back to back presentation in labour

• Pregnancy |
• Labour and Birth

My baby is back to back – what do I do?

In the weeks leading up to your due date , your baby will be getting into position ready to make their way into the world. The best position for your baby to be in prior to birth is head-down (cephalic presentation), with the back of their head towards the front of your tummy (anterior position). But this isn't always the case. Sometimes babies present bottom first or with the back of their head towards your back (occipito-posterior). The latter is more commonly known as "back to back".

What is a "occipito-posterior" or "back-to-back" position?

A back-to-back position is where your baby's head is down, but the back of their head and their spine is against your spine. At least one in ten babies are back-to-back when labour starts.

Most back-to-back babies are born vaginally, but this position can make labour longer and more difficult.

Back-to-back baby symptoms

If your baby is back-to-back at the beginning of labour, you might feel some of the following things:

• Backache, as your baby's skull is pushing against your spine

• Long and slow labour, with contractions stopping and starting

What happens when you're in labour with a back-to-back baby?

Most back-to-back babies turn to the anterior position during labour. While you're giving birth, the majority of back-to-back babies turn almost 180 degrees when they reach your pelvis.

This can take time, or your baby might decide they don't want to turn around after all, which means they'll come out face-up. You might also need an episiotomy or an assisted birth with forceps or ventouse to help them out. If none of this works, you may possibly need a caesarean section .

Why are some babies back-to-back?

Your baby might be back to back because of the size and shape of your pelvis. If you have a narrow and oval-shaped (anthropoid) pelvis, or a wide and heart-shaped (android) pelvis, your baby is more likely to settle in a back-to-back position.

There is also some evidence to suggest that the way you sit and move during late pregnancy can cause your baby to settle in a back-to-back position. When you're sat down for long periods of time, your pelvis is tipped backwards, which can cause the back of your baby's head (the heaviest part) to swing round to the back due to gravity and they'll end up lying against your spine.

How do you help your baby get into the anterior position?

Some experts think that you can help your baby get out of back-to-back position by adopting certain movements before and during labour. This is known as optimal fetal positioning (OFP). There isn't a whole host of scientific evidence that this will work, but many midwives think it's worth a try and for some women, it works well.

If you'd like to try some OFP techniques, you can have a go at the below positions:

• Adopt a hands-and-knees position for 10 minutes, twice a day.

• Tilt your pelvis forward, rather than back, when you're sitting. Ensure your knees are always lower than your hips.

• Check that your favourite seat or car seat doesn't make your bottom go down and your knees come up. If it does, sit on a cushion to lift up your bottom.

• Move around if your job involves a lot of sitting, and take regular breaks.

• Watch TV leaning forward over a birth ball, or sitting on the ball. If you are sitting, make sure that your hips are higher than your knees.

Other tips from NCT include:

• Sit on a wedge cushion in the car, so your pelvis is tilted forwards

• Use yoga positions, like sitting with your back upright and the soles of the feet together, knees out to the sides

• Sleep on your side, not on your back

• Avoid: deep squats, crossing your legs, sitting with feet raised, leaning back into a sofa or armchair

Try getting used to these positions all the way through your pregnancy, so you'll be well practised for when labour starts.

Lifestyle and parenting blogger Eilidh Wells talks about her experiences having a back-to-back birth with her son Oliver. She hadn't been told that her baby was back-to-back until she was in labour, and she said it helped her to understand where the pain was coming from.

"It was so so painful, but because he was back-to-back I remember thinking this pain feels like somebody is hitting the bottom of my spine with a hammer," she says.

"At one point the pain changed, I still don't know what happened at this point and me and Andy [her partner] thought that maybe he'd turned...and it happened really suddenly," she also says.

How can I improve the chances of anterior position during labour?

You can use the above tips to help turn your baby, although there is little evidence to support the success of the movements, it might help relieve back pain caused by your baby being back-to-back.

You should also try to move around as much as possible, finding the most comfortable position for you. You might find that being on all fours helps, as this means your baby drops away from your spine, alleviating backache.

You could also try knees-to-chest positions, on your knees with your head, shoulders and upper chest on the floor or mattress and your bottom in the air. Lean forwards during your contractions by using a birth ball, beanbag, your partner, or the bed.

Rocking your pelvis during contractions can help your baby turn as they pass through the pelvis. Using a birthing ball  is great for pelvic rocking.

Adopting lunge positions, either when standing on one foot, kneeling on one knee, or when you're lying on the bed can help give the baby more room to turn.

Walk or move every now and again. Don't stay sitting in a chair, or on a bed in a leaning-back position, for too long.

Try not to have an epidural or strong labour pain relief  too early on in labour if you can, as epidurals may increase the chance of your baby being in a posterior position at birth. Epidurals also increase the likelihood of you having an assisted birth.

My baby's not back to back, but I've got an anterior placenta, should I be worried?

It shouldn't be a worry if your placenta is in the anterior position, it will still nourish your baby, but you might not be able to feel your baby kick as much as you would if your placenta was in a different position.

This is because the placenta provides a cushion between your baby and your stomach. This might also make it more difficult for you to hear your baby's heartbeat.

There can be potential complications with an anterior placenta, although it's not normally a cause for concern. Sometimes if you have an anterior placenta, your placenta can grow down instead of up, towards your cervix.

This could possibly block baby’s way on delivery day and cause bleeding. This condition is known as placenta previa. If the placenta blocks all or a portion of your cervix during labour, a cesarean delivery, commonly known as a C-section, is required.

Parenting , Pregnancy

The truth about ‘back to back’ birth

*This article was originally published in April 2015. It is my most read article to date, frequently appearing at the top of my analytics. I’m re-sharing this on that basis*.

Before having children I had only ever heard a couple of references to ‘ back to back birth ‘. These were vague and pretty much just about where contractions are felt during a labour, where the baby is lying on the mother’s spine. Phrases like ‘back contractions’ and the description of the location of the pain being ‘all in the back’ were used.

I never gave it much thought.

I filed it away safely at the back of my mind along with the description of newborn poo and the fact that the car park machine at the hospital required several £1 coins.

I knew that in order to prevent a back to back delivery, I needed to get my baby into the ‘optimal’ birth position and well, I had been swimming; in the gym; taking aqua natal sessions and pregnancy yoga so I had this optimal birth position thing nailed right anyway?

Baby number 1

My first baby was two weeks late and following multiple sweeps and several goes at induction , labour spanned the best part of four days and resulted in a very tightly wedged back to back baby that had to be dragged out with forceps.

Baby number 2

A breeze in comparison to the first – not easy, as I would never describe giving birth as being easy, 9 days late and a sweep later he finally got moving and was born in water .

Baby number 3

Now, clearly I was hoping things would be getting easier, or at least that this would resemble baby 2’s arrival, more than baby 1’s. 12 days late and three sweeps later, nothing. Received a date for induction which seemed to frighten me into action. One very long, drawn out labour later, another tightly wedged back to back baby arrived, narrowly avoiding the need for forceps.

Baby number 4

I knew this would be the last baby, so was clearly once again hoping for the relaxed, hypnobirth in water . Baby had other ideas and decided to be 12 days late just like his brother. This time five sweeps and lots of trampolining didn’t move anything and I ended up being induced again. Another back to back baby started coming quickly and then got stuck and delayed things somewhat in the latter stages of labour, causing some concern, before eventually making an appearance, thankfully without the forceps.

I lost count of the number of people who told me after my first baby that they would all “fly out” or that I would only be in labour for 30 minutes. That’s just not how I have my babies clearly, they like to make me work hard for them.

I can tell you that a back to back labour is hard work. It can last a very long time and you can feel you make very little progress for all your hard work. A baby is in the ‘back to back’ or ‘occipito-posterior’ (OP) position when he/she is lying head down but instead of the back facing frontwards it faces the mother’s back. About 10% of labours involve babies in the ‘back to back’ position and in over half of these cases the baby will turn around naturally. None of mine did.

If you have a back to back baby you might be asked if you lounged on the sofa a lot, as this can cause the baby to go into that position. That couldn’t have been further from the truth with me, I’m not exactly a lounging on the sofa kind of person, quite the opposite. So not only will you be tackling a back to back birth, but you might also be fighting off disapproving and unwarranted comments.

