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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.

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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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Position and Presentation of the Fetus

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Normal Labor

Fetal Lie The relation of the fetal long axis to that of the mother is termed fetal lie and is either longitudinal or transverse . Occasionally, the fetal and the maternal axes may cross at a 45-degree angle, forming an oblique lie . This lie is unstable and becomes longitudinal or transverse during labor. A longitudinal lie is present in more than 99 percent of labors at term. Predisposing factors for transverse fetal position include multiparity, placenta previa, hydramnios, and uterine anomalies ( Chap. 23 , p. 468 ). Fetal Presentation The presenting part is that portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. It typically can be felt through the cervix on vaginal examination. Accordingly, in longitudinal lies, the presenting part is either the fetal head or breech, creating cephalic and breech presentations , respectively. When the fetus lies with the long axis transversely, the shoulder is the presenting part. Table 22-1 describes the incidences of the various fetal presentations. TABLE 22-1. Fetal Presentation in 68,097 Singleton Pregnancies at Parkland Hospital Cephalic Presentation Such presentations are classified according to the relationship between the head and body of the fetus ( Fig. 22-1 ). Ordinarily, the head is flexed sharply so that the chin is in contact with the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation . Much less commonly, the fetal neck may be sharply extended so that the occiput and back come in contact, and the face is foremost in the birth canal— face presentation ( Fig. 23-6 , p. 466 ). The fetal head may assume a position between these extremes, partially flexed in some cases, with the anterior (large) fontanel, or bregma, presenting— sinciput presentation —or partially extended in other cases, to have a brow presentation ( Fig. 23-8 , p. 468 ). These latter two presentations are usually transient. As labor progresses, sinciput and brow presentations almost always convert into vertex or face presentations by neck flexion or extension, respectively. Failure to do so can lead to dystocia, as discussed in Chapter 23 ( p. 455 ). Figure 22-1 Longitudinal lie. Cephalic presentation. Differences in attitude of the fetal body in (A) vertex, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude in relation to fetal vertex as the fetal head becomes less flexed. The term fetus usually presents with the vertex, most logically because the uterus is piriform or pear shaped. Although the fetal head at term is slightly larger than the breech, the entire podalic pole of the fetus—that is, the breech and its flexed extremities—is bulkier and more mobile than the cephalic pole. The cephalic pole is composed of the fetal head only. Until approximately 32 weeks, the amnionic cavity is large compared with the fetal mass, and the fetus is not crowded by the uterine walls. Subsequently, however, the ratio of amnionic fluid volume decreases relative to the increasing fetal mass. As a result, the uterine walls are apposed more closely to the fetal parts. If presenting by the breech, the fetus often changes polarity to make use of the roomier fundus for its bulkier and more mobile podalic pole. As discussed in Chapter 28 ( p. 559 ), the incidence of breech presentation decreases with gestational age. It approximates 25 percent at 28 weeks, 17 percent at 30 weeks, 11 percent at 32 weeks, and then decreases to approximately 3 percent at term. The high incidence of breech presentation in hydrocephalic fetuses is in accord with this theory, as the larger fetal cephalic pole requires more room than its podalic pole. Breech Presentation When the fetus presents as a breech, the three general configurations are frank, complete , and footling presentations and are described in Chapter 28 ( p. 559 ). Breech presentation may result from circumstances that prevent normal version from taking place. One example is a septum that protrudes into the uterine cavity ( Chap. 3 , p. 42 ). A peculiarity of fetal attitude, particularly extension of the vertebral column as seen in frank breeches, also may prevent the fetus from turning. If the placenta is implanted in the lower uterine segment, it may distort normal intrauterine anatomy and result in a breech presentation. Fetal Attitude or Posture In the later months of pregnancy, the fetus assumes a characteristic posture described as attitude or habitus as shown in Figure 22-1 . As a rule, the fetus forms an ovoid mass that corresponds roughly to the shape of the uterine cavity. The fetus becomes folded or bent upon itself in such a manner that the back becomes markedly convex; the head is sharply flexed so that the chin is almost in contact with the chest; the thighs are flexed over the abdomen; and the legs are bent at the knees. In all cephalic presentations, the arms are usually crossed over the thorax or become parallel to the sides. The umbilical cord lies in the space between them and the lower extremities. This characteristic posture results from the mode of fetal growth and its accommodation to the uterine cavity. Abnormal exceptions to this attitude occur as the fetal head becomes progressively more extended from the vertex to the face presentation (see Fig. 22-1 ). This results in a progressive change in fetal attitude from a convex (flexed) to a concave (extended) contour of the vertebral column. Fetal Position Position refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal. Accordingly, with each presentation there may be two positions—right or left. The fetal occiput, chin (mentum), and sacrum are the determining points in vertex, face, and breech presentations, respectively ( Figs. 22-2 to 22-6 ). Because the presenting part may be in either the left or right position, there