fetal presentation defined

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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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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.

Was this article helpful?

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BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

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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Fetal Positions for Labor and Birth

Knowing your baby's position can you help ease pain and speed up labor

In the last weeks of pregnancy , determining your baby's position can help you manage pain and discomfort. Knowing your baby's position during early labor can help you adjust your own position during labor and possibly even speed up the process.

Right or Left Occiput Anterior

Illustration by JR Bee, Verywell 

Looking at where the baby's head is in the birth canal helps determine the fetal position.The front of a baby's head is referred to as the anterior portion and the back is the posterior portion. There are two different positions called occiput anterior (OA) positions that may occur.

The left occiput anterior (LOA) position is the most common in labor. In this position, the baby's head is slightly off-center in the pelvis with the back of the head toward the mother's left thigh.

The right occiput anterior (ROA) presentation is also common in labor. In this position, the back of the baby is slightly off-center in the pelvis with the back of the head toward the mother's right thigh.

In general, OA positions do not lead to problems or additional pain during labor or birth.  

Right or Left Occiput Transverse

Illustration by JR Bee, Verywell  

When facing out toward the mother's right thigh, the baby is said to be left occiput transverse (LOT). This position is halfway between a posterior and anterior position. If the baby was previously in a posterior position (in either direction), the LOT position indicates positive movement toward an anterior position.

When the baby is facing outward toward the mother's left thigh, the baby is said to be right occiput transverse (ROT). Like the previous presentation, ROT is halfway between a posterior and anterior position. If the baby was previously in a posterior position, ROT is a sign the baby is making a positive move toward an anterior position.

When a baby is in the left occiput transverse position (LOT) or right occiput transverse (ROT) position during labor, it may lead to more pain and a slower progression.

Tips to Reduce Discomfort

There are several labor positions a mother can try to alleviate pain and encourage the baby to continue rotating toward an anterior position, including:

• Pelvic tilts
• Standing and swaying

A doula , labor nurse, midwife , or doctor may have other suggestions for positions.

Right or Left Occiput Posterior

When facing forward, the baby is in the occiput posterior position. If the baby is facing forward and slightly to the left (looking toward the mother's right thigh) it is in the left occiput posterior (LOP) position. This presentation can lead to more back pain (sometimes referred to as " back labor ") and slow progression of labor.

In the right occiput posterior position (ROP), the baby is facing forward and slightly to the right (looking toward the mother's left thigh). This presentation may slow labor and cause more pain.

To help prevent or decrease pain during labor and encourage the baby to move into a better position for delivery, mothers can try a variety of positions, including:

• Hands and knees
• Pelvic rocking

Mothers may try other comfort measures, including:

• Bathtub or shower (water)
• Counter pressure
• Movement (swaying, dancing, sitting on a birth ball )
• Rice socks (heat packs)

How a Doctor Determines Baby's Position

Leopold's maneuvers are a series of hands-on examinations your doctor or midwife will use to help determine your baby's position. During the third trimester , the assessment will be done at most of your prenatal visits.   Knowing the baby's position before labor begins can help you prepare for labor and delivery.

Once labor begins, a nurse, doctor, or midwife will be able to get a more accurate sense of your baby's position by performing a vaginal exam. When your cervix is dilated enough, the practitioner will insert their fingers into the vagina and feel for the suture lines of the baby's skull as it moves down in the birth canal.   It's important to ensure the baby is head down and moving in the right direction.

Labor and delivery may be more complicated if the baby is not in a head-down position, such as in the case of a breech presentation.

How You Can Determine Baby's Position

While exams by health practitioners are an important part of your care, from the prenatal period through labor and delivery, often the best person to assess a baby's position in the pelvis is you. Mothers should pay close attention to how the baby moves and where different movements are felt.

A technique called belly mapping can help mothers ask questions of themselves to assess their baby's movement and get a sense of the position they are in as labor approaches.

For example, the position of your baby's legs can be determined by asking questions about the location and strength of the kicking you feel. The spots where you feel the strongest kicks are most likely where your baby's feet are.

Other landmarks you can feel for include a large, flat plane, which is most likely your baby's back. Sometimes you can feel the baby arching his or her back.

At the top or bottom of the flat plane, you may feel either a hard, round shape (most likely your baby's head) or a soft curve (most likely to be your baby's bottom).

Guittier M, Othenin-Girard V, de Gasquet B, Irion O, Boulvain M. Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial .  BJOG: An International Journal of Obstetrics & Gynaecology . 2016;123(13):2199-2207. doi:10.1111/1471-0528.13855

Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli G. Women’s Choice of Positions during Labour: Return to the Past or a Modern Way to Give Birth? A Cohort Study in Italy .  Biomed Res Int . 2014;2014:1-7. doi:10.1155/2014/638093

Ahmad A, Webb S, Early B, Sitch A, Khan K, MacArthur C. Association between fetal position at onset of labor and mode of delivery: a prospective cohort study .  Ultrasound in Obstetrics & Gynecology . 2014;43(2):176-182. doi:10.1002/uog.13189

Nishikawa M, Sakakibara H. Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment .  Reprod Health . 2013;10(1). doi:10.1186/1742-4755-10-12

Choi S, Park Y, Lee D, Ko H, Park I, Shin J. Sonographic assessment of fetal occiput position during labor for the prediction of labor dystocia and perinatal outcomes .  The Journal of Maternal-Fetal & Neonatal Medicine . 2016;29(24):3988-3992. doi:10.3109/14767058.2016.1152250

Bamberg C, Deprest J, Sindhwani N et al. Evaluating fetal head dimension changes during labor using open magnetic resonance imaging .  J Perinat Med . 2017;45(3). doi:10.1515/jpm-2016-0005

Gabbe S, Niebyl J, Simpson J et al.  Obstetrics . Philadelphia, Pa.: Elsevier; 2012.

By Robin Elise Weiss, PhD, MPH Robin Elise Weiss, PhD, MPH is a professor, author, childbirth and postpartum educator, certified doula, and lactation counselor.

Position and Presentation of the Fetus

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

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• Introduction
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Abnormal Fetal Lie and Presentation

Introduction.

The normal process of parturition relies in part, on the physical relationships between the fetus and maternal bony outlet. In addition, fetal posture, placental and cord locations, as well as maternal soft tissues also are factors in the efficiency and safety of the birth process.

This chapter discusses how to define, diagnose, and manage the clinical impact of abnormalities of fetal lie and malpresentation. The most common clinical correlation of the abnormal fetal lies and presentations is the breech-presenting fetus.

DEFINITIONS

In describing fetopelvic relationships, the clinician should carefully adhere to standard obstetrical nomenclature. Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother. The possibilities include a longitudinal lie, a transverse lie, and, on occasion, an oblique lie. Fetal presentation is a reference to the part of the fetus that is overlying the maternal pelvic inlet.

The most common relationship between fetus and mother is the longitudinal lie, cephalic presentation. A breech fetus also is a longitudinal lie, with the fetal buttocks as the presenting part. Breech fetuses also are referred to as malpresentations because of the many problems associated with them. Fetuses that are in a transverse lie may present the fetal back (or shoulders, as in the acromial presentation), small parts (arms and legs), or the umbilical cord (as in a funic presentation) to the pelvic inlet. In an oblique lie, the fetal long axis is at an angle to the bony inlet, and no palpable fetal part generally is presenting. This lie usually is transitory and occurs during fetal conversion between other lies.

The most dependent portion of the presenting part is known as the point of direction. The occiput is the point of direction of a well-flexed fetus in cephalic presentation. The fetal position refers to the location of the point of direction with reference to the four quadrants of the maternal outlet as viewed by the examiner. Thus, position may be right or left as well as anterior or posterior.

Fetal attitude refers to the posture of a fetus during labor. Mammalian fetuses have a tendency to assume a fully flexed posture during development and during parturition. Flexion of the fetal head on the chest allows for the delivery of the head by its smallest bony diameter. A loss of this flexed posture presents a progressively larger fetal head to the bony pelvis for labor and delivery (Fig. 1). The fetal arms and legs also tend to assume a fully flexed posture. The longitudinal posture of the fetus likewise is flexed under normal circumstances.

The mechanism of labor and delivery, as well as its inherent safety and efficacy, is determined by the specifics of the fetopelvic relationship at the onset of labor. Further correlations with fetopelvic relationships are important before birth.

The relative incidence of differing fetopelvic relations varies with diagnostic and clinical approaches to care. Among longitudinal lies, about 1 in 25 fetuses are not cephalic but breech at the onset of labor. 1 Of the differing lies a fetus may assume, about 1 in 100 is transverse or oblique, also referred to as nonaxial.

As pregnancy proceeds to term, most fetuses assume a longitudinal lie with relationship with the maternal outlet. Conversely, when labor and delivery are considered to be remote from term, the proportion of fetuses in abnormal and suboptimal locations increases ( Table 1 ).

Table 1. Breech presentation by gestational age

Transverse and oblique lies also are seen with greater frequency earlier in gestation. A fetus in a transverse lie may present the shoulder or acromion as a point of reference to the examiner. As term approaches, spontaneous conversion to a longitudinal lie is the norm. As seen with breech presentation, there is a rapid decrease in nonaxial lie during the third trimester. With the comprehensive application of ultrasound in the antepartum period, discovery of a transverse or oblique lie has increased. However, nonaxial fetal lies usually are transitory.

