lie and presentation of fetus

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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• 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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Malpresentation

8-minute read

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 .

• Malpresentation is when your baby is not facing head-first down the birth canal as birth approaches.
• The most common type of malpresentation is breech — when your baby’s bottom or feet are facing downwards.
• A procedure called external cephalic version can sometimes turn a breech baby into a head-first position at 36 weeks.
• Most babies with malpresentation are born by caesarean, but you may be able to have a vaginal birth if your baby is breech.
• There is a serious risk of cord prolapse if your waters break and your baby is not head-first.

What are 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, with the crown (top) of the baby’s head against the cervix, with the chin tucked 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 goes down the birth canal first, the risks to you and your baby may be higher. Malpresentation increases the chance that you will have a more complex vaginal birth or 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, with their face against the cervix.

Transverse lie

This is when your baby is lying sideways. Their back, shoulders, arms or legs may be the 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 an emergency if it leads to cord prolapse (when the cord is born before your baby, potentially reducing placental blood flow to your baby).

What is malposition?

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

If your baby is facing the front of your body (posterior position) or facing your side (transverse position) this is called malposition. Transverse position is not the same as transverse lie. A transverse position means your labour may take a bit longer and you might feel more pain in your back. Often your baby will move into a better position before or during labour.

Why might my baby be in the wrong position?

Malpresentation may be caused by:

• 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.

Is it likely that my baby will be in the wrong position?

Many babies are in a breech position during pregnancy. They usually turn head-first as pregnancy progresses, and more than 9 in 10 babies in Australia have a vertex presentation (ideal presentation, head-first) at birth.

You are more likely to have a malpresentation if:

• this is your first baby
• you are over 40 years old
• you've had a previous breech baby
• you go into labour prematurely

How is malpresentation diagnosed?

Malpresentation is normally diagnosed when your doctor or midwife examines you, from 36 weeks of pregnancy. If it’s not clear, it can be confirmed with an ultrasound.

Can my baby’s position be changed?

If you are 36 weeks pregnant , it may be possible to gently turn your baby into a head-first position. This is done by an obstetrician using a technique called external cephalic version (ECV).

Some people try different postures or acupuncture to correct malpresentation, but there isn’t reliable evidence that either of these work.

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

Most babies with a malpresentation close to birth are born by caesarean . You may be able to have a vaginal birth with a breech baby, but you will need to go to a hospital that can offer you and your baby specialised care.

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.

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. These include how big your baby is, the position of your baby, the structure of your pelvis and whether you’ve had a caesarean in the past.

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

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

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 an emergency

Risks to you include:

• blood loss or blood clots
• infection in the wound
• problems with the anaesthetic
• damage to other organs nearby, such as your bladder
• a higher chance of problems 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

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, but it won’t necessarily happen in future pregnancies. If you’re worried, it may help to talk to your doctor or midwife so they can explain what happened.

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Last reviewed: July 2022

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Labour complications.

• Interventions during labour
• Giving birth - stages of labour

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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.

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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

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.

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

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Presentation and position of baby through pregnancy and at birth

Presentation and position refer to where your baby’s head and body is in relation to your birth canal. Learn why it’s important for labour and birth.

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

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What Is a Transverse Baby Position?

Why It Happens, How to Turn Your Baby, and Tips for a Safe Delivery

Causes and Risk Factors

Turning the fetus, complications, frequently asked questions.

A transverse baby position, also called transverse fetal lie, is when the fetus is sideways—at a 90-degree angle to your spine—instead of head up or head down. This development means that a vaginal delivery poses major risks to both you and the fetus.

Sometimes, a transverse fetus will turn itself into the head-down position before you go into labor. Other times, a healthcare provider may be able to turn the position.

If a transverse fetus can't be turned to the right position before birth, you're likely to have a cesarean section (C-section).

This article looks at causes and risk factors for a transverse baby position. It also covers how it's diagnosed and treated, the possible complications, and how you can plan ahead for delivery.

Marko Geber / Getty Images

How Common Is Transverse Baby Position?

An estimated 2% to 13% of babies are in an unfavorable position at delivery —meaning they're not in the head-down position .

Certain physiological issues can lead to a transverse fetal lie. These include:

• A bicornuate uterus : The uterus has a deep V in the top that separates the uterus into two sides; it may only be able to hold a near-term fetus sideways.
• Oligohydramnios or polyhydramnios : Abnormally low or high amniotic fluid volume (respectively).

Several risk factors can make it more likely for the fetus to be in a transverse lie, such as:

• The placenta being in an unusual position, such as blocking the opening to the cervix ( placenta previa ), which doesn't allow the fetus to reach the head-down position
• Going into labor early, before the fetus has had a chance to get into the right position
• Being pregnant with twins or other multiples, as the uterus is crowded and may not allow for much movement
• An abnormal pelvic structure that limits fetal movement
• Having a cyst or fibroid tumor blocking the cervix

Transverse fetal positioning is also more common after your first pregnancy.

It’s not uncommon for a fetus to be in a transverse position during the earlier stages of pregnancy. In most cases, though, they shift on their own well before labor begins. The transverse fetal position doesn't cause any signs or symptoms.

Healthcare professionals diagnose a transverse lie through an examination called Leopold’s Maneuvers. That involves feeling your abdomen to determine the fetal position. It's usually confirmed by an ultrasound.

You may also discover a transverse fetal lie during a routine ultrasound.

Timing of Transverse Position Diagnosis

The ultrasound done at your 36-week checkup lets your healthcare provider see the fetal position as you get closer to labor and delivery. If it's still a transverse lie at that time, your medical team will look at options for the safest labor and delivery.

Approximately 97% of deliveries involve a fetus positioned with the head down, in the best position to slide out. That makes a vaginal delivery easier and safer.

A transverse position only happens in about 1% of deliveries. In that position, the shoulder, arm, or trunk of the fetus may present first. This isn't a good scenario for either of you because a vaginal delivery is nearly impossible.

In these cases, you have two options:

• Turning the fetal position
• Having a C-section

If the fetus is in a transverse lie late in pregnancy, you or your healthcare provider may be able to change the position. Turning into the proper head-down position may help you avoid a C-section.

Medical Options

A healthcare provider can use one of the following techniques to attempt re-positioning a fetus:

• External cephalic version (ECV) : This procedure typically is performed at or after 36 weeks of pregnancy; involves using pressure on your abdomen where the fetal head and buttocks are.
• Webster technique : This is a chiropractic method in which a healthcare professional moves your hips to allow your uterus to relax and make more room for the fetus to move itself. (Note: No evidence supports this method.)

A 2020 study reported a 100% success rate for trained practitioners who used turning to change a transverse fetal lie. Real-world success rates are closer to 60%.

At-Home Options

You may be able to encourage a move out of the transverse position at home. You can try:

• Getting on your hands and knees and gently rocking back and forth
• Lying on your back with your knees bent and feet flat on the floor, then pushing your hips up in the air (bridge pose)
• Talking or playing music to stimulate the fetus to become more active
• Applying some cold to your abdomen where the fetal head is, which may make them want to move away from it

These methods may or may not work for you. While there's anecdotal evidence that they sometimes work, they haven't been researched.

Talk to your healthcare provider before attempting any of these techniques to ensure you're not doing anything unsafe.

Can Babies Go Back to Transverse After Being Turned?

Even if the fetus does change position or is successfully moved, it is possible that it could return to a transverse position prior to delivery.

Whether your child is born via C-section or is successfully moved so you can have a vaginal delivery, potential complications remain.

Cesarean Sections

C-sections are extremely common and are generally safe for both you and the fetus. Still, some inherent risks are associated with the procedure, as there are with any surgery.

The transverse position can force the surgeon to make a different type of incision, as the fetal lie may be right where they'd usually cut. Possible C-section complications for you can include:

• Increased bleeding
• Bladder or bowel injury
• Reactions to medicines
• Blood clots
• Death (very rare)

In rare cases, a C-section can result in potential complications for the baby , including:

• Breathing problems, if fluid needs to be cleared from their lungs

Most C-sections are safe and result in a healthy baby and parent. In some situations, a surgical delivery is the safest option available.

Vaginal Delivery

If the fetus is successfully moved out of the transverse lie position, you'll likely be able to deliver it vaginally. However, a few complications are possible even after the fetus has been moved:

• Labor typically takes longer.
• Your baby’s face may be swollen and appear bruised for a few days.
• The umbilical cord may be compressed, potentially causing distress and leading to a C-section.

Studies suggest that ECV is safe, effective, and may help lower the C-section rate.

Planning Ahead

As with any birth, if you experience a transverse fetal position, you should work with your healthcare provider to develop a delivery plan. If the transverse position has been maintained throughout the pregnancy, the medical team will evaluate the position at about 36 weeks and make plans accordingly.

Remember that even if the fetal head is down late in pregnancy, things can change quickly during labor and delivery. That means it's worthwhile to discuss options for different types of delivery in case they become necessary.

A transverse baby position, or transverse fetal lie, is the term for a fetus that's lying sideways in the uterus. Vaginal delivery usually isn't possible in these cases.

If the fetus is in this position near the time of delivery, the options are to turn it to make vaginal delivery possible or to have a C-section. A trained healthcare provider can use turning techniques. You may also be able to get the fetus to turn at home with some simple techniques.

Both C-section and vaginal delivery pose a risk of certain complications. However, these problems are rare and the vast majority of deliveries end with a healthy baby and parent.

A Word From Verywell

Pregnancy comes with many unknowns, and the surprises can continue up through labor and delivery.

Talking to your healthcare provider early on about possible scenarios can give you time to think about possible outcomes. This helps to avoid a situation where you’re considering risks and benefits during labor when quick decisions need to be made.

Ideally, a baby should be in the cephalic position (head down) at 32 weeks. If not, a doctor will examine the fetal position at around the 36-week mark and determine what should happen next to ensure a smooth delivery. Whether this involves a cesarian section will depend on the specific case.