are left and right occipital, left and right mental, and left and right sacral presentations. These are abbreviated as LO and RO, LM and RM, and LS and RS, respectively. FIGURE 22-2 Longitudinal lie. Vertex presentation. A. Left occiput anterior (LOA). B. Left occiput posterior (LOP). FIGURE 22-3 Longitudinal lie. Vertex presentation. A . Right occiput posterior (ROP). B . Right occiput transverse (ROT). FIGURE 22-4 Longitudinal lie. Vertex presentation. Right occiput anterior (ROA). FIGURE 22-5 Longitudinal lie. Face presentation. Left and right mentum anterior and right mentum posterior positions. FIGURE 22-6 Longitudinal lie. Breech presentation. Left sacrum posterior (LSP). Varieties of Presentations and Positions For still more accurate orientation, the relationship of a given portion of the presenting part to the anterior, transverse, or posterior portion of the maternal pelvis is considered. Because the presenting part in right or left positions may be directed anteriorly (A), transversely (T), or posteriorly (P), there are six varieties of each of the three presentations as shown in Figures 22-2 to 22-6 . Thus, in an occiput presentation, the presentation, position, and variety may be abbreviated in clockwise fashion as: Approximately two thirds of all vertex presentations are in the left occiput position, and one third in the right. In shoulder presentations, the acromion (scapula) is the portion of the fetus arbitrarily chosen for orientation with the maternal pelvis. One example of the terminology sometimes employed for this purpose is illustrated in Figure 22-7 . The acromion or back of the fetus may be directed either posteriorly or anteriorly and superiorly or inferiorly. Because it is impossible to differentiate exactly the several varieties of shoulder presentation by clinical examination and because such specific differentiation serves no practical purpose, it is customary to refer to all transverse lies simply as shoulder presentations . Another term used is transverse lie , with back up or back down , which is clinically important when deciding incision type for cesarean delivery ( Chap. 23 , p. 468 ). FIGURE 22-7 Transverse lie. Right acromiodorsoposterior (RADP). The shoulder of the fetus is to the mother’s right, and the back is posterior. Diagnosis of Fetal Presentation and Position Several methods can be used to diagnose fetal presentation and position. These include abdominal palpation, vaginal examination, auscultation, and, in certain doubtful cases, sonography. Rarely, plain radiographs, computed tomography, or magnetic resonance imaging may be used. Abdominal Palpation—Leopold Maneuvers Abdominal examination can be conducted systematically employing the four maneuvers described by Leopold in 1894 and shown in Figure 22-8 . The mother lies supine and comfortably positioned with her abdomen bared. These maneuvers may be difficult if not impossible to perform and interpret if the patient is obese, if there is excessive amnionic fluid, or if the placenta is anteriorly implanted. FIGURE 22-8 Leopold maneuvers (A–D) performed in a fetus with a longitudinal lie in the left occiput anterior position (LOA). The first maneuver permits identification of which fetal pole—that is, cephalic or podalic—occupies the uterine fundus. The breech gives the sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile and ballottable. Performed after determination of fetal lie, the second maneuver is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is felt—the back. On the other, numerous small, irregular, mobile parts are felt—the fetal extremities. By noting whether the back is directed anteriorly, transversely, or posteriorly, fetal orientation can be determined. The third maneuver is performed by grasping with the thumb and fingers of one hand the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The differentiation between head and breech is made as in the first maneuver. If the presenting part is deeply engaged, however, the findings from this maneuver are simply indicative that the lower fetal pole is in the pelvis, and details are then defined by the fourth maneuver. To perform the fourth maneuver, the examiner faces the mother’s feet and, with the tips of the first three fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder may be differentiated readily by the third maneuver. Abdominal palpation can be performed throughout the latter months of pregnancy and during and between the contractions of labor. With experience, it is possible to estimate the size of the fetus. According to Lydon-Rochelle and colleagues (1993), experienced clinicians accurately identify fetal malpresentation using Leopold maneuvers with a high sensitivity—88 percent, specificity—94 percent, positive-predictive value—74 percent, and negative-predictive value—97 percent. Vaginal Examination Before labor, the diagnosis of fetal presentation and position by vaginal examination is often inconclusive because the presenting part must be palpated through a closed cervix and lower uterine segment. With the onset of labor and after cervical dilatation, vertex presentations and their positions are recognized by palpation of the various fetal sutures and fontanels. Face and breech presentations are identified by palpation of facial features and fetal sacrum, respectively. In attempting to determine presentation and position by vaginal examination, it is advisable to pursue a definite routine, comprising four movements. First, the examiner inserts two fingers into the vagina and the presenting part is found. Differentiation of vertex, face, and breech is then accomplished readily. Second, if the vertex is presenting, the fingers are directed posteriorly and then swept forward over the fetal head toward the maternal symphysis ( Fig. 22-9 ). During this movement, the fingers necessarily cross the sagittal suture and its linear course is delineated. Next, the positions of the two fontanels are ascertained. For this, fingers are passed to the most anterior extension of the sagittal suture, and the fontanel encountered there is examined and