presentation unstable means

• Mammary Glands
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• RBC Isoimmunisation
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• Prolonged Pregnancy
• Multiple Pregnancy
• Miscarriage
• Recurrent Miscarriage
• Ectopic Pregnancy
• Hyperemesis Gravidarum
• Gestational Trophoblastic Disease
• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
• Oligohydramnios
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• Placenta Praevia
• Placental Abruption
• Pre-Eclampsia
• Gestational Diabetes
• Headaches in Pregnancy
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• Thyroid Disease in Pregnancy
• Epilepsy in Pregnancy
• Induction of Labour
• Operative Vaginal Delivery
• Prelabour Rupture of Membranes
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• Cord Prolapse
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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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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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Malpresentation

10-minute read

If your waters break and you have been told that your baby is not in a head-first position, seek medical help immediately.

• Malpresentation is when your baby is not in a head-first position towards the birth canal as birth approaches.
• The most common type of malpresentation is breech — when your baby’s bottom or feet are facing towards the birth canal.
• A procedure called external cephalic version can be used to try and turn a breech baby into a head-first position after 36 weeks of pregnancy.
• Most babies with malpresentation are born by caesarean, but some doctors or midwives may be able to help you birth a breech baby vaginally.
• There is a serious risk of cord prolapse if your waters break and your baby is not in a head-first position.

What is presentation and malpresentation?

‘Presentation’ describes how your baby is facing down the birth canal. The ‘presenting part’ is the part of your baby’s body that is against the cervix .

The ideal presentation is head-first, where the crown (top) of the baby’s head is against the cervix, and the chin tucked is into the baby’s chest. This is called ‘vertex presentation’.

If your baby is in any other position, it’s called ‘malpresentation’. Malpresentation can mean your baby’s face, brow, buttocks, foot, back, shoulder, arms or legs or the umbilical cord are against the cervix.

It’s safest for your baby’s head to come out first. If any other body part enters the birth canal first, there is a higher risk of complications for both you and your baby. Malpresentation increases the chance that you will have a more complex vaginal birth or need a caesarean.

If my baby is not head-first, what position could they be in?

Malpresentation is caused by your baby’s position (‘lie’). There are different types of malpresentation.

Breech presentation

This is when your baby is lying with their bottom or feet facing down. Sometimes, one foot may enter the birth canal first (called a ‘footling presentation’).

Breech presentation is the most common type of malpresentation.

Face presentation

This is when your baby is head-first, but stretching their neck, so their face is pressed against the cervix.

Transverse lie

This is when your baby is lying sideways. Their back, shoulders, arms or legs may be first to enter the birth canal.

Oblique lie

This is when your baby is lying diagonally. No particular part of their body is against the cervix.

Unstable lie

This is when your baby continually changes their position after 36 weeks of pregnancy.

Cord presentation

This is when the umbilical cord is against the cervix, between your baby and the birth canal. It can happen in any situation where your baby’s presenting part is not sitting snugly in your pelvis. It can become a medical emergency if it leads to cord prolapse (when the cord comes down the birth canal before your baby, potentially reducing blood flow to your baby).

What is malposition?

‘Position’ refers to which direction your baby is facing.

If your baby is head-first, the best position for labour is with their face is towards your back.

If your baby is head-first, but facing the front of your body (posterior position) or facing your side (transverse or lateral position) this is called malposition. It means your labour may take longer and you might feel more pain in your back. Babies who are malpositioned may move into a better position before or during labour.

What causes malpresentation?

Often, no cause is found, but malpresentation is more likely:

• a low-lying placenta
• too much or too little amniotic fluid
• many previous pregnancies, making the muscles of the uterus less stable
• carrying twins or more

Often, no cause is found.

What is the chance I will have a malpresentation?

Many babies maintain a breech position during pregnancy. They usually turn head-first as pregnancy progresses. More than 9 in 10 babies in Australia are in a head-first position at birth.

You are more likely to have a malpresentation if:

• this is your first baby
• you've had a breech presentation in a past pregnancy
• you go into labour prematurely

How is malpresentation diagnosed?

Your doctor or midwife can diagnose malpresentation by examining your abdomen and feeling the baby’s position. If they aren’t sure, it can be confirmed with an ultrasound .

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Can my baby’s position be changed?

If your baby is still in a breech position when you are 36 weeks pregnant , it’s less likely that they will turn head-first on their own. Your obstetrician may recommend a procedure called an called external cephalic version (ECV) to try and gently turn your baby to a head-first position.

