meaning of presentation in cephalic

• Health Conditions

Cephalic Position: Getting Baby in the Right Position for Birth

You know your busy bean is exploring their digs because sometimes you can feel those little feet kick you in the ribs (ouch!) to help propel them along. Just think of them as a little astronaut attached to you — the mother ship — with their oxygen (umbilical) cord.

Your baby may start moving around before you’re barely 14 weeks pregnant. However, you probably won’t feel anything until about the 20 th week of pregnancy.

If your baby is bouncing around or turning in your womb, it’s a good sign. A moving baby is a healthy baby. There are even cute names for when you first feel your baby moving, like “fluttering” and “quickening.” Your baby’s movement is most important in the third trimester .

By this time, your growing baby may not be moving that much because the womb isn’t as roomy as it used to be. But your baby can probably still do acrobatic flips and turn himself upside down. Your doctor will closely monitor where your baby’s head is as your due date nears.

Your baby’s position inside you can make all the difference in how you give birth. Most babies automatically get into the head-first cephalic position just before they are born.

What is cephalic position?

If you’re getting closer to your exciting due date, you might have heard your doctor or midwife mention the term cephalic position or cephalic presentation. This is the medical way of saying that baby is bottom and feet up with their head down near the exit, or birth canal.

It’s difficult to know which way is up when you’re floating in a warm bubble, but most babies (up to 96 percent) are ready to go in the head-first position before birth. The safest delivery for you and your baby is for them to squeeze through the birth canal and into the world headfirst.

Your doctor will start checking your baby’s position at week 34 to 36 of your pregnancy. If your baby is not head down by week 36, your doctor might try to gently nudge them into position.

Keep in mind, though, that positions can continue to change, and your baby’s position really doesn’t come into play until you’re ready to deliver.

There are two kinds of cephalic (head-down) positions that your little one might assume:

• Cephalic occiput anterior . Your baby is head down and facing your back. Almost 95 percent of babies in the head-first position face this way. This position is considered to be the best for delivery because its easiest for the head to “crown” or come out smoothly as you give birth.
• Cephalic occiput posterior . Your baby is head down with their face turned toward your belly. This can make delivery a bit harder because the head is wider this way and more likely to get stuck. Only about 5 percent of cephalic babies face this way. This position is sometimes called a “ sunny side up baby .”

Some babies in the head-first cephalic position might even have their heads tilted back so they move through the birth canal and enter the world face first. But this is very rare and most common in preterm (early) deliveries.

What are the other positions?

Your baby might settle into a breech (bottom-down) position or even a transverse (sideways) position.

A breech baby can cause complications for both mom and baby. This is because the birth canal has to open wider if your baby decides to come out bottom first. It’s also easier for their legs or arms to get tangled up a bit as they slide out. However, only about four percent of babies are in the bottom-first position when it’s time for delivery.

There are also different kinds of breech positions your baby could be in:

• Frank breech. This is when your baby’s bottom is down and their legs are straight up (like a pretzel) so their feet are close to their face. Babies are definitely flexible!
• Complete breech . This is when your baby is settled into an almost legs crossed position with their bottom down.
• Incomplete breech . If one of your baby’s legs are bent (like sitting cross-legged) while the other one is trying to kick toward their head or another direction, they’re in an incomplete breech position.
• Footling breech . Just like it sounds, this is one when or both of baby’s feet are down in the birth canal so they would exit foot first.

A sideways position where your baby is lying horizontally across your stomach is also called a transverse lie. Some babies start like this close to your due date but then decide to shift all the way into the head-first cephalic position.

So if your baby is settled across your stomach like they’re swinging in a hammock, they may just be tired and taking a break from all the moving before another shift.

In rare cases, a baby can get wedged sideways in the womb (and not because the poor thing didn’t try moving). In these cases, your doctor might recommend a cesarean section (C-section) for your delivery.

How do you know what position your baby is in?