A back to back baby might mean that the head does not engage fully; it might mean you have a longer early labour phase ; you might have a longer pushing stage; you might feel the bulk of your pain in your back – for me it was in my back and the tops of my legs. Leaning forward helped hugely, as did having the TENS machine on my back, and firm pressure being applied to the base of my spine gave some relief as well.

With this type of birth you are more likely to tear, more likely to need an assisted delivery and more likely to have a birth that ends in in a c-section, BUT this is not always the case. I had an episiotomy with my first baby, only 5 stitches with my water birth, and then quite a substantial tear with both the following back to back births, but nothing that didn’t mend pretty quickly. Out of three back to back births, only one of them was assisted and I managed with Gas and Air with all of them.

It can be done, it doesn’t feel like it at the time, but it can be. It was without a doubt the most pain I have every experienced, and each time I said “never again”.

If you’ve been told your baby is back to back don’t panic. There is lots of time for the baby to turn before labour and if they don’t you can still do it. There were a few concerned looking faces during my last two births but I was so determined to get my babies out without forceps that I eventually started to shift them in the right direction.

Good luck and trust your body! It will all be worth it.

This article contains affiliate links.

Charlotte Camplejohn

Mum of four active children. Lover of skiing, marathons, kettle bells, family walks, random acts of kindness, movie nights, green tea and dark chocolate.

18 comments

Two out of my five were back to back and I had natural deliveries with just gas and air and no stitches either. The pain was very different to my other three labours, it was all in my back and bum but still no more painful than the others really? I think that there is such a fear of back to back babies when actually, your body just does what it is supposed to!! Thanks for sharing! #sharewithme

Yes exactly – it’s manageable isn’t it but very different. Thanks for sharing your experience !

Oh just reading this makes me hold my breathe. I won’t say I can relate I have heard so much about back to back labor being the hardest and toughest labors. You are so strong and brave to go through it four times. Mother of steel I call you. While I think I am a big wimp and couldn’t handle that I had my babies both very quickly so I think the big man upstairs knew I was a wimp and helped. You really did work hard for your babies darling. 🙂 Impressive. Thank you so much for linking up to Share With Me blog hop. I hope to see you again this week for another great round. #sharewithme

Ah thanks Jenny – they certainly made me work for them. I guess everyone gets a unique experience and mine were just never going to come easily x

My daughter was born back to back it was a hard dilivery and I pained for my wife, my little girl was finally born after a hard labour but had a lot of bruising and 2 black eyes we also had to go back a few days later as she was jaundace I would never wish this on any other expectant mother child birth is hard enough without all the extra problems I tilt my hat to you after having 4 x

Sounds very similar to my first. Not straight forward is it. So traumatic for everyone.

Both my girls were back to back, with my first I had very poor midwife care and was kept on my back with feet up in stirrups!!! Pushing for over an hour before forceps delivery in theatre 🙁 but with second I was determined to have minimal intervention and got to hospital only an hour before delivery! 🙂 which was waterbirth with only small tear. It can be done without intervention but good midwifery care plays big part. Midwives at hospital I had my second were amazing! They also explained to me that some ladies just have pelvises that have back to back babies and also having a toned tummy can also encourage back to back baby! Far from lounging on sofa!! 😉

Thanks for sharing your experience Anna – the stirrups are familiar as that happened with my first and third. You are right about the pelvis too I’m sure, I think mine were always going to be that way by preference lol. Sounds as if you had a much better experience second time around which is so great to hear 🙂

My last baby was back to back with his hand and shoulder presenting first. I hadn’t even heard of it before till I was in labour and was getting contractions in my back. Let’s just say it was an interesting experience. I managed it naturally with gas and hair but after that experience said never again. Fair play to anyone that goes back for more. Interestingly though tearing I had the best post birth experience with him and feel I recovered quite quickly. It can be done with the right midwife helping you out.

I had a back to back labour with my first and that’s why 5 yrs later she’s still my only child haha. http://www.earningbythesea.co.uk

My last delivery was back to back and it was the worst. I thought something was wrong because there was no break in pain, just waves of even worse pain and it was all in a different place. I really want another baby but I’m too scared since the last delivery and it’s been 2 years!

Easy labour ! No such thing – never knew if you ” lounged” you are more likely to have a back to back Great read

I know – apparently that’s a ‘thing’

My first baby was back to back. I was told I was fully dilated but baby was very high up and they were worried about a cord prolapse if my waters burst. After being put on a drip to speed things up she was born 6 hours after being told I was fully dilated weighing 9lb. I had gas and air and pethidine. Sadly I was rushed straight off to theatre after she was born. I had torn very badly. I even needed more surgery when she was a year old because of the scar tissue. I did ‘lounge’ a lot in late pregnancy as my back was in bits and I was signed off work weeks early. I was a lot bigger with my son but he was not back to back and I didn’t have the excruiating back pain in late pregnancy.

Oh gosh sounds traumatic! They certainly make us work for them these babies!

I can concur back birthing is painful and needs good or experienced midwives. Mine was with my first and it’s a relentless pain, I opted for epidural but it slowed everything down and in the end gave birth with gas and air, that was the most pain free part!! Hoping it will be a normal delivery this time….!!

All 3 of my babies were back to back (or face to pubes as one no nonsense midwife put it). Long hard labours definitely. No forceps or vacuum but a lovely episiotomy and plenty of stitches. Getting cut had been my worst fear but after 24 hours it was that or emergency c section. Quick snip and 3 minutes later my beautiful bruised 7lb 11 son shot out. Years later when I was getting coil fitted my GP remarked that I have a tilted womb which probably explained the back to back births. Only advice…poo before you push! Oh and the other 2 were 8lb 12 and 9lb 4 (the babies, not the poos)! ?

Very interesting reading this as I had a back to back birth with my first but it wasn’t until she came out face up that the midwives realised. She was a bit bashed and I tore a bit. It was a long painful birth I think it helped that she was only small 5 1bs. I still had no idea exactly what had happened, so fortunately I had no worries about my next 2 pregnancies as no one discussed it with me at all. my second was quicker but a bit traumatic as his shoulders got stuck (he is 30 now but still struggles to get non stretchy tops over his head and fasten shirts at the neck). The third was in a hurry so only 2 hours from waking up to giving birth but cord around his neck and I went into shock ( that was the only time in his life that he has ever been in a hurry to do anything). Even though it was 32 years ago that I gave birth to my daughter it helps knowing a bit more about it. So thanks to everyone for their experiences.

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What Back Labor Is Really Like

Back labor is characterized by contractions in your lower back, just above the tailbone. Learn more about why it happens and how to relieve back labor pain.

What Causes Back Labor?

• What Back Labor Feels Like

Back Labor vs. Back Pain in Pregnancy

When to go to the hospital for back labor, does back labor affect delivery, relieving back labor symptoms.

Laboring people don't always feel contractions solely in their abdomen. In fact, as labor contractions become longer, more frequent, and more intense, they can cause sensations throughout the body, including the back. When that back pain is severe and shows up with intensity during (and sometimes even between) contractions, it is often referred to as back labor.

Back labor usually happens in the lower back, just above the tailbone, and it can be a sign that your baby is in the occiput posterior (OP) position (sometimes called "sunny-side up"). While back labor can be extremely uncomfortable for you, it's usually not a problem for your baby. The majority of babies in the sunny-side up position will rotate on their own by the time it's time to push. Only around 5% to 8% of babies will remain in the OP position, and even when they do, most babies can be born vaginally without complications.

Although it's good news that your baby likely won't have complications because of being in the sunny-side up position, the bad news is that it can cause severe back pain for you. Fortunately, there are strategies that can help relieve back labor pain. Here's what you need to know about what back labor pain feels like and how to cope with back pain during labor.

Back labor is thought to be caused by the baby's position in the pelvis during labor and delivery.

There are many positions that a baby can be in during labor. The most ideal position for labor and delivery is head down facing the pregnant person's spine. This is called the occiput anterior (OA) position.