Abnormal fetal lie frequently is seen in multifetal gestation, particularly with the second twin. A transverse lie may be encountered with large discrepancies in fetopelvic parameters, such as exist with extreme prematurity and macrosomia. This tendency is greater in women of grand parity, in whom relaxation of the abdominal and uterine musculature is cited as the predisposing factor. Distortion of the uterine cavity shape, such as that seen with leiomyomas, prior uterine surgery, or developmental anomalies (Mullerian fusion defects), coexists with both abnormalities in fetal lie and malpresentation. Placental location also may play a contributing role. Fundal and cornual implantation are seen more frequently in breech presentation. Placenta previa is a well-described concomitant in both transverse lie and breech presentation. 2

Congenital anomalies of the fetus also are seen in association with abnormalities in either presentation or lie. 3 Whether a cause (as in fitting the uterine cavity optimally) or effect (the fetus with a neuromuscular condition that prevents the normal turning mechanism), the finding of an abnormal lie or malpresentation requires a thorough search for fetal maldevelopment. Abnormalities seen include chromosomal (autosomal trisomy) and structural abnormalities (hydrocephalus), as well as syndromes of multiple effects (fetal alcohol syndrome) ( Table 2 ).

Table 2. Anomalies frequently diagnosed in breech fetuses

Congenital anomalies of major structures are seen in 3–5% of all births. The incidence in breech delivery is three times greater when controlled for gestational age. Among premature breech infants, the incidence is even greater, as it is for all fetuses born prematurely.

Prematurity is a crucial factor in the incidence as well as the clinical implications of abnormal fetal lie and malpresentation. Fetal size and shape undergo dramatic change during the second and third trimester (Fig. 2, Table 3 ).

Table 3. Head circumference: abdominal circumference ratio by gestational age

SD, standard deviations (Adapted from Campbell S, Metreweli C [eds]: Practical Abdominal Ultrasound. Chicago, Year Book Medical Publishers, 1978)

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

Breech presentation is more common at earlier gestation and therefore is seen more frequently among low-birth weight infants 4 ( Table 4 ). Breech infants are more likely to be small for gestational age regardless of their gestation at delivery.

Table 4. Incidence of breech presentation by birth weight

The small size of the premature fetus is further compromised by the specific malpresentations that occur. With less neurologic and muscular control, deflexed or even extended varieties of fetal presentations are seen. Most common are the “incomplete” types of breech presentation, such as footling breech presentations (Fig. 3, Tables 5 and 6 ). Deflexion of the fetal head, more commonly seen in preterm fetuses, results in the potential for further compromise at delivery.

Table 5. Varieties of breech presentation

Table 6. Type of breech presentation in labor by gestational age

(Adapted from Gimovsky M, Petrie RH: Breech presentation. In Evans M, Fletcher J, Dixler A et al [eds]: Fetal Diagnosis and Therapy, pp 276–295. Philadelphia, JB Lippincott, 1989.)

Thus, the problems associated with abnormal lie and malpresentation are most frequent and of greatest consequence in preterm labor and delivery. At term, similar, though usually less dramatic, consequences may be seen with fetuses who are in abnormal positions.

PERINATAL MORBIDITY AND MORTALITY

Perinatal morbidity and mortality is threefold higher in breech presentation than cephalic presentation. Much of this excessive compromise is caused by factors that are not directly preventable. According to Kaupilla, 5 64% of deaths among term breech infants resulted from congenital malformations or infection. In a different population, Todd and Steer 6 found that 23 of 34 term breech deaths among 1006 term infants were not related to complications of breech delivery but were associated with anomalies, infection, and isoimmunization.

As noted earlier, preterm and small-for-gestational age infants commonly are associated with breech labor and delivery. As for term breech infants, experience indicates that most of the adverse outcomes seen are unrelated to breech delivery. Thus, for all breech fetuses, about one third of the excessive perinatal loss falls to birth trauma and asphyxia.

COMPLICATIONS AND COUNSELING

The complications associated with abnormal fetal lie and malpresentations include both maternal and fetal. As noted earlier, prematurity and malpresentation are strongly related. Circumstances in which premature birth may occur also include maternal complications such as pregnancy-induced hypertension and medical complications (cardiovascular, neoplastic), as well as obstetric problems such as premature rupture of membranes and chorioamnionitis. The circumstances dictating delivery may further compromise the preterm fetus.

The obstetric complications for the fetus include a diverse group of misadventures. Prolapse of the umbilical cord, intrauterine infection, maldevelopment as a result of oligohydramnios, asphyxia, and birth trauma all are concerns.

Birth trauma, particularly to the head and cervical spine, is a significant risk to both term and preterm infants who present as breech presentation or in a nonaxial lie. 7 , 8 , 9 Unlike the cephalic fetus in whom hours of adaptation to the maternal bony pelvis (molding) may occur, the after-coming head of the breech fetus must descend and deliver rapidly and without significant change in shape. Therefore, small alterations in the dimensions or shape of the maternal bony pelvis or the attitude of the fetal head may have grave consequences. As discussed earlier, this process is of greater risk to the preterm infant because of the relative size of the fetal head and body. Trauma to the head is not eliminated by cesarean section; both intracranial and cervical spine trauma may result from entrapment in either the uterine or abdominal incisions. 10

The fetus in the transverse lie, regardless of gestational age, generally requires cesarean delivery. At cesarean section, delivery may be aided by converting the fetus to a longitudinal lie for the delivery after entering the abdomen. This conversion may allow for the use of a transverse incision into the uterus instead of the more morbid vertical incision.

External cephalic version (ECV) should be considered in a nonlaboring patient. When the diagnosis is first made at term, spontaneous conversion to a longitudinal lie is less common than for its breech counterpart. This results from the higher incidence of structural causes for the transverse lie.

When abnormal presentation or lie occurs in a twin gestation, management includes a greater range of options. The conversion of a backup transverse second twin, either by internal or external version at the time of delivery, is an option for the experienced clinician. When the back is down at the time of delivery, the prudent course for the delivery of a fetus in transverse lie is by cesarean section. Strong consideration should be given to the incisions at delivery in this circumstance, with a vertical uterine incision being used liberally.

When a fetus in a transverse lie is diagnosed remote from delivery, as occurs at time of ultrasound, the physician is faced with an additional dilemma. Spontaneous rupture of membranes may result in cord prolapse or compromise with the risk of fetal asphyxia. Delivery at the time of antepartum ultrasound before term may result in jeopardy because of prematurity. External version, as a correction, may be attempted as long as ultrasound excludes placenta previa and documents an appropriate amount of amniotic fluid. Experience has demonstrated some success, although in general, the use of ECV is more likely to be successful for a breech-presenting fetus.

The patient should be carefully counseled about the problem and its inherent risks. Hospitalization and observation may be considered. However, the cost–benefit ratio in this era of managed care makes prolonged hospitalization unlikely under most circumstances. I recommend twice-weekly fetal surveillance to assess for cord compromise. The patient should be warned about the signs and symptoms of preterm labor and encouraged to present to labor and delivery should these conditions arise. Under certain circumstances, home uterine activity monitoring may provide a useful adjunct.

The antepartum diagnosis of persistent breech presentation is accompanied by similar concerns. In addition, careful evaluation for fetal anomalies is warranted. A targeted ultrasound by an experienced ultrasonographer is useful to diagnosis structural fetal defects and to ascertain appropriate fetal growth. Prenatal diagnosis by maternal screening or amniocentesis may be indicated.

When premature rupture of membranes occurs, consideration of a timely delivery should ensue. Depending on gestational age, amniotic fluid volume, and cervical evaluation, a limited course of tocolysis, antibiotics, and steroid administration may be indicated. When a fetus with an abnormal lie or malpresentation presents under these circumstances, hospital care is best managed within the confines of labor and delivery, where fetal surveillance can be maintained on a continual basis. This is indicated primarily because of the risk of cord prolapse or compromise. With severe oligohydramnios, the high incidence of intrauterine infection adds measurably to the risks of maintaining the fetus in utero, and an expedited delivery is warranted routinely.

INTRAPARTUM COMPLICATIONS AND COUNSELING

As previously discussed, the new intrapartum diagnosis of a transverse lie generally results in an expedited cesarean delivery. When a transverse lie is associated with prolapse of the umbilical cord, a true obstetric emergency may arise. Pelvic examination, with relief of pressure against the umbilical cord, should be performed and parenteral tocolysis administered if contraindications are not present. Changes in maternal positioning, particularly the lateral supine position, usually are well tolerated by both patient and practitioner.

Transport to a delivery room equipped for cesarean delivery should be accomplished promptly. When setup is complete, abdominal delivery is performed. A consideration for a limited attempt at version may play a role in this clinical scenario after anesthesia has been satisfactorily obtained.