Less than 1% of babies are born in the transverse position. In many cases, a doctor might recommend a cesarian delivery to ensure a more safe delivery. The risk of giving birth in the transverse lie position is greater before a due date or if twins or triplets are also born.

A planned cesarian section, or C-section, is typically performed in the 39th week of gestation. This is done so the fetus is given enough time to grow and develop so that it is healthy.

In some cases, a doctor may perform an external cephalic version (ECV) to change a transverse fetal lie. This involves the doctor using their hands to apply firm pressure to the abdomen so the fetus is moved into the cephalic (head-down) position.

Most attempts of ECV are successful, but there is a chance the fetus can move back to its previous position; in these cases, a doctor can attempt ECV again.

The American College of Obstetricians and Gynecologists. If your baby is breech .

Tempest N, Lane S, Hapangama D.  Babies in occiput posterior position are significantly more likely to require an emergency cesarean birth compared with babies in occiput transverse position in the second stage of labor: a prospective observational study .  Acta Obstet Gynecol Scand . 2020;99(4):537-545. doi:10.1111/aogs.13765

National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Congenital uterine anomalies .

Figueroa L, McClure EM, Swanson J, et al.  Oligohydramnios: a prospective study of fetal, neonatal and maternal outcomes in low-middle income countries .  Reprod Health.  2020;17 (article 19). doi:10.1186/s12978-020-0854-y

National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Placenta previa .

National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Your baby in the birth canal .

Van der Kaay DC, Horsch S, Duvekot JJ.  Severe neonatal complication of transverse lie after preterm premature rupture of membranes .  BMJ Case Rep . 2013;bcr2012008399. doi:10.1136/bcr-2012-008399

Oyinloye OI, Okoyomo AA.  Longitudinal evaluation of foetal transverse lie using ultrasonography .  Afr J Reprod Health ; 14(1):129-133.

Nishikawa M, Sakakibara H. Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment .  Reprod Health  2013;10 (article 12). doi.org/10.1186/1742-4755-10-12

National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Delivery presentations .

Dalvi SA. Difficult deliveries in Cesarean section .  J Obstet Gynaecol India . 2018;68(5):344-348. doi:10.1007/s13224-017-1052-x

Zhi Z, Xi L. Clinical analysis of 40 cases of external cephalic version without anesthesia .  J Int Med Res . 2021;49(1):300060520986699. doi:10.1177/0300060520986699

National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Questions to ask your doctor about labor and delivery .

Nemours KidsHealth. Cesarean sections .

By Elizabeth Yuko, PhD Yuko has a doctorate in bioethics and medical ethics and is a freelance journalist based in New York.

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Fetal Malpresentation and Malposition

Fetal presentation describes which part of the fetus will enter through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy first, while position is the orientation Orientation Awareness of oneself in relation to time, place and person. Psychiatric Assessment of the fetus compared to the maternal bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy . Presentations include vertex (the fetal occiput will present through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy first), face, brow, shoulder, and breech. If a fetal limb is presenting next to the presenting part (e.g., the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy is next to the head), this is known as a compound presentation. Malpresentation refers to any presentation other than vertex, with the most common being breech presentations. Vaginal delivery of a breech infant increases the risk for head entrapment and hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage , so, especially in the United States, mothers are generally offered a procedure to help manually rotate the baby to a head-down position instead (known as an external cephalic version) or a planned cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery .

Last updated: Feb 14, 2023

Fetal Lie and Presentation

Presenting diameter, management of cephalic and compound presentations, risks and management of breech and transverse presentations.

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• The “presenting part” refers to the part of the baby that will come through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy first. 
• The position refers to how that body part (and thus the baby) is oriented within the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy . 
• The uterine fundus Fundus The superior portion of the body of the stomach above the level of the cardiac notch. Stomach: Anatomy is typically roomier, so babies tend to orient themselves head down so that their body and limbs occupy the larger portion of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy .

Clinical relevance

• The maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy has a diameter of about 10 cm, through which the fetus must pass.
• The presentation and position of the fetus will determine how wide the fetus is (known as the “presenting fetal diameter”) as it attempts to pass through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .
• Certain presentation/positions are more difficult (or even impossible) to pass through the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy because of their large presenting diameter.
• Knowledge of the presentation and position are required to safely manage labor and delivery.

Risk factors for fetal malpresentation

• Multiparity (which can result in lax abdominal walls)
• Multiple gestations (e.g., twins)
• Prematurity Prematurity Neonatal Respiratory Distress Syndrome
• Uterine abnormalities (e.g., leiomyomas, uterine septa)
• Narrow pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy shapes
• Fetal anomalies (e.g., hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage )
• Placental anomalies (e.g.,   placenta previa Placenta Previa Abnormal placentation in which the placenta implants in the lower segment of the uterus (the zone of dilation) and may cover part or all of the opening of the cervix. It is often associated with serious antepartum bleeding and premature labor. Placental Abnormalities , in which the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity covers the internal cervical os)
• Polyhydramnios Polyhydramnios Polyhydramnios is a pathological excess of amniotic fluid. Common causes of polyhydramnios include fetal anomalies, gestational diabetes, multiple gestations, and congenital infections. Patients are often asymptomatic but may present with dyspnea, extremity swelling, or abdominal distention. Polyhydramnios (too much fluid)
• Oligohydramnios Oligohydramnios Oligohydramnios refers to amniotic fluid volume less than expected for the current gestational age. Oligohydramnios is diagnosed by ultrasound and defined as an amniotic fluid index (AFI) of ‰¤ 5 cm or a single deep pocket (SDP) of Oligohydramnios (not enough fluid)
• Malpresentation in a previous pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care

Epidemiology

Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency rates for different malpresentations at term:

• Vertex presentation, occiput posterior position: 1 in 19 deliveries
• Breech presentation: 1 in 33 deliveries
• Face presentation: 1 in 600–800 deliveries
• Transverse lie: 1 in 833 deliveries
• Compound presentation: 1 in 1500 deliveries 

Related videos

Fetal lie is how the long axis of the fetus is oriented in relation to the mother. Possible lies include:

• Longitudinal: fetus and mother have the same vertical axis (their spines are parallel).
• Transverse: fetal vertical axis is at a 90-degree angle to mother’s vertical axis (their spines are perpendicular).
• Oblique: fetal vertical axis is at a 45-degree angle to mother’s vertical axis (unstable, and will resolve to longitudinal or transverse during labor).

Presentation

Presentation describes which body part of the fetus will pass through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy first. Presentations include:

• Cephalic: head down
• Breech: bottom/feet down
• Transverse presentation: shoulder 
• Compound presentation: an extremity presents alongside the primary presenting part

Cephalic presentations

Cephalic presentations can be categorized as:

• Vertex presentation: chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma flexed, with the occipital Occipital Part of the back and base of the cranium that encloses the foramen magnum. Skull: Anatomy fontanel as the presenting part
• Face presentation
• Brow presentation: forehead Forehead The part of the face above the eyes. Melasma is the presenting part

Vertex presentation

Face presentation (mentum anterior position)

Brow presentation (mentum posterior position)

Breech presentations

Breech presentations can be categorized as:

• Frank breech: bottom down, legs extended (50%–70%) 
• Complete breech: bottom down, hips and knees both flexed
• Incomplete breech: 1 or both hips not completely flexed
• Footling breech: feet down

Breech presentations: Frank (bottom down, legs extended), complete (bottom down, hips and knees both flexed), and footling (feet down) breech presentations

Transverse and compound presentations

• Uncommon, but when they occur, the presenting fetal part is the shoulder.
• If the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy begins dilating, the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy may prolapse through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy .
• In compound presentations, the most common situation is a hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy or arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy presenting with the head.

Shoulder presentation (transverse lie)

Neglected shoulder presentation resulting in arm prolapse during labor

Vertex presentation with a compound hand

Fetal malpresentation

• Any presentation other than vertex
• Clinically, this means breech, face, brow, and shoulder presentations.

Position describes the relation of the fetal presenting part to the maternal bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .

Vertex positions

Positions for vertex presentations describe the position of the fetal occiput .

• Identified on cervical exam as the area in the midline between the anterior and posterior fontanelles Fontanelles Physical Examination of the Newborn
• Anterior, posterior, or transverse in relation to the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
• Being on the maternal right or left
• Right or left occiput anterior
• Right or left occiput posterior
• Right or left occiput transverse
• Direct occiput anterior or posterior
• The most common positions (and easiest for vaginal delivery) are occiput anterior.

Overview of different vertex positions LOA: left occiput anterior LOP: left occiput posterior LOT: left occiput transverse OA occiput anterior OP: occiput posterior ROA: right occiput anterior ROP: right occiput posterior ROT: right occiput transverse

Face and brow positions

Positions for face and brow presentations describe the position of the chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma .

• The chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma is referred to as the mentum.
• Right or left mentum anterior
• Right or left mentum posterior
• Right or left mentum transverse
• Direct mentum anterior or posterior

Face presentation (mentum posterior position)

Breech and shoulder positions

• Positions for breech presentations describe the position of the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy . Similar to other presentations, they include anterior, posterior, and transverse and right, left, and direct.
• Dorso-superior (back up)
• Dorso-inferior (back down)

Dorso-inferior shoulder presentation

Dorso-superior shoulder presentation

Attitude and asynclitism

• Attitude: amount of flexion Flexion Examination of the Upper Limbs or extension Extension Examination of the Upper Limbs of the fetal head
• Lateral deflection of the sagittal Sagittal Computed Tomography (CT) suture to 1 side or the other
• Mild degrees of asynclitism are normal.
• More severe asynclitism increases the presenting fetal diameter and makes it more difficult for the fetal head to pass through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .

Fetal malposition

• Commonly refers to any position other than right occiput anterior, left occiput anterior, or direct occiput anterior
• All nonvertex presentations are also malpositioned.
• The terms fetal malpresentation and fetal malposition are often used interchangeably.
• The presenting diameter refers to the width of the presenting part.
• The maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy is about 10 cm at its narrowest point; the infant must orient itself so that it can fit through.
• Most commonly, the infant will move into a cephalic, vertex presentation, in 1 of the occiput anterior positions → presents the narrowest diameter
• Vertex presentation: suboccipitobregmatic diameter, approximately 9.5 cm
• Vertex presentation with deflexed head: occipitofrontal diameter, approximately 11.5 cm
• Brow presentation: occipitomental diameter, approximately 13 cm
• Face presentation: submentobregmatic diameter, approximately 9.5 cm

Diameters of the fetal head

Comparison of presentation, attitude, and presenting diameter

How to establish lie, presentation, and position

Delivery is managed differently depending on the presentation and position of the infant. This information can be established in several different ways:

Leopold’s maneuvers

Ultrasonography.

• Cervical examination
• Techniques using abdominal palpation Abdominal Palpation Abdominal Examination to determine the presentation of the fetus
• The fetal head will be hard and round.
• The lower body will be bulkier, nodular, and mobile.
• The back will be hard and smooth.
• The other side (anterior surface of the fetus) will be filled with irregular, mobile fetal parts.
• Experienced providers can also estimate the fetal weight using these maneuvers.
• Bedside abdominal ultrasonography can easily identify the fetal head and its orientation Orientation Awareness of oneself in relation to time, place and person. Psychiatric Assessment .
• Quick bedside ultrasonography Bedside Ultrasonography ACES and RUSH: Resuscitation Ultrasound Protocols on admission to labor and delivery to assess fetal presentation is considered standard of care Standard of care The minimum acceptable patient care, based on statutes, court decisions, policies, or professional guidelines. Malpractice .
• The fetal head will typically encompass the entire window and appear like a large white circle (the fetal skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy ).
• Identification Identification Defense Mechanisms of the eyes can help determine position.
• It is quick and easy to perform and presents minimal risk to mother and infant.
• Allowing mothers to labor with infants in a noncephalic presentation significantly increases the risks to both of them.

Suprapubic bedside ultrasound showing the large white circle of the fetal skull, confirming a cephalic presentation F: fetal falx

Vaginal and cervical examination

• As the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy dilates, the fetal fontanelles Fontanelles Physical Examination of the Newborn can be directly palpated.
• Identifying the location of the fetal fontanelles Fontanelles Physical Examination of the Newborn allows the practitioner to establish the position.
• Insert 1–2 fingers through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy posteriorly.
• Sweep fingers along the fetal head moving anteriorly.
• This maneuver allows for identification Identification Defense Mechanisms of the sagittal Sagittal Computed Tomography (CT) suture.
• The fontanelles Fontanelles Physical Examination of the Newborn are then identified by moving along the sagittal Sagittal Computed Tomography (CT) suture.

Vertex presentations

• Expectant management
• All have high chances of successful vaginal delivery.

Compound presentations

• Observation when labor is progressing normally (many compound presentations will resolve spontaneously intrapartum).
• Can attempt to gently pinch the compound extremity trying to provoke the fetus into withdrawing the part (no good quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement evidence, but unlikely to be harmful)
• Can attempt to manually replace the compound extremity
• If labor is prolonged and the compound part remains, cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery (CD) should be performed.
• Prolonged labor
• Umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity prolapse
• Increased maternal morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status from lacerations
• Ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage of the compound part

Brow presentations

• The majority spontaneously convert to a vertex presentation.
• Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery may be required if labor is prolonged.

Face presentations

• Management depends on the position.
• Can be delivered vaginally by an experienced provider
• Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery may be required.
• Head is fully extended and unable to pass through the birth canal Birth canal Pelvis: Anatomy .
• Normally, the fetal head flexes as it passes under the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types ; however, this is impossible in an MP position.
• Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery is always required (unless the infant spontaneously rotates to a mentum anterior (MA) position).

There are 3 primary options for managing breech presentations: performing CD, attempting an external cephalic version to manually rotate the baby into a vertex presentation for attempted vaginal delivery, or a planned vaginal breech delivery (which is generally not done in the United States).

Natural history of breech presentations

Most infants will spontaneously rotate to a vertex presentation as the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care progresses. At different gestational ages, the prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of breech presentations is:

• < 28 weeks: 20%–25%
• 32 weeks: 10%–15%
• Term (> 37 weeks): 3% 
• Spontaneous version is possible even at > 40 weeks.
• Flexed fetal legs
• Polyhydramnios Polyhydramnios Polyhydramnios is a pathological excess of amniotic fluid. Common causes of polyhydramnios include fetal anomalies, gestational diabetes, multiple gestations, and congenital infections. Patients are often asymptomatic but may present with dyspnea, extremity swelling, or abdominal distention. Polyhydramnios
• Longer umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity
• Lack of fetal/uterine anomalies
• Multiparity

Fetal risks associated with breech presentations

The following risks are associated with breech presentations in utero, regardless of mode of delivery:

• ↑ Association with congenital Congenital Chorioretinitis malformations
• Torticollis Torticollis A symptom, not a disease, of a twisted neck. In most instances, the head is tipped toward one side and the chin rotated toward the other. The involuntary muscle contractions in the neck region of patients with torticollis can be due to congenital defects, trauma, inflammation, tumors, and neurological or other factors. Cranial Nerve Palsies
• Developmental hip dysplasia 

Fetal risks associated with vaginal breech delivery

The primary risk of a vaginal breech delivery is fetal head entrapment:

• The fetal body delivers, but the head remains trapped in the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy .
• Causes compression Compression Blunt Chest Trauma of the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity running past the head (between the delivered umbilicus and the undelivered placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity ) 
• Leads to hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage until head is delivered → ↑ risk of fetal death
• The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy may not be fully dilated enough to accommodate the head.
• The fetal head may not fit through the bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .
• The mother’s expulsive efforts are unable to quickly deliver the head.
• Umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity prolapse during labor → requires emergent CD
• Birth injuries to the fetus (e.g., brachial plexus Brachial Plexus The large network of nerve fibers which distributes the innervation of the upper extremity. The brachial plexus extends from the neck into the axilla. In humans, the nerves of the plexus usually originate from the lower cervical and the first thoracic spinal cord segments (c5-c8 and T1), but variations are not uncommon. Peripheral Nerve Injuries in the Cervicothoracic Region injury)

Vaginal breech delivery

Vaginal breech deliveries for singleton gestations may be considered for certain low-risk women if vaginal delivery is strongly desired by the mother. In contrast, vaginal breech deliveries are done frequently for breech 2nd twins; the procedure is known as a breech extraction.

• Mothers must be fully counseled on risks.
• Mothers and infants should be monitored throughout labor with continuous electronic fetal heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology (FHR) and tocometry monitors.
• Mothers should understand that a CD will be recommended if there are signs of fetal distress or prolonged labor.
• Avoid artificial rupture of membranes to ↓ risk of cord prolapse.
• Frank or complete breech presentation with no hyperextension of the fetal head on ultrasonography
• No contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to a vaginal birth
• No prior CDs
• Prior successful vaginal deliveries (i.e., multiparity)
• Gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care ≥ 36 weeks
• Spontaneous labor
• Normal bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy shown on X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests
• Estimated fetal weight Estimated Fetal Weight Obstetric Imaging between approximately 2500 and 3500 grams (exact range varies based on clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship )
• Immediately after delivery of the 1st twin in the cephalic presentation, the physician reaches up into the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy , manually grabs the infant’s legs, and gently guides them down through the birth canal Birth canal Pelvis: Anatomy while the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is still fully dilated.
• ↓ Risk of head entrapment compared to singleton vaginal breech deliveries

External cephalic version

An external cephalic version (ECV) is a procedure in which the physician attempts to manually rotate the fetus from a breech to a cephalic presentation by pushing on the maternal abdomen.

• Approximately 50%–60% (higher in multiparous Multiparous A woman with prior deliveries Normal and Abnormal Labor than in nulliparous women) 
• 97% of infants remained cephalic at birth.
• 86% delivered vaginally.
• Women who are candidates for ECV should be counseled on their options to attempt an ECV, or they may simply elect to schedule a CD.
• Infant is full term in case emergent CD is required because of complications from the procedure (e.g., placental abruption Placental Abruption Premature separation of the normally implanted placenta from the uterus. Signs of varying degree of severity include uterine bleeding, uterine muscle hypertonia, and fetal distress or fetal death. Antepartum Hemorrhage ).
• Better ratio of infant size to fluid level than later in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
• Allows infant more time for spontaneous version than if the procedure was done earlier
• After a successful version, the mother can await spontaneous labor or be induced immediately, depending on the situation.
• There is still a chance that the infant may spontaneously rotate between the failed ECV and the planned CD date; therefore, presentation should always be checked immediately prior to CD.
• Another contraindication for a vaginal delivery (e.g., placenta previa Placenta Previa Abnormal placentation in which the placenta implants in the lower segment of the uterus (the zone of dilation) and may cover part or all of the opening of the cervix. It is often associated with serious antepartum bleeding and premature labor. Placental Abnormalities )
• Severe oligohydramnios Oligohydramnios Oligohydramnios refers to amniotic fluid volume less than expected for the current gestational age. Oligohydramnios is diagnosed by ultrasound and defined as an amniotic fluid index (AFI) of ‰¤ 5 cm or a single deep pocket (SDP) of Oligohydramnios
• Nonreassuring fetal monitoring Fetal monitoring The primary goals of antepartum testing and monitoring are to assess fetal well-being, identify treatable situations that may cause complications, and evaluate for chromosomal abnormalities. These tests are divided into screening tests (which include cell-free DNA testing, serum analyte testing, and nuchal translucency measurements), and diagnostic tests, which provide a definitive diagnosis of aneuploidy and include chorionic villus sampling (CVS) and amniocentesis. Antepartum Testing and Monitoring prior to the procedure
• A hyperextended fetal head
• Significant fetal or uterine anomalies
• Leads to fetal and maternal hemorrhage
• An immediate CD is required.
• If the version was successful, labor should be induced immediately.
• If the version was unsuccessful, the mother should undergo immediate CD.
• Cord prolapse: can occur with PROM PROM Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, refers to the rupture of the amniotic sac before the onset of labor. Prelabor rupture of membranes may occur in term or preterm pregnancies. Prelabor Rupture of Membranes and requires immediate/emergent CD.
• Common during the procedure, but typically resolves shortly after pressure on the abdomen is released.
• If distress persists, the mother should undergo an immediate CD.

Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery

• Scheduled at 39 weeks’ gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care (WGA) if the infant is known to be in the breech presentation.
• Alternative option to attempting ECV
• Postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage
• Postpartum endomyometritis
• Maternal injury
• Longer recovery time postpartum
• Complications in future pregnancies (e.g., placenta previa Placenta Previa Abnormal placentation in which the placenta implants in the lower segment of the uterus (the zone of dilation) and may cover part or all of the opening of the cervix. It is often associated with serious antepartum bleeding and premature labor. Placental Abnormalities , placenta accreta Placenta Accreta Abnormal placentation in which all or parts of the placenta are attached directly to the myometrium due to a complete or partial absence of decidua. It is associated with postpartum hemorrhage because of the failure of placental separation. Placental Abnormalities , uterine rupture Uterine Rupture A complete separation or tear in the wall of the uterus with or without expulsion of the fetus. It may be due to injuries, multiple pregnancies, large fetus, previous scarring, or obstruction. Antepartum Hemorrhage )
• Maternal request (mother declines ECV attempt)
• ECV contraindicated
• ECV unsuccessful
• Fetal distress during labor

Management of transverse presentations

• As with breech presentations, mothers may be offered an attempt at ECV or a CD.
• Unlike breech presentations, vaginal transverse delivery is always contraindicated.
• Hofmeyr, G.J. (2021). Overview of breech presentation. In Barss, V.A. (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/overview-of-breech-presentation  
• Hofmeyr, G.J. (2021). Delivery of the singleton fetus in breech presentation. In Barss, V.A. (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/delivery-of-the-singleton-fetus-in-breech-presentation  
• Hofmeyr, G.J. (2021). External cephalic version. In Barss, V.A. (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/external-cephalic-version  
• Julien, S., and Galerneau, F. (2021). Face and brow presentations in labor. In Barss, V.A., (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor  
• Strauss, R.A., Herrera, C.A. (2021). Transverse fetal lie. In Barss, V.A., (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/transverse-fetal-lie  
• Barth, W.H. (2021). Compound fetal presentation. In Barss, V.A., (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/compound-fetal-presentation  
• Cunningham, F. G., Leveno, K. J., et al. (2010). Williams Obstetrics, 23rd ed., pp. 374‒382. 

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• Introduction
• Definitions
• Complications
• External Cephalic Version
• Management of Labor And Delivery
• Cesarean Delivery
• Perinatal Outcome
• Practice Recommendations
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This chapter should be cited as follows: Okemo J, Gulavi E, et al , Glob. libr. women's med ., ISSN: 1756-2228; DOI 10.3843/GLOWM.414593

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Common obstetric conditions

Volume Editor: Professor Sikolia Wanyonyi , Aga Khan University Hospital, Nairobi, Kenya

Abnormal Lie/Presentation

First published: February 2021

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INTRODUCTION

The mechanism of labor and delivery, as well as the safety and efficacy, is determined by the specifics of the fetal and maternal pelvic relationship at the onset of labor. Normal labor occurs when regular and painful contractions cause progressive cervical dilatation and effacement, accompanied by descent and expulsion of the fetus. Abnormal labor involves any pattern deviating from that observed in the majority of women who have a spontaneous vaginal delivery and includes:

• Protraction disorders (slower than normal progress);
• Arrest disorders (complete cessation of progress).

Among the causes of abnormal labor is the disproportion between the presenting part of the fetus and the maternal pelvis, which rather than being a true disparity between fetal size and maternal pelvic dimensions, is usually due to a malposition or malpresentation of the fetus.

This chapter reviews how to define, diagnose, and manage the clinical impact of abnormalities of fetal lie and malpresentation with the most commonly occurring being the breech-presenting fetus.

DEFINITIONS

At the onset of labor, the position of the fetus in relation to the birth canal is critical to the route of delivery and, thus, should be determined early. Important relationships include fetal lie, presentation, attitude, and position .

Fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99% of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent when the fetal and maternal axes may cross at a 90 ° angle, and predisposing factors include multiparity, placenta previa, hydramnios, and uterine anomalies. Occasionally, the fetal and maternal axes may cross at a 45 ° angle, forming an oblique lie . 

Fetal presentation

The presenting part is the portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. Thus, in longitudinal lie, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations , respectively. The shoulder is the presenting part when the fetus lies with the long axis transversely.

Commonly the baby lies longitudinally with cephalic presentation. However, in some instances, a fetus may be in breech where the fetal buttocks are the presenting part. Breech fetuses are also referred to as malpresentations. Fetuses that are in a transverse lie may present the fetal back (or shoulders, as in the acromial presentation), small parts (arms and legs), or the umbilical cord (as in a funic presentation) to the pelvic inlet. When the fetal long axis is at an angle to the bony inlet, and no palpable fetal part generally is presenting, the fetus is likely in oblique lie. This lie usually is transitory and occurs during fetal conversion between other lies during labor.

The point of direction is the most dependent portion of the presenting part. In cephalic presentation in a well-flexed fetus, the occiput is the point of direction.

The fetal position refers to the location of the point of direction with reference to the four quadrants of the maternal outlet as viewed by the examiner. Thus, position may be right or left as well as anterior or posterior.

Unstable lie

Refers to the frequent changing of fetal lie and presentation in late pregnancy (usually refers to pregnancies >37 weeks).

Fetal position

Fetal position refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal. With each presentation there may be two positions – right or left. The fetal occiput, chin (mentum) and sacrum are the determining points in vertex, face, and breech presentations. Thus:

• left and right occipital presentations
• left and right mental presentations
• left and right sacral presentations.

Fetal attitude

The fetus instinctively forms an ovoid mass that corresponds to the shape of the uterine cavity towards the third trimester, a characteristic posture described as attitude or habitus. The fetus becomes folded upon itself to create a convex back, the head is flexed, and the chin is almost in contact with the chest. The thighs are flexed over the abdomen and the legs are bent at the knees. The arms are usually parallel to the sides or lie across the chest while the umbilical cord fills the space between the extremities. This posture is as a result of fetal growth and accommodation to the uterine cavity. It is possible that the fetal head can become progressively extended from the vertex to face presentation resulting in a change of fetal attitude from convex (flexed) to concave (extended) contour of the vertebral column.

The categories of frank, complete, and incomplete breech presentations differ in their varying relations between the lower extremities and buttocks (Figure 1). With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. With a complete breech, both hips are flexed, and one or both knees are also flexed. With an incomplete breech, one or both hips are extended. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. A footling breech is an incomplete breech with one or both feet below the breech.

Types of breech presentation. Reproduced from WHO 2006, 1 with permission.

The relative incidence of differing fetal and pelvic relations varies with diagnostic and clinical approaches to care.

About 1 in 25 fetuses are breech at the onset of labor and about 1 in 100 are transverse or oblique, also referred to as non-axial. 2

With increasing gestational age, the prevalence of breech presentation decreases. In early pregnancy the fetus is highly mobile within a relatively large volume of amniotic fluid, therefore it is a common finding. The incidence of breech presentation is 20–25% of fetuses at <28 weeks, but only 7–16% at 32 weeks, and only 3–4% at term. 2 , 3

Face and brow presentation are uncommon. Their prevalence compared with other types of malpresentations are shown below. 4

• Occiput posterior – 1/19 deliveries;
• Breech – 1/33 deliveries;
• Face – 1/600–1/800 deliveries;
• Brow – 1/500–1/4000 deliveries;
• Transverse lie – 1/833 deliveries;
• Compound – 1/1500 deliveries.

Transverse lie is often unstable and fetuses in this lie early in pregnancy later convert to a cephalic or breech presentation.

The fetus has a relatively larger head than body during most of the late second and early third trimester, it therefore tends to spend much of its time in breech presentation or in a non-axial lie as it rotates back and forth between cephalic and breech presentations. The relatively large volume of amniotic fluid present facilitates this dynamic presentation.

Abnormal fetal lie is frequently seen in multifetal gestation, especially with the second twin. In women of grand parity, in whom relaxation of the abdominal and uterine musculature tends to occur, a transverse lie may be encountered. Prematurity and macrosomia are also predisposing factors. Distortion of the uterine cavity shape, such as that seen with leiomyomas, prior uterine surgery, or developmental anomalies (Mullerian fusion defects), predisposes to both abnormalities in fetal lie and malpresentations. The location of the placenta also plays a contributing role with fundal and cornual implantation being seen more frequently in breech presentation. Placenta previa is a well-described affiliate for both transverse lie and breech presentation.

Fetuses with congenital anomalies also present with abnormalities in either presentation or lie. It is possibly as a cause (i.e. fitting the uterine cavity optimally) or effect (the fetus with a neuromuscular condition that prevents the normal turning mechanism). The finding of an abnormal lie or malpresentation requires a thorough search for fetal abnormalities. Such abnormalities could include chromosomal (autosomal trisomy) and structural abnormalities (hydrocephalus), as well as syndromes of multiple effects (fetal alcohol syndrome).

In most cases, breech presentation appears to be as a chance occurrence; however, up to 15% may be owing to fetal, maternal, or placental abnormalities. It is commonly thought that a fetus with normal anatomy, activity, amniotic fluid volume, and placental location adopts the cephalic presentation near term because this position is the best fit for the intrauterine space, but if any of these variables is abnormal, then breech presentation is more likely.