identified. Then, with a sweeping motion, the fingers pass along the suture to the other end of the head until the other fontanel is felt and differentiated ( Fig. 22-10 ). Last, the station, or extent to which the presenting part has descended into the pelvis, can also be established at this time ( p. 449 ). Using these maneuvers, the various sutures and fontanels are located readily ( Fig. 7-11 , p. 139 ). FIGURE 22-9 Locating the sagittal suture by vaginal examination. FIGURE 22-10 Differentiating the fontanels by vaginal examination. Sonography and Radiography Sonographic techniques can aid fetal position identification, especially in obese women or in women with rigid abdominal walls. Zahalka and associates (2005) compared digital examinations with transvaginal and transabdominal sonography for fetal head position determination during second-stage labor and reported that transvaginal sonography was superior. Occiput Anterior Presentation In most cases, the vertex enters the pelvis with the sagittal suture lying in the transverse pelvic diameter. The fetus enters the pelvis in the left occiput transverse (LOT) position in 40 percent of labors and in the right occiput transverse (ROT) position in 20 percent (Caldwell, 1934). In occiput anterior positions—LOA or ROA— the head either enters the pelvis with the occiput rotated 45 degrees anteriorly from the transverse position, or this rotation occurs subsequently. The mechanism of labor in all these presentations is usually similar. The positional changes of the presenting part required to navigate the pelvic canal constitute the mechanisms of labor . The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion ( Fig. 22-11 ). During labor, these movements not only are sequential but also show great temporal overlap. For example, as part of engagement, there is both flexion and descent of the head. It is impossible for the movements to be completed unless the presenting part descends simultaneously. Concomitantly, uterine contractions effect important modifications in fetal attitude, or habitus, especially after the head has descended into the pelvis. These changes consist principally of fetal straightening, with loss of dorsal convexity and closer application of the extremities to the body. As a result, the fetal ovoid is transformed into a cylinder, with the smallest possible cross section typically passing through the birth canal. Figure 22-11 Cardinal movements of labor and delivery from a left occiput anterior position. Engagement The mechanism by which the biparietal diameter—the greatest transverse diameter in an occiput presentation—passes through the pelvic inlet is designated engagement . The fetal head may engage during the last few weeks of pregnancy or not until after labor commencement. In many multiparous and some nulliparous women, the fetal head is freely movable above the pelvic inlet at labor onset. In this circumstance, the head is sometimes referred to as “floating.” A normal-sized head usually does not engage with its sagittal suture directed anteroposteriorly. Instead, the fetal head usually enters the pelvic inlet either transversely or obliquely. Segel and coworkers (2012) analyzed labor in 5341 nulliparous women and found that fetal head engagement before labor onset did not affect vaginal delivery rates in either spontaneous or induced labor. Asynclitism. The fetal head tends to accommodate to the transverse axis of the pelvic inlet, whereas the sagittal suture, while remaining parallel to that axis, may not lie exactly midway between the symphysis and the sacral promontory. The sagittal suture frequently is deflected either posteriorly toward the promontory or anteriorly toward the symphysis ( Fig. 22-12 ). Such lateral deflection to a more anterior or posterior position in the pelvis is called asynclitism . If the sagittal suture approaches the sacral promontory, more of the anterior parietal bone presents itself to the examining fingers, and the condition is called anterior asynclitism . If, however, the sagittal suture lies close to the symphysis, more of the posterior parietal bone will present, and the condition is called posterior asynclitism . With extreme posterior asynclitism, the posterior ear may be easily palpated. FIGURE 22-12 Synclitism and asynclitism. Moderate degrees of asynclitism are the rule in normal labor. However, if severe, the condition is a common reason for cephalopelvic disproportion even with an otherwise normal-sized pelvis. Successive shifting from posterior to anterior asynclitism aids descent. Descent This movement is the first requisite for birth of the newborn. In nulliparas, engagement may take place before the onset of labor, and further descent may not follow until the onset of the second stage. In multiparas, descent usually begins with engagement. Descent is brought about by one or more of four forces: (1) pressure of the amnionic fluid, (2) direct pressure of the fundus upon the breech with contractions, (3) bearing-down efforts of maternal abdominal muscles, and (4) extension and straightening of the fetal body. Flexion As soon as the descending head meets resistance, whether from the cervix, pelvic walls, or pelvic floor, it normally flexes. With this movement, the chin is brought into more intimate contact with the fetal thorax, and the appreciably shorter suboccipitobregmatic diameter is substituted for the longer occipitofrontal diameter ( Figs. 22-13 and 22-14 ). FIGURE 22-13 Lever action produces flexion of the head. Conversion from occipitofrontal to suboccipitobregmatic diameter typically reduces the anteroposterior diameter from nearly 12 to 9.5 cm. FIGURE 22-14 Four degrees of head flexion. The solid line represents the occipitomental diameter, whereas the broken line connects the center of the anterior fontanel with the posterior fontanel. A. Flexion poor. B. Flexion moderate. C. Flexion advanced. D. Flexion complete. Note that with complete flexion, the chin is on the chest. The suboccipitobregmatic diameter, the shortest anteroposterior diameter of the fetal head, is passing through the pelvic