Clinically more common is the diagnosis of a breech presentation at or near term. Prenatal visits in the third trimester should include Leopold maneuvers and should frequently include ultrasound as an adjunct. Also, they should always include the consideration that malpresentation may exist. The diagnosis of this situation before the onset of labor should be the goal because this allows for a larger and safer range of options. 11

After a diagnosis is confirmed, the patient deserves as thorough an explanation as is called for by the specific situation. She likely has heard, at least peripherally, that a breech baby means a mandatory cesarean section.

Whereas there is some truth in this simple association, I strongly believe that as the patient's advocate, physicians undertake the responsibility to provide a fuller discussion. Most breech fetuses at term are not a complex problem. Most do not have congenital anomalies or other adverse obstetric problems. Their potential problem centers on the risks of asphyxia and trauma during labor and delivery.

Clearly, this group of risks, however clinicians clinically work to minimize them, are best avoided if possible. Therefore, the diagnosis of breech presentation before labor allows the patient to undergo ECV and hopefully delivery as a cephalic fetus (Fig. 4). ECV is a time-honored approach to correct a “malpresentation.” It was used in the past as soon as the diagnosis of a breech fetus was made. This led to many second-trimester and early third-trimester procedures. Given the size of the fetus and the quantity of amniotic fluid present, it is not surprising that the failure rate was high. Because most of these fetuses would have spontaneously converted to cephalic presentations at the time of labor, using ECV resulted in many unnecessary procedures 12 ( Table 7 ).

Table 7. Spontaneous conversion of breech to cephalic presentation

(Adapted from Westgren M, Edvall H, Nordstrom L et al: Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol 92:19, 1985)

In fact, the earlier practitioners of the 20th century used sufficient force to avoid the need for a cesarean section under these circumstances that general anesthesia was used, as well as regional anesthesia and analgesics. Unfortunately, the great forces were associated with serious trauma to the placenta and uterus. Spontaneous rupture of both the uterus and the membranes, placental abruption, and fetal isoimmunization also were seen and resulted in the abandonment of this approach.

ECV performed on a fetus at term and in the absence of maternal anesthesia or analgesia made a return to practice in the 1970s. 13 , 14 By performing ECV at term, spontaneous conversion reduced the population at need for a cesarean section for breech presentation. 12 By performing ECV at term and within the labor and delivery area, means were available for immediate cesarean delivery if a problem ensued. Several groups have demonstrated a high degree of success with ECV in the late third trimester. 15 , 16 , 17

Even under these circumstances and safeguards, ECV is not entirely risk free. Although usually of no clinical consequence, fetal bradycardia is common during the procedure. Antepartum bleeding, isoimmunization, and fetal death (acute and remote) have been described. 18 Furthermore, conversion may cause deflexion of the fetal head or result in a funic presentation, either of which might require a cesarean delivery in and of itself. 19 , 20

If ECV fails or if the patient finds it unacceptable, at least two further choices remain. The first is delivery by cesarean section. If the patient is a candidate, the second is a selective trial of labor.

Once the diagnosis of breech presentation has been confirmed and attempts at ECV have failed, both patient and physician require a heightened effort at communication to ensure that a plan of care is established that is mutually acceptable. Potential risks for the breech fetus approaching term include umbilical cord prolapse, prolapse of the fetus before complete cervical dilation is achieved, and a rapidly progressive labor, with delivery imminent on arrival or even en route to labor and delivery.

Prolapse of the umbilical cord is an unusual complication in a term fetus in the early stages of labor. Because a breech fetus presents a smaller and less complete covering to the pelvic inlet, this risk is greater for all breech fetuses in comparison with all cephalic fetuses. Among breech fetus, the less complete the flexion of the lower extremities—such as occurs in footling breech presentations—the greater the risk.

Other factors, however, play a role in mitigating or increasing this risk. The nonasphyxiated fetus generally possesses a turgid umbilical cord, coated in Wharton jelly. With normal blood flow, cord prolapse is unlikely, regardless of position. Prolapse of the cord also is decidedly more common in the second stage of labor, when maternal expulsive efforts result in expression of the uterine contents ( Table 8 ).

Table 8. External cephalic version late in pregnancy

The exception occurs when the cord is located as the most dependent fetal part at the onset of labor, as seen in funic presentations. Ultrasound examination, in conjunction with color Doppler scan, can help to locate the exact position of the umbilical cord and should be performed at the time of ECV.

Prolapse of the fetus before achieving full cervical dilation, particularly in a rapidly progressive labor, is another concern. The fetus most likely to experience adverse consequences from this complication has a low birth weight and usually is preterm. 21 The breech fetus that is incomplete in flexion (the single- and double-footling varieties) has a greater tendency to prolapse under this premature descent. Unfortunately, this group is disproportionately represented in fetuses delivering preterm. The most common breech fetuses, frank and complete presentations, comprise most breech fetuses at term. Their risk of cord prolapse, or body prolapse before second stage, is only marginally greater than their cephalic counterparts. Thus, the patient and physician confronted with a frank or complete breech presentation at term and after a failed attempt at ECV should be reassured that although these risks exist, their occurrence is rare, in the order of 1 to 3 per 1000. 22

What about the woman with extremely rapid labor, or the patient who resides at a great distance from the hospital? Delivery of a breech fetus requires an experienced clinician to ensure the maximum safety of both infant and mother. Serious consideration should be given to induction of labor at term, after fetal lung maturation is assured. Cervical ripening and induction of labor may be conducted in the same manner as for a cephalic fetus. By scheduling the delivery of a breech fetus, either by cesarean section or by induction, the proper resources, both personnel and equipment, can be assured. 23 , 24

If a cesarean section is chosen, appropriate arrangements can be made, as delineated earlier in reference to a scheduled induction of labor. Cesarean section before the onset of labor avoids the additional risks of both cord prolapse and body prolapse before complete dilation and is associated with a lessened risk of anesthesia for the parturient. 25

INTRAPARTUM MANAGEMENT

Cesarean delivery has been liberally used to decrease perinatal mortality and morbidity for the breech fetus. The potential to avoid birth trauma and asphyxia led to its application to a greater extent even in the early part of the 20th century, when the safety of cesarean delivery was in greater question. As its use increased, the perinatal mortality associated with a live, nonanomalous fetus at term dropped dramatically 26 (Fig. 5).

Wright, in 1959, 27 called for the exclusive use of cesarean delivery for breech fetuses. In this and earlier eras, prematurity, low birth weight, or congenital anomalies went untreated or undertreated, and so the only group of breech fetuses that had a chance for survival were those infants born of normal weight at term. With the avoidance of intrapartum asphyxia or birth trauma sustained during delivery, the outcome could be improved. Indeed, a great difference in outcome was attributed by some to the risks of labor and delivery 28 ( Table 9 ).

Table 9. Outcome of breech infants weighing more than 2500 g, 1973–1980

(Adapted from Weingold AB: The Management of Breech Presentation. In Iffy L, Charles C [eds]: Operative Perinatology, pp 357–553. New York, Macmillan, 1984)

Although the liberal use of cesarean delivery is indicated for breech fetuses, there is concern about whether its routine use is warranted. In a study by Green and coworkers, 29 the rate of cesarean delivery for breech increased from 22% to 94% on the same medical service over a 15-year interval. Despite this extensive application of cesarean delivery, the perinatal outcome, as measured by evidence of asphyxia, trauma, or intrapartum death, was unchanged ( Table 10 ).

Table 10. Outcome of breech presenting fetuses at term by method of delivery

Cesarean delivery increases maternal morbidity and mortality, albeit to a lesser extent than in the past. The relative risks and benefits to both mother and infant should be presented by the physician to the patient ( Table 11 ). The cost, both economic and psychological, of cesarean delivery also has been debated. In past eras, a greater dollar cost was associated with abdominal delivery. With shorter stays and improved approaches to cesarean delivery, the difference has narrowed.

Table 11. Perinatal and maternal morbidity associated with breech labor and delivery

Another approach is the selective use of a trial of labor. By identifying which breech fetuses and mothers have the greatest predictable risk, cesarean delivery can be used for the group likely to have the greatest gain. By avoiding cesarean delivery in the low-risk pairings, use of cesarean delivery can be minimized, with subsequent savings to the health system of limited resources.

Many authors realize the potential benefits of such an approach. 30 , 31 , 32 At a 4% incidence and at 4 million births a year, some 160,000 pregnancies are complicated by a breech-presenting fetus at term on an annual basis. At a rate of cesarean delivery of about 90%, this results in 144,000 procedures, almost one-fifth that of cesarean delivery. By selecting a low-risk group for a trial of labor, the overall use of cesarean delivery for this indication might be reduced to 50%, saving more than 60,000 major surgeries a year, or 8% of the total cesarean deliveries performed.

This savings would be moot if there were a corresponding increase in perinatal morbidity and mortality associated with this practice shift. The available data on selective trials of labor support such an approach and suggest that the additional fetal risk is minimal and justified by the reduction in maternal morbidity and mortality.