But some babies who are head down instead face up toward the ceiling with their back facing the pregnant person's spine. This position is known as the occiput posterior (OP) position (sometimes referred to as "sunny-side up" or "back-to-back"). Around 15% to 20% of babies who are in the head down position are in the OP position.

It is this OP position that is thought to contribute to back labor, since the baby's head can press painfully against the spine and tailbone, says Laura Riley, MD, medical director of labor and delivery at Massachusetts General Hospital in Boston.

It isn't known why some babies end up in the occiput posterior position while others don't. It could be influenced by factors like the baby's size or the pregnant person's anatomy, but more often than not, the reason is unknown.

Risk Factors for OP Position

While experts often don't know why babies end up sunny-side up during labor, there are some risk factors that increase the chances of occiput posterior position, such as:

• Previous pregnancies 
• Older maternal age
• The baby being larger than average size
• Having an anterior placenta
• Having an epidural in the first stage of labor

What Does Back Labor Feel Like?

With back labor, pain is generally concentrated in your lower back because the back of the baby's head is pressing against your tailbone or spine, says Dr. Riley. Some people who have experienced back contractions say they're excruciatingly painful, while others find that the pain of back labor isn't worse than ordinary labor (merely different).

Just like with other types of labor pain, back labor can be experienced differently by everyone. Some people might have back pain instead of or in addition to the abdominal discomfort of contractions.

As your baby moves down into the pelvis, back labor pain can become more severe. In some cases, back labor may also not let up between contractions. Some people may also experience painful muscle spasms with back labor.

Back pain is a common symptom of pregnancy. At least half of pregnant people experience back pain in the first trimester of pregnancy while that number can reach as high as 70% to 80% of pregnant people in the third trimester. Pregnancy back pain has a few culprits, including your growing abdomen affects the center of gravity and the pregnancy hormone relaxin loosens ligaments.

So how can you tell if you're experiencing normal back pain or back labor? In general, back labor pain won't start until you're in labor while back pain during pregnancy can be felt all throughout your pregnancy. In some cases, however, back pain can be a sign of premature labor , so call your doctor right away if you're earlier than 37 weeks pregnant and experiencing sudden back pain.

First things first, if you are experiencing any sudden pain, vaginal bleeding, or leaking fluid at any time during pregnancy, call your doctor right away, but especially if you are less than 37 weeks pregnant.

Once you're past 37 weeks, if you are experiencing pain and think that you may be in labor, follow your doctor or midwife's advice regarding the timeline of when to go to the hospital. Oftentimes, they'll admit you when you're having frequent contractions that are getting closer together. You should also contact your doctor if your water breaks .

People who experience back labor commonly have labors that last longer and deliveries that require more pushing than people who don't experience back labor, says Dr. Riley. Most babies in a posterior position will rotate the necessary 180 degrees on their own as labor progresses. Sometimes a doctor or midwife will attempt to rotate the baby with their hands.

If the baby stays in a posterior position, they can still be delivered vaginally if they fit through the birth canal. However, if a posterior baby is angled in such a way that they need a little extra space, and there is not enough room in the birth canal, the doctor may recommend a cesarean delivery . Back labor also increases the risk for prolonged labor and interventions such as an episiotomy , assistance with forceps or vacuum extraction, or medications to keep labor going.

If you experience back labor, it's recommended to change positions, because lying on your back can substantially exacerbate back contractions during labor. In addition, any position that puts more pressure on the baby's head against the tailbone can increase back labor pain. To relieve the pressure, try positions such as kneeling on all fours, rolling onto your side, or squatting.

Some movements, such as pelvic tilts, might help reposition the baby. To do a pelvic tilt, get down on your hands and knees and gently rock your pelvis by tucking your bottom in and then releasing it. This tips your baby slightly out of the pelvis and relieves some pressure. It also gives the baby optimal room to rotate.

A technique called counterpressure can also significantly relieve back labor pain. To use counterpressure, ask your partner, doula , or nurse to push against your back where you feel pain. They can press on it with their hands, a tennis ball, or another round object to help relieve pressure from the baby's head against the tailbone. They can also help apply ice or heat to your lower back or massage your lower back to help decrease the pain.

Pain medications or an epidural can also help, although an epidural may not completely take away all of the pain of back labor. But even if the epidural doesn't completely take away back labor pain, an epidural can help your body relax more to allow the baby to move into a different position and relieve some of the pain.

Key Takeaways

Back labor pain is caused by the pressure of a baby's head on the tailbone during labor. It can range from mild pressure to severe pain. Some people, such as those of higher weights or with larger babies, can be at higher risk for back labor. Strategies such as back massage, counterpressure, and pain medication can help relieve back labor pain.

Maternal positioning to correct occipito-posterior fetal position in labour: a randomised controlled trial . BMC Pregnancy Childbirth . 2014.

What is back labor? . American College of Obstetrics and Gynecologists . 2020.

Delivery presentations . Medline Plus . 2022.

Factors affecting rotation of occiput posterior position during the first stage of labor . Journal of Gynecology Obstetrics and Human Reproduction . 2017.

Risk Factors Associated with Low Back Pain among A Group of 1510 Pregnant Women . Journal of Personalized Medicine . 2020.

Persistent Occiput Posterior position - OUTcomes following manual rotation (POP-OUT): study protocol for a randomised controlled trial . Trials . 2015.

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What Is Back Labor?

When to call a healthcare provider.

• Complications

Frequently Asked Questions

Back labor is a common occurrence. As many as one in four pregnant people reportedly experience intense back pain during the birthing process.

Back labor is a term that describes the discomfort that a person in labor experiences in the region of the lower back. The pain of back labor typically is felt in the lower back, but it may also occur in the hips, and it sometimes radiates (spreads) to the thigh area.

Usually, a person in labor will feel pain from contractions in the abdomen and pelvis. But, according to a 2018 study, 33% of participants felt continuous and severe pain in the lower back during labor.

filadendron / Getty Images

Is It Back Pain or Back Labor?

Most laboring people will experience some type of discomfort in their back during the labor and delivery process. This pain may be mild and may exhibit itself as soreness or slight cramps. But, in some people—those in back labor—the pain is very intense, occurring during the contractions of active labor and also present between contractions. 

Causes of Back Labor

Causes of back labor may include:

• Being short-waisted: This may create an angle that forces the baby’s head into the pelvis, which results in the head pressing on the sacrum, a triangular bone in the lower back between the hip bones.
• Having an exaggerated swayback: This can create an angle that may put more pressure on the pregnant person’s lower back.
• Maternal spinal abnormalities: Such as scoliosis (a condition involving a sideways curvature of the spine).
• Unknown causes: The elements at play in back labor may be the same as those that cause back pain with menstrual cramps.

Types of Back Labor

Back labor can refer to several scenarios during labor, including back pain that is:

• Experienced mostly during a contraction
• Felt during and between contractions
• Experienced during parts of labor but not throughout labor

Symptoms of Back Labor

Some of the back pain a person feels at full term may not be related to back labor. Rather, it could be the result of general aches and pains, which commonly occur from excess weight of the pregnancy straining the back muscles.

 Back labor usually involves symptoms such as:

• Intense pain and muscle soreness that may or may not subside between regular contractions
• Lower back pain that feels like painful spasms and may worsen with each subsequent contraction
• A continuous, severe pain in the lower back that worsens at the peak of a contraction
• Intense pain located in the lumbosacral region, which encompasses the lumbar (lower back) and the sacrum

In general, you should contact your healthcare provider anytime you notice new symptoms during your pregnancy. Experiencing back pain for hours at full term can be an indication that labor is about to begin.

Here are signs that labor may have started and indications that your healthcare provider should be notified:

• Regular, painful contractions occurring at least every five minutes and lasting for at least one minute
• Sudden onset of diarrhea
• Bloody show (blood-tinged mucus coming from the vagina)
• Water breaking (or ruptured membranes, when the amniotic sac releases some of the fluid surrounding the baby)

Note, if you are having regular, painful contractions, accompanied by back pain, you will likely have back labor.

Complications of Back Labor

Having back labor is not known to cause any serious complications for the baby or the pregnant person, but there are some risks. This is due to the position of the baby.