Some people try different postures, acupuncture or moxibustion to correct malpresentation, but there is limited evidence that this work. Although if moxibustion is done before 37 weeks of pregnancy there is some evidence to suggest that this may reduce the chance of your baby being breech at birth. It’s a good idea to talk to your maternity care provider before trying alternative therapies to understand what is right for you.

Will I need a caesarean if my baby has a malpresentation?

Most babies with a malpresentation close to birth are born by caesarean . If your baby is breech, you may be able to have a vaginal birth, but it’s important that you are cared for in a hospital that can offer you and your baby specialised care. Ask your doctor or midwife for advice.

If your baby is breech, an elective (planned) caesarean is safer for your baby than a vaginal birth in the short term. However, in the longer term their health will be similar, on average, regardless of how they were born.

A vaginal birth is safer for you than an elective caesarean. However, about 4 in 10 people planning a vaginal breech birth end up needing an emergency caesarean . If this happens to you, the risk of complications will be higher than an elective caesarean.

Your doctor can talk to you about your options. Whether it’s safe for you to try a vaginal birth will depend on many factors, such as:

• your baby’s size
• the position of your baby
• whether you’ve had a caesarean in the past
• the expertise of your doctor and the services available at your hospital

What are the risks if I have my baby when it’s not head-first?

This will vary based on your individual circumstance. Talk to your maternity care provider about what your baby’s position means for your pregnancy, labour and birth. This will help you make informed decision that are right for you.

If your waters break when your baby is not head-first, there is a risk of cord prolapse. This is a medical emergency.

If you feel your waters break and you have been told that your baby is not in a head-first position, seek medical help immediately.

Vaginal breech birth

Risks to your baby can include:

• Erb’s palsy
• fractures, dislocations or other injuries
• bleeding in your baby’s brain
• low Apgar scores
• their head getting stuck – this is a medical emergency

Risks to you include:

• excessive blood loss
• blood clots
• infection in the wound
• problems with the anaesthetic
• damage to other organs nearby, such as your bladder
• a higher chance of complications in future pregnancies
• a longer recovery time than after a vaginal birth

Risks to your baby include:

• trouble with breathing — this is temporary
• getting a small cut during the surgery by accident

Will I have a malpresentation in my future pregnancies?

If you had a malpresentation in one pregnancy, you have a higher chance of it happening again. If you’re worried, it may help to talk to your doctor or midwife.

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

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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• > High-Risk Pregnancy: Management Options
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Book contents

• Frontmatter
• List of Contributors
• Section 1 Prepregnancy Problems
• Section 2 Early Prenatal Problems
• Section 3 Late Prenatal – Fetal Problems
• Section 4 Problems Associated with Infection
• Section 5 Late Pregnancy – Maternal Problems
• Section 6 Late Prenatal – Obstetric Problems
• 52 Abdominal Pain in Pregnancy
• 53 Nonmalignant Gynecology in Pregnancy
• 54 Bleeding in Late Pregnancy
• 55 Multiple Pregnancy
• 56 Threatened and Actual Preterm Labor
• 57 Prelabor Rupture of the Membranes
• 58 Breech Presentation, Unstable Lie, Malpresentation, and Malpositions
• 59 Prolonged Pregnancy
• 60 Induction of Labor and Termination of the Previable Pregnancy
• 61 Dysfunctional Labor
• 62 Shoulder Dystocia
• 63 Fetal Compromise in Labor
• 64 Neuraxial Analgesia and Anesthesia in Obstetrics
• 65 Perineal Repair and Pelvic Floor Injury
• 66 Assisted Vaginal Delivery
• 67 Delivery After Previous Cesarean Section
• 68 Cesarean Section
• Section 7 Postnatal Problems
• Section 8 Normal Values

58 - Breech Presentation, Unstable Lie, Malpresentation, and Malpositions

from Section 6 - Late Prenatal – Obstetric Problems

Introduction

The concepts of breech presentation, unstable lie, malpresentations, and malposition have not changed for many years but the diagnostic tools and management options change periodically as new management techniques are developed and the evidence for their use improves. Early in pregnancy the position, presentation, and lie of a fetus are irrelevant, and they only become important near term and at delivery.

Definitions

Lie . The relationship of the longitudinal axis of the fetus to the longitudinal axis of the mother's uterus. The terms commonly used are:

• Longitudinal lie: the fetal longitudinal axis is parallel to the uterine longitudinal axis.

• Oblique lie: The fetal axis is diagonal to the uterine axis.

• Transverse lie: The fetal longitudinal axis is perpendicular to the uterine axis.

