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. 

Authors' conclusions: 

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.

Read the full abstract...

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. 

Search strategy: 

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

Selection criteria: 

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.

Data collection and analysis: 

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.

Main results: 

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).