Your doctor can find out exactly where your baby is by:

• A physical exam: feeling and pressing over your belly to get an outline of your baby
• An ultrasound scan: provides an exact image of your baby and even which way they’re facing
• Listening to your baby’s heartbeat: honing in on the heart gives your doctor a good estimate of where your baby is settled inside your womb

If you’re already in labor and your baby is not turning into a cephalic presentation — or suddenly decides to acrobat into a different position — your doctor might be concerned about your delivery.

Other things that your doctor has to check include where the placenta and umbilical cord are inside your womb. A moving baby can sometimes get their foot or hand caught in their umbilical cord. Your doctor might have to decide on the spot whether a C-section is better for you and your baby.

How can you tell your baby’s position?

You might be able to tell what position your baby is in by where you feel their little feet practice their soccer kick. If your baby is in a breech (bottom-first) position, you might feel kicking in your lower stomach or groin area. If your baby is in the cephalic (head-down) position, they might score a goal in your ribs or upper stomach.

If you rub your belly, you might be able to feel your baby well enough to figure out what position they’re in. A long smooth area is likely your little one’s back, a round hard area is their head, while bumpy parts are legs and arms. Other curved areas are probably a shoulder, hand, or foot. You might even see the impression of a heel or hand against the inside of your belly!

What is lightening?

Your baby will likely naturally drop into a cephalic (head-down) position sometime between weeks 37 to 40 of your pregnancy. This strategic positional change by your brilliant little one is called “lightening.” You might feel a heavy or full sense in your lower stomach — that’s baby’s head!

You might also notice that your belly button is now more of an “outie” than an “innie.” That’s also your baby’s head and upper body pushing against your stomach.

As your baby gets into cephalic position, you might suddenly notice that you can breathe more deeply because they’re not pushing up any longer. However, you might have to pee even more often because your baby is pushing against your bladder.

Can your baby be turned?

Stroking your belly helps you feel your baby, and your baby feels you right back. Sometimes stroking or tapping your stomach over the baby will get them to move . There are also some at-home methods for turning a baby, like inversions or yoga positions.

Doctors use a technique called external cephalic version (ECV) to get a breech baby into cephalic position. This involves massaging and pushing on your belly to help nudge your baby in the right direction. In some cases, medications that help you and your muscles relax can help turn your baby.

If your baby is already in cephalic position but not quite facing the right way, a doctor can sometimes reach through the vagina during labor to help gently turn baby the other way.

Of course, turning a baby also depends on how large they are — and how petite you are. And if you’re pregnant with multiples, your babies can be changing positions even during birth as the space in your womb opens up.

About 95 percent of babies drop down into the head-first position a few weeks or days before their due date. This is called the cephalic position, and it’s safest for mom and baby when it comes to giving birth.

There are different kinds of cephalic positions. The most common and safest one is where baby is facing your back. If your little one decides to change positions or refuses to float head down in your womb, your doctor might be able to coax him into the cephalic position.

Other baby positions like breech (bottom first) and transverse (sideways) might mean that you must have a C-section delivery. Your doctor will help you decide what’s best for you and your little one when it’s time for delivery.

• 3rd Trimester

How we reviewed this article:

• BirthPlace. (n.d.) https://www.stmarysregional.com/services/women/birthplace
• Glezerman M. (2014). Planned vaginal breech delivery: Current status and the need to reconsider. DOI: https://doi.org/10.1586/eog.12.2
• Horsager-Boehrer R. (2015). Feeling your baby move during pregnancy. https://utswmed.org/medblog/fetal-movements/
• Mayo Clinic Staff. (2017). Fetal presentation before birth. https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615
• Your baby’s movement and position. (2019). https://wa.kaiserpermanente.org/healthAndWellness/index.jhtml?item=%2Fcommon%2FhealthAndWellness%2Fpregnancy%2Fpregnancy%2FthirdMove.html

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• Pregnancy week by week
• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Presentation and position of baby through pregnancy and at birth

9-minute read

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

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

What does presentation and position mean?