• Unstable lie: The fetal lie continues to change at or near term (usually from 37 weeks onwards). The lie varies between longitudinal, oblique, and transverse.

Presentation . The fetal body part that is adjacent to the birth canal in the lower uterine segment closest to the cervix. The presentations seen in practice are cephalic (head), face, brow, shoulder, arm, hand, breech, or compound (combination of head or limbs with a limb or cord)

Position . The relationship of the presenting part to the maternal pelvis.

• In a cephalic presentation the occiput (vertex) is used to describe the fetal position.

• In a breech presentation the sacrum is used to describe the position.

• In a brow position the bregma is used to describe the position.

• In a face presentation the mentum is used to describe the position.

With a cephalic presentation, any position other than an occipitoanterior (OA) position is considered a malposition. Examples of malpositions in a cephalic presentation include occipitoposterior (OP) and occipitotransverse (OT). Asynclitism, a sideways tilt of the head, is also a malposition.

Other Important Definitions

Breech presentation. The fetus is in a longitudinal lie with buttocks adjacent to the birth canal.

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• Breech Presentation, Unstable Lie, Malpresentation, and Malpositions
• By Catherine A. Cluver , Department of Obstetrics & Gynaecology, Stellenbosch University, Stellenbosch, South Africa, G. Justus Hofmeyr , Effective Care Research Unit, University of Witwatersrand/Fort Hare/Walter Sisulu, Eastern Cape Department of Health, East London, South Africa
• Edited by David James , Philip Steer , Imperial College London , Carl Weiner , University of Kansas , Bernard Gonik , Wayne State University, Detroit , Stephen Robson
• Book: High-Risk Pregnancy: Management Options
• Online publication: 13 October 2017

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Obstetrics Simplified - Diaa M. EI-Mowafi

Shoulder Presentation (Transverse or Oblique lie)

• The longitudinal axis of the foetus does not coincide with that of the mother.
• These are the most hazardous malpresentations due to mechanical difficulties that occur during labour .
• The oblique lie which is deviation of the head or the breech to one iliac fossa, is less hazardous as correction to a longitudinal lie is more feasible.

3-4% during the last quarter of pregnancy but 0.5% by the time labour commences.

Factors that

• change the shape of pelvis, uterus or foetus,
• allow free mobility of the foetus or
• Contracted pelvis.           
• Lax abdominal wall.
• Uterine causes as bicornuate, subseptate and fibroid uterus.
• Pelvic masses as ovarian tumours.
• Multiple pregnancy.     
• Polyhydramnios.    
• Placenta praevia.           
• Prematurity.
• Intrauterine foetal death.

The scapula is the denominator

• Left scapulo-anterior.
• Right scapulo-anterior.
• Right scapulo-posterior.
• Left scapulo-posterior.

Scapulo-anterior are more common than scapulo-posterior as the concavity of the front of the foetus tends to fit with the convexity of the maternal spines.

During pregnancy

• The abdomen is broader from side to side.
• Fundal level: lower than that corresponds to the period of amenorrhoea.
• Fundal grip: The fundus feels empty.
• Umbilical grip: The head is felt on one side while the breech one the other. In transverse lie, they are at the same level, while in oblique lie one pole, usually the head as it is heavier, is in a lower level i.e. in the iliac fossa.
• First pelvic grip: Empty lower uterine segment.
• FHS are best heard on one side of the umbilicus towards the foetal head.
• Confirms the diagnosis and may identify the cause as multiple pregnancy or placenta praevia.

During labour

In addition to the previous findings, vaginal examination reveals:

• The presenting part is high.
• Membranes are bulging.
• Premature rupture of membranes with prolapsed arm or cord is common. The dorsum of the supinated hand points to the foetal back and the thumb towards the head. The right hand of the foetus can be shacked, correctly by the right hand of the obstetrician and the left hand by the left one.
• When the cervix is sufficiently dilated particularly after rupture of the membranes, the scapula, acromion, clavicle, ribs and axilla can be felt.

Mechanism of Labour

As a rule no mechanism of labour should be anticipated in transverse lie and labour is obstructed.

If a patient is allowed to progress in labour with a neglected or unrecognized transverse lie, one of the following may occur:

• This is the usual and most common outcome.
• The lower uterine segment thins and ultimately ruptures.
• The foetus becomes hyperflexed, placental circulation is impaired, cord is prolapsed and compressed leading to foetal asphyxia and death.
• Rarely the foetal lie may be corrected by the splinting effect of the contracted uterine muscles so that the head presents.
• Rarely, by similar process the breech may come to present.
• Very rarely, if the foetus is very small or dead and macerated, the shoulder may be forced through the pelvis followed by the head and trunk.
• Very rarely, the head is retained above the pelvic brim, the neck greatly elongates, the breech descends followed by the trunk and the after -coming head, i.e. spontaneous version occurs in the pelvic cavity.

External cephalic version

Can be done in late pregnancy or even early in labour if the membranes are intact and vaginal delivery is feasible. In early labour, if version succeeded apply abdominal binder and rupture the membranes as if there are uterine contractions.

Internal podalic version

It is mainly indicated in 2nd twin of transverse lie and followed by breech extraction.

Prerequisites:

• General or epidural anaesthesia.
• Fully dilated cervix.
• Intact membranes or just ruptured.

Caesarean section

• It is the best and safest method of management in nearly all cases of persistent transverse or oblique lie even if the baby is dead.
• As rupture of membranes carries the risk of cord prolapse, an elective caesarean section should be planned before labour commences.

Neglected (Impacted) shoulder

Clinical picture (impending rupture uterus)

• Exhaustion and distress of the mother.
• Shoulder is impacted may be with prolapsed arm and / or cord.
• Membranes are ruptured since a time.
• Liquor is drained.
• The uterus is tonically contracted.
• The foetus is severely distressed or dead.
• Caesarean section is the safest procedure even if the baby is dead. A classical or low vertical incision in the uterus facilitates extraction of the foetus as a breech in such a condition.
• Any other manipulations will lead eventually to rupture uterus so they are contraindicated.

UNSTABLE LIE

A foetus which changes its lie frequently from transverse to oblique to longitudinal.

• Polyhydramnios.
• Prematurity and IUFD.
• Contracted pelvis.
• Placenta praevia.
• Pelvic tumours. 
• Multiparae with a lax uterus and abdominal wall.
• Can be done whenever the woman is examined but in majority of cases it will recur so it is better to defer it until full term (37-40 weeks).
• After correcting the foetal lie to longitudinal, apply an abdominal binder, start oxytocin infusion and do amniotomy when the uterine contractions started and the presenting part is well settled into the pelvic brim.
• Failure of external version .
• Some do it selectively in cases discovered after 40 weeks’ gestation.
• Shoulder dystocia : Guidelines, reviews

When a Person Is Told They Have an Unstable Lie

• By: Gail Tully
• January 29, 2020
• Birth Anatomy , Pregnancy , Preparing for Birth

Lie means how the baby lies in the womb. The head-down baby is in a vertical lie, sometimes called cephalic to use a Latin term to mean the head is coming. Breech is an old English term to mean the baby’s pelvis is coming first. Both a head up (breech) and a head-down (cephalic) baby are in a vertical lie. When a baby is lying across the abdomen or sideways, we say baby is in a “ Transverse lie ”. An oblique lie is when baby’s body is diagonal in the womb. The head or pelvis is towards one hip and the opposite “pole” or end of the baby is under the opposite rib. A baby in an oblique lie might have their head by the right hip and their bottom beneath the left ribs, for instance.

Using Spinning Babies® techniques for an Unstable Lie

Forward-leaning Inversion

She wrote, “My 38-week baby had flipped head down twice (once from Spinning Babies® and once from a version [ECV] at the hospital), but wouldn’t stay that way- what’s considered unstable lie. I was 5 days away from having a version at the hospital, if it worked they would have induced me. If not, C-section.” About this time, I was able to call Crista and offer a plan for helping baby flip head down and gave her the name of a breech-skilled provider in our area.

Suggestions for Unstable Lie

Side-lying Release

Planning to wear the pregnancy belt and continue (one FLI a day) and Side-lying Releases (SLR) to keep him this way (and walking and sitting on the ball )- no ironing board inversions. Thank you, thank you, thank you!” I replied, “Such good news! Wow! Walk, walk walk! With a good stride and shoes. If you do decide to induce, please consider one FLI the morning before starting the IV. The SLR and FLI can support the normal progress of labor, whether natural or induced . Remember their helpfulness before getting frustrated or tired. Same for pain, as this combination of techniques will also help reduce pain in labor.” Crista agreed,  “Yes! There is no reason to induce now, so I’m just like every other pregnant lady waiting for labor to start. Thanks for the advice for during labor, I will do it! I loved that your approach is so physiological and practical. My super, by-the-book OBGYN even recommended Spinning Babies® and she is usually very skeptical of anything outside medical guidelines. I wish everybody knew how much control you can actually have over how your baby interacts with your body! I am a believer and am excited to use some of the techniques during labor. Please share my story. I can’t thank you enough.”

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Malpresentations and malpositions

Peer reviewed by Dr Laurence Knott Last updated by Dr Colin Tidy, MRCGP Last updated 22 Jun 2021

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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our  health articles  more useful.

In this article :

Malpresentation, malposition.

Usually the fetal head engages in the occipito-anterior position (more often left occipito-anterior (LOA) rather than right) and then undergoes a short rotation to be directly occipito-anterior in the mid-cavity. Malpositions are abnormal positions of the vertex of the fetal head relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex.

Obstetrics - the pelvis and head

Continue reading below

Predisposing factors to malpresentation include:

Prematurity.

Multiple pregnancy.

Abnormalities of the uterus - eg, fibroids.

Partial septate uterus.

Abnormal fetus.

Placenta praevia.

Primiparity.

Breech presentation

See the separate Breech Presentations article for more detailed discussion.

Breech presentation is the most common malpresentation, with the majority discovered before labour. Breech presentation is much more common in premature labour.

Approximately one third are diagnosed during labour when the fetus can be directly palpated through the cervix.

After 37 weeks, external cephalic version can be attempted whereby an attempt is made to turn the baby manually by manipulating the pregnant mother's abdomen. This reduces the risk of non-cephalic delivery 1 .

Maternal postural techniques have also been tried but there is insufficient evidence to support these 2 .

Many women who have a breech presentation can deliver vaginally. Factors which make this less likely to be successful include 3 :

Hyperextended neck on ultrasound.

High estimated fetal weight (more than 3.8 kg).

Low estimated weight (less than tenth centile).

Footling presentation.

Evidence of antenatal fetal compromise.

Transverse lie 4

When the fetus is positioned with the head on one side of the pelvis and the buttocks in the other (transverse lie), vaginal delivery is impossible.

This requires caesarean section unless it converts or is converted late in pregnancy. The surgeon may be able to rotate the fetus through the wall of the uterus once the abdominal wall has been opened. Otherwise, a transverse uterine incision is needed to gain access to a fetal pole.

Internal podalic version is no longer attempted.

Transverse lie is associated with a risk of cord prolapse of up to 20%.

Occipito-posterior position

This is the most common malposition where the head initially engages normally but then the occiput rotates posteriorly rather than anteriorly. 5.2% of deliveries are persistent occipito-posterior 5 .

The occipito-posterior position results from a poorly flexed vertex. The anterior fontanelle (four radiating sutures) is felt anteriorly. The posterior fontanelle (three radiating sutures) may also be palpable posteriorly.

It may occur because of a flat sacrum, poorly flexed head or weak uterine contractions which may not push the head down into the pelvis with sufficient strength to produce correct rotation.

As occipito-posterior-position pregnancies often result in a long labour, close maternal and fetal monitoring are required. An epidural is often recommended and it is essential that adequate fluids be given to the mother.

The mother may get the urge to push before full dilatation but this must be discouraged. If the head comes into a face-to-pubis position then vaginal delivery is possible as long as there is a reasonable pelvic size. Otherwise, forceps or caesarean section may be required.

Occipito-transverse position

The head initially engages correctly but fails to rotate and remains in a transverse position.

Alternatives for delivery include manual rotation of fetal head using Kielland's forceps, or delivery using vacuum extraction. This is inappropriate if there is any fetal acidosis because of the risk of cerebral haemorrhage.

Therefore, there must be provision for a failure of forceps delivery to be changed immediately to a caesarean. The trial of forceps is therefore often performed in theatre. Some centres prefer to manage by caesarean section without trial of forceps.

Face presentations

Face presents for delivery if there is complete extension of the fetal head.

Face presentation occurs in 1 in 1,000 deliveries 5 .

With adequate pelvic size, and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour.

Backwards rotation of the head to a mento-posterior position requires a caesarean section.

Brow positions

The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents.

Brow presentation occurs in 0.14% of deliveries 5 .

Brow presentation is usually only diagnosed once labour is well established.

The anterior fontanelle and super orbital ridges are palpable on vaginal examination.

Unless the head flexes, a vaginal delivery is not possible, and a caesarean section is required.

Further reading and references

• Hofmeyr GJ, Kulier R, West HM ; External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015 Apr 1;(4):CD000083. doi: 10.1002/14651858.CD000083.pub3.
• Hofmeyr GJ, Kulier R ; Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;10:CD000051. doi: 10.1002/14651858.CD000051.pub2.
• Management of Breech Presentation ; Royal College of Obstetricians and Gynaecologists (Mar 2017)
• Szaboova R, Sankaran S, Harding K, et al ; PLD.23 Management of transverse and unstable lie at term. Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A112-3. doi: 10.1136/archdischild-2014-306576.324.
• Gardberg M, Leonova Y, Laakkonen E ; Malpresentations - impact on mode of delivery. Acta Obstet Gynecol Scand. 2011 May;90(5):540-2. doi: 10.1111/j.1600-0412.2011.01105.x.

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Next review due: 21 Jun 2026

22 jun 2021 | latest version.

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Abnormal Fetal Lie - An Overview

A baby's abnormal position (abnormal fetal lie) in the womb during the later stages of pregnancy may lead to severe consequences. Read this article to know more.

Dr. Ankita Balar

Medically reviewed by

Dr. Richa Agarwal

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What Is a Fetal Lie and Its Types?

The baby's position in the uterus is known as the fetal lie or presentation of the fetus. During pregnancy , the baby tends to move around in the uterus, a normal phenomenon. In the earlier stages of pregnancy, the baby is small enough to move around freely. But, when the baby gets larger, its movement becomes limited.

As the delivery day approaches, the baby starts to move into the position for birth. This position involves flipping over so that the baby's head is down and with the face towards the mother's back. The baby starts to move down in the uterus and prepares to go through the birth canal (cervix, vagina, and vulva) during childbirth.

1) Normal Fetal Lie- This position is ideal for labor and baby delivery. In this position, the baby is head-down with the chin tucked into its chest. The back of the head is positioned as it is ready to enter the pelvis. The baby is facing the mother's back. This position is called cephalic presentation, and most babies settle in this position at 32 weeks to 36 weeks of the pregnancy.

2) Abnormal Fetal Lie- Sometimes, the baby cannot get into the perfect cephalic presentation before birth. There are several positions that the baby can attain, and all these positions can render complications during childbirth. The different types of abnormal fetal lies are as follows-

Occiput or Cephalic Posterior Position- When the baby is positioned head down but facing the mother's abdomen. With the head in this position, the baby is looking up. This position is nicknamed sunny-side-up. This position can increase the chance of a long, painful delivery.

Frank Breech- In a frank breech, the baby's buttocks enter the birth canal, and the hips are flexed while the knees are extended. This position can cause an umbilical cord loop formation, and the baby can get injured during vaginal delivery .

Complete Breech- The baby is positioned with the buttocks in front, and both the hips and the knees are flexed. This position increases the risk of forming an umbilical cord loop and injuring the baby if delivered vaginally.

Transverse Lie- The baby lies crosswise in the uterus such that the shoulder enters the pelvis first. A cesarean (C-section) delivery is used for babies in this position.

Footling Breech- The baby's feet are pointed toward the birth canal, which increases the chances of the umbilical cord coming down into the mouth of the womb, thereby cutting off the blood supply to the baby.

Does Abnormal Fetal Lie Pose Any Risk?

An abnormal fetal position or breech makes the baby's delivery very complicated. The baby is safe inside the mother's womb, and vaginal delivery is considered a safe form of childbirth. However, when the baby is in an abnormal fetal position, vaginal delivery can get complicated.

The reason is that the baby's head is larger than the bottom and feet, so there is a risk of head entrapment in the uterus. In this situation, it becomes difficult for the doctor to deliver the baby. Some babies in the breech position are in a hurry to come out during labor, thus making it more difficult for the doctor and the mother.

Sometimes, the doctor may recommend a cesarean birth (c-section) instead of vaginal birth. Cesarean birth is a surgical procedure in which an incision is made in the mother's abdomen, and the baby is delivered in an operating room. The risk involved is much less for the baby during this procedure than vaginal birth if the baby has an abnormal fetal lie.

What Is the Ideal Time for a Baby to Attain the Birth Position?

The baby drops down in the uterus and moves into the birth position, usually in the third trimester. This happens between weeks 32 and week 36 of the pregnancy. The doctor can check the baby's position by touching the mother's abdomen during regular appointments or with the help of an ultrasound.

Can a Doctor Modify or Turn the Baby in Abnormal Fetal Lie?

There are several ways that a doctor can try and turn the baby before beginning labor. These methods may or may not work, as sometimes, the baby turns back into the abnormal fetal position again. The success rate is very low, but if the mother wishes to avoid cesarean delivery, they can try them. The following techniques can be tried to encourage the baby to turn on its own-

1) External Cephalic Version (ECV)- It is a non-invasive way to turn the baby and improve the chance of having a vaginal birth. In this method, on the delivery table, nurses or helpers apply pressure through the abdominal wall to the uterus while trying to rotate the baby's head forward or backward.