The most advantageous way for the baby’s head to be positioned during labor is with the head down and the baby facing the mother’s back. When the baby’s head is down but the baby is facing the mother’s abdomen (the occiput posterior, or OP, position), back labor pain may result. This position can increase the risk of:

• The need for pain medication or other pain management interventions
• Requiring a cesarean delivery (or C-section, an incision in the mother's abdomen to remove the baby)
• Needing an assisted vaginal delivery (such as a forceps delivery or vacuum-assisted birth)
• The need for an episiotomy (a small incision at the vaginal opening that helps with a difficult delivery)
• Perineal tears (tears between the vagina and the anus)
• Postpartum hemorrhage (bleeding after giving birth)

Prevention of Back Labor

Prevention strategies for back labor include:

• Avoid positions such as semi-reclining with your knees up (higher than the hips).
• When sitting for long periods (such as when driving or at work) take frequent breaks to walk and move around.
• Don’t cross your legs when sitting.
• Use an ergonomic back chair if you need to sit for long periods.
• Lean over chair backs, counters, or other objects when standing (this encourages the baby to be positioned at the correct angle).
• During the last month of your pregnancy, practice doing pelvic tilt movements on the floor. You can find instructions on exercises to do during pregnancy (including pelvic rocking ) online.
• Sleep on your side with a pillow or other means of support behind your back, top leg resting forward (the knee of the top leg should touch the mattress). You may wish to try putting an extra pillow between your thighs for comfort, as well.
• Swim laps by performing simple movements, like the crawl or breaststroke. The motion from swimming may help the baby move into the proper position. The buoyancy of being in water may also take weight off your muscles and back and help reduce swelling in the limbs.

A spinal block (epidural) may be considered for pain control in people with back labor, particularly when the baby is in the OP position. When the baby is not in the optimal birthing position, known as left occiput anterior (LOA), it is more difficult for the baby to descend through the birth canal, causing an increase in the need for pain medication for the pregnant person.

Other medical treatments for back labor include sterile water injections. This can be an alternative to getting drugs for the pain. One study showed that people with severe pain from back labor exhibited lower pain scores approximately 30 minutes after the injection. This may be not commonly available or used.

What does back labor feel like?

Back labor feels like very strong pain and pressure in the lower back that worsens as labor progresses. There may be continuous lower back pain that doesn't subside between contractions.

How do you prevent back labor?

There are several preventive measures believed to help prevent back labor such as doing pelvic tilt exercises and bouncing on an exercise ball.

How long can back labor last?

Back labor can last a few hours or throughout the entire labor process.

A Word From Verywell

Back labor is not easy to endure. The best way to prepare yourself for labor and its complications is to arm yourself with information beforehand.

Although it isn't easy to recall remedies while in a painful labor, practicing exercises to improve fetal positioning and learning of ways to ease discomfort in the lower back during pregnancy and while in labor can help you physically and mentally prepare. Ask your doctor if you have questions about ways to prevent back labor and how to get through it if it occurs.

Birthcenter. Back labor .

Genç Koyucu R, Demirci N, Yumru AE, et al. Effects of intradermal sterile water injections in women with low back pain in labor: a randomized, controlled, clinical trial . Balkan Med J. 2018;35(2):148-154. doi:10.4274/balkanmedj.2016.0879 

American College of Obstetrics and Gynecology. Back pain during pregnancy .

Tzeng Y-L, Su T-J. Low back pain during labor and related factors. Journal of Nursing Research. 2008;16(3):231-240. doi:10.1097/01.jnr.0000387310.27117.6d 

Cleveland Clinic. Labor and delivery .

Phipps H, Hyett JA, Kuah S, et al. Persistent occiput posterior position - Outcomes following manual rotation (Pop-out): study protocol for a randomized controlled trial . Trials. 2015;16(1):96.t study. BMC Pregnancy Childbirth 17, 377 (2017). https://doi.org/10.1186/s12884-017-1556-5. doi:10.1186/s13063-015-0603-7

By Sherry Christiansen Christiansen is a medical writer with a healthcare background. She has worked in the hospital setting and collaborated on Alzheimer's research.

OP Truths & Myths

• OP Truths & Myths

Myths of Occiput Posterior

There are some myths about laboring with a posterior baby.

Let’s start with appreciation for Penny Simkin’s brave confrontation of a dogmatic trend that has arisen over the years. Penny Simkin has a wonderful literature review presentation she calls, “The OP Fetus: How little we know.” Parents and professionals alike have some misunderstandings about the influence of posterior presentation on labor. We might hear surprise at finding an OP baby even in a long labor.

• “She didn’t have back labor, so I didn’t think the baby was posterior.”
• “We did everything we could…  we tried hands-and-knees position.”
• When is Breech an Issue?
• Belly Mapping® Breech
• Flip a Breech
• When Baby Flips Head Down
• Breech & Bicornuate Uterus
• Breech for Providers
• What if My Breech Baby Doesn't Turn?
• Belly Mapping ®️ Method
• After Baby Turns
• Head Down is Not Enough
• Sideways/Transverse
• Asynclitism
• Oblique Lie
• Left Occiput Transverse
• Right Occiput Anterior
• Right Occiput Posterior
• Right Occiput Transverse
• Face Presentation
• Left Occiput Anterior
• Anterior Placenta
• Body Balancing

Sometimes a midwife or doctor will say they don’t pay much attention to a head-down baby’s position in late pregnancy because some posterior babies come out vaginally.

Spinning Babies ® is concerned about the 15-30% of OP babies that need more help than strong labor and the hands-and-knees position.

A 2005 study by Ellice Lieberman and her research group in Boston busted some of the myths about posterior labors. Unfortunately, people reading the study could also conclude that fetal position changes at random throughout the course of labor. Yet, in reading the data carefully, we find several consistencies with previous research on the posterior fetal presentation and its effects on labor.

The back of the baby’s head is to the mother’s left or right (Occiput Transverse position) in about half (48.9%) of babies. Jean Sutton re-introduced attention to the shape of the human uterus. It is higher on the right than the left, making the right wall steeper and the left wall rounder. Babies, therefore, may be curled in a way that makes birth easier if they come down from the left (head-down babies, that is). So the conclusion that fetal rotation is random may be somewhat premature.

First babies may have more challenges with an occiput posterior or right occiput transverse position than subsequent babies, but that, too, isn’t always true.

There may be the truth and maybe myth in what we believe about fetal positioning. So, I’d like to start with the myths of the OP position which Penny Simkin has helped us identify and then give my two cents worth– and some of that I ask you to take on credit! I’ll talk about bony and soft tissue contributors to whether or not a posterior baby may get stuck or delayed.

MYTH: It is important to know the fetal position.

Penny Simkin lists this myth in her talk about What We Don’t Know About the OP Baby. Midwives have been debating the importance of fetal position — gently — for years. And I agree this is a myth.

Gail’s thought: Finding a solution for a non-progressing labor can occur without knowing the fetal position.

The muscles, ligaments and pelvic diameters may need accommodation in a slow, or a painful, labor regardless of fetal position. In other words, tension in the psoas pair of muscles or pelvic floor can delay an anterior baby and a posterior baby. Extension of the anterior baby’s head can prevent engagement in some pelvises. The main point is that we can, when needed, promote progress regardless of fetal position.

MYTH: If we prevent OP before labor than we can prevent OP in labor

To answer this question correctly we would have to study 2nd trimester prevention exercises among one group of women with no prevention methods in another group. Why? Because while most babies that start labor in an OP position will rotate to OA before the end of labor, there is a consistent small group of babies who are OP throughout labor.

These need Spinning Babies ® . But how do we identify this group? Why not help the other mothers, too?

The point I’m making is, that just because most OP babies rotate to OA (about 87%, according to Gardberg), we shouldn’t ignore the 15% (Lieberman) who are OP when they are born, either vaginally or via   cesarean .

MYTH: If the baby is Occiput Anterior (OA, the “best” starting position) in early labor the baby will stay in a good position throughout labor.

The recent Lieberman study confirmed statistical trends of earlier studies. 83% of the OA babies who were OA in early labor were OA when they came out. But a small 5.4% rotated to a   direct Occiput Posterior   position for birth.

MYTH: Midwives and Doctors can tell the baby’s position.