Some of the factors for consideration in determining the risks for an individual patient already have been mentioned. Given the size and shape of the low birth weight breech fetus, most authors agree that fetuses who are breech and require delivery between 1000 and 2000 g are best served by cesarean delivery. The group of preterm fetuses weighing less than 1000 g and in need of delivery require individual assessment. The trauma to be avoided at vaginal delivery may occur at cesarean delivery. The need for vertical uterine incisions, which may require extension into the fundus, makes breech extraction difficult. This is particularly true in the presence of ruptured membranes. Entrapment of the after-coming head is of particular concern in this weight group. As outlined earlier, the head–abdomen ratio and the incidence if “incomplete” types of breech fetuses are predisposing factors. Entrapment occurs at both cesarean delivery and vaginal deliveries with these low birth weight infants. Delivery “en caul” may mitigate against head entrapment at cesarean delivery or vaginal delivery after the delivery of the small fetus.

At the other extreme, the macrosomic breech fetus also is an indication for cesarean delivery. Even with a favorable head–abdomen ratio at term, dystocia may be encountered with the delivery of either the fetal abdomen or after-coming head.

When the fetal head is extended, there is increased concern for the safety of delivery by either route. 8 , 33 A careful evaluation by radiograph or ultrasound should be a part of the predelivery examination of a patient with a breech fetus, regardless of the route of delivery chosen. 34 Extension of the after-coming head, diagnosed as an angle of greater than 105 degrees between the mandible and the cervical spine, may compromise the cervical spinal cord during delivery (see Fig. 1). Extension is uncommon (less than 5%) and may result from fetal goiter, a nuchal cord, or abnormalities of the shape of the uterine cavity. Additionally, extension may be caused by, or may be a sign of, fetal neurologic compromise, with an inability of the fetus to adequately flex his head on his chest. Extension should result in delivery by cesarean delivery. Extra care should be taken at cesarean delivery to cause the fetal head to flex during delivery by applying force on the fetal head during delivery. This ameliorates the tendency to fetal extension that occurs with the breech extraction used by some in a cesarean delivery. 35

Prolapse of the umbilical cord is decidedly rare in the first stage of labor. However, with single- and double-footling breech fetuses, the risk increases greatly during the second stage. Therefore, some authors exclude these specific types of breech fetuses from consideration for a trial of labor.

For the more common frank and complete types of breech presentation, the risk of cord prolapse is the same or only marginally greater than for a cephalic fetus. It is within this group, who constitute most breech fetuses at term, that a selective trial of labor will have the greatest benefit 36 ( Table 12 ).

Table 12. Selection characteristics for a trial of labor in a breech presentation

Measurement of the bony pelvis is performed to exclude borderline pelvic diameters. I advocate the use of radiologic measurement of the maternal bony pelvis. Computed tomography scan reliably measures pelvic dimensions and the attitude of the fetal head. Magnetic resonance imaging also has been successfully used in this setting. 37 The outcome of term breech delivery may be facilitated by only allowing a trial in women with pelvic measurements shown to be associated with successful breech delivery. 38 Todd and Steer, 6 in reviewing more than 1000 breech deliveries at term, demonstrated a critical difference in perinatal outcome when the pelvic inlet measured greater than 12 cm at the transverse of the inlet, and greater than 11 cm for the AP diameter. Gimovsky and associates 38 expanded this to include a midpelvic diameter of greater than 10 cm ( Table 13 ). Several authors have demonstrated the efficacy of this measure. 39 The use of computed tomography scanning results in a limited exposure of the fetus to ionizing radiation. 40 An additional benefit is the reproducibility and ease with which pelvic measurements may be obtained.

Table 13. Results of X-ray pelvimetry in a group of women undergoing a successful trial of labor under protocol

Typically, three views are obtained (Fig. 6). Because most patients will have undergone a failed attempt at ECV, I obtain pelvimetry at that time for the patient selected for a trial of labor. Patients in whom we are unable to convert a breech presentation are unlikely to undergo spontaneous conversion. Alternatively, pelvimetry may be obtained on presentation in early labor.

MANAGEMENT OF LABOR AND DELIVERY

When a trial of labor is undertaken with a breech-presenting fetus, it is crucial for an expedited cesarean delivery to be continuously available. The usual indicators of fetal well-being, as well as the adequacy of the progression of labor, will give rise to the indication for cesarean delivery on occasion. The criteria clinically used in supervising the labor of a cephalic fetus should be applied to the selected term breech fetus. In my experience, as well as others, cervical ripening, oxytocin induction, and partographic analysis of labor are safe and efficacious. Augmentation, when indicated, should call for a thoughtful re-evaluation of all aspects of the situation. For example, is the fetal size less than 4000 g? Has descent occurred progressively during the second stage? Have adequate maternal expulsive efforts failed to effect “crowning?” Oxytocin augmentation should be used only after an internal pressure transducer indicates inadequate contractions. Cesarean delivery should be used liberally in all other circumstances.

Fetal surveillance during labor and delivery should be continuous. After spontaneous rupture of membranes, internal monitoring may be used. Fetal heart rate patterns, particularly in the second stage of labor, may have pronounced variable decelerations. In breech labor and delivery, compromise to the umbilical circulation may be more frequent but generally is without sequelae. In addition, the intensity and duration of vagal stimulation with its concomitant effects on the fetal heart rate is different than in cephalic labor and delivery. Study of acid–base status at birth demonstrates a tendency to respiratory acidosis in breech vaginal delivery. This might explain a greater proportion of infants with lower Apgar scores at 1 minute. However, the base deficit in these infants generally is within the normal range. 41

Anesthesia considerations dictate the usefulness of regional anesthesia, as opposed to earlier approaches that used a combination of local and general techniques. As shown by Crawford, 42 regional anesthesia prevents premature maternal expulsive efforts, which should enhance the safety of delivery ( Table 14 ).

Table 14. Effect of anesthesia on breech delivery

(Adapted from Weingold AB: The Management of Breech Presentation. In Iffy L, Charles D [eds]: Operative Perinatology, pp 537–553. New York, Macmillan, 1984)

The second stage of labor should be managed under double-setup conditions. A gowned and gloved assistant, as well as anesthesia and pediatrics personnel, should be present. The patient should be instructed and encouraged to push effectively. The fetal heart rate should be continuously monitored. A nullipara should be allowed to push for up to 2 hours, a multipara up to 1 hour. If delivery is not imminent, cesarean delivery should be performed, the diagnosis being a failure of descent.

After lateral flexion of the trunk, the anterior hip is forced against and underneath the symphysis. Expulsion follows, with delivery of the anterior and then the posterior buttock. During “crowning,” an episiotomy should be performed to facilitate delivery.

Using a modified Bracht maneuver, a warm wet towel is placed around the fetal abdomen, and the fetus is grasped on the posterior aspect of the fetal pelvic girdle with care to avoid the fetal kidneys and adrenal. A gentle downward traction is exerted.

After the buttocks are fully expulsed, the back is born by rotation anteriorly. This allows the shoulders to enter the pelvis in the transverse diameter of the pelvic inlet. If there is a failure of anterior rotation, the fetus will be born as a posterior breech, and the sequence of maneuvers used to help in delivery will differ as appropriate.

As the anterior shoulder is seen at the introitus, the operator sweeps the right humerus across the infant's chest. Gentle rotation allows for the posterior shoulder and humerus to be born, completing the Løvset maneuver (Fig. 7).

With the infant delivered to the umbilicus, some authors recommend the use of uterine relaxants to facilitate the remainder of the delivery. The use of general anesthesia with halothane has been supplanted by parenteral betamimetics. We have used small aliquots of intravenous nitroglycerin for this purpose. 43 , 44

Delivery of the after-coming head follows with manual aid or forceps.

A Mauriceau–Smellie–Viet maneuver follows (Fig. 8). The fetus is placed abdomen down on the operator's right arm. The left hand supports the fetal neck. The index and middle fingers of the right hand are placed on the fetal maxilla to help maintain flexion of the head. The assistant may apply suprapubic pressure to expel the after-coming head (Naujok maneuver; Fig. 9). When delivery is further complicated by rotation of the fetal back posteriorly, a Prague maneuver allows for delivery of the occiput posterior breech variant.

Forceps may be used to facilitate delivery of the after-coming head (Fig. 10). Maintenance of head flexion is crucial. Traction is not required. The Piper forceps are specially designed for this task 45 and act as a class 1 lever. Because the fetal head is visible and should be aligned as in an occiput anterior position, any outlet forceps that may be applied as a simple pelvic application are indicated. Elliott forceps are particularly useful in this situation. Use of forceps may be helpful in a nulligravida or when the fetus is small and at term (less than 2500 g).

The infant then should be handed to the pediatrician in attendance. A segment of umbilical cord for acid–base analysis should be routinely obtained. Attention then can be directed to completion of the third stage of labor, as well as the repair of the episiotomy and genital tract lacerations.

A full dictated operative note should be completed at the time of delivery. The entire process of the labor, delivery, and immediate neonatal outcome should be referenced. Mention of each specific step is warranted, along with clinical observations regarding the relative ease or difficulty of the delivery process.

CESAREAN DELIVERY

Most breech-presenting fetuses will be born by cesarean delivery. Attention to the details of delivery are of no less consequence in this group.