inlet. Internal Rotation This movement consists of a turning of the head in such a manner that the occiput gradually moves toward the symphysis pubis anteriorly from its original position or, less commonly, posteriorly toward the hollow of the sacrum ( Figs. 22-15 to 22-17 ). Internal rotation is essential for completion of labor, except when the fetus is unusually small. FIGURE 22-15 Mechanism of labor for the left occiput transverse position, lateral view. A. Engagement. B. After engagement, further descent. C. Descent and initial internal rotation. D. Rotation and extension. FIGURE 22-16 Mechanism of labor for left occiput anterior position. FIGURE 22-17 Mechanism of labor for right occiput posterior position showing anterior rotation. Calkins (1939) studied more than 5000 women in labor to ascertain the time of internal rotation. He concluded that in approximately two thirds, internal rotation is completed by the time the head reaches the pelvic floor; in about another fourth, internal rotation is completed shortly after the head reaches the pelvic floor; and in the remaining 5 percent, rotation does not take place. When the head fails to turn until reaching the pelvic floor, it typically rotates during the next one or two contractions in multiparas. In nulliparas, rotation usually occurs during the next three to five contractions. Extension After internal rotation, the sharply flexed head reaches the vulva and undergoes extension. If the sharply flexed head, on reaching the pelvic floor, did not extend but was driven farther downward, it would impinge on the posterior portion of the perineum and would eventually be forced through the perineal tissues. When the head presses on the pelvic floor, however, two forces come into play. The first force, exerted by the uterus, acts more posteriorly, and the second, supplied by the resistant pelvic floor and the symphysis, acts more anteriorly. The resultant vector is in the direction of the vulvar opening, thereby causing head extension. This brings the base of the occiput into direct contact with the inferior margin of the symphysis pubis (see Fig. 22-16 ). With progressive distention of the perineum and vaginal opening, an increasingly larger portion of the occiput gradually appears. The head is born as the occiput, bregma, forehead, nose, mouth, and finally the chin pass successively over the anterior margin of the perineum (see Fig. 22-17 ). Immediately after its delivery, the head drops downward so that the chin lies over the maternal anus. External Rotation The delivered head next undergoes restitution (see Fig. 22-11 ). If the occiput was originally directed toward the left, it rotates toward the left ischial tuberosity. If it was originally directed toward the right, the occiput rotates to the right. Restitution of the head to the oblique position is followed by external rotation completion to the transverse position. This movement corresponds to rotation of the fetal body and serves to bring its bisacromial diameter into relation with the anteroposterior diameter of the pelvic outlet. Thus, one shoulder is anterior behind the symphysis and the other is posterior. This movement apparently is brought about by the same pelvic factors that produced internal rotation of the head. Expulsion Almost immediately after external rotation, the anterior shoulder appears under the symphysis pubis, and the perineum soon becomes distended by the posterior shoulder. After delivery of the shoulders, the rest of the body quickly passes. Occiput Posterior Presentation In approximately 20 percent of labors, the fetus enters the pelvis in an occiput posterior (OP) position (Caldwell, 1934). The right occiput posterior (ROP) is slightly more common than the left (LOP). It appears likely from radiographic evidence that posterior positions are more often associated with a narrow forepelvis. They also are more commonly seen in association with anterior placentation (Gardberg, 1994a). In most occiput posterior presentations, the mechanism of labor is identical to that observed in the transverse and anterior varieties, except that the occiput has to internally rotate to the symphysis pubis through 135 degrees, instead of 90 and 45 degrees, respectively (see Fig. 22-17 ). Effective contractions, adequate head flexion, and average fetal size together permit most posteriorly positioned occiputs to rotate promptly as soon as they reach the pelvic floor, and labor is not lengthened appreciably. In perhaps 5 to 10 percent of cases, however, rotation may be incomplete or may not take place at all, especially if the fetus is large (Gardberg, 1994b). Poor contractions, faulty head flexion, or epidural analgesia, which diminishes abdominal muscular pushing and relaxes pelvic floor muscles, may predispose to incomplete rotation. If rotation is incomplete, transverse arrest may result. If no rotation toward the symphysis takes place, the occiput may remain in the direct occiput posterior position, a condition known as persistent occiput posterior . Both persistent occiput posterior and transverse arrest represent deviations from the normal mechanisms of labor and are considered further in Chapter 23 . Fetal Head Shape Changes Caput Succedaneum In vertex presentations, labor forces alter fetal head shape. In prolonged labors before complete cervical dilatation, the portion of the fetal scalp immediately over the cervical os becomes edematous ( Fig. 33-1 , p. 647 ). This swelling, known as the caput succedaneum , is shown in Figures 22-18 and 22-19 . It usually attains a thickness of only a few millimeters, but in prolonged labors it may be sufficiently extensive to prevent differentiation of the various sutures and fontanels. More commonly, the caput is formed when the head is in the lower portion of the birth canal and frequently only after the resistance of a rigid vaginal outlet is encountered. Because it develops over the most dependent area of the head, one may deduce the original fetal head position by noting the location of the caput succedaneum. FIGURE 22-18 Formation of caput succedaneum and head molding.