While this is sometimes truth, in reality sometimes we can and sometimes we can’t. There are three common ways a baby’s position is sought:

• By hands-on palpation, or feeling the abdomen. The bumps in the belly mean something to a practiced hand. The problem is in the variation of bellies and bumps. Sometimes they don’t make a picture that the person feeling can make out. Bellies come in different thicknesses. Babies sometimes are curled up in interesting ways. Lots of amniotic fluid or muscle strength can hide details that might be needed to “see” the position.
• Feeling inside, through the open cervix, sometimes gives clues. But the little sutures (not stitches, but lines showing where the skull bones meet) can be just out of reach or the edge of the soft spot (fontanel) can feel like a suture, oddly enough. Feeling babies position is not as simple as it looks in the books or on the plastic chart some hospital labor and delivery units have.
• Ultrasound can tell the baby’s position. Funny we rely so wholeheartedly on technology. We are looking through dark water to see a 3-D person displayed on a 2-D computer screen. There can be blurred pictures of the crucial landmarks of the baby’s head or the viewer can make a mistake.

Dr. Karen Davidson, the ultrasound sonologist for the Lieberman group studying 1,766 women in labor (see a discussion on this interesting study by clicking on a link below), found she had to exclude 162 women because their ultrasound pictures were uninterpretable. In the first six-months of the study she found 13% of early labor ultrasounds were uninterpretable. She got really good at it as the study went on, but she was their expert to begin with, so I would think her early rates must be at least on par with the nation’s ultrasound interpreters.

Of the 1,562 births remaining in the Lieberman study, 51% had an interpretable ultrasound picture in late labor. That means 49% didn’t. I don’t think we can hang our hats on ultrasound. And furthermore, how the baby’s back is situated doesn’t always tell us how the head is facing.

MYTH: Back pain is a sign of an Occiput Posterior (OP) baby.

Some women in each of these categories are likely to get some back pain in labor:

• Short women
• Women who aren’t flexible
• Women who’ve had accidents
• Women who have weak back muscles
• Some of the women with posterior babies or babies who have one of their arms up in late labor

The women with OP babies in early labor (3 to 4 cm mostly) enrolling in the Lieberman study did not report more back pain at 3-4 cm dilation. As a doula of women with and without epidural pain relief, many without, I have noted that OP back pain, when it does come, often comes between 4 and 6 cm.

Some women have relatively straightforward OP labors if we are still permitted to call laborers by the fetal position name. These women often do not report back pain at an intensity to get attention. Some have no more labor pain in their backs than they do in the front. A few women have severe back pain early in labor, at 2 cm. These women are candidates for inversion   as soon as possible if they are up for it. Back pain is more about the fit of the baby than the position. Some posterior babies fit their mother’s pelvises better than others.

MYTH: When a woman is having prolonged labor without back pain, it is from a reason other than a posterior position.

Oh, thank you, Penny, for bringing this myth to our attention. I can’t list the times a midwife, doula or nurse has told me their frustration at not being able to think of a labor progress trick to help a woman in a long labor. They often say something quite close to this, “I thought of the   Open-Knee Chest   position (or another technique) but didn’t try it because she didn’t have back pain. While the   cesarean   was being done, the doctor said the baby was posterior and that’s why the baby wasn’t coming through the pelvis.”

A delay or a stall in labor, with or without back pain can often be corrected by one form of inversion or another. Check out Labor Progress and more technical information   here .

Back pain, with or without a stall in labor, may also be soothed by inversion.

Sometimes back pain is from a spasm in a ligament low in the back of the uterus, such as the ligament holding the cervix to the sacrum. Inversion gives that ligament a gentle stretch and then when the mom gets up the ligament can relax. Ahhh.

There are some protective guidelines about inversion. See   the article   and ask your care provider: “Is there a medical reason not to do it?” This great little question also comes to us via Penny Simkin.

There is   new research on a stall in the progress of dilation during the active phase of labor . In his study, California researcher Aaron Caughey found patience reduces cesareans by 1/3 (400,000 a year).

MYTH: Position changes can change the OP position in the labor

This hasn’t been studied like I’d like to it to be studied. The studies aren’t designed in a way that will answer anything, but regardless, 30 minutes of position changes are not enough to overcome the tension in the womb holding the baby in an unfavorable position.

These studies are why I developed the The Three Principles of Spinning Babies ® .

First, you have to relax the involuntary muscles, and release tension or torsion in the muscle fibers and fascia making up the uterine ligaments. Second, you get gravity helping and third, move the pelvis in ways that open the level of the pelvis that the baby’s head is resting at.

If the head is stuck at the brim, you don’t open the bottom of the pelvis, for instance, and wonder why squatting works for some women and not for others. If your front doorbell rings, do you open the back door and wonder where your company is at?

Pelvic shape and size   do have an effect on the course of posterior labor in a small percentage of women. A pelvic shape which is longer front to back allows a few women to have a posterior baby without back labor, as long as there isn’t another reason for backache, like a muscle spasm.

A pelvic shape which is triangularly (once called an android pelvis) can make it hard for a larger, posterior baby to fit through. A woman with a smaller than average android pelvis will need to, in my observations, eat carefully to get good protein and vegetables without a lot of sweets and white bread. Baby’s position is considered more important in the 2nd Trimester so baby can come into the brim months later from the left side, especially if in a first-birth or first vaginal birth. This may help avoid the scenario I have often seen of trying to help a large OP baby to turn around at 8 months to get settled into position for birth.

The baby’s back shifts right and left and right again, trying to turn his little forehead out of the narrow pointy space at the mother’s pubic bone. But the pelvis isn’t round so he can’t. He’ll have to come up and out, away from the brim to turn. He can only do that if the mom relaxes her ligaments, and gets upside down a bit each day.

It isn’t always comfortable, of course, to be 8 months pregnant and hang upside down for a minute. And even then, some of these moms need bodywork to overcome the muscle spasms in their round or broad ligaments. It’s much easier to do at 4 and 5 months pregnant. Even 6 months. If these few OP babies aren’t able to navigate their mother’s pelvic brim, they will have to be born by   cesarean. The problem is that few people, and I mean providers, can tell who will be the one that gets stuck and who will be the one to get through.

Someone with a round pelvic brim has a much better chance of experiencing their   posterior baby   rotate in labor. Depending on various factors, like eating in labor, keeping hydrated, leaning forward, being patient, resting belly down (somewhat), avoiding positions on her back, having her water broke or an epidural that increases the likelihood of a challenge with the labor (length, vacuum or surgery), baby may come around readily or only eventually. A long labor can soften up tight spots on the route out.

The pelvic shape isn’t the only consideration, of course. The soft tissues are more often the case, especially when they aren’t soft at all! Remember, a pelvis shape isn’t a pelvic type . Learn more about the racist roots of name calling the pelvis by typing the pelvic according to racial heritage. And at the same time, consider the personal environment of the baby you are caring for (as provider or parent) and their needs for engagement, rotation, and descent through the pelvis they get to be born through!

• The OP fetus: How little we know , Penny Simkin
• Changes in Fetal Position During Labor and their Association with Epidural Analgesia , Ellice Lieberman et al.
• Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries,   M Gardberg et al.
• Human Labor and Birth , Oxorn and Foote
• Holistic Midwifery, Vol II , Anne Frye
• Labor Progress Handbook , Penny Simkin and Ruth Ancheta

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: October 2023

Related pages

External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

• Foetal Version
• Breech Presentation

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Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. It may be possible to move the baby, but a caesarean may be safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Planned or elective caesarean

There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Mothers' positions in labour when baby is lying 'back-to-back'

What is the issue?

Malposition is when the back of the baby's head lies towards the mother's back. As a result, labour and birth can be long and difficult, sometimes resulting in an operative birth (where the baby is delivered by caesarean section or with special tools to help the baby through the birth canal) and more perineal trauma (damage to the pelvic floor). The baby may be more likely to go to a neonatal care unit. Also, women may experience stress or disappointment with the birth experience. 

Why is this important?

The way a pregnant woman is positioned during labour may help rotate a baby so that the back of the baby's head lies towards the front of the mother's abdomen. This improved position may help the mother and baby have a more normal labour and birth. However, it is not yet known which posture, if any, is effective and when is the best time to use it.

