomy, forceps, vacuum use, and fundal pressure. These results are even better when you change positions often during the passive phase of the second stage. Staff can help with turning, so this option works even with limited movement.
Modified Upright and Supported Positions after Epidural
With an epidural, you may still use modified upright and supported positions. Standing may be limited in some hospitals because of fall risk, but other options remain. Many beds adjust for semi-sitting or supported kneeling. You might also use a birth ball for support while kneeling or sitting.
Working closely with your care team helps make these options possible. With a low-dose epidural, you may have enough muscle control to shift with assistance. Doulas and nurses can help with props and creative setups to keep you off your back. Share your preferences clearly and ask for positions that keep the pelvis moving and lower strain on the perineum, even if feeling is reduced.
What Can Be Done During Labor to Reduce Tearing?
Beyond picking helpful positions, several simple methods during labor can lower tear risk. These steps support steady stretching of tissues and a slow, gentle birth of the head.
Controlled Pushing and Spontaneous Bearing Down
How you push affects the perineum. Research suggests that pushing with your natural urge, instead of long, coached pushing, can reduce tearing. Letting your body lead gives the perineum more time to stretch around the baby’s head.
As the head crowns, midwives may suggest short panting breaths instead of hard pushes. This slows the birth of the head so the tissues stretch slowly. This steady approach helps avoid fast, forceful stretching that can cause bigger tears. Many people find cues like “breathe the head out” or thinking of a “downward” gentle effort helpful.
Perineal Support: Warm Compresses and Hands-On Techniques
Supporting the perineum during the last part of birth can help lower tearing. Two common methods are warm compresses and manual support.
- Warm Compresses: A warm, moist cloth on the perineum as the head stretches the tissues can help. Warmth brings more blood flow, relaxes muscles, and makes tissues more stretchy, which can reduce tearing. It can also feel soothing.
- Hands-On Techniques (Manual Perineal Protection): A provider can support the perineum with their hands while the head is born. Gentle counter-pressure can guide the head and limit extra stretch. This can be done in many positions, though it can be harder in water or on a birth stool. Older methods used firm “perineal massage” during pushing, but current research favors gentle support and a slow birth of the head. In many cases, a light-touch or “hands-off” approach with careful watching and slow crowning protects the perineum well.
Key Takeaways: Choosing the Best Position to Avoid Tearing
Giving birth involves many choices, and position is one of the most helpful. There is no single best position for everyone, but the best approach is to learn what different positions do, prepare your body, and speak up about what you want.
Aim for positions that work with gravity and let your pelvis open naturally, which lowers strain on the perineum. Try to avoid back-lying or lithotomy, which are linked to more interventions and higher rates of severe tears. Favor positions that let the sacrum and coccyx move and widen the pelvis. Side-lying, hands-and-knees, and upright options like squatting or kneeling-often with a birth ball or partner for support-are strong choices.
Your birth is your own, and you can pick positions that feel right to you. Talk about your plans with your provider during pregnancy. If your provider does not support upright or mobile positions, you might choose one who does. An advocate-such as a doula or a well-informed partner-can help your wishes be followed during labor. Prenatal movement, pelvic floor care, and practice with gentle pushing can all help lower tear risk. Even with an epidural, creative positioning and good support open many options beyond lying on your back. Your body is built for birth, and by choosing positions that respect that design, you can help yourself have a gentler, more positive birth with less tearing.