Factors associated with breech presentation are shown in Table 1.

Risk factors for breech presentation.

Spontaneous version may occur at any time before delivery, even after 40 weeks of gestation. A prospective longitudinal study using serial ultrasound examinations reported the likelihood of spontaneous version to cephalic presentation after 36 weeks was 25%. 5

In population-based registries, the frequency of breech presentation in a second pregnancy was approximately 2% if the first pregnancy was not a breech presentation and approximately 9% if the first pregnancy was a breech presentation. After two consecutive pregnancies with breech presentation at delivery, the risk of another breech presentation was approximately 25% and this rose to 40% after three consecutive breech deliveries. 6 , 7

In addition, parents who themselves were delivered at term from breech presentation were twice as likely to have their offspring in breech presentation as parents who were delivered in cephalic presentation. This suggests a possible heritable component to fetal presentation. 8

Leopold’s maneuvers

The Leopold’s maneuvers: palpation of fetus in left occiput anterior position. Reproduced from World Health Organization, 2006, 1   with permission.

Abdominal examination can be conducted systematically employing the four maneuvers described by Leopold in 1894. 9 , 10 In obese patients, in polyhydramnios patients or those with anterior placenta, these maneuvers are difficult to perform and interpret.

The first maneuver is to assess the uterine fundus. This allows the identification of fetal lie and determination of which fetal pole, cephalic or podalic – occupies the fundus. In breech presentation, there is a sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile.

The second maneuver is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is felt – the back. On the other, numerous small, irregular, mobile parts are felt – the fetal extremities. By noting whether the back is directed anteriorly, transversely, or posteriorly, fetal orientation can be determined.

The third maneuver aids confirmation of fetal presentation. The thumb and fingers of one hand grasp the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The differentiation between head and breech is made as in the first maneuver.

The fourth maneuver helps determine the degree of descent. The examiner faces the mother’s feet, and the fingertips of both hands are positioned on either side of the presenting part. They exert inward pressure and then slide caudad along the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder or the space created by the neck may be differentiated readily from the hard head.

According to Lyndon-Rochelle et al ., 11 experienced clinicians have accurately identified fetal malpresentation using Leopold maneuvers with a high sensitivity 88%, specificity 94%, positive-predictive value 74%, and negative-predictive value 97%.

Vaginal examination

Prelabor diagnosis of fetal presentation is difficult as the presenting part cannot be palpated through a closed cervix. Once labor begins and the cervix dilates, and palpation through vaginal examination is possible. Vertex presentations and their positions are recognized by palpation of the various fetal sutures and fontanels, while face and breech presentations are identified by palpation of facial features or the fetal sacrum and perineum, respectively.

Sonography and radiology

Sonography is the gold standard for identifying fetal presentation. This can be done during antenatal period or intrapartum. In obese women or in women with muscular abdominal walls this is especially important. Compared with digital examinations, sonography for fetal head position determination during second stage labor is more accurate. 12 , 13

COMPLICATIONS

Adverse outcomes in malpresented fetuses are multifactorial. They could be due to either underlying conditions associated with breech presentation (e.g., congenital anomalies, intrauterine growth restriction, preterm birth) or trauma during delivery.

Neonates who were breech in utero are more at risk for mild deformations (e.g., frontal bossing, prominent occiput, upward slant and low-set ears), torticollis, and developmental dysplasia of the hip.

Other obstetric complications include prolapse of the umbilical cord, intrauterine infection, maldevelopment as a result of oligohydramnios, asphyxia, and birth trauma and all are concerns.

Birth trauma especially to the head and cervical spine, is a significant risk to both term and preterm infants who present breech. In cephalic presenting fetuses, the labor process prepares the head for delivery by causing molding which helps the fetus to adapt to the birth canal. Conversely, the after-coming head of the breech fetus must descend and deliver rapidly and without significant change in shape. Therefore, small alterations in the dimensions or shape of the maternal bony pelvis or the attitude of the fetal head may have grave consequences. This process poses greater risk to the preterm infant because of the relative size of the fetal head and body. Trauma to the head is not eliminated by cesarean section; both intracranial and cervical spine trauma may result from entrapment in either the uterine or abdominal incisions.

In resource-limited countries where ultrasound imaging, urgent cesarean delivery, and neonatal intensive care are not readily available, the maternal and perinatal mortality/morbidity associated with transverse lie in labor can be high. Uterine rupture from prolonged labor in a transverse lie is a major reason for maternal/perinatal mortality and morbidity.

EXTERNAL CEPHALIC VERSION

External cephalic version (ECV) is the manual rotation of the fetus from a non-cephalic to a cephalic presentation by manipulation through the maternal abdomen (Figure 3).

External version of breech presentation . Reproduced from WHO 2003 , 14  with  permission .

This procedure is usually performed as an elective procedure in women who are not in labor at or near term to improve their chances of having a vaginal cephalic birth. ECV reduces the risk of non-cephalic presentation at birth by approximately 60% (relative risk [RR] 0.42, 95% CI 0.29–0.61) and reduces the risk of cesarean delivery by approximately 40% (RR 0.57, 95% CI 0.40–0.82). 7

In a 2008 systematic review of 84 studies including almost 13,000 version attempts at term, the pooled success rate was 58%. 15  

A subsequent large series of 2614 ECV attempts over 18 years reported a success rate of 49% and provided more details): 16

• The success rate was 40% in nulliparous women and 64% in parous women.
• After successful ECV, 97% of fetuses remained cephalic at birth, 86% of which were delivered vaginally.
• Spontaneous version to a cephalic presentation occurred after 4.3% of failed attempts, and 2.2% of successfully vertexed cases reverted to breech.

Factors associated with lower ECV success rates include nulliparity, anterior placenta, lateral or cornual placenta, decreased amniotic fluid volume, low birth weight, obesity, posteriorly located fetal spine, frank breech presentation, ruptured membranes.

The following factors should be considered while managing malpresentations: type of malpresentation, gestational age at diagnosis, availability of skilled personnel, institutional resources and protocols and patient factors and preferences.

Breech presentation

According to a term breech trial, 17 planned cesarean delivery carries a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to vaginal breech delivery. When planning a breech vaginal birth, appropriate patient selection and skilled personnel in breech delivery are key in achieving good neonatal outcomes. In appropriately selected patients and skilled personnel in vaginal breech deliveries, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned cesarean section. 18 , 19 The choice of the route of delivery should therefore be made considering the availability of skilled personnel in conducting breech vaginal delivery; providing competent newborn care; conducting rapid cesarean delivery should need arise and performing ECV if desired; availability of resources for continuous intrapartum fetal heart rate and labor monitoring; patient clinical features, preferences and values; and institutional policies, protocols and resources.

Four approaches to the management of breech presentation are shown in Figure 4: 8

Management of breech presentation. ECV, external cephalic version.

The options available are:

• Attempting external cephalic version (ECV) before labor with a trial of labor if successful and conducting cesarean delivery if unsuccessful.
• Footling or kneeling breech presentation;
• Fetal macrosomia;
• Fetal growth restriction;
• Hyperextended fetal neck in labor;
• Previous cesarean delivery;
• Unavailability of skilled personnel in breech delivery;
• Other contraindications to vaginal delivery like placenta previa, cord prolapse;
• Fetal anomaly that may interfere with vaginal delivery like hydrocephalus.
• Planned cesarean delivery without an attempt at ECV.
• Planned trial of vaginal breech delivery in patients with favorable clinical characteristics for vaginal delivery without an attempt at ECV.

All the four approaches should be discussed in detail with the patient, and in light of all the considerations highlighted above, a safe plan of care agreed upon by both the patient and the clinician in good time.

Transverse and oblique lie

If a diagnosis of transverse/oblique fetal lie is made before onset of labor and there are no contraindications to vaginal birth or ECV, ECV can be attempted at 37 weeks' gestation. If the malpresentation recurs, further attempts at ECV can be made at 38–39 weeks with induction of labor if successful.

ECV can also be attempted in early labor with intact fetal membranes and no contraindications to vaginal birth.

If ECV is declined or is unsuccessful, then planned cesarean section should be arranged after 39 weeks' gestation.

MANAGEMENT OF LABOR AND DELIVERY

Skills to conduct vaginal breech delivery are very important as there are women who may opt for planned vaginal breech birth and even among those who choose planned cesarean delivery, about 10% may go into labor and end up with a vaginal breech delivery. 17 Some implications of cesarean delivery such as need for repeat cesarean deliveries, placental attachment disorders and uterine rupture make vaginal birth more desirable to some individuals. In addition, vaginal birth has advantages such as affordability, quicker recovery, shorter hospital stay, less complications and is more favorable for resource poor settings.

In appropriately selected women, planned vaginal breech birth is not associated with any significant long-term neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1,000 breech births, and abnormal neurological development occurs in approximately 3/100. 18 Careful patient selection is very important for good outcomes and it is generally agreed that women who choose to undergo a trial of labor and vaginal breech delivery should be at low risk of complications from vaginal breech delivery. Some contraindications to vaginal breech delivery have been highlighted above.

Women with breech presentation near term, pre- or early-labor ultrasound should be performed to assess type of breech presentation, flexion of the fetal head and fetal growth. If a woman presents in labor and ultrasound is unavailable and has not recently been performed, cesarean section is recommended. Vaginal breech deliveries should only take place in a facility with ability and resources readily available for emergency cesarean delivery should the need arise.

Induction of labor may be considered in carefully selected low-risk women. Augmentation of labor is controversial as poor progress of labor may be a sign of cephalo-pelvic disproportion, however, it may be considered in the event of weak contractions. A cesarean delivery should be performed if there is poor progress of labor despite adequate contractions. Labor analgesia including epidural can be used as needed.

Vaginal breech delivery should be conducted in a facility that is able to carry out continuous electronic fetal heart rate monitoring sufficient personnel to monitor the progress of labor. From the term breech trial, 17 the commonest indications for cesarean section are poor progress of labor (50%) and fetal distress (29%). There is an increased risk of cord compression which causes variable decelerations. Since the fetal head is at the fundus where contractions begin, the incidence of early decelerations arising from head compression is also higher. Due to the irregular contour of the presenting part which presents a high risk of cord prolapse, immediate vaginal examination should be undertaken if membranes rupture to rule out cord prolapse. The frequency of cord prolapse is 1% with frank breech and more than 10% in footling breech. 8

Fetal blood sampling from the buttocks is not recommended. A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes. 18

During planned vaginal breech birth, a skilled clinician experienced in vaginal breech birth should supervise the first stage of labor and be present for the active second stage of labor and delivery. Staff required for rapid cesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labor.

The optimum maternal position in second stage has not been extensively studied. Episiotomy should be undertaken as needed and only after the fetal anus is visible at the vulva. Breech extraction of the fetus should be avoided. The baby should be allowed to deliver spontaneously with maternal effort only and without any manipulations at least until the level of the umbilicus. A loop of the cord is then pulled to avoid cord compression. After this point, suprapubic pressure can be applied to facilitate flexion of the fetal head and descent.

Delay of arm delivery can be managed by sweeping them across the face and downwards towards in front of the chest or by holding the fetus at the hips or bony pelvis and performing a 180° rotation to deliver the first arm and shoulder and then in the opposite direction so that the other arm and shoulder can be delivered i.e.,  Lovset’s maneuver (Figure 5).

Lovset’s maneuver. Reproduced from WHO 2006 , 1  with  permission . 

The fetal head can deliver spontaneously or by the following maneuvers:

• Turning the body to the floor with application of suprapubic pressure to flex the head and neck.

Mauriceau-smellie-veit maneuver . Reproduced from WHO 2003, 14 with permission.

• By use of Piper’s forceps.
• Burns-Marshall maneuver  where the baby’s legs and trunk are allowed to hang until the nape of the neck is visible at the mother’s perineum so that its weight exerts gentle downwards and backwards traction to promote flexion of the head. The fetal trunk is then swept in a wide arc over the maternal abdomen by grasping both the feet and maintaining gentle traction; the aftercoming head is slowly born in this process.

If the above methods fail to deliver the fetal head, symphysiotomy and zavanelli maneuver with cesarean section can be attempted. Duhrssen incisions where 1–3 full length incisions are made on an incompletely dilated cervix at the 6, 2 and 10 o’clock positions can be done especially in preterm.

Face presentation

The diagnosis of face presentation is made during vaginal examination where the presenting portion of the fetus is the fetal face between the orbital ridges and the chin. At diagnosis, 60% of all face presentations are mentum anterior, 26% are mentum posterior and 15% are mentum transverse. Since the submentobregmatic (face presentation) and suboccipitobregmatic (vertex presentation) have the same diameter of 9.5 cm, most face presentations can have a successful vaginal birth and not necessarily require cesarean section delivery. 6 The position of a fetus in face presentation helps in guiding the management plan. Over 75% of mentum anterior presentations will have a successful vaginal delivery, whereas it is impossible to have a vaginal birth in mentum posterior position unless it converts spontaneously to mentum anterior position. In mentum posterior position the neck is maximally extended and cannot extend further to deliver beneath the symphysis pubis (Figure 7).

Face presentation. Reproduced from WHO 2003, 14 with permission.

As in breech management, face presentation also requires continuous fetal heart rate monitoring, since abnormalities of fetal heart rate are more common. 5 , 6 In one study , 20 only 14% of pregnancies had normal tracings, 29% developed variable decelerations and 24% had late decelerations. Internal fetal heart rate monitoring with an electrode is not recommended, as it may cause facial and ophthalmic injuries if incorrectly placed. Labor augmentation and cesarean sections are performed as per standard obstetric indications. Vacuum and midforceps delivery should be avoided, but an outlet forceps delivery can be attempted. Attempts to manually convert the face to vertex or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality, and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment.

Brow presentation

The diagnosis of brow presentation is made during vaginal examination in second stage of labor where the presenting portion of the fetal head is between the orbital ridge and the anterior fontanel.

Brow presentation may be encountered early in labor, but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation. The majority of brow presentations diagnosed early in labor convert to a more favorable presentation and deliver vaginally. Once brow presentation is confirmed, continuous fetal heart rate monitoring is necessary and labor progress should be monitored closely in order to pick any signs of abnormal labor. Since the brow diameter is large (13.5 cm), persistent brow presentation usually results in prolonged or arrested labor requiring a cesarean delivery. Labor augmentation and instrumental deliveries are therefore not recommended.

CESAREAN DELIVERY

This is an option for women with breech presentation at term to choose cesarean section as their preferred mode of delivery, for those with unsuccessful ECV who do not want to attempt vaginal breech delivery, have contraindications for vaginal breech delivery or in the event that there is no available skilled personnel to safely conduct a vaginal breech delivery. Women should be given enough and accurate information about pros and cons for both planned cesarean section and planned vaginal delivery to help them make an informed decision.

Since the publication of the term breech trial, 17 , 19 there has been a dramatic global shift from selective to planned cesarean delivery for women with breech presentation at term. This study revealed that planned cesarean section carried a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to planned vaginal birth (RR 0.33, 95% CI 0.19–0.56). The cesarean delivery rate for breech presentation is now about 70% in European countries, 95% in the United States and within 2 months of the study’s publication, there was a 50–80% increase in rates of cesarean section for breech presentation in The Netherlands.

A planned cesarean delivery should be scheduled at term between 39–41 weeks' gestation to allow maximum time for spontaneous cephalic version and minimize the risk of neonatal respiratory problems. 8 Physical exam and ultrasound should be performed immediately prior to the surgery to confirm the fetal presentation. A detailed consent should be obtained prior to surgery and should include both short- and long-term complications of cesarean section and the alternatives of care that are available. The abdominal and uterine incisions should be sufficiently large to facilitate easy delivery. Thereafter, extraction of the fetus is similar to what is detailed above for vaginal delivery.

Cesarean section for face presentation is indicated for persistent mentum posterior position, mentum transverse and some mentum anterior positions where there is standard indication for cesarean section.

Persistent brow presentation usually necessitates cesarean delivery due to the large presenting diameter that causes arrest or protracted labor.

Transverse/oblique lie

Cesarean section is indicated for patients who present in active labor, in those who decline ECV, following an unsuccessful ECV or in those with contraindications to vaginal birth.

For dorsosuperior (back up) transverse lie, a low transverse incision is made on the uterus and an attempt to grasp the fetal feet with footling breech extraction is made. If this does not succeed, a vertical incision is made to convert the hysterotomy into an inverted T incision.

Dorsoinferior (back down) transverse lie is more difficult to deliver since the fetal feet are hard to grasp. An attempt at intraabdominal version to cephalic or breech presentation can be done if membranes are intact before the uterine incision is made. Another option is to make a vertical uterine incision; however, the disadvantage of this is the risk of uterine rupture in subsequent pregnancies.

PERINATAL OUTCOME

Availability of skilled neonatal care at delivery is important for good perinatal outcomes to facilitate resuscitation if needed for all fetal malpresentations. 8 All newborns born from fetal malpresentations require a thorough examination to check for possible injuries resulting from birth or as the cause of the malpresentation.

Neonates who were in face presentation often have facial edema and bruising/ecchymosis from vaginal examinations that usually resolve within 24–48 hours of life and low Apgar scores. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress and difficulties in resuscitative efforts.

PRACTICE RECOMMENDATIONS

• Diagnosis of unstable lie is made when a varying fetal lie is found on repeated clinical examination in the last month of pregnancy.
• Consider external version to correct lie if not longitudinal.
• Consider ultrasound to exclude mechanical cause.
• Inform woman of need for prompt admission to hospital if membranes rupture or when labor starts.
• If spontaneous rupture of membranes occurs, perform vaginal examination to exclude the presence of a cord or malpresentation.
• If the lie is not longitudinal in labor and cannot be corrected perform cesarean section.

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• Mammary Glands
• Fallopian Tubes
• Supporting Ligaments
• Reproductive System
• Gametogenesis
• Placental Development
• Maternal Adaptations
• Menstrual Cycle
• Antenatal Care
• Small for Gestational Age
• Large for Gestational Age
• RBC Isoimmunisation
• Prematurity
• Prolonged Pregnancy
• Multiple Pregnancy
• Miscarriage
• Recurrent Miscarriage
• Ectopic Pregnancy
• Hyperemesis Gravidarum
• Gestational Trophoblastic Disease
• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
• Oligohydramnios
• Polyhydramnios
• Placenta Praevia
• Placental Abruption
• Pre-Eclampsia
• Gestational Diabetes
• Headaches in Pregnancy
• Haematological
• Obstetric Cholestasis
• Thyroid Disease in Pregnancy
• Epilepsy in Pregnancy
• Induction of Labour
• Operative Vaginal Delivery
• Prelabour Rupture of Membranes
• Caesarean Section
• Shoulder Dystocia
• Cord Prolapse
• Uterine Rupture
• Amniotic Fluid Embolism
• Primary PPH
• Secondary PPH
• Psychiatric Disease
• Postpartum Contraception
• Breastfeeding Problems
• Primary Dysmenorrhoea
• Amenorrhoea and Oligomenorrhoea
• Heavy Menstrual Bleeding
• Endometriosis
• Endometrial Cancer
• Adenomyosis
• Cervical Polyps
• Cervical Ectropion
• Cervical Intraepithelial Neoplasia + Cervical Screening
• Cervical Cancer
• Polycystic Ovary Syndrome (PCOS)
• Ovarian Cysts & Tumours
• Urinary Incontinence
• Genitourinary Prolapses
• Bartholin's Cyst
• Lichen Sclerosus
• Vulval Carcinoma
• Introduction to Infertility
• Female Factor Infertility
• Male Factor Infertility
• Female Genital Mutilation
• Barrier Contraception
• Combined Hormonal
• Progesterone Only Hormonal
• Intrauterine System & Device
• Emergency Contraception
• Pelvic Inflammatory Disease
• Genital Warts
• Genital Herpes
• Trichomonas Vaginalis
• Bacterial Vaginosis
• Vulvovaginal Candidiasis
• Obstetric History
• Gynaecological History
• Sexual History

Obstetric Examination

• Speculum Examination
• Bimanual Examination
• Amniocentesis
• Chorionic Villus Sampling
• Hysterectomy
• Endometrial Ablation
• Tension-Free Vaginal Tape
• Contraceptive Implant
• Fitting an IUS or IUD

Original Author(s): Minesh Mistry Last updated: 12th November 2018 Revisions: 7

• 1 Introduction
• 2 Preparation
• 3 General Inspection
• 4 Abdominal Inspection
• 5.1 Fundal Height
• 5.3 Presentation
• 5.4 Liquor Volume
• 5.5 Engagement
• 6 Fetal Auscultation
• 7 Completing the Examination

The obstetric examination is a type of abdominal examination performed in pregnancy.