When cesarean delivery is selected, the fetus should be evaluated before surgery using bedside ultrasound examination. A careful review of the fetus to diagnose extension of the head, the presence or absence of nuchal arms, and the location of the placenta should be made. Although estimates of fetal weight may be less accurate for breech-presenting fetuses, an estimated fetal weight should be made using a standardized formula. 46 Amniotic fluid volume and location of the umbilical cord also should be observed.

These observations may be important in understanding neonatal concerns after cesarean delivery. They allow both physician and patient to estimate the fetal condition just before birth. Important observations that have been confirmed before delivery include the presence of abnormal postures, broken bones, and the occasional transverse lie (or even an undiagnosed second twin).

Cesarean delivery should be expedited if the patient is in labor. Short-term tocolysis has been used so that the most appropriate anesthesia can be administered. Emergency cesarean delivery, with the greater risks of morbidity for both mother and child, should be chosen as a last resort.

The abdomen generally is opened with a transverse-type incision. Surgical choice of incision may vary by maternal habitus, prior surgery, or operator preference. Any incision may be used, as long as adequate visualization occurs and mobilization of the fetus is expedited.

Palpation of the uterus before the uterine incision should confirm the presentation. A low cervical transverse incision should be made carefully in the midline and extended to a depth necessary to expose the membranes. This is easier to do in practice if the membranes are intact. The important point is that the fetus may be incidentally incised if care is not taken. The infant born by cesarean delivery should be carefully examined after birth in this regard.

The fetus should be rotated (if necessary) so that the back is anterior before delivery. The assistant applies fundal pressure as the operator guides the buttocks up through the uterine incision. The use of force on the fundus allows the after-coming head of the breech fetus to remain in a flexed attitude. This approach also should minimize the loss of flexion of the fetal arms, which may result in a nuchal displacement.

A warm, wet towel is wrapped around the fetal abdomen to protect the fetus from traumatic injury and to mitigate against the onset of breathing movements before delivery.

Thus, by the use of an assistant giving fundal pressure, delivery of a breech fetus at cesarean delivery mirrors an assisted vaginal breech delivery. Avoid total breech extraction at cesarean delivery: it is inherently more of a risk to the fetus than an assisted or spontaneous breech delivery.

As with vaginal delivery, a section of umbilical cord should be sent for acid–base status. Attention is given to the description of the delivery process within the operative report.

PERINATAL OUTCOME

The most important factor in neonatal outcome for all infants is gestational age. This also is true for breech infants.

Many series, generally retrospective, some aided by meta-analysis, have studied the effect of mode of delivery on both immediate and long-term outcome. In the absence of congenital anomalies, laboring fetuses born ultimately by cesarean or vaginal delivery have similar outcomes, which are determined by gestational age and weight. Prolapse of the umbilical cord that occurs before hospitalization or goes unrecognized, although uncommon at term, plays a serious and compromising role for preterm infants. Such also is the case for prolapse of the fetal body through an incompletely dilated cervix. Entrapment of the after-coming head may have serious adverse consequences for the infant who likewise is preterm. This may occur at either cesarean or vaginal delivery.

Infants who are born immediately after admission to labor and delivery also have the greatest risk of asphyxia- and trauma-related injuries manifest in the immediate neonatal period. Women and their fetuses in whom breech presentation is not detected until labor, and who ultimately are delivered by cesarean delivery are subject to the greatest risk of maternal morbidity. 47

Regardless of the rate of cesarean delivery, breech infants have an increased risk of perinatal and neonatal morbidity and mortality. Cesarean delivery plays a role in decreasing but not eliminating this problem. Breech-presenting infants have higher rates of neurologic sequelae than their cephalic peers. The route of delivery plays little role in this difference. 48 .

The International Term Breech Trial 47 , 48 , 49 was undertaken to determine the best approach to term breech delivery management. This trial proved to be limited and controversial in several repects 49 and, subsequently, the PREMODA trial 50 was reported. With a much larger cohort studied, the authors determined that there was no difference in the neonatal outcome between vaginal and cesarean delivery in the term frank breech fetus. Consequently, the American College of Obstetricians and Gynecologists issued a revised Committee Opinion (#340, July 2006) concluding that with adaptation of strict protocol management and based on provider experience, a trial of labor for the term frank breech fetus was an acceptable option. 51 A Practice Bulletin from the Society of Obstetricians and Gynecologists of Canada in 2009 was in agreement with this selective approach to delivery management. 52  

The issues encountered in attempting to reach the optimal outcome for every pregnancy complicated by breech presentation include psychological, sociologic, and societal values. A strictly medical paradigm cannot perfectly fit each individual situation. Thus, a variety of approaches conform to the standard of care for medical practice. Resident training in breech delivery should include both the approach to delivery at cesarean section as well as vaginal delivery. 53 All parties involved must understand the risks and benefits of any suggested approaches. Because economic concerns have been emphasized more, a shift of decision making from the individual patient–physician pair to the consideration of the entire population has occurred. Both strategies must be made consistent.

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Malpresentation

8-minute read

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

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

What are presentation and malpresentation?

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

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

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

It’s safest for your baby’s head to come out first. If any other body part goes down the birth canal first, the risks to you and your baby may be higher. Malpresentation increases the chance that you will have a more complex vaginal birth or a caesarean.

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

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

Breech presentation

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

Breech presentation is the most common type of malpresentation.

Face presentation

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

Transverse lie

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

Oblique lie

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

Unstable lie

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

Cord presentation

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

What is malposition?

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

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

Why might my baby be in the wrong position?

Malpresentation may be caused by:

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

Often no cause is found.

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

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

You are more likely to have a malpresentation if:

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

How is malpresentation diagnosed?

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

Can my baby’s position be changed?

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

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

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

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

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

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

Your doctor can talk to you about your options. Whether it’s safe for you to try a vaginal birth will depend on many factors. These include how big your baby is, the position of your baby, the structure of your pelvis and whether you’ve had a caesarean in the past.

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

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

Vaginal breech birth

Risks to your baby can include:

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

Risks to you include:

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

Risks to your baby include:

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

Will I have a malpresentation in my future pregnancies?

If you had a malpresentation in one pregnancy, you have a higher chance of it happening again, but it won’t necessarily happen in future pregnancies. If you’re worried, it may help to talk to your doctor or midwife so they can explain what happened.

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Last reviewed: July 2022

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

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Abnormal Fetal Position and Presentation

Under normal circumstances, a baby is in the vertex (cephalic) position before delivery. In the vertex position, the baby’s head is at the lower part of the abdomen, and the baby is born head-first. However, some babies present differently before delivery. In these cases, abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma (1). Types of abnormal fetal positions and presentations include the following. We’ll cover each in more detail on this page.

What is the difference between fetal presentation and position?

In the womb, a fetus has both a presentation and a position . Presentation refers to the baby’s body that leads, or is expected to lead, out of the birth canal (9). For example, if a baby’s rear is set to come out of the birth canal first, the baby is said to be in “breech presentation.” Position refers to the direction the baby is facing in relation to the mother’s spine (9). A baby could be lying face-first against a mother’s spine, or face up towards the mother’s belly.

What way should a baby come out during birth?

Vertex presentation is the ‘normal’ way that a baby is positioned for birth and the lowest-risk presentation for vaginal birth (1). In vertex presentation, the baby is positioned head-first with their occiput (the part of the head close to the base of the skull) entering the birth canal first. In this position, the baby’s chin is tucked into their chest and they are facing the mother’s back (occipito-anterior position). Any position other than vertex position is abnormal and can make vaginal delivery much more difficult or sometimes impossible (2). If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury (1).

What happens if a baby isn’t in the standard vertex position during birth?

Before delivery, it is critical that the fetus is in the standard vertex presentation and within the normal range for weight and size. This helps ensure the safety of both baby and mother during labor. When the baby’s size or position is abnormal, physician intervention is usually warranted (1). This may mean simple manual procedures to help reposition the baby or, in many cases, a planned C-section delivery . The failure of healthcare professionals to identify and quickly resolve issues related to fetal size, weight, and presentation is medical malpractice . There are numerous complications related to abnormal weight, size, abnormal position, or abnormal presentation.

Compound presentation

In the safest presentation (vertex presentation), the baby is born head first, with the rest of the body following. In a compound presentation, however, there are multiple presenting parts. Most commonly, this means that the baby’s head and an arm come out first at the same time. Sometimes compound presentation can occur with twins where the head of the first twin presents with the extremity of the second twin (3).

Risk factors for compound presentation include (3):

• Prematurity
• Intrauterine growth restriction (IUGR)
• Multiple gestations ( twins , triplets, etc.)
• Polyhydramnios
• A large pelvis
• External cephalic version
• Rupture of membranes at high station

Compound presentations can be detected via ultrasound before the mother’s water breaks. During labor, compound presentation is identified as an irregular finding during a cervical examination (3).

If a mother has polyhydramnios, the risk of compound presentation is higher, as the flow of amniotic fluid when the membranes rupture can sweep extremities into the birth canal, or cause a cord prolapse , which is a medical emergency (3). If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency (3). Often, the safest way to deliver a baby with compound presentation is C-section, because complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy , intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE) (3).