A systematic review of studies of positions (postures) used by women in labour with a baby in a malposition can provide answers on whether the postures improve birth and other health outcomes for mothers and babies. The summary of this review can be used to update clinical practice guidelines.

A Cochrane Review in 2007 reported that the use of the 'hands and knees' posture in labour was ineffective for malposition, but it did reduce labouring women's backache. Since then, more trials have been conducted, some using other postures; these need evaluating to see if those postures work.

What evidence did we find?

We searched for evidence (published to 13 July 2021) and identified eight studies  in nine different countries involving 1766 women and their babies. Women in the included studies were either first-time mothers or mothers who had birthed before. All the women's  pregnancies were at least at 36 weeks. 

The trials compared use of 'hands and knees' posture or 'side-lying' (lateral) postures (lying on the same side as the baby, lying on the opposite side to the baby, and lying semi-prone) to other postures (free posture, lying on back, leaning back, lying on the same side as the baby). 

For both the hands and knees posture and side-lying positions during labour, there may be little or no difference in the numbers of operative births, haemorrhage (profuse bleeding of the mother), severe perineal trauma, and women's satisfaction with their labour and delivery, but there was insufficient evidence to be sure. Many of our outcomes of interest were not reported in the included studies.

Overall, we have little to no confidence in the evidence, mainly because there were too few women and babies in the studies, and some studies used unclear methods.

What does this mean?

Overall, it is uncertain whether hands and knees or side-lying positions in labour improve the health of mother and baby when a baby is in a malposition. However, if women find the use of hands and knees, side-lying, or other postures in labour comfortable, there is no reason why they should not choose to use them.

Further research is needed to enable optimal fetal positioning. In particular, further research is needed on variations in the postures, the impact of longer use of these postures during labour, and on long-term outcomes for women and their babies. 

We found low- and very low-certainty evidence which indicated that the use of hands and knees posture or lateral postures in women in labour with a fetal malposition may have little or no effect on health outcomes of the mother or her infant. If a woman finds the use of hands and knees or lateral postures in labour comfortable there is no reason why they should not choose to use them. Further research is needed on the use of hands and knees and lateral postures for women with a malposition in labour. Trials should include further assessment of semi-prone postures, same-side-as-fetus lateral postures with or without hip hyperflexion, or both, and consider interventions of longer duration or that involve the early second stage of labour.

Fetal malposition (occipito-posterior and persistent occipito-transverse) in labour is associated with adverse maternal and infant outcomes. Whether use of maternal postures can improve these outcomes is unclear. This Cochrane Review of maternal posture in labour is one of two new reviews replacing a 2007 review of maternal postures in pregnancy and labour.

To assess the effect of specified maternal postures for women with fetal malposition in labour on maternal and infant morbidity compared to other postures. 

We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov , the World Health Organization (WHO) International Clinical Trials Registry Platform ( ICTRP ) (13 July 2021), and reference lists of retrieved studies.

We included randomised controlled trials (RCTs) or cluster-RCTs conducted among labouring women with a fetal malposition confirmed by ultrasound or clinical examination, comparing a specified maternal posture with another posture. Quasi-RCTs and cross-over trials were not eligible for inclusion.

Two review authors independently assessed trials for inclusion, risk of bias, and performed data extraction. We used mean difference (MD) for continuous variables, and risk ratios (RRs) for dichotomous variables, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach.

We included eight eligible studies with 1766 women. 

All studies reported some form of random sequence generation but were at high risk of performance bias due to lack of blinding. There was a high risk of selection bias in one study, detection bias in two studies, attrition bias in two studies, and reporting bias in two studies.

Hands and knees

The use of hands and knees posture may have little to no effect on operative birth (average RR 1.14, 95% CI 0.87 to 1.50; 3 trials, 721 women; low-certainty evidence) and caesarean section (RR 1.34, 95% CI 0.96 to 1.87; 3 trials, 721 women; low-certainty evidence) but the evidence is uncertain; and very uncertain for epidural use (average RR 0.74, 95% CI 0.41 to 1.31; 2 trials, 282 women; very low-certainty evidence), instrumental vaginal birth (average RR 1.04, 95% CI 0.57 to 1.90; 3 trials, 721 women; very low-certainty evidence), severe perineal tears (average RR 0.88, 95% CI 0.03 to 22.30; 2 trials, 586 women; very low-certainty evidence), maternal satisfaction (average RR 1.02, 95% CI 0.68 to 1.54; 3 trials, 350 women; very low-certainty evidence), and Apgar scores less than seven at five minutes (RR 0.71, 95% CI 0.21 to 2.34; 2 trials, 586 babies; very low-certainty evidence). 

No data were reported for the hands and knees comparisons for postpartum haemorrhage, serious neonatal morbidity, death (stillbirth or death of liveborn infant), admission to neonatal intensive care, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy. 

Lateral postures

The use of lateral postures may have little to no effect on reducing operative birth (average RR 0.72, 95% CI 0.43 to 1.19; 4 trials, 871 women; low-certainty evidence), caesarean section (average RR 0.78, 95% CI 0.44 to 1.39; 4 trials, 871 women; low-certainty evidence), instrumental vaginal birth (average RR 0.73, 95% CI 0.39 to 1.36; 4 trials, 871 women; low-certainty evidence), and maternal satisfaction (RR 0.96, 95% CI 0.84 to 1.09; 2 trials, 451 women; low-certainty evidence), but the evidence is uncertain. The evidence is very uncertain about the effect of lateral postures on severe perineal tears (RR 0.66, 95% CI 0.17 to 2.48; 3 trials, 609 women; very low-certainty evidence), postpartum haemorrhage (RR 0.90, 95% CI 0.48 to 1.70; 1 trial, 322 women; very low-certainty evidence), serious neonatal morbidity (RR 1.41, 95% CI 0.64 to 3.12; 3 trials, 752 babies; very low-certainty evidence), Apgar scores less than seven at five minutes (RR 0.25, 95% CI 0.03 to 2.24; 1 trial, 322 babies; very low-certainty evidence), admissions to neonatal intensive care (RR 1.41, 95% CI 0.64 to 3.12; 2 trials, 542 babies; very low-certainty evidence) and neonatal death (stillbirth or death of liveborn) (1 trial, 210 women and their babies; no events). 

For the lateral posture comparisons, no data were reported for epidural use, neonatal encephalopathy, need for respiratory support, and neonatal jaundice requiring phototherapy. We were not able to estimate the outcome death (stillbirth or death of liveborn infant) due to no events (1 trial, 210 participants). 

Baby positions in the womb before birth

Read time 6 minutes

You might be wondering how your baby’s position will impact on the birth. We talk you through the positions your baby might be in and what it could mean for labour. 

How to know what position the baby is in 

From the 24 week appointment in pregnancy, the midwife will be checking the position of your baby (NHS, 2023) . Your baby is likely to continue changing position until around 37 weeks when it is expected to settle (RCOG, 2014) .  

There are a few different positions that your baby can be lying in (Viccars, 2003) :

Occiput Anterior (OA) 

This is the most common position. The baby is head down in the parent’s womb and the crown of their head (occiput) is at the front (anterior).  

If the baby is lying to the left, it is called Left Occiput Anterior (LOA) 

If the baby is lying to the right, it is called Right Occiput Anterior (ROA) 

Occiput Posterior (OP) 

This is when the baby is head down and facing the front, so in a ‘back-to-back' position with the parent. 

Occiput Transverse (OT) 

This is when the baby is lying at a right angle across the parent’s abdomen. 

Breech is when the baby is lying bottom down in the womb. 

Oblique 

Oblique is when the baby is lying at an angle. 

Unstable lie 

This is when the baby doesn’t settle into a usual position after 37 weeks. 

Ideally, at the end of pregnancy, the baby’s chin will be tucked into their chest. This means the narrowest part of their head (the occiput or crown) presses on the cervix, helping it to open (Hofmeyr & Moreri-Ntshabele, 2024; Simkin, 2010; Viccars, 2003) . 

Can you tell at home where the baby is in the womb?