It is unique in the fact that the clinician is simultaneously trying to assess the health of two individuals – the mother and the fetus.

In this article, we shall look at how to perform an obstetric examination in an OSCE-style setting.

Introduction

• Introduce yourself to the patient
• Wash your hands
• Explain to the patient what the examination involves and why it is necessary
• Obtain verbal consent

Preparation

• In the UK, this is performed at the booking appointment, and is not routinely recommended at subsequent visits
• Patient should have an empty bladder
• Cover above and below where appropriate
• Ask the patient to lie in the supine position with the head of the bed raised to 15 degrees
• Prepare your equipment: measuring tape, pinnard stethoscope or doppler transducer, ultrasound gel

General Inspection

• General wellbeing – at ease or distressed by physical pain.
• Hands – palpate the radial pulse.
• Head and neck – melasma, conjunctival pallor, jaundice, oedema.
• Legs and feet – calf swelling, oedema and varicose veins.

Abdominal Inspection

In the obstetric examination, inspect the abdomen for:

• Distension compatible with pregnancy
• Fetal movement (>24 weeks)
• Surgical scars – previous Caesarean section, laproscopic port scars
• Skin changes indicative of pregnancy – linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum (‘stretch marks’), striae albicans (old, silvery-white striae)

Fig 1 – Skin changes in pregnancy. A) Linea nigra. B) Striae gravidarum and albicans.

Ask the patient to comment on any tenderness and observe her facial and verbal responses throughout. Note any guarding.

Fundal Height

• Use the medial edge of the left hand to press down at the xiphisternum, working downwards to locate the fundus.
• Measure from here to the pubic symphysis in both cm and inches. Turn the measuring tape so that the numbers face the abdomen (to avoid bias in your measurements).
• Uterus should be palpable after 12 weeks, near the umbilicus at 20 weeks and near the xiphisternum at 36 weeks (these measurements are often slightly different if the woman is tall or short).
• The distance should be similar to gestational age in weeks (+/- 2 cm).
• Facing the patient’s head, place hands on either side of the top of the uterus and gently apply pressure
• Move the hands and palpate down the abdomen
• One side will feel fuller and firmer – this is the back. Fetal limbs may be palpable on the opposing side

Fig 2 – Assessing fetal lie and presentation.

Presentation

• Palpate the lower uterus (below the umbilicus) to find the presenting part.
• Firm and round signifies cephalic, soft and/or non-round suggests breech. If breech presentation is suspected, the fetal head can be often be palpated in the upper uterus.
• Ballot head by pushing it gently from one side to the other.

Liquor Volume

• Palpate and ballot fluid to approximate volume to determine if there is oligohydraminos/polyhydramnios
• When assessing the lie, only feeling fetal parts on deep palpation suggests large amounts of fluid
• Fetal engagement refers to whether the presenting part has entered the bony pelvis
• Note how much of the head is palpable – if the entire head is palpable, the fetus is unengaged.
• Engagement is measured in 1/5s

Fig 3 – Assessing fetal engagement.

Fetal Auscultation

• Hand-held Doppler machine >16 weeks (trying before this gestation often leads to anxiety if the heart cannot be auscultated).
• Pinard stethoscope over the anterior shoulder >28 weeks
• Feel the mother’s pulse at the same time
• Should be 110-160bpm (>24 weeks)

Completing the Examination

• Palpate the ankles for oedema and test for hyperreflexia (pre-eclampsia)
• Thank the patient and allow them to dress in private
• Summarise findings
• Blood pressure
• Urine dipstick
• Hands - palpate the radial pulse.
• Skin changes indicative of pregnancy - linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum ('stretch marks'), striae albicans (old, silvery-white striae)
• One side will feel fuller and firmer - this is the back. Fetal limbs may be palpable on the opposing side

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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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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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‘I’m living a lie’: On the streets of a Colorado city, pregnant migrants struggle to survive

Ivanni Herrera looks on during an interview in a park Friday, May 18, 2024, in Aurora, Colo. (AP Photo/Jack Dempsey)[ASSOCIATED PRESS/Jack Dempsey]

AURORA, Colo. (AP) — She was eight months pregnant when she was forced to leave her Denver homeless shelter. It was November.

Ivanni Herrera took her 4-year-old son Dylan by the hand and led him into the chilly night, dragging a suitcase containing donated clothes and blankets she’d taken from the Microtel Inn & Suites. It was one of 10 hotels where Denver has housed more than 30,000 migrants , many of them Venezuelan, over the last two years.

First they walked to Walmart. There, with money she and her husband had collected from begging on the street, they bought a tent.

They waited until dark to construct their new home. They chose a grassy median along a busy thoroughfare in Aurora, the next town over, a suburb known for its immigrant population.

“We wanted to go somewhere where there were people,” Herrera, 28, said in Spanish. “It feels safer.”

Ivanni Herrera holds her baby Milan Guzman during an interview in a park Friday, May 18, 2024, in Aurora, Colo. (AP Photo/Jack Dempsey)

Photo: ASSOCIATED PRESS/Jack Dempsey

That night, temperatures dipped to 32 degrees. And as she wrapped her body around her son’s to keep him warm enough that he could sleep, Ivanni Herrera cried.

Seeking better lives, finding something else

Over the past two years, a record number of families from Venezuela have come to the United States seeking a better life for themselves and their children. Instead, they’ve found themselves in communities roiling with conflict about how much to help the newcomers — or whether to help at all.

Unable to legally work without filing expensive and complicated paperwork, some are homeless and gambling on the kindness of strangers to survive. Some have found themselves sleeping on the streets — even those who are pregnant.

Like many in her generation, regardless of nationality, Herrera found inspiration for her life’s ambitions on social media. Back in Ecuador, where she had fled years earlier to escape the economic collapse in her native Venezuela , Herrera and her husband were emboldened by images of families like theirs hiking across the infamous Darién Gap from Colombia into Panama. If all those people could do it, they thought, so can we.

They didn’t know many people who had moved to the United States, but pictures and videos of Venezuelans on Facebook and TikTok showed young, smiling families in nice clothes standing in front of new cars boasting of beautiful new lives. U.S. Border Patrol reports show Herrera and the people who inspired her were part of an unprecedented mass migration of Venezuelans to America. Some 320,000 Venezuelans have tried to cross the southern border since October 2022 — more than in the previous nine years combined.

Just weeks after arriving in Denver, Herrera began to wonder if the success she had seen was real. She and her friends had developed another theory: The hype around the U.S. was part of some red de engaño, or network of deception.

After several days of camping on the street and relieving herself outside, Herrera began to itch uncontrollably with an infection. She worried: Would it imperil her baby?

She was seeing doctors and social workers at a Denver hospital where she planned to give birth because they served everyone, even those without insurance. They were alarmed their pregnant patient was now sleeping outside in the cold.

Days after she was forced to leave the Microtel, Denver paused its policy and allowed homeless immigrants to stay in its shelters through the winter. Denver officials say they visited encampments to urge homeless migrants to come back inside. But they didn’t venture outside the city limits to Aurora.

As Colorado’s third-largest city, Aurora, on Denver’s eastern edge, is a place where officials have turned down requests to help migrants. In February, the Aurora City Council passed a resolution telling other cities and nonprofits not to bring migrants into the community because it “does not currently have the financial capacity to fund new services related to this crisis.” Yet still they come, because of its lower cost of living and Spanish-speaking community.

In fact, former President Donald Trump last week called attention to the city, suggesting a Venezuelan gang had taken over an apartment complex. Authorities say that hasn’t happened .

The doctors treated Herrera’s yeast infection and urged her to sleep at the hospital. It wouldn’t cost anything , they assured her, just as her birth would be covered by emergency Medicaid, a program that extends the health care benefits for poor American families to unauthorized immigrants for labor and delivery.

Herrera refused.

“How,” she asked, “could I sleep in a warm place when my son is cold on the street?”

Another family, cast out into the night

It was March when David Jaimez, his pregnant wife and their two daughters were evicted from their Aurora apartment. Desperate for help, they dragged their possessions into Thursday evening Bible study at Jesus on Colfax, a church and food pantry inside an old motel. Its namesake and location, Colfax Avenue, has long been a destination for the drug-addicted, homeless veterans and new immigrants.

When the Jaimez family arrived, the prayers paused. The manager addressed the family in elementary Spanish, supplementing with Google Translate on her phone.

After arriving from Venezuela in August and staying in a Denver-sponsored hotel room, they’d moved into an apartment in Aurora. Housing is cheaper in that eastern suburb, but they never found enough work to pay their rent. “I owe $8,000,” Jaimez said, his eyes wide. “Supposedly there’s work here. I don’t believe it.”

Jaimez and his wife are eligible to apply for asylum or for “ Temporary Protected Status ” and, with that, work permits. But doing so would require an attorney or advisor, months of waiting and $500 in fees each.

At the prayer group, Jaimez’s daughters drank sodas and ate tangerines from one participant, a middle-aged woman and Aurora native. She stroked the ponytail of the family’s 8-year-old daughter as the young girl smiled.

When the leader couldn’t find anywhere for the family to stay, they headed out into the evening, pushing their year-old daughter in her stroller and lugging a suitcase behind them. After they left, the middle-aged woman leaned forward in her folding chair and said: “It’s kind of crazy that our city lets them in but does not help our veterans.” Nearby, a man nodded in agreement.

That night, Jaimez and his family found an encampment for migrants run by a Denver nonprofit called All Souls and moved into tent number 28. Volunteers and staff brought in water, meals and other resources. Weeks later, the family was on the move again: Camping without a permit is illegal in Denver, and the city closed down the encampment. All Souls re-established it in six different locations but closed it permanently in May.

At its peak, nearly 100 people were living in the encampment. About half had been evicted from apartments hastily arranged before their shelter time expired, said founder Candice Marley. Twenty-two residents were children and five women were pregnant, including Jaimez’s wife. Marley is trying to get a permit for another encampment, but the permit would only allow people over 18.

“Even though there are lots of kids living on the street, they don’t want them all together in a camp,” Marley said. “That’s not a good public image for them.”

A city’s efforts, not enough

Denver officials say they won’t tolerate children sleeping on the street. “Did you really walk from Venezuela to be homeless in the U.S.? I don’t think so,” said Jon Ewing, spokesman for Denver’s health and human services department. “We can do better than that.”

Still, Denver struggled to keep up with the rush of migrants, many arriving on buses chartered by Texas to draw attention to the impact of immigration. All told, Denver officials say they have helped some 42,700 migrants since last year, either by giving them shelter or a bus fare to another city .

Initially, the city offered migrants with families six weeks in a hotel. But in May, on pace to spend $180 million this year helping newcomers, the city scaled back its offer to future migrants while deepening its investment in people already getting help.

Denver paid for longer shelter stays for 800 migrants already in hotels and offered them English classes and help applying for asylum and work permits. But any migrants arriving since May have received only three days in a hotel. After that, some have found transportation to other cities, scrounged for a place to sleep or wandered into nearby towns like Aurora.

Today, fewer migrants are coming to the Denver area, but Marley still receives dozens of outreaches per week from social service agencies looking to help homeless migrants. “It’s so frustrating that we can’t help them,” she said. “That leaves families camping on their own, unsupported, living in their cars. Kids can’t get into school. There’s no stability.”

After the encampment closed, Jaimez and his family moved into a hotel. He paid by holding a cardboard sign at an intersection and begging for money. Their daughter only attended school for one month last year, since they never felt confident that they were settled anywhere more than a few weeks. The family recently moved to a farm outside of the Denver area, where they’ve been told they can live in exchange for working.

On the front lines of begging

When Herrera started feeling labor pains in early December, she was sitting on the grass, resting after a long day asking strangers for money. She waited until she couldn’t bear the pain anymore and could feel the baby getting close. She called an ambulance.

The paramedics didn’t speak Spanish but called an interpreter. They told Herrera they had to take her to the closest hospital, instead of the one in Denver, since her contractions were so close together.

Her son was born healthy at 7 pounds, 8 ounces. She brought him to the tent the next day. A few days later the whole family, including the baby, had contracted chicken pox. “The baby was in a bad state,” said Emily Rodriguez, a close friend living with her family in a tent next to Herrera’s.

Herrera took him to the hospital, then returned to the tent before being offered a way out. An Aurora woman originally from Mexico invited the family to live with her — at first, for free. After a couple weeks, the family moved to a small room in the garage for $800 a month.

To earn rent and pay expenses, Herrera and Rodriguez have cleaned homes, painted houses and shoveled snow while their children waited in a car by themselves. Finding regular work and actually getting paid for it has been difficult. While their husbands can get semi-regular work in construction, the women’s most consistent income comes from something else: standing outside with their children and begging.

Herrera and her husband recently became eligible to apply for work permits and legal residency for Venezuelans who arrived in the United States last year. But it will cost $800 each for a lawyer to file the paperwork, along with hundreds of dollars in government fees. They don’t have the money.

One spring weekday, Herrera and Rodriguez stand by the shopping carts at the entrance to a Mexican grocery store. While their sons crawl along a chain of red shopping carts stacked together and baby Milan sleeps in his stroller, they try to make eye contact with shoppers.

Some ignore them. Others stuff bills in their hands. On a good day, each earns about $50.

It comes easier for Rodriguez, who’s naturally boisterous. “One day a man came up and gave me this iPhone. It’s new,” she says, waving the device in the air.

“Check out this body,” she says as she spins around, laughing and showing off her ample bottom. “I think he likes me.”

Herrera grimaces. She won’t flirt like her friend does. She picks up Milan and notices his diaper is soaked, then returns him to the stroller. She has run out of diapers.

Milan was sick, but Herrera has been afraid to take him to the doctor. Despite what the hospital had said when she was pregnant, she was never signed up for emergency Medicaid. She says she owes $18,000 for the ambulance ride and delivery of her baby. Now, she avoids going to the doctor or taking her children because she’s afraid her large debt will jeopardize her chances of staying in the U.S. “I’m afraid they’re going to deport me,” she says.

But some days, when she’s feeling overwhelmed, she wants to be deported — as long as she can take her children along. Like the day in May when the security guard at the Mexican grocery store chased off the women and told them they couldn’t beg there anymore. “He insulted us and called us awful names,” Rodriguez says.

The two women now hold cardboard signs along a busy street in Denver and then knock on the doors of private homes, never returning to the same address. They type up their request for clothes, food or money on their phones and translate it to English using Google. They hand their phones to whoever answers the door.

The American Dream, still out of reach

In the garage where Herrera and her family live, the walls are lined with stuffed animals people have given her and her son. Baby Milan, on the floor, pushes himself up to look around. Dylan sleeps in bed.

Herrera recently sent $500 to her sister to make the months-long trip from Venezuela to Aurora with Herrera’s 8-year-old daughter. “I’ll have my family back together,” she says. And she believes her sister will be able to watch her kids so Herrera can look for work.

“I don’t feel equipped to handle all of this on my own,” she says.

The problem is, Herrera hasn’t told her family back in Venezuela how she spends her time. “They think I’m fixing up homes and selling chocolate and flowers,” she says. “I’m living a lie.”

When her daughter calls in the middle of the day, she’s sure not to answer and only picks up after 6 p.m. “They think I’m doing so well, they expect me to send money,” she says. And Herrera has complied, sending $100 a week to help her sister pay rent and buy food for her daughter.

Finally, her sister and daughter are waiting across the border in Mexico. When we come to the U.S., her sister asks, could we fly to Denver? The tickets are $600.

She has to come clean. She doesn’t have the money. She lives day to day. The American Dream hasn’t happened for Ivanni Herrera — at least, not yet. Life is far more difficult than she has let on.

She texts back:

The Associated Press’ education coverage receives financial support from multiple private foundations. AP is solely responsible for all content. Find AP’s standards for working with philanthropies, a list of supporters and funded coverage areas at AP.org.

Copyright 2024 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed without permission.

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Lucy Letby: Victims’ family ‘deeply shocked’ at ‘lies and misinformation’ of court case claims

The serial killer nurse is currently serving 15 whole-life sentences after murdering seven babies, article bookmarked.

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The parents of twin boys who were victims of serial killer nurse Lucy Letby have condemned recent questions regarding her conviction , saying: “We would like to say, shame on you all.”

The convicted NHS worker, who is currently serving 15 life sentences, has recently built a new legal team, appointing the leading human rights barrister Mark McDonald to challenge her case.

In recent weeks, doubts and questions have been raised as to whether the 34-year-old is the victim of a miscarriage of justice, despite a jury at Manchester Crown Court finding her guilty of murdering seven babies and attempting to murder six while working in the neonatal ward at Countess of Chester Hospital.

Letby was also found guilty of the attempted murder of a baby at a retrial on one count for which the original jury could not reach a verdict.

For the parents of babies E and F, as they are known for legal reasons, calls to release Letby have compounded their grief and distress after enduring a 10-month long traumatic trial.

“Our family is deeply shocked by the ongoing speculation surrounding what is being referred to as a miscarriage of justice,” the parents told The Sunday Times .

“Certain pieces of evidence being discussed in the media are grossly out of context and misrepresented. Misinformation is being circulated about what transpired in court. Having attended the trial ourselves, we are fully aware of what was said.”

Letby was convicted of murdering baby E by fatally injecting him with air and an attack on baby F by poisoning him with insulin, which he survived.

The family said the traumatic experience had “made us question humanity”, adding: “Why are people going out of their way to support a serial killer of babies?”

They said the prosecution case put together “individual bricks” of evidence, adding: “Once they were all put together the wall of evidence was overwhelming. To take each brick out separately is simply taking evidence out of context.

“The spread of lies and misinformation is deeply distressing and makes us sick to our cores. We just want some peace to grieve, knowing the person who caused so much agony is where she belongs.”

Among those questioning the conviction is former Brexit minister and Conservative MP David Davis , who has said he is willing to visit Letby in prison if his research into the evidence persuaded him she was innocent.

Asked on Channel 5 News whether there was a strong case for her innocence, Letby’s new lawyer Mr McDonald said: “Absolutely, there is. And I will be drafting the application to the Criminal Cases Review Commission (CCRC).

“You know, I’ve been so encouraged by the amount of people that have come forward: experts in neonatology, anaesthetists, pathology, statistics; that have come forward and have identified flaws in the trial that now want to give evidence for her, and we’ll want to draft reports to put in to the CCRC to assist.”

Letby is said to be aware of the growing campaign to revisit the convictions, and has been visited by Mr McDonald in prison.

A public inquiry examining events at the Countess of Chester Hospital following Letby’s multiple convictions is due to begin on 10 September in Liverpool.

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