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

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

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

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

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

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

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

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

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

Read more on breech presentation .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resources and support

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

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

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

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Last reviewed: October 2023

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

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Management of Labour and Delivery – Questions

Rekha Wuntakal, Madhavi Kalidindi, Tony Hollingworth in Get Through , 2014

For each clinical scenario below, choose the single most appropriate stage of labour from the above list of options. Each option may be used once, more than once or not at all. A 30-year-old para 3 woman was admitted at term with regular uterine activity at 5 cm cervical dilatation and 4 hours later she delivered a female neonate with APGARs 9, 10, 10 at 1, 5 and 10 minutes. Syntometrine injection was given immediately after delivery and placenta with membranes was delivered completely 20 minutes after the delivery of the baby by continuous cord traction.A 23-year-old para 3 woman was admitted after spontaneous rupture of membranes at 39 weeks’ gestation. She is contracting 4 in 10 minutes and pushing involuntarily. On vaginal examination the cervix was fully dilated, vertex was 2 cm below the spines in direct occipito-anterior position with minimal caput and moulding.A 30-year-old nulliparous woman was admitted at term with uterine contractions once in every 5 minutes. On examination, the fetus is in cephalic presentation with two fifths palpable per abdomen. The cervix is central, soft, fully effaced and 2 cm dilated with intact membranes.

Biometric Measurements and Normal Growth Parameters in a Child

Nirmal Raj Gopinathan in Clinical Orthopedic Examination of a Child , 2021

In cephalic presentation, the intra-uterine fetal position is of universal flexion, which is carried by the child to the immediate post-partum period. The hips and knees are flexed. The lower legs are internally rotated. The feet are further internally rotated with respect to the lower legs. At times there is an external rotational contracture of the hip that tends to mask the true femoral rotational profile. The anatomy of the lower limbs changes significantly as the child grows. This is primarily in response to the development of motor abilities and the ability of the child to crawl, cruise, stand, walk, and finally run. These changes are seen right from the hip joints, the femoral neck, knees, and tibia to the feet.

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External cephalic version: Used to convert a breech presentation to cephalic presentation.Not contraindicated if there is a prior Caesarean section scar.Can cause premature labour.Contraindicated in hypertension.Can be performed after 33 weeks' gestation in a rhesus-negative mother.

Complex maternal congenital anomalies – a rare presentation and delivery through a supra-umbilical abdominal incision

Published in Journal of Obstetrics and Gynaecology , 2018

Samantha Bonner, Yara Mohammed

She had a spontaneous conception and booked at 9 weeks of gestation under consultant-led care. A scan confirmed the pregnancy was in the right uterus. She had no other significant medical history but did suffer from recurrent urinary tract infections and hence was on low-dose antibiotic prophylaxis. There was no sonographic evidence of hydronephrosis. Her body mass index (BMI) was 18 at the time of booking. Combined screening was low risk and she had a normal 20 week anomaly scan. She had serial growth scans which demonstrated a normal growth trajectory on a customised chart. The baby was consistently a cephalic presentation. She had multidisciplinary antenatal care, including specialist urologists, general surgeons, obstetricians and anaesthetists. An antenatal MRI scan had shown extensive adhesions over the lower segment of the uterus. She was extensively counselled regarding the mode of delivery and this was scheduled at 37 weeks of gestation to avoid the potential of spontaneous labour and an emergency Caesarean section.

Utilization of epidural volume extension technique for external cephalic version

Published in Baylor University Medical Center Proceedings , 2021

Hanna Hussey, James Damron, Mark F. Powell, Michelle Tubinis

Repeat ultrasound demonstrated breech presentation, normal amniotic fluid volume, and fetal head toward the maternal left abdomen. After 0.25 mg of intramuscular terbutaline injection, a forward roll was initiated by applying pressure from behind the fetal head toward the maternal left. Continuous progress was made and bedside ultrasound showed cephalic presentation. Immediately after successful ECV, the fetal heart rate was 70 beats/min but returned to baseline with conservative measures. Motor blockade regressed after approximately 1.5 hours. After 4 hours of fetal heart rate monitoring and tocometry, the patient was deemed stable for discharge. Follow-up discussion with the patient via phone call on postprocedure day 1 confirmed that she was not experiencing pain or concerning symptoms for neuraxial complications. She returned to the labor and delivery unit at 40 weeks’ gestation for elective induction of labor and had a successful vaginal delivery.

Antenatal scoring system in predicting the success of planned vaginal birth following one previous caesarean section

Aida Kalok, Shahril A. Zabil, Muhammad Abdul Jamil, Pei Shan Lim, Mohamad Nasir Shafiee, Nirmala Kampan, Shamsul Azhar Shah, Nor Azlin Mohamed Ismail

The inclusion criteria were pregnant women at 36 weeks of gestation or more with singleton foetus in cephalic presentation, who agreed for trial of vaginal delivery after one lower segment caesarean section. We excluded women with contraindication for vaginal birth, or who declined trial of vaginal delivery from this study. Previous antenatal history was noted and recorded during the 36-week assessment, including year and indication for previous caesarean section. Recurrent indications involved were cephalopelvic disproportion and obstructed labour. While non-recurrent indications were foetal distress and malpresentation. Past operative notes were checked for any operative complications such as extended uterine tear, organ injury and post-partum haemorrhage. Information regarding current pregnancy including pre-existing medical disorder was recorded. Estimated foetal weight based on ultrasound scan at 36 weeks of gestation was used in this study.

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Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

How many c-sections can you have : Tap this post to know the total number of c-sections that you can safely have.

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

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

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

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

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

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

• Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

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Delivery, face and brow presentation.

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• Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the interprofessional team's role in safely managing delivery for both the mother and the baby.

• Identify the mechanism of labor in the face and brow presentation.
• Differentiate potential maternal and fetal complications during the face and brow presentations.
• Evaluate different management approaches for the face and brow presentation.
• Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference. Face presentation is an abnormal form of cephalic presentation where the presenting part is the mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]  In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation, with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, and black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, and polyhydramnios. [2] [4] [5]  These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. Palpating orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation is possible. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, the anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse. Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6]  Ultrasound imaging can show a reduced angle between the occiput and the spine or the chin is separated from the chest. However, ultrasound does not provide much predictive value for the outcome of labor. [7]

• Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements. 

Planes and Diameters of the Pelvis

The 3 most important planes in the female pelvis are the pelvic inlet, mid-pelvis, and pelvic outlet. Four diameters can describe the pelvic inlet: anteroposterior, transverse, and 2 obliques. Furthermore, based on the landmarks on the pelvic inlet, there are 3 different anteroposterior diameters named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these 3 diameters is obstetrical conjugate, which measures approximately 10.5 cm and is the distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5 cm and is the widest distance between the innominate line on both sides. The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. 

Fetal Skull Diameters

There are 6 distinguished longitudinal fetal skull diameters:

• Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the diameter presented in the vertex presentation. 
• Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm 
• Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5 cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the diameter in the face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5 cm 
• Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation. 

Cardinal Movements of Normal Labor

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (restitution)
• Expulsion (delivery of anterior and posterior shoulders)

Some key movements are impossible in the face or brow presentations. Based on the information provided above, it is obvious that labor be arrested in brow presentation unless it spontaneously changes to the face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery are explained in later sections.

• Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

• Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore, the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations. Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous. Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8]  External transducer devices are advised to prevent damage to the eyes. When internal monitoring is inevitable, monitoring devices on bony parts should be placed carefully. 

Consultations that are typically requested for patients with delivery of face/brow presentation include the following:

• Experienced midwife, preferably looking after laboring women 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (eg, epidural)
• Theatre team  - in case of failure to progress, an emergency cesarean section is required.
• Preparation

No specific preparation is required for face or brow presentation. However, discussing the labor options with the mother and birthing partner and informing members of the neonatal, anesthetic, and theatre co-ordinating teams is essential.

• Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and the pressure of the amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery. If the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

The pubis is described as mentum-anterior when the fetal chin is rotated towards the maternal symphysis. In these cases, further descent through the vaginal canal continues, with approximately 73% of cases delivering spontaneously. [9]  The fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot occur. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

• Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]  However, some complications are still associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor. Prolonged labor itself can provoke fetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications. Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

• Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5 cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head engages later, and labor progresses more slowly. Failure to progress in labor is also more common in both presentations compared to the vertex presentation. Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descending through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section. Manual attempts to change face presentation to vertex or manual or forceps rotation to mentum anterior are considered dangerous and discouraged.

• Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

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• Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2024] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2024 Mar; 230(3S):S890-S900. Epub 2023 May 19.
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• Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. [Am J Obstet Gynecol. 2021] Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. Dall'Asta A, Rizzo G, Masturzo B, Di Pasquo E, Schera GBL, Morganelli G, Ramirez Zegarra R, Maqina P, Mappa I, Parpinel G, et al. Am J Obstet Gynecol. 2021 Aug; 225(2):171.e1-171.e12. Epub 2021 Mar 4.
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Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

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Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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Chapter 27:  Compound Presentations

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Prolapse of hand and arm or foot and leg.

• MANAGEMENT OF COMPOUND PRESENTATIONS
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A presentation is compound when there is prolapse of one or more of the limbs along with the head or the breech, both entering the pelvis at the same time. Footling breech or shoulder presentations are not included in this group. Associated prolapse of the umbilical cord occurs in 15 to 20 percent of cases.

Easily detectable compound presentations occur probably once in 500 to 1000 confinements. It is impossible to establish the exact incidence because:

Spontaneous correction occurs frequently, and examination late in labor cannot provide the diagnosis

Minor degrees of prolapse are detected only by early and careful vaginal examination

Classification of Compound Presentation

Upper limb (arm–hand), one or both

Lower limb (leg–foot), one or both

Arm and leg together

Breech presentation with prolapse of the hand or arm

By far the most frequent combination is that of the head with the hand ( Fig. 27-1 ) or arm. In contrast, the head–foot and breech–arm groups are uncommon, about equally so. Prolapse of both hand and foot alongside the head is rare. All combinations may be complicated by prolapse of the umbilical cord, which then becomes the major problem.

FIGURE 27-1.

Compound presentation: head and hand.

The etiology of compound presentation includes all conditions that prevent complete filling and occlusion of the pelvic inlet by the presenting part. The most common causal factor is prematurity. Others include high presenting part with ruptured membranes, polyhydramnios, multiparity, a contracted pelvis, pelvic masses, and twins. It is also more common with inductions of labor involving floating presenting parts. Another predisposing factor is external cephalic version. During the process of external version, a fetal limb (commonly the hand–arm, but occasionally the foot) can become “trapped” before the fetal head and thus become the presenting part when labor ensues.

Diagnosis is made by vaginal examination, and in many cases, the condition is not noted until labor is well advanced and the cervix is fully dilated.

The condition is suspected when:

There is delay of progress in the active phase of labor

Engagement fails to occur

The fetal head remains high and deviated from the midline during labor, especially after the membranes rupture

In the absence of complications and with conservative management, the results should be no worse than with other presentations.

Mechanism of Labor

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You and your baby at 32 weeks pregnant

Your baby at 32 weeks.

By about 32 weeks, the baby is usually lying with their head pointing downwards, ready for birth. This is known as cephalic presentation.

If your baby is not lying head down at this stage, it's not a cause for concern – there's still time for them to turn.

The amount of amniotic fluid in your uterus is increasing, and your baby is still swallowing fluid and passing it out as urine.

You at 32 weeks

Being active and fit during pregnancy will help you adapt to your changing shape and weight gain. It can also help you cope with labour and get back into shape after the birth.

Find out about exercise in pregnancy .

You may develop pelvic pain in pregnancy. This is not harmful to your baby, but it can cause severe pain and make it difficult for you to get around.

Find out about ways to tackle pelvic pain in pregnancy .

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Abnormal Fetal lie, Malpresentation and Malposition

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

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

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

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

Definitions

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

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

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

Risk Factors

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

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

Identifying Fetal Lie, Presentation and Position

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

For more information on the obstetric examination, see here .

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

Presentation

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

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

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

Fig 2 – Assessing fetal lie and presentation.

Investigations

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

Abnormal Fetal Lie

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

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

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

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

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

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

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

Malposition

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

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

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

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

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Your baby in the birth canal

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Childbirth is really a series of four stages that culminate in the actual birth and short period thereafter. For more specific information regarding emergency delivery see the information on childbirth, emergency delivery.

Emergency measures are indicated when childbirth is imminent and no health care professional is present. Indications of late labor include rupturing of the amniotic sac, dilation of the cervix, and appearance of the baby's head at the vaginal opening.

Cephalic (head first) presentation is considered normal, but a breech (feet or buttocks first) delivery can be very difficult, even dangerous for the mother and the baby.

In a normal pregnancy, the baby is positioned head down in the uterus.

The term fetal presentation refers to the part of your baby's body that is closest to the birth canal. In most full-term pregnancies, the baby is positioned head down, or cephalic, in the uterus.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Version Info

Last reviewed on: 11/10/2022

Reviewed by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned cesarean section.

History and exam

Key diagnostic factors.

• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic tests

1st tests to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation and in labor, ≥37 weeks' gestation not in labor, ≥37 weeks' gestation in labor: no imminent delivery, ≥37 weeks' gestation in labor: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Caesarean birth
• Mode of term singleton breech delivery

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If Your Baby Is Breech

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Frequently Asked Questions Expand All

In the last weeks of pregnancy, a fetus usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation . A breech presentation occurs when the fetus’s buttocks, feet, or both are in place to come out first during birth. This happens in 3–4% of full-term births.

It is not always known why a fetus is breech. Some factors that may contribute to a fetus being in a breech presentation include the following:

You have been pregnant before.

There is more than one fetus in the uterus (twins or more).

There is too much or too little amniotic fluid .

The uterus is not normal in shape or has abnormal growths such as fibroids .

The placenta covers all or part of the opening of the uterus ( placenta previa )

The fetus is preterm .

Occasionally fetuses with certain birth defects will not turn into the head-down position before birth. However, most fetuses in a breech presentation are otherwise normal.

Your health care professional may be able to tell which way your fetus is facing by placing his or her hands at certain points on your abdomen. By feeling where the fetus's head, back, and buttocks are, it may be possible to find out what part of the fetus is presenting first. An ultrasound exam or pelvic exam may be used to confirm it.

External cephalic version (ECV) is an attempt to turn the fetus so that he or she is head down. ECV can improve your chance of having a vaginal birth. If the fetus is breech and your pregnancy is greater than 36 weeks your health care professional may suggest ECV.

ECV will not be tried if:

You are carrying more than one fetus

There are concerns about the health of the fetus

You have certain abnormalities of the reproductive system

The placenta is in the wrong place

The placenta has come away from the wall of the uterus ( placental abruption )

ECV can be considered if you have had a previous cesarean delivery .

The health care professional performs ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the fetus rolls into a head-down position. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning.

The fetus's heart rate is checked with fetal monitoring before and after ECV. If any problems arise with you or the fetus, ECV will be stopped right away. ECV usually is done near a delivery room. If a problem occurs, a cesarean delivery can be performed quickly, if necessary.

Complications may include the following:

Prelabor rupture of membranes

Changes in the fetus's heart rate

Placental abruption

Preterm labor

More than one half of attempts at ECV succeed. However, some fetuses who are successfully turned with ECV move back into a breech presentation. If this happens, ECV may be tried again. ECV tends to be harder to do as the time for birth gets closer. As the fetus grows bigger, there is less room for him or her to move.

Most fetuses that are breech are born by planned cesarean delivery. A planned vaginal birth of a single breech fetus may be considered in some situations. Both vaginal birth and cesarean birth carry certain risks when a fetus is breech. However, the risk of complications is higher with a planned vaginal delivery than with a planned cesarean delivery.

In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily. There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord . It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

Although a planned cesarean birth is the most common way that breech fetuses are born, there may be reasons to try to avoid a cesarean birth.

A cesarean delivery is major surgery. Complications may include infection, bleeding, or injury to internal organs.

The type of anesthesia used sometimes causes problems.

Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications with the placenta.

With each cesarean delivery, these risks increase.

If you are thinking about having a vaginal birth and your fetus is breech, your health care professional will review the risks and benefits of vaginal birth and cesarean birth in detail. You usually need to meet certain guidelines specific to your hospital. The experience of your health care professional in delivering breech babies vaginally also is an important factor.

Amniotic Fluid : Fluid in the sac that holds the fetus.

Anesthesia : Relief of pain by loss of sensation.

Breech Presentation : A position in which the feet or buttocks of the fetus would appear first during birth.

Cervix : The lower, narrow end of the uterus at the top of the vagina.

Cesarean Delivery : Delivery of a fetus from the uterus through an incision made in the woman’s abdomen.

External Cephalic Version (ECV) : A technique, performed late in pregnancy, in which the doctor attempts to manually move a breech baby into the head-down position.

Fetus : The stage of human development beyond 8 completed weeks after fertilization.

Fibroids : Growths that form in the muscle of the uterus. Fibroids usually are noncancerous.

Oxygen : An element that we breathe in to sustain life.

Pelvic Exam : A physical examination of a woman’s pelvic organs.

Placenta : Tissue that provides nourishment to and takes waste away from the fetus.

Placenta Previa : A condition in which the placenta covers the opening of the uterus.

Placental Abruption : A condition in which the placenta has begun to separate from the uterus before the fetus is born.

Prelabor Rupture of Membranes : Rupture of the amniotic membranes that happens before labor begins. Also called premature rupture of membranes (PROM).

Preterm : Less than 37 weeks of pregnancy.

Ultrasound Exam : A test in which sound waves are used to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus.

Umbilical Cord : A cord-like structure containing blood vessels. It connects the fetus to the placenta.

Uterus : A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus.

Vagina : A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

Vertex Presentation : A presentation of the fetus where the head is positioned down.

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

• Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

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2,395 allegations of sexual abuse at religious schools - inquiry finds

Social Affairs & Religion Correspondent

The scoping inquiry into allegations of abuse at schools run by religious orders has found that there were 2,395 allegations of sexual abuse in respect of 308 schools recorded by the religious orders that ran those schools.

The allegations were made in respect of 884 distinct alleged abusers.

The inquiry has recommended that the Government consider a redress scheme for survivors of historical sexual abuse in day and boarding schools.

It has also recommended that the Government approach relevant religious orders about contributing to redress.

The religious orders' records indicate that over half of the 884 people accused of historical sexual abuse are known to be deceased and there is a particularly high number of allegations in special schools.

17 special schools recorded 590 allegations involving 190 alleged abusers.

The number of schools with allegations of historical sexual abuse also shows that such allegations were not confined to schools in any particular geographic or social category.

The report outlines how people were invited to register their interest in participating in the process, which was open to all former students of day and boarding schools run by religious orders.

205 people - the overwhelming majority of whom were men - completed questionnaires about their experiences.

In their questionnaire responses, survivors spoke of experiences of historical sexual abuse in schools in at least 22 counties in Ireland, naming over 80 schools, run by 24 religious orders.

The incidents of sexual abuse were, in the main, described as having occurred between the early 1960s and the early 1990s, with the highest number of reported incidents occurring in the early to mid-1970s.

Of those completing questionnaires, 182 were assessed as falling within the scoping inquiry’s terms of reference and invited to the second stage.

149 participants opted to take part in the second stage of the process, where they could choose to give an interview to a trauma-informed facilitator or provide a written submission.

137 participants completed in-person interviews and 12 participants provided written submissions.

Read more: Live: Updates as they happen Cabinet agrees to set up statutory inquiry into sexual abuse in schools Report in full: Volume 1 | Volume 2 | Volume 3 | Volume 4 | Volume 5 (including list of schools)

Accounts of victims and survivors

The accounts given by survivors of their experiences of sexual abuse in schools set out in the report are distressing and often harrowing to read.

In some cases, this was the first time they had told the full extent of their experience of sexual abuse and its impact on their lives.

The report says that for many participants, their stories explain that there was no place or sense of safety in their schools or indeed, their lives, as a result of their experiences of sexual abuse.

Appalling childhood sexual abuse is described by participants and is reported as occurring in various locations including in classrooms, dormitories, sports facilities, and at musical and extra-curricular activities.

Some reported being sexually abused in their own homes by adults associated with their school who had gained their family’s trust, only to abuse that trust egregiously.