It’s not easy to accurately assess the position of a baby in the womb without an ultrasound. In one study, ultrasound confirmed that only 16 out of 100 baby positions described by midwives were correct (Webb et al, 2011) .  

However, it is possible at home to get an idea of how your baby is lying. If there’s a dip in the belly when the pregnant woman or person lies down, your baby might be back-to-back (Simkin, 2011) .

While resting, imagine the belly in four quarters (Simkin, 2011) :

• Which side is firm?  This might be where your baby’s torso is lying 
• A big bulge will be your baby’s head or bottom 
• If the pregnant woman or person feels stretching this is probably leg movements 
• Where kicking is felt, it might be your baby’s knees or feet 
• Smaller movements might be hands or elbows 

What does the baby’s position mean for birth?

The position might affect your plans for birth (NICE, 2023; RCOG, 2014) .

• Transverse lie means your baby is sideways. You may be offered birth in hospital with doctors and possibly a caesarean. 
• Breech position may involve turning the baby, having a caesarean, or continuing with a vaginal birth. 
• Unstable lie might also mean that you will be offered birth in hospital with doctors present. 

What does it mean if the baby is ‘back-to-back'?

Most babies who are ‘back-to-back’ (OP) at the start of labour turn into a better position during labour (Reed, 2016; Simkin, 2010) .  

In a study of babies who were all OP at the start of labour (Othenin-Girard et al, 2018) :  

• 20 in 100 were born by caesarean before or during labour 
• 61 in 100 rotated to an OA or forwards position during labour 
• 19 in 100 were born OP  

If your baby is OP, recent research suggests that the labour is likely to be longer as the baby has further to turn. This can be exhausting and may raise the likelihood of having a caesarean birth (Eide et al, 2024; Gaillongo et al, 2024; Othenin-Girard et al, 2018) .  

However, in the past, having a baby in the OP position wasn’t thought to be a problem. Some specialists feel it is modern maternity practices and beliefs that have led to longer, slower labours (Reed, 2016) .

For example, back pain is common in labour, regardless of the baby’s position. There is no evidence that back pain is more severe when the baby is back-to-back (Lee et al, 2015) .  It might help to consider that labour might be different, rather than better or worse (Reed, 2016) . Medical care will be available if needed. 

Can a baby’s position be changed?

Research shows that a parent’s positions during pregnancy can change the space within the pelvis (Reitter et al, 2014; Hemmerich et al, 2019) . However, there is no strong proof that this changes the baby’s position at the end of pregnancy (Hofmeyr & Moreri-Ntshablele, 2024) .  

Rather than trying to move the baby, it can be beneficial for the pregnant woman or parent to try and ease tension in their body.  This could increase symmetry and create space which allows the baby to move (Oleksy et al, 2019; O’Brien, 2022; Andrew, 2010; Siccardi et al, 2019) .  

People with previous injuries to their pelvis or legs may benefit from physical therapy or exercise to address any imbalance. Those with strong pelvic muscles or who are inactive might also find it helpful. Some ideas for helping to ease tension might be (O’Brien, 2022) :

• brisk walking for 30 mins each day 
• pregnancy yoga 
• sitting with hips higher than knees 
• swimming 
• wearing low shoes and calf stretching 
• getting up and moving every 30 mins  
• wearing the right size bra to help the diaphragm move 
• eating a healthy diet to avoid constipation 
• seeing a physical therapist, osteopath or chiropractor trained in pregnancy to address any old injuries. 

Further information

Our NCT infant feeding line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.

Make friends with other parents-to-be and new parents in your local area and see what NCT activities are happening nearby. 

This article was last reviewed in August 2024

Andrew CG. (2010) Considering non-optimal fetal positioning and pelvic girdle dysfunction in pregnancy: increasing the available space. Journal of Clinical Chiropractic Pediatrics. 11(2):783-788.  http://jccponline.com/jccp_v11_n2.pdf [6 Aug 24]

Eide B, Sande RK, Von Brandis P, Kessler J, Tappert C, Eggebø TM. (2024) Associations between fetal position at delivery and duration of active phase of labor: A historical cohort study. Acta Obstet Gynecol Scand. ; 00: 1-10. https://doi.org/10.1111/aogs.14929

Gaillongo E. Webster AC. (2024) Perinatal outcomes in persistent occiput posterior fetal position: a systematic review and meta-analysis. BJM. 32(2). https://www.britishjournalofmidwifery.com/content/literature-review/per… [6 Aug 24]

Hemmerich A, Bandrowska T, Dumas GA. (2019) The effects of squatting while pregnant on pelvic dimensions: A computational simulation to understand childbirth. J Biomech. 18;87:64-74. https://doi.org/10.1016/j.jbiomech.2019.02.017  

Hofmeyr GJ, Moreri-Ntshabele B. (2024) Maternal postures for fetal malposition in late pregnancy for improving the health of mothers and their infants. Cochrane Database Syst Rev. 8;2(2):CD014616. https://doi.org/10.1002/14651858.CD014616

NHS (2023) Your antenatal care. https://www.nhs.uk/pregnancy/your-pregnancy-care/your-antenatal-care/ [7 Aug 24]

NICE (2023) Intrapartum care [NG235]. https://www.nice.org.uk/guidance/ng235 [7 Aug 24]

Lee N, Kildea S, Stapleton H (2015) ‘Facing the wrong way’: Exploring the Occipito Posterior position/back pain discourse from women׳s and midwives perspectives, Midwifery, 31(10) 1008-1014. https://doi.org/10.1016/j.midw.2015.06.003

O’Brien M (2022) Biomechanics for birth. [Online course] https://www.optimalbirth.co.uk/ [29 Oct 22]

Oleksy, Łukasz; Mika, Anna; Kielnar, Renata; Grzegorczyk, Joanna; Marchewka, Anna; Stolarczyk, Artur. (2019) The influence of pelvis reposition exercises on pelvic floor muscles asymmetry: A randomized prospective study. Medicine 98(2):p e13988. https://doi.org/10.1097/MD.0000000000013988

Othenin-Girard V, Boulvain M, Guittier MJ. (2018) Occiput posterior presentation at delivery: Materno-foetal outcomes and predictive factors of rotation. Gynecologie, Obstetrique, Fertilite & Senologie. 46(2):93-98. https://doi.org/10.1016/j.gofs.2017.11.006

RCOG (2014) Green top guidelines No. 50. Umbilical cord prolapse. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelin… [7 Aug 24]

Reed R (2016) In celebration of the OP baby. https://midwifethinking.com/2016/06/08/in-celebration-of-the-op-baby/ [7 Aug 24]

Simkin P. (2010) The fetal occiput posterior position: state of the science and a new perspective. Birth. 37(1):61-71. https://doi.org/10.1111/j.1523-536X.2009.00380.x

Simkin P (2011) The Labour progress handbook.  3rd edition. Chichester. Wiley-Blackwell. 

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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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US Department of Labor recovers $105K in back wages, damages for 28 Grand Rapids restaurant workers after owner withheld tips

Employer:      The Saucy Crab Grand Rapids LLC operating as The Saucy Crab

                              Jixi Qiu, owner

                              5039 28th St. SE

                              Grand Rapids, MI

Action:            Fair Labor Standards Act consent judgment and order

Courts :           U.S. District Court for the Western District of Michigan

Findings:        A federal court ordered The Saucy Crab and its owner Jixi Qiu to pay $105,000 in back wages and liquidated damages to 28 former employees of the Grand Rapids restaurant that ceased operating in October 2022.   

Entered on Oct. 3, 2024, the consent judgment and order  resolves a complaint filed by the U.S. Department of Labor on July 14, 2023.

An investigation by the  department’s Wage and Hour Division found the restaurant and Qiu violated provisions of the Fair Labor Standards Act when they illegally used a tip pool and denied employees correct minimum and overtime wages from at least August 2020 through October 2022.

The court also ordered the Saucy Crab and Qiu to pay an additional $10,000 in civil money penalties for its willful FLSA violations. The consent judgment restrains and forbids the restaurant and Qiu from future violations of the FLSA’s tip pooling, minimum wage, overtime and retaliation provisions.                                                 

Quotes: “The Saucy Crab’s owner took tips from servers and bartenders to benefit his company and denied servers, cooks and dishwashers their fully earned wages. This judgment puts those wages back in the hands of former employees shortchanged by Qiu and the restaurant,” said Wage and Hour Division District Director Mary O’Rourke in Grand Rapids, Michigan. “The Department of Labor will always protect the rights of workers in all industries to receive the pay they have rightfully earned.” 

“The Saucy Crab joins a list of U.S. restaurant employers we’ve found shortchanging workers by misusing some of their tips,” said Regional Solicitor of Labor Christine Heri in Chicago. “Federal law forbids employers from keeping employees’ tips - either direct from customers or shared in a tip pool - for any purpose.”

Attorney Haley R. Jenkins in the department’s Regional Office of the Solicitor in Chicago litigated the case.

Background : The department’s Quick Service Restaurants Compliance Assistance Toolkit explains wage laws for the industry. Learn more about the Wage and Hour Division .

Teamsters engage fellow members to boost Harris in battleground Wisconsin

OSHKOSH, Wisconsin — On a crisp fall morning last week, a UPS worker donning a brown uniform rushed toward the warehouse here to start his shift when a group of fellow Teamsters handed him campaign literature supporting Kamala Harris for president.

The worker grew visibly agitated, gestured with his arms and raised his voice.

But he wasn’t angry at those offering him a sample ballot. He was going on about former Republican Gov. Scott Walker’s 2011 war on unions that gutted labor power in the state. He also talked about how former President Donald Trump had promised to bring a deluge of work to the state, like through Foxconn, that never materialized .

“Don’t they remember the history of Republicans attacking unions? Their memories are so short,” the man said, incredulous that any union member in Wisconsin is now backing Trump. “This is great,” he said, holding up a sample ballot and separate flyers for Harris and Gov. Tim Walz, as well as to re-elect Democratic Sen. Tammy Baldwin.

It was just one of dozens of conversations that took place here over 90 minutes in between shifts at this UPS facility. Teamsters members who backed Harris carried out what’s considered by the campaign to be among the most persuasive of arguments: those made peer to peer. It was a slice of a broader strategy playing out again and again throughout Wisconsin as well as the battlegrounds of Michigan and Pennsylvania that aimed ultimately to reach white working class voters who surveys show prefer Trump in massive numbers.

A recent NBC News national poll showed Trump held a 56%-42% lead with white voters and a 65%-33% lead among whites without college degrees. Those numbers reflect the battle that’s up ahead for Harris’ team as it grinds out the final days of the campaign.

But with essential blue-wall battleground states still seemingly in a dead heat, according to polls, part of the strategy behind the Harris campaign has been to work at gaining at the margins among various groups that have favored Trump in the past.

This kind of union organizing is just one example of the various efforts — from reaching out to soft Republicans to canvassing rural counties — a well-funded Harris campaign has employed to target specific demographics with just 12 days to the Nov. 5 election.

“I will contrast this with the type of top-down astroturf organizing that Elon Musk is attempting somewhat unsuccessfully,” Josh Orton, Harris’ senior adviser for labor, said of the Teamsters efforts. “For these types of peer-to-peer conversations to be successful, to be trusted, to be persuasive, there has to be an existing relationship. There has to be trust, and it has to be based on facts.”

Sean O’Brien, the general president of the International Brotherhood of Teamsters, announced last month that the national union would not endorse in the race, in what was considered a blow to Harris after the group backed President Joe Biden in 2020. (However, there were signs in July , according to Reuters reporting, that after Biden’s concerning debate performance the group was considering not endorsing.) After the news broke that the national organization wouldn’t endorse Harris, however, local Teamsters groups , including many of the largest, swiftly backed Harris. In all, the campaign says, 1.5 million Teamsters nationally have backed Harris.

Trump spokeswoman Karoline Leavitt, however, credited Trump for the lack of endorsement from the national union, saying he “neutralized the endorsement for the first time in decades.”

“Team Trump has a data-driven, people-powered ground operation in every single battleground state,” Leavitt said. “We have trained tens of thousands of volunteer captains, who are specifically focused on getting out the vote and encouraging Americans in their respective communities to vote for President Trump and President Trump has more enthusiasm on the ground than Kamala Harris, as reflected by the Real Clear Politics average that has him winning in every battleground state.”

Analysts, however, have warned of putting too much stock into that polling average, noting that it includes a bevy of surveys from red-leaning firms that can warp averages. Regardless, even those numbers hover within the margin of error.

Still, Leavitt pointed to an internal Teamsters survey that showed overwhelming support for Trump.

There were other highlights of labor support for Harris. Later in the same day as the Teamsters canvassing, Jim Ridderbush, vice president of the United Food and Commercial Workers Local 1473, spoke at a rally in Green Bay.

“She walked the picket line with striking autoworkers in 2019,” Ridderbush said to cheers. He contrasted that with Trump, arguing the former president didn’t think about working people but instead gave massive tax breaks to companies that shifted new jobs overseas.

“He went even further to attack the ability of unions to organize,” Ridderbush said. “The bottom line is, Trump’s a scab.”

Chants broke out in the crowd: “Trump’s a scab! Trump’s a scab!”

The United Auto Workers union, which has a vast representation in the swing state of Michigan, has also put its weight behind Harris. It recently released its own internal polling data conducted by Democratic pollster Celinda Lake, where it says among UAW members without a college degree, Harris now holds a 5-point lead.

“When members hear directly from other members about what’s at stake and which candidate will have their backs, we’re able to break through,” UAW President Shawn Fain said in a statement. “By engaging our members and highlighting the issues that matter — their paychecks, their families, and their futures — the union makes a real difference.”

Back in Oshkosh, several laborers in Wisconsin cited massive infrastructure buildup under the Biden administration that they say will boost union jobs for at least a decade.

That investment included providing more than $1 billion in funding to replace the John A. Blatnik Bridge between Duluth, Minnesota, and Superior, Wisconsin.

Daniel Jones a 37-year Teamster, pointed to that project and to both Biden and Harris walking picket lines as signs that they would back labor.

“That’s going to give building trades unions, as well as the ironworkers, gainful employment for many years. It’s my tax money going to union workers,” Jones said. “Donald Trump had four years to create an infrastructure bill. He would promise it, he’d never get it done.”

Bill Carroll, secretary-treasurer of Teamsters Local 344, pointed to the conservative policy document Project 2025 and Trump’s ties to it as among the warning signs if Trump returns to the White House.

“The labor section of Project 2025 is just a continuation of Scott Walker policies: attack public sector bargaining, national right to work, eliminating prevailing wage laws — right down the line, things that will damage the ability of average working Americans, especially in organized labor,” he said.

Trump has disavowed Project 2025, even though many of his allies were involved in drafting it.

Some workers gave a thumbs-up as they quickly walked by grabbing the flyers. One called out with a smile, “Already did it!” while others shared a similar sentiment.

Some complained about Trump, noting that he and billionaire Tesla mogul Elon Musk held a public conversation in which they laughed about firing striking workers.

There were sporadic critics too. One man, who would not give his name, walked past the group while indicating he was a solid Trump supporter.

“I’m Trump all the way,” he said. When asked about Trump seeming to praise firing striking workers, he paused, “Well, you would hate to see it.”

Jacob Ralph, a 28-year-old from Oshkosh, quietly took the flyers. He said he hadn’t thought much about the election yet but that he was leaning toward Harris.

“She’s a lot safer,” he said. Another union member, Lori Jensen of Neenah, said she did not want to say whom she supported, citing a highly volatile political environment in Wisconsin and deep divisions in her family.

“It’s too explosive for me,” she said.

She noted, however, that she supported her local council, which has backed Harris.

At one point, a worker turned to walk closer to the group once he learned they were advocating for Harris. He antagonized them.

“You didn’t hear about Sean O’Brien? How come Sean O’Brien didn’t endorse her?” he said.

“I can’t speak for Sean,” one of the organizers said and noted that members were free to back whom they pleased.

The man shot back: “You don’t follow your president?”

The organizer responded, “I’ll let Sean speak for himself.”

Natasha Korecki is a senior national political reporter for NBC News.