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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.

• MSD careers

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant patient's spine) with the face and body angled to one side and the neck flexed.

Abnormal presentations include face, brow, breech, and shoulder. Occiput posterior position (facing toward the pregnant patient's pubic bone) is less common than occiput anterior position.

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

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Obstetric Examination

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

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

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

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

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

Introduction

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

Preparation

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

General Inspection

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

Abdominal Inspection

In the obstetric examination, inspect the abdomen for:

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

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

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

Fundal Height

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

Fig 2 – Assessing fetal lie and presentation.

Presentation

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

Liquor Volume

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

Fig 3 – Assessing fetal engagement.

Fetal Auscultation

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

Completing the Examination

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

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Presentation and position of baby through pregnancy and at birth

9-minute read

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

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

What does presentation and position mean?

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

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

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

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

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

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

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

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

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

Read more on breech presentation .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resources and support

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

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

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

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: October 2023

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

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Leopold Maneuvers |Steps

Last updated on December 28th, 2023

In this post, you will learn about Leopold Maneuvers, its purpose, and how to perform four maneuvers systematically.

What are Leopold Maneuvers?

Leopold maneuvers are a systematic four-step physical examination performed to evaluate the fetal lie, presentation, and position of the fetus in the uterus.

These obstetric maneuvers are performed after 26 weeks of gestation.  It is when the fetus is matured enough that when you palpate the abdomen its outline can be easily distinguished. 

According to studies, the accuracy of the Leopold maneuvers varies between 94% to 95% in a cephalic presentation when compared with ultrasonography. However, when the fetus is not in a cephalic presentation, the clinician’s ability to correctly determine the fetal position significantly decreases.

History of Leopold Maneuvers

The four classic obstetric grips known as Leopold maneuvers were first described and named after a German Gynecologist Dr. Christian Gerhard Leopold (1846–1911).

Since then it has become an essential clinical skill to assess the presentation, lie, and position of the baby within the uterus.