Participants described being sexually abused in the private offices and residential quarters of school staff and religious order members.

Many spoke of being sexually abused in the presence of other children or adults, and others reported being sexually abused when alone with a teacher, priest or religious brother, other school staff or a visitor to their school.

Many recounted that the sexual abuse had been ongoing, whilst others said it had occurred randomly, or followed a period of grooming, and was often reported as having been accompanied by ferocious violence.

Participants described being molested, stripped naked, raped and drugged amidst an atmosphere of terror and silence.

Many spoke of their strong belief that what was happening was so pervasive that it could not possibly have gone unnoticed by other staff, and the members and leadership of the religious orders.

Many participants were very clear in their belief that there had been a cover-up in their schools or by the religious order and some believed there was collusion between some institutions of the State and the Church.

Participants spoke of their fear, shock and naivety about the sexual abuse when it occurred.

They described how it evoked in them feelings of shame, responsibility, isolation, powerlessness and secrecy. Participants described trying to avoid the sexual abuse, avoiding their favourite activities, their friends and ultimately their school.

Some described how, as children, they began to experience mental health problems and adopted unhealthy coping mechanisms including the misuse of alcohol and drugs, and how some of those problems followed them into adulthood.

Many described their confusion about why it happened to them and some said that other children sometimes tried to warn them about risky situations or certain staff.

Repercussions

Participants spoke of their confusion about their own developing sexuality, and also of declining academic performance which limited their opportunities in education and employment later on.

Many participants said they felt the power of the Catholic Church permeated their lives in every way and, for the majority, they felt there was no one they could tell, including their parents.

For some this has led to lifelong estrangement or difficult family relationships. Many said their childhood stopped the day the abuse started.

As adults, participants said the impact of the sexual abuse led to serious and ongoing difficulties in relationships, mental and physical health problems, addiction issues, lost career opportunities, and damage to their sense of place and/or community.

Many described failed early intimate relationships and marriage breakdowns.

Some said that, as a result of the sexual abuse, they decided not to have children, or when they did, it impacted their parenting, with many participants describing the effects of inter-generational trauma on their families.

Many spoke with very real sadness of the impact of telling their elderly parents of their experiences.

Participants spoke of difficulties with authority figures in employment, with their long-term solution being to undertake contract work or self-employment.

Other impacts on careers included lost opportunities to go to university as a result of poor academic progress or inappropriate behaviour in employment resulting from mental health difficulties and addiction.

Some participants outlined how they had successful careers as they worked excessively, at the cost of their close relationships, to distract themselves from their early trauma.

Participants spoke of emigrating and creating distances from family and friends to avoid traumatic memories.

Many described becoming alienated from religion and church-related services to the extent that some avoided attending a parent’s funeral or other family event, as they could not enter a church.

Participants frequently described a crisis in adulthood, such as a suicide attempt or time in a rehabilitation programme, as a time when their childhood experiences came to the fore for the first time and were identified as a source of their difficulties, and this realisation began the process of healing.

The majority of participants who, in later years, approached the religious order seeking acknowledgement said the encounter had not been helpful, especially where it involved a defended legal process, although a minority found the experience helpful where a sincere apology was offered with compassion and meaning.

Recommendations

Most survivors said that they wanted a statutory inquiry and most said an inquiry process that was the least adversarial possible was desirable.

The view of the inquiry team is that any inquiry process should be as inclusive as possible.

However, it pointed out that more court-like processes of a tribunal risk discouraging survivors from coming forward and would pose a greater risk of retraumatisation.

"The procedural flexibility of a commission affords the least adversarial model of inquiry, and therefore the greatest prospect of reducing the risk of retraumatisation."

It has recommended that a Commission of Investigation pursuant to the Commissions of Investigation Act 2004 be established.

It also recommended that, in early course, consideration be given by the Government to establishing a redress scheme for survivors of historical sexual abuse in day and boarding schools run by the religious orders.

"We further recommend that the Government approach the relevant religious orders about contributing to a redress scheme."

It has also recommended that a Survivor Engagement Programme be established by the Commission in accordance with the proposed Terms of Reference of the report.

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