Limb presentation

Limb presentation during childbirth means that the part of the baby’s body that emerges first is a limb – an arm or a leg. Babies with limb presentation cannot be delivered safely via vaginal delivery; they must be delivered quickly by emergency C-section (4). Limb presentation poses a large risk for dystocia (the baby getting stuck on the mother’s pelvis), which is a medical emergency.

Occipitoposterior (OP) position

Approximately 1 out of 19 babies present  in a posterior position rather than an anterior position. This  is called an occipitoposterior (OP) position or occiput posterior position (3)  In OP position, the baby is head-first with the back part of the head turned towards the mother’s back, rotated to the right  (right occipitoposterior position, or ROP), or to the left (left occipitoposterior position, or LOP) of the sacroiliac joint. Occipitoposterior position increases the baby’s risk of experiencing prolonged labor , prolapsed umbilical cord , and use of delivery instruments, such as forceps and vacuum extractors (5). These conditions can cause brain bleeds , a lack of oxygen to the brain, and birth asphyxia .

When OP position is present, if a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section (5).  A C-section can help prevent oxygen deprivation caused by prolonged labor, umbilical cord prolapse, or forceps and vacuum extractor use.

A nurse explains posterior position

Breech presentation

Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should turn to the cephalic position in time for labor. Breech presentation occurs when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because when vaginal delivery is attempted, a baby is at increased risk for prolapsed umbilical cord, traumatic head injury, spinal cord fracture, fatality, and other serious problems with labor (6).

There are 4 types of breech positions:

• Footling breech presentation : In footling position, one or both feet enter the birth canal first, with the buttocks at a higher position than the feet.
• Kneeling breech presentation : This is when the baby has one or both legs extended at the hips and flexed at the knees.
• Frank breech presentation : This is when the baby’s buttocks present first, the legs are flexed at the hip and extended at the knees, and the feet are near the ears.
• Complete breech presentation : In this position, the baby’s hips and knees are flexed so that the baby is sitting cross-legged, with the feet beside the buttocks.

When a baby is in breech position, physicians often try to maneuver the baby into a head-first position. This should only be attempted if fetal heart tracings are normal (the baby is not in distress ) (7). The only type of breech position that may allow for a vaginal delivery is frank breech , and the following conditions must be met:

• The baby’s heart rate is being closely monitored and the baby is not in distress.
• Cephalopelvic disproportion (CPD) is not present; x-rays and ultrasound show that the size of the mother’s pelvis will allow a safe vaginal birth.
• The hospital is equipped for and the physician is skilled in performing an emergency C-section .

If these conditions are not present, vaginal birth should not be attempted. Most experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth injuries (6). Mismanaged breech birth can result in the following conditions:

• Brain bleeds, intracranial hemorrhages
• Spinal cord fractures
• Hypoxic-ischemic encephalopathy (HIE)
• Cerebral palsy
• Intellectual disabilities
• Developmental delays

Face presentation

A face presentation occurs when the face is the presenting part of the baby. In this position, the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. This prevents head engagement and descent of the baby through the birth canal. In some cases of face presentation, the trauma of a vaginal delivery causes face deformation and fluid build-up (edema) in the face and upper airway, which often means the baby will need a breathing tube placed in the airway to maintain airway patency and assist breathing (1).

Image by healthhand.com

There are three types of face presentation:

• Mentum anterior (MA) : In this position, the chin is facing the front of the mother.
• Mentum posterior (MP) : The chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, the baby’s head, neck, and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
• Mentum transverse (MT) : The baby’s chin is facing the side of the birth canal in this position.

Trauma is very common during vaginal delivery of a baby in face presentation, so parents must be warned that their baby may be bruised and that a C-section is available to avoid this trauma.

Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position (1). Safe vaginal delivery of a term-sized infant in persistent MP position is impossible due to the presenting part of the baby compared to the size of the mother’s pelvis (1). Babies in MP position must be delivered by C-section. Babies in MT position must also be delivered by C-section. Some babies in the MP and MT positions will spontaneously convert to the MA position during the course of labor, which makes vaginal delivery a possibility. If the baby is in the MA position and vaginal delivery is able to proceed, engagement of the presenting part of the baby probably will not occur until the face is at a +2 station (1).

The management of face presentation requires close observation of the progress of labor due to the high incidence of CPD with face presentation. In face presentation, the diameter of the presenting part of the head is, on average, 0.7 cm greater than in the normal vertex position (1).

In any face presentation situation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section. In fact, when face presentation occurs, experts recommend liberal use of C-section (1).

Since there is an increased risk of trauma to the baby when the face presents, the physician should not try to rotate the baby internally. In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to extract the baby from the uterine cavity. Outlet forceps should only be used by experienced physicians; these forceps increase the risk of trauma and brain bleeds. In almost all clinical circumstances a cesarean delivery is the safest method of delivery.

Listed below are complications that can occur if face presentation is mismanaged by the medical team:

• Prolonged labor
• Facial trauma
• Facial and upper airway edema (fluid build-up in the face, often caused by trauma)
• Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
• Respiratory distress or difficulty in ventilation (the baby being able to move air in and out of lungs) due to upper airway trauma and edema
• Spinal cord injury
• Abnormal fetal heart rate patterns
• 10-fold increase in fetal compromise
• Brain bleeds
• Intracranial hemorrhages
• Permanent brain damage

Brow presentation

Brow presentation is similar to face presentation, but the baby’s neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backward. As the term “brow presentation” suggests, the brow (forehead) is the part that is situated to go through the pelvis first. Vaginal delivery can be difficult or impossible with brow presentation, because the diameter of the presenting part of the head may be too big to safely fit through the pelvis.

Risk factors and conditions associated with brow presentation

Brow presentation has been linked to several risk factors and co-occurring conditions. These include:

• Multiparity (having previously given birth)
• Premature delivery
• Fetal anomalies such as anencephaly (an absence of major parts of the brain and skull) or anterior neck mass (a growth on the front of the neck)
• Previous c-section delivery
• Polyhydramnios (excessive amniotic fluid: infants swallow amniotic fluid while in utero, but this may be difficult if their neck is extended)

Diagnosis of brow presentation

Brow presentation can often be diagnosed through a vaginal examination during labor. If there are no conclusive signs from the physical examination alone, an ultrasound can also be used. Warning signs of brow presentation may include signs of fetal distress or lack of labor progression.

Management of brow presentation

Infants who assume a brow presentation early in labor may spontaneously move into a more optimal position during the delivery process. Additionally, safe delivery in brow presentation may be possible if the infant is unusually small and/or the mother’s pelvic opening is unusually large. For these reasons, physicians occasionally recommend vaginal delivery of infants in brow presentation.

Doctors attempting vaginal delivery of a baby in brow presentation must be very careful to watch for signs of fetal distress (such as an abnormal heart rate), and to monitor the progression of labor. Prolonged labor can cause extended periods of fetal oxygen deprivation, which can cause birth asphyxia and permanent injury. Signs of fetal distress can indicate that a baby is in danger of sustaining serious brain damage if action is not quickly taken to prevent this. If an infant in brow presentation begins to show signs of distress, or if labor progress stops or slows significantly, physicians should be ready to move on to a cesarean delivery.

Labor induction or augmentation with the drug Pitocin (synthetic oxytocin) is very dangerous in cases of brow presentation. Pitocin can lead to excessive uterine contractions, which can put pressure on the infant’s head and cut off their oxygen supply; this is especially risky when safe fetal descent is already compromised, such as in cases of brow presentation.

Complications of brow presentation

If brow presentation is diagnosed in a timely fashion and is appropriately managed, there are typically no serious negative effects on the mother or baby. However, if medical professionals fail to recognize brow presentation and intervene as necessary, there can be lasting consequences. Infants may suffer  oxygen deprivation  due to prolonged labor, or  traumatic injuries from a difficult delivery. Some of the most severe conditions resulting from mismanaged brow presentation births include:

• Hypoxic-ischemic encephalopathy
• Periventricular leukomalacia
• Seizure disorders
• Developmental disabilities

Shoulder presentation (transverse lie)

Shoulder presentation (transverse lie) is when the arm, shoulder or trunk of the baby enter the birth canal first. When a baby is in a transverse lie position during labor, C-section is almost always used as the delivery method (8).  Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa, or have a baby with intrauterine growth restriction (IUGR) are more likely to have a baby in the transverse lie position (8). Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position; thus, a C-section should ideally be performed before the membranes break (8). Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe birth asphyxia due to cord compression and trauma to the baby. This can cause hypoxic-ischemic encephalopathy (HIE), seizures, permanent brain damage, and cerebral palsy.

Legal help for birth injuries from abnormal position or presentation

The award-winning birth injury attorneys at ABC Law Centers: Birth Injury Lawyers have over 100 years of joint experience handling birth trauma cases related to abnormal position or presentation. If you believe your loved one’s birth injury resulted from an instance of medical malpractice, you may be entitled to compensation from a medical malpractice or personal injury case. During your free legal consultation, our birth injury attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you.