Purpose of Leopold Maneuver

The purpose of Leopold maneuvers are to determine:

• Fetal position (fetal position is described as fetal presentation in relation to mother’s pelvis. For example, right occiput anterior [ROA], left occiput anterior [LOA], left sacrum anterior [LSA], and more…)
• Fetal lie (fetal lie is described as where the fetus lies in relation to the mother’s back. For example, longitudinal lie, transverse lie, and oblique lie)
• Fetal presentation (first fetal part that presents into the maternal pelvis)
• Fetal attitude (fetal attitude can be determined after head is engaged)
• Fetal malposition
• Approximate fetal weight and amount of amniotic fluid

Prerequisites before the procedure

• Explain the Leopold maneuvers and their purpose to the pregnant mother
• Obtain verbal consent
• Ask the client to empty her bladder
• Position patient in supine and legs partially flexed from knees
• Ensure the patient is comfortable and relaxed
• Expose the tummy (from the xiphoid process to pubic symphsis) and cover lower part of the body with a sheet to provide privacy
• Ensure your hands are warm prior to palpation

Leopold maneuver steps

Step 1: fundal grip.

The first step of the Leopold maneuver is known as the fundal grip . Here, you palpate the uppermost part of the abdomen. This maneuver answers the question “ What fetal part (i.e., head or buttocks) occupies the fundus (i.e., top of the uterus)? “

Hence, you will know the fetal lie by performing fundal grip or first Leopold maneuver. Additionally, at this step, fundal height is also measured.

Fundal height will give you information about gestational age. It can be measured using a measuring tape – McDonald’s rule or just by palpating with finger breadths.

Purpose of the first Leopold maneuver or the fundal grip is to determine fetal lie and fundal height .

How to perform the first Leopold maneuver – Fundal grip

• Stand client’s right side facing towards her face
• Warm-up both the hands
• Place both the hands over the fundal area
• Then, palpate from one hand while applying steady firm pressure with the other hand to make it easier to identify fetal parts

• If you feel broad, firm, irregular soft mass indicates fetal buttocks is in the fundus. It means presentation is cephalic and the lie is longitudinal . This is the normal findings which promotes normal vaginal delivery.
• If you feel smooth, globular mass which is ballotable [bounces between the palpating hands – beacuse head can move independly from its body] indicates fundus occupies the fetal head. It means presentation is breech – a malpresentation which must be documented and confirmed with ultrsonography for planning the safest mode of delivery for the mother and baby.
• If you feel the upper pole is empty, indicates a transverse lie .

Step 2: Lateral or Umbilical grip

The second Leopold maneuver is called lateral or the umbilical grip . The second step answers “ On which maternal side does the fetal back is located? ” The fetal’s back is the best location to auscultate its heart sound.

Hence, the aim of this step is to locate the fetal back and limbs . Additionally, you can determine the position (i.e., ROA, LOA, etc) of the fetus at this step.

How to perform the second Leopold maneuver – Lateral or Umbilical grip

• Stand facing the client as the first maneuver
• Place both hands on either side of the abdomen between flanks and umblicus
• Then, while steadily supporting with the right hand, palpate with the left hand. Palpate using deep gentle pressure in slightly circular motion – It will helps to easily identify the fetal parts .
• Repeat the steps on the other side as well using opposite hands

• If you feel continuous smooth structure indicates its fetal back. It is the best place to monitor fetal heart rate. You may use a fetoscope, stethoscope, or doppler to monitor fetal heart rate (FHR).
• If you feel irregular multiple knoblike structures indicates its fetal limbs
• Also, you will be able identify fetal body parts from amniotic fluids and the fetal position, whether its ROA, LOA, and more
• If the lie is transverse, head or breech may be palpable from one of the sides of maternal torso.

Step 3: Pawlik’s grip

The third Leopold maneuver is known as the Pawlik’s grip which answers the question “ what is the presenting part? “ This step was modified by Czech Gynecologist  Karel Pawlík (1849–1914). Hence, named Pawlik’s grip.

Sometimes the third Leopold maneuver is also referred as the first pelvic grip.

The aim of this maneuver is to evaluate presenting part into the pelvis and engagement .

How to perform the third Leopold maneuver – Pawlik’s grip

• Stand facing the client’s face same as the first and second maneuvers
• Wide open your right hand – thumb on one side and four fingers on the other side, grasp the lower pole of the uterus just above the symphsis pubis. Use your left hand to grasp the fundus at the same time.
• Then, try to move presenting fetal part between your thumb and four fingers.
• This maneuver usually causes some discomfort to the mother. So, be gentle and cautious during this step.

• If the lie is longitudinal and presentation is vertex, and head not engaged – you will feel the head of the fetus between your fingers. And it will be ballotable.
• If the presenting part is engaged (i.e, presenting part has already decended into the pelvic inlet), you will feel the less distinct mass.
• If the presenting part is breech, the mass will feel much softer and smaller. Also, it won’t move independently of the body.
• If the lie is transverse, like the empty fundus, the lower pole of the uterus will also be empty. Hence no fetal parts will be palpable.