2) Exercises- The exercises may or may not work, but they might encourage the baby to turn, avoiding a c-section delivery. The exercise involves yoga-like poses. The following two specific movements are recommended-

Getting on the hands and knees and then gently rocking in back and forth directions.

While laying on the back with knees bent and feet flat on the floor, pushing the hips up in the air (bridge pose).

3) Sound Therapy- Music, temperature changes, talking, and light could interest the baby in the womb.

The mother can place headphones on the belly, towards the bottom, to see if this attracts the baby.

Applying cold objects to the top of the abdomen where the baby's head is present might encourage the baby to move away and downward.

A chiropractic technique (webster technique) can move the hips. This allows the uterus to relax. Relaxation can promote baby movement and help the baby to get into the best possible birth position.

What Factors Promote an Abnormal Fetal Lie?

Premature delivery and early labor.

Abnormal placental position.

Multiple pregnancies.

Anatomical defects in the uterus.

Uterine fibroids .

Conclusion:

Knowing about abnormal fetal lies before delivery can add to the mother's anxiety surrounding childbirth. However, it can help doctors form an ideal labor and delivery birth plan. Most pregnant women do not have a c-section as a part of their birth plan. But the main goal is to safely deliver the baby and protect the mother's health.

Frequently Asked Questions

What is the reason for an abnormal fetal lie, what are the types of fetal lies, what do you mean by a normal fetal lie, what is the optimal position for normal delivery, what are the factors responsible for fetal abnormalities during pregnancy, what does abnormal fetal ultrasound indicate, what are the clinical features of an abnormal fetus, does stress lead to an abnormal pregnancy, what is the prevalence of fetal abnormalities.

NIH- Abnormal fetal presentation or lie

https://pubmed.ncbi.nlm.nih.gov/1919834/

ACOG- If Your Baby Is Breech

https://www.acog.org/womens-health/faqs/if-your-baby-is-breech

Obstetrics and Gynecology

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Abnormal Fetal Lie, Presentation, and Position

Hasan, Rabale BS; Bystry, Lisa R. MD; Morosky, Christopher M. MD, MS

Ms. Hasan is a Medical Student, Dr. Bystry is Assistant Professor, and Dr. Morosky is Associate Professor, Department of Obstetrics and Gynecology, UConn Health, 263 Farmington Ave, Farmington, CT 06030; E-mail: [email protected] .

The authors, faculty, and staff in a position to control the content of this CME/CNE activity, and their spouses/life partners (if any), have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations relevant to this educational activity. CME Accreditation Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This CME activity expires on February 27, 2022 . CNE Accreditation Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Lippincott Professional Development will award 1.0 contact hours for this continuing nursing education activity. Instructions for earning ANCC contact hours are included on the test page of the newsletter. This CNE activity expires on December 3, 2021 .

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• Volume 99, Issue Suppl 1
• PLD.23 Management of transverse and unstable lie at term
• Article Text
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• R Szaboova ,
• S Sankaran ,
• K Harding ,
• King’s Health Partners, London, UK

Aims To determine current practice and outcomes in women admitted to antenatal ward with diagnosis of transverse or unstable lie.

Background Fetal lie (other than longitudinal) at term may predispose to prolapse of cord or fetal arm and uterine rupture. Local guidelines recommend admission at 37+0 (RCOG guidelines after 37+6 weeks) but give no specific recommendations regarding further management.

Methods A retrospective study was conducted at St Thomas’ Hospital, London from 2009–2012 of all women admitted with unstable/transverse lie. The diagnosis was based on ultrasound examination. Women with placenta praevia and non-singleton deliveries were excluded.

Results Study included 198 cases of unstable/transverse lie. 58% were admitted before 38 weeks. The average length of admission was 7 days (IQR 4–11). There were no cases of cord prolapse or need for an immediate caesarean section from the antenatal ward. 73% of women had a caesarean section at a median gestation of 39+1 weeks (IQR 38+4 – 40+2) although almost half of these (41%) had a cephalic presentation at the time of elective caesarean sections. None of these had an absolute indication for Caesarean section.

Discussion and conclusions The diagnosis of unstable/transverse lie leads to a prolonged inpatient stay and a high Caesarean section rate. From our study and the evidence from the available literature, we recommend delaying admission until at least 38 weeks and awaiting spontaneous version. Future research should focus on the safety of outpatient management with consideration of utilising techniques such as cervical length and fetal fibronectin.

https://doi.org/10.1136/archdischild-2014-306576.324

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Definition of unstable

inconstant , fickle , capricious , mercurial , unstable mean lacking firmness or steadiness (as in purpose or devotion).

inconstant implies an incapacity for steadiness and an inherent tendency to change.

fickle suggests unreliability because of perverse changeability and incapacity for steadfastness.

capricious suggests motivation by sudden whim or fancy and stresses unpredictability.

mercurial implies a rapid changeability in mood.

unstable implies an incapacity for remaining in a fixed position or steady course and applies especially to a lack of emotional balance.

Examples of unstable in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'unstable.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

13th century, in the meaning defined above

Phrases Containing unstable

unstable angina

Dictionary Entries Near unstable

unstability

Cite this Entry

“Unstable.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/unstable. Accessed 24 Sep. 2024.

Kids Definition

Kids definition of unstable, medical definition, medical definition of unstable, more from merriam-webster on unstable.

Nglish: Translation of unstable for Spanish Speakers

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Screen Rant

90 day fiancé’s shaeeda sween reveals new "marriage problems" with bilal while pregnant with their baby.

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Shaeeda Sween from 90 Day Fiancé: Happily Ever After? opens up about marital issues with Bilal Hazziez as they prepare for the arrival of their first baby . The couple tied the knot in December 2021 after initially connecting through Facebook. Over the past two years, Shaeeda and Bilal have encountered many challenges in their relationship, including two miscarriages. At one point, there were rumors of a possible divorce when Shaeeda briefly stopped sharing pictures with Bilal on social media. However, in recent months, they seemed to be in a better place as they looked forward to welcoming their first child.

Recently, Shaeeda shared an Instagram Story, playfully revealing new problems in her marriage to Bilal. As she expects her first baby boy, she mentions wanting a second baby to her husband, who thinks she's ridiculous . Shaeeda wrote, "me telling my husband - 'I'm ready for baby #2.' He looked at me like I'm crazy!" Since Bilal responded disapprovingly, the 90 Day Fiancé: Happily Ever After? alum jokingly mentioned that she was already facing "marriage problems." Shaeeda also humorously blamed her "pregnancy hormones" for making her feel "so unstable" while pregnant with her first baby.

What Shaeeda Sween's Pregnancy Hormones Mean For Her Marriage With Bilal

Shaeeda & billal might have some disagreements coming up.

Both Shaeeda and Bilal have strong, level-headed personalities, which is likely why they've faced challenges in their marriage. Initially, Shaeeda argued with Bilal about signing a prenuptial agreement. However, once that issue was somehow resolved, Bilal continued to delay their plan to have a baby despite Shaeeda's advanced age, making it difficult to conceive naturally. Now, as the couple finally enjoys marital bliss and is expecting their first baby, they face another disagreement. Although Shaeeda only jokingly mentioned wanting another child with Bilal, his response indicates he isn't ready for such a significant responsibility .

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Shaeeda may have blamed her pregnancy hormones for wanting another child, but it seems that she actually wants more than one baby with her American husband. However, it appears that Bilal, who already has two children with his first wife, isn't keen on having a big family. Despite Shaeeda's strong motherly instinct and long-held desire to be a nurturing mom, her hope for a second child may meet resistance from her husband . Although the 90 Day Fiancé: Happily Ever After? couple's marriage seems stronger than ever, they are likely to encounter numerous disagreements in the future regarding their baby plans.

Our Take On Shaeeda Sween's Pregnancy Hormones

Shaeeda may become hesitant about having another baby.

Shaeeda's pregnancy hormones might be influencing her wish for a second child, and she may not truly desire another baby.

Perhaps she was just playfully poking fun at her husband, who had been stalling their baby plans for months. Although Shaeeda has expressed her desire to be a mother, she hasn't really specified how many children she wants with Bilal. After giving birth to her first son and experiencing the highs and lows of motherhood, Shaeeda may reevaluate her desire for more children. Nevertheless, the 90 Day Fiancé: Happily Ever After? cast member will hopefully have a healthy pregnancy.

90 Day Fiancé: Before The 90 Days airs Sundays at 8 p.m. EDT on TLC.

Source: Shaeeda Sween /Instagram

90 Day Fiancé: Happily Ever After?

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90 Day Fiancé: Happily Ever After? follows couples from previous seasons of 90 Day Fiancé as they navigate married life post-K-1 visa process. The series explores the ups and downs of their relationships, including cultural clashes and family dynamics, while attempting to build their lives together in the United States. By chronicling the ongoing personal and relationship challenges, the show provides a glimpse into the aftermath of the 90-day journey.

• 90 Day Fiance