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• Julien, S., and Galerneau, F. (2017). Face and brow presentations in labor. Retrieved from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor .
• World Health Organization, UNICEF, and United Nations Population Fund. Malpositions and malpresentations. Retrieved from http://hetv.org/resources/reproductive-health/impac/Symptoms/Malpositions__malpresetations_S69_S81.html .
• Barth, W. (2016). Compound fetal presentation. Retrieved from https://www.uptodate.com/contents/compound-fetal-presentation .
• Gabbe, S.G., … Grobman, W.A. (2017). Compound Presentation. Retrieved from https://expertconsult.inkling.com/read/gabbe-obstetrics-normal-problem-pregnancies-7e/chapter-17/compound-presentation .
• Argani, C.H. and Satin, A.J. (2018) Occiput posterior position. Retrieved from https://www.uptodate.com/contents/occiput-posterior-position .
• Hofmeyr, G.J. (2018). Overview of issues related to breech presentation. Retrieved from https://www.uptodate.com/contents/overview-of-issues-related-to-breech-presentation .
• Hofmeyr, G.J. (2017). Delivery of the fetus in breech presentation. Retrieved from https://www.uptodate.com/contents/delivery-of-the-fetus-in-breech-presentation .
• Strauss, R.A. (2017). Transverse fetal lie. Retrieved from https://www.uptodate.com/contents/transverse-fetal-lie .
• Moldenhauer, J.S. (2018). Abnormal Position and Presentation of the Fetus. Retrieved from https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/abnormal-position-and-presentation-of-the-fetus .

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

• Variations in Fetal Position and Presentation |

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

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

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

Occiput posterior position

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

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

Breech presentation

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

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

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

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

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

Labor starts too soon (preterm labor).

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

Other presentations

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

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

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

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

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FETAL PRESENTATION

the way the fetus is oriented during the birth process, specifically whether the fetus is exiting the birth canal head first or not. A breech birth means the baby is coming buttocks first.

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Fetal Station Maternity Nursing Review

This review will cover fetal station in preparation for maternity nursing exams.

For exams, you want to be familiar with how to interpret fetal station measurements and the meaning of the measurement. In this review you will learn:

• What is fetal station?
• How it’s measured?
• How to identify and interpret fetal station

Fetal Station Lecture for Maternity Nursing

Fetal station review.

Fetal means baby and station means location or position.

Therefore, fetal station is where the baby’s presenting part is located in the pelvis.

What is a presenting part? The presenting part is usually the head, but can be other parts of the baby like the foot etc. In a nutshell, it is whatever part of the baby that is closest to the exit of the uterus, which is the internal os of the cervix. This structure is the “doorway” that allows the baby to leave the uterus.

How is fetal station measured?

• This measurement gives us an idea of how much the baby has descended down into the pelvis. Example: whether the baby is engaged (lightening has occurred…meaning the head or presenting part has entered into the pelvic inlet and is at the ischial spines…meaning fetal station is 0).
• It also helps the healthcare team be prepared for the delivery of the baby.
• It will look at the amount of cm from the top of the ischial spine line and bottom of the ischial spine line. Therefore, we are assessing 5 cm from the top of the ischial spine line to 5 cm below the ischial spine line
• However, fetal station is not referred to in centimeters but as minus or plus numbers.
• If the baby’s presenting part is at 5 cm above the ischial spines…the fetal station would be –5 .
• If the baby’s presenting part is at 2 cm above the ischial spines…the fetal station would be -2 .
• If the baby’s presenting part is at the ischial spines …the fetal station would be 0 . Remember this is referred to as the engagement of the baby and tends to happen around 38 weeks for first time moms, but later for women who’ve had other babies.
• If the baby’s presenting part is at 1 cm below the ischial spines…the fetal station would be +1.
• When fetal station is 4 cm (+4) or 5 cm (+5) baby’s birth is very near so be prepared for delivery.

Test your knowledge: Fetal Station Quiz

References:

Labor and birth | Womenshealth.gov. Retrieved 7 February 2020, from https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/labor-and-birth

Your baby in the birth canal: MedlinePlus Medical Encyclopedia. Retrieved 7 February 2020, from https://medlineplus.gov/ency/article/002060.htm

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Fetal alcohol syndrome.

Demetrios Vorgias ; Francine D. Bynum ; Bettina Bernstein .

Affiliations

Last Update: May 27, 2023 .

• Continuing Education Activity

Fetal alcohol syndrome is one of the five disorders that comprise fetal alcohol spectrum disorders (FASD). These fetal alcohol spectrum disorders classify the wide-ranging physical and neurological effects that prenatal alcohol exposure can inflict on a fetus. This activity describes the pathophysiology, evaluation, and management of fetal alcohol syndrome and highlights the role of the interprofessional team in preventing this pathology.

• Review the epidemiology of fetal alcohol syndrome.
• Describe the presentation of a patient with fetal alcohol syndrome.
• Outline the management options for fetal alcohol syndrome.
• Describe interprofessional team strategies for improving coordination and communication to advance the prevention of fetal alcohol syndrome.
• Introduction

Fetal alcohol syndrome is one of a spectrum of disorders under the umbrella term of fetal alcohol spectrum disorder (FASD). There is a total of five disorders that comprise fetal alcohol spectrum disorders. They are fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND), a neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE), and alcohol-related birth defects (ARBD). All of these fetal alcohol spectrum disorders are used to classify the wide-ranging physical and neurological effects that prenatal alcohol exposure can inflict on a fetus. [1] [2]

All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a fetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the fetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder. [3] [4] [5]

Risk Factors

• Women more than age 30 with a long history of alcohol are more likely to give birth to an infant with fetal alcohol syndrome
• Poor nutrition
• Having one child with fetal alcohol syndrome increases the risk for subsequent children
• Women with genetic susceptibility may metabolize alcohol slowly may be at a higher risk
• Epidemiology

Prenatal alcohol exposure is the leading cause of preventable congenital disabilities. Because the presentation of fetal alcohol spectrum disorders can vary so widely, and because of recent changes to the diagnostic criteria that define these conditions, the exact prevalence is difficult to determine. Across the United States, in the 1980s and 1990s, fetal alcohol syndrome was estimated to occur in the range of 0.5 to 2 cases per 1000 live births. However, it is widely accepted that these studies underreported the problem as the other conditions that comprise fetal alcohol spectrum disorders were not defined at the time and thus not recognized. Using the more recent definitions of fetal alcohol spectrum disorders that take into account the wide range of effects that prenatal alcohol exposure can elicit, recent studies in the United States have shown that currently, fetal alcohol syndrome ranges from six to nine cases per 1000. Fetal alcohol spectrum disorders range from 24 to 48 cases per 1000. The higher ends of these ranges are seen in high-risk populations such as those with low socioeconomic status and those of racial and ethnic minority populations. American Indians have some of the highest rates overall. The prevalence of fetal alcohol syndrome has been reported to be as high as 1.5% among children in the foster care system. [6] [7]

In many cases, prenatal alcohol exposure is unintentional because women continue their normal drinking patterns before they know they are pregnant. Most women stop drinking alcohol once made aware of their pregnancy. Despite this fact, 7.6% of women report continued drinking during pregnancy.

• Pathophysiology

The exact mechanism by which alcohol causes its teratogenic effects is not known. For obvious ethical reasons, formal studies on the effects of alcohol on human brain development are limited. Most of our data come from animal models and associations with alcohol exposure.

We do know that alcohol is a teratogen that causes irreversible damage to the central nervous system (CNS). From associations with alcohol exposure, we are aware that that damage is widespread, causing not only a decrease in brain volume but also damage to structures within the brain. We also know from associations that high levels of alcohol consumption in the first trimester resulted in an increased likelihood of facial and brain anomalies. High levels of alcohol consumption in the second trimester are associated with increased incidences of spontaneous abortions. Lastly, in the third trimester, high levels of alcohol consumption are associated with decreased height, weight, and brain volume. Associations with alcohol exposure show that the neurobehavioral deficits associated with fetal alcohol spectrum disorders can occur within a wide range of exposure to alcohol and at any point in the pregnancy.

From animal models, we know that prenatal alcohol exposure affects all stages of brain development through a variety of mechanisms, the most significant of which result in cognitive, motor, and behavioral dysfunction.

• Toxicokinetics

According to an article by Zhang et al., in the November 5, 2017 issue of  Toxicology Letters, animal research that exposed the chick embryo to alcohol may help to understand the exact etiology of brain injury in fetal alcohol spectrum disorder. The cranial neural crest cells (NCCs) contribute to the formation of the craniofacial bones. Exposure to 2% ethanol (alcohol) induced craniofacial defects in the developing chick fetus. Immunofluorescent staining revealed that ethanol treatment downregulated Ap-2, Pax7, and HNK-1 expressions by cranial NCCs. The use of double-immunofluorescent stainings for Ap-2/pHIS3 and Ap-2/c-caspase 3 showed that alcohol treatment inhibited cranial NCC proliferation and increased NCC apoptosis. Alcohol exposure of the dorsal neuroepithelium increased laminin, N-cadherin, and cadherin 6B expressions while Cadherin 7 expression was repressed. In situ hybridization also revealed that ethanol treatment up-regulated cadherin 6B expression but down-regulated slug, Msx1, FoxD3, and BMP4 expressions, thus affecting proliferation and apoptosis.