Step 4: Pelvic grip

The fourth Leopold maneuver is known as pelvic grip. This final step of the Leopold maneuver answers the question “ Is the fetal head engaged in the pelvis and what is the attitude? “

This step will help you to confirm the presenting part of the fetus and its descent into the pelvis. If the presentation is vertex, you can determine the relation of the cephalic prominence to the fetal back to evaluate the fetal attitude .

Additionally, you can determine the degree of engagement. Hence, confirming the findings of the third maneuver.

How to perform the fourth Leopold maneuver – Deep pelvic grip

• In this step, stand facing towards client’s feet. This is the only maneuver performed facing towards the woman’s feet.
• Place hands below the umbilicus, parallel to inguinal, and walk fingers aroung presenting part towards the midline and symphysis pubis.

• If the fingers of both hands meet (converge) below presenting part indicates presenting part is floating (i.e., not engaged yet)
• If the fingers of both hands diverge below the presenting part indicates presenting part is now engaged.
• In vertex presentation, if cephalic prominence is felt on the opposite side of the back indicates that the fetal head is well flexed.
• If the head is deflexed or extended as in brow and face presentation – you can palpate cephalic prominence on the same side as the back, but you will feel a groove between the cephalic prominence and fetal back.
• You should be able to confirm the findings od Pawlik’s grip

Contraindication

Leopold maneuvers should not be performed during uterine contractions.

Complications

Leopold maneuvers do not have any significant complications. It may cause mild discomfort to the mother especially during the third maneuver. And some very rare cases, it may trigger uterine contractions.

Leopold maneuvers are a systematic method of palpating a pregnant woman’s abdomen to assess fetal position in utero. It helps determine presentation, lie, position, and attitude.

Leopold maneuvers are an easy and cost-effective method of assessing pregnant women. However, the accuracy of the findings is heavily dependent on the skills and competency of the examiner.

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Evans, A. (2007). Manual of obstetrics (7th ed.). Lippincott Williams & Wilkins.

Kennedy, B., Ruth, D., & Martin, E. (2009). Intrapartum management modules (4th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Ricci, S., & Kyle, T. (2009). Maternity and Pediatric Nursing . Wolters Kluwer Health/Lippincott Williams & Wilkins.

Saxena, R. (2014). Bedside Obstetrics & Gynecology . Jaypee Brothers Medical Publisher (P) Ltd.

Simkin, P., & Hanson, L. (2017). Labor Progress Handbook (4th ed.). Wiley Blackwell.

Weber, J., Kelley, J., Sprengel, A., & Weber, J. (2010). Lab Manual to Accompany Health Assessment in Nursing (7th ed.). Lippincott Williams & Wilkins.Weber, J. R., & Kelley, J. H. (2017). Health Assessment in Nursing (6th ed.). Lippincott Williams and Wilkins.

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Variation in fetal presentation

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At the time the article was last revised Yuranga Weerakkody had no financial relationships to ineligible companies to disclose.

• Delivery presentations
• Variation in delivary presentation
• Abnormal fetal presentations

There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os . This includes:

cephalic presentation : fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations which include

left occipito-anterior (LOA)

left occipito-posterior (LOP)

left occipito-transverse (LOT)

right occipito-anterior (ROA)

right occipito-posterior (ROP)

right occipito-transverse (ROT)

straight occipito-anterior

straight occipito-posterior

breech presentation : fetal rump presenting towards the internal cervical os, this has three main types

frank breech presentation  (50-70% of all breech presentation): hips flexed, knees extended (pike position)

complete breech presentation  (5-10%): hips flexed, knees flexed (cannonball position)

footling presentation  or incomplete (10-30%): one or both hips extended, foot presenting

other, e.g one leg flexed and one leg extended

shoulder presentation

cord presentation : umbilical cord presenting towards the internal cervical os

• 1. Fox AJ, Chapman MG. Longitudinal ultrasound assessment of fetal presentation: a review of 1010 consecutive cases. Aust N Z J Obstet Gynaecol. 2006;46 (4): 341-4. doi:10.1111/j.1479-828X.2006.00603.x - Pubmed citation
• 2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon

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Malpresentation and Malposition of the Fetus

A malpresentation or malposition of the fetus is when the fetus is in any abnormal position, other than vertex (head down) with the occiput anterior or posterior.