• History and Physical

Because prenatal alcohol exposure has multiple effects on multiple organ systems, history, and physical findings associated with fetal alcohol spectrum disorders vary widely. In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation. However, the different conditions under fetal alcohol spectrum disorders have different diagnostic criteria, and some require documentation of maternal alcohol use during pregnancy.

In general, the physical findings that should raise the index of suspicion for fetal alcohol spectrum disorders are the characteristic facial features of short palpebral fissures, a thin vermillion border, and a smooth philtrum. In-utero and postnatal growth retardation and microcephaly are also highly prevalent in children with prenatal alcohol exposure. Other common physical features that are associated with but not diagnostic of fetal alcohol spectrum disorders are maxillary hypoplasia, micrognathia, decreased interpupillary distance, among many others. Structural defects may also occur in the cardiovascular, renal, musculoskeletal, ocular, and auditory systems.

Like the physical findings, the CNS system deficits associated with fetal alcohol spectrum disorders can vary widely. They can range from irritability, jitteriness, and developmental delays in infancy to hyperactivity, inattention, and learning disabilities in childhood that can be misdiagnosed as simple attention-deficit hyperactivity disorder (ADHD). In adolescence, the CNS abnormalities can manifest themselves in a number of ways from poor coordination, abnormal reflexes, poor academic performance, impaired problem-solving, poor social skills, deficiencies in executive functions such as cognitive planning and concept formation, poor understanding of consequences of actions, difficulties with the activities of daily living and problems with impulse control which can manifest, disrupting school, inability to maintain employment, or inappropriate sexual behavior.

The history that is associated with undiagnosed fetal alcohol spectrum disorders is fairly wide. In neonates, it is crucial to get a good prenatal history to determine prenatal alcohol exposure. For older children and young adults, the primary indicative history will be those areas pertaining to neurocognitive and behavioral impairment. Their history will point to the fact that those with fetal alcohol spectrum disorders have a high incidence of emotional and behavioral problems. Past experience with the juvenile justice system or foster care system, having a sibling with fetal alcohol spectrum disorders, recurrent unemployment, a history of substance abuse, and a history of inappropriate sexual behaviors such as improper touching and inappropriate exposure are some of the historical findings that should raise the index of suspicion for fetal alcohol spectrum disorders.

When evaluating a patient for fetal alcohol spectrum disorders, each of the five conditions that comprise fetal alcohol spectrum disorders has specific diagnostic criteria.

Fetal alcohol syndrome (FAS) is diagnosed by the presence of all of the following criteria: two of the three characteristic facial features (short palpebral fissures, thin vermillion border, and a smooth philtrum), growth retardation (prenatally and/or postnatally), and central nervous system defects. Because all of these criteria are met for diagnosis, fetal alcohol syndrome does not require documentation of prenatal alcohol exposure. Partial fetal alcohol syndrome (pFAS) has two of the characteristic facial features plus, depending on where alcohol exposure was documented, varies in its other criteria. Alcohol-related birth defects (ARBD) is the term used to describe those with physical defects secondary to known fetal alcohol exposure, but who do not have neurobehavioral deficits. On the opposite end of the spectrum, alcohol-related neurodevelopmental disorder (ARND) describes those with neurobehavioral impairment in the setting of documented prenatal alcohol exposure but have minimal to no physical findings and cannot be diagnosed before three years of age. Neurobehavioral disorders associated with prenatal alcohol exposure (ND-PAE) are very similar to alcohol-related congenital disabilities but may involve some physical features.

Because of the wide-ranging presentation and large overlap with other genetic and environmental etiologies such as illicit drug and tobacco use, a primary care provider cannot make a definitive diagnosis of fetal alcohol spectrum disorders. Once a primary care provider has a strong suspicion for fetal alcohol spectrum disorders, their patient should be referred to a team of specialists to rule out other possible conditions and make a definitive diagnosis.

The composition diagnostic team varies based on the age of the patient. In general, the diagnostic team includes a pediatrician and/or physician who may have expertise in fetal alcohol spectrum disorders, an occupational therapist, a speech-language pathologist, and a psychologist.

• Treatment / Management

Given that the CNS damage from prenatal alcohol exposure is permanent, there is no cure for fetal alcohol spectrum disorders. However, treatment to mitigate the effects of fetal alcohol spectrum disorders is available. Given the extensive variation in presentation and damage that prenatal exposure to alcohol can cause, treatment for fetal alcohol spectrum disorders is often tailored and specific to individuals. One of the most common treatment approaches is using the medical home to coordinate developmental and educational resources. This treatment modality takes into account the fact that fetal alcohol spectrum disorders disrupt normal neurobehavioral development and that each person can have different manifestations of those disruptions. This treatment methodology seeks to tailor specific therapies to reinforce and address any delays or deficiencies with additional education, practice, and reminders. In summary, when it comes to fetal alcohol spectrum disorders, as is true of most conditions in medicine, the best treatment is prevention. [8] [9] [10] [11]

• Differential Diagnosis
• Dubowitz syndrome
• Fetal toluene embryopathy
• Maternal phenylketonuria (PKU)
• Phenocopies
• Some cases of 22q11 deletion

Besides affecting the fetus, alcohol can induce the risk of spontaneous abortions, preterm delivery, placental abruption, stillbirth, and amnionitis.

Prognosis is guarded; however, recent research with chick embryos may help guide future treatments to reverse the damage caused to the brain by prenatal alcohol exposure.

• Complications

As mentioned previously, complications range in quality and severity. Sequelae include perturbations to affect regulation and cognition, as well as to physical appearance manifested via pathognomonic anomalies. 

• Deterrence and Patient Education

Treatment is deterrence in the setting of fetal alcohol syndrome. Public health officials can use epidemiological data to identify at-risk populations and offer education and encourage abstinence from teratogenic substances. 

• Enhancing Healthcare Team Outcomes

Prevention of fetal alcohol syndrome is the responsibility of all healthcare workers. The composition diagnostic team varies based on the age of the patient. In general, the diagnostic team includes a pediatrician and/or physician who may have expertise in fetal alcohol spectrum disorders, nurse practitioner, social worker, occupational therapist, speech-language pathologist, and psychologist.

Clinicians should be fully aware that fetal alcohol syndrome is preventable. In many cases, prenatal alcohol exposure is unintentional because women continue their normal drinking patterns before they know they are pregnant. Most women stop drinking alcohol once made aware of their pregnancy. Despite this fact, 7.6% of women report continued drinking during pregnancy. To improve outcomes, education emphasizing abstinence from alcohol is vital. Clinicians should not wait to educate the female about the adverse effects of alcohol when she gets pregnant but start the education process at every clinic visit before the pregnancy. A mental health nurse should offer to counsel to patients who have alcohol use disorder and are of childbearing age. Only through the combined efforts of the interprofessional team can fetal alcohol syndrome be prevented.

Prevention of FAS can help reduce the costs of healthcare and, more importantly, ensure that the children will have a better quality of life and normal functioning.

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Disclosure: Demetrios Vorgias declares no relevant financial relationships with ineligible companies.

Disclosure: Francine Bynum declares no relevant financial relationships with ineligible companies.

Disclosure: Bettina Bernstein declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Vorgias D, Bynum FD, Bernstein B. Fetal Alcohol Syndrome. [Updated 2023 May 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Similar articles in PubMed

• Secondary physical features in children with FASD. [Eur J Med Genet. 2024] Secondary physical features in children with FASD. Del Campo M, Kable JA, Coles CD, Suttie M, Chambers CD, Bandoli G. Eur J Med Genet. 2024 Feb; 67:104890. Epub 2023 Nov 30.
• Comparing diagnostic classification of neurobehavioral disorder associated with prenatal alcohol exposure with the Canadian fetal alcohol spectrum disorder guidelines: a cohort study. [CMAJ Open. 2017] Comparing diagnostic classification of neurobehavioral disorder associated with prenatal alcohol exposure with the Canadian fetal alcohol spectrum disorder guidelines: a cohort study. Sanders JL, Breen RE, Netelenbos N. CMAJ Open. 2017 Jan-Mar; 5(1):E178-E183. Epub 2017 Feb 24.
• Brain structural differences in children with fetal alcohol spectrum disorder and its subtypes. [Front Neurosci. 2023] Brain structural differences in children with fetal alcohol spectrum disorder and its subtypes. Boateng T, Beauchamp K, Torres F, Ruffaner-Hanson CD, Pinner JFL, Vakamudi K, Cerros C, Hill DE, Stephen JM. Front Neurosci. 2023; 17:1152038. Epub 2023 Aug 9.
• Review The quest for a neurobehavioral profile of heavy prenatal alcohol exposure. [Alcohol Res Health. 2011] Review The quest for a neurobehavioral profile of heavy prenatal alcohol exposure. Mattson SN, Riley EP. Alcohol Res Health. 2011; 34(1):51-5.
• Review Fetal alcohol spectrum disorders: a practical clinical approach to diagnosis. [Neurosci Biobehav Rev. 2007] Review Fetal alcohol spectrum disorders: a practical clinical approach to diagnosis. Manning MA, Eugene Hoyme H. Neurosci Biobehav Rev. 2007; 31(2):230-8. Epub 2006 Sep 7.

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