The following are considered malpresentations or malpositions:

Unstable lie

• Transverse presentation
• Oblique presentation

Face presentation

Brow presentation

Shoulder presentation

High head at term

• Prolapsed arm

The cause of a malpresentation can often not be clearly identified but it can be associated with the following:

• Preterm pregnancy
• Uterine anomalies
• Pelvic tumors eg f ibroids
• Placenta previa
• Grandmultiparty
• Contracted maternal pelvis
• Multiple gestation
• Too much amniotic fluyid (polyhydramnios)
• Short umbilical cord
• Fetal anomalies (e.g. anencephaly, hydro-cephalus)
• Abnormal fetal motor ability

There is an increased risk of neonatal and maternal complications associated with a malpresentation including neonatal and maternal trauma. If delivery is indicated, doing a cesarean delivery can significantly decrease the risk of complications.

Transverse lie

Oblique lie

In most cases of a normal vertex (head down) presentation, the baby's head is flexed with the chin close to the baby's chest. In these cases, the presenting part is the occiput, the posterior part of the baby's head. If the baby's head is more but not completekly extended then the baby's brow presents towards the vagina. A brow presentation is rare, maybe happening in about 1 in 2,000 births, more likely in pwomen with their second or subsequent births. A baby with a brow presentation can only deliver vaginally if the head flexes or extends.

Prolapsed arm 

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  Original Article   Review  Case Report  Short Communication   Letter to the Editor  Editorial

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• Case Report

Volume 9, Number 4, December 2020, pages 129-133

Rare Presentation of Fetus in Fetu - Laparoscopic Approach: A Case Report

Vandana Menon a, c , Bedaya Amro a , Tasnim E.V. Keloth b , Arnaud Wattiez a , Maan Hachmi b

a Latifa Women and Children Hospital, Dubai, UAE b Dubai Hospital, Dubai, UAE c Corresponding Author: Vandana Menon, Latifa Women and Children Hospital, Dubai, UAE

Manuscript submitted July 30, 2020, accepted October 12, 2020, published online December 15, 2020 Short title: Rare Presentation of FIF doi: https://doi.org/10.14740/jcgo681

• Introduction

Fetus in fetu (FIF) is an extremely rare condition in which a malformed fetus is found most commonly in the abdomen of a living twin. We report a case of FIF in a young adult woman, which presented as a twisted ovarian cyst and was successfully managed by laparoscopy. This is the first reported case of FIF with an acute presentation, the first case in an adult ovary and the first to be managed successfully by laparoscopy. The excised ovarian mass was diagnosed as FIF with benign teratoma based on histopathological examination and radiography.

Keywords: Case report; Fetus in fetu; Dermoid; Laparoscopy; Abdominal mass

Fetus in fetu (FIF) is a rare condition which usually presents as a vertebrate fetiform mass in a newborn or a child and occasionally in an adult man. It occurs in about 1 in 500,000 live births [ 1 ] and less than 200 cases have been reported in the medical literature. This is the third case in an adult female [ 2 ] and the first case managed by laparoscopy.

We present the case of a 26-year-old nulliparous woman who attended our emergency department with acute, severe lower abdominal pain associated with vomiting. She did not have any relevant medical, gynecological or surgical history. She had an ultrasound in another facility which revealed a twisted multiloculated cyst of 11 × 7 cm size, most probably dermoid cyst.

Clinical examination revealed a tender abdomen with guarding. A firm mass of 16 cm size was palpable arising from the pelvis. A bedside ultrasound revealed a cyst of 16 cm with solid and cystic areas with significantly compromised vascularity. The tumour markers (beta-human chorionic gonadotropin (hCG), alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA)) were found to be normal. CA125 was slightly elevated at 78 U/mL (reference range: 0 - 35). Imaging modalities like magnetic resonance imaging (MRI) and computed tomography (CT) could not be performed due to the severe pain at presentation and non-availability of MRI and CT in our facility. With a provisional diagnosis of twisted ovarian cyst, probably dermoid, we decided to perform emergency diagnostic laparoscopy and to proceed accordingly. Consent was taken for ovarian cystectomy and/or adnexectomy. Intraoperatively, the left ovary was found to be twisted six times around its pedicle with an ovarian cyst of 18 × 16 cm ( Fig. 1 ) containing both solid and cystic areas. The whole ovary was grayish with a hemorrhagic surface, indicating ischemic changes. However, it had a smooth surface and had no suspicious features. Peritoneal fluid was aspirated for cytology. A systematic examination of the rest of the pelvis and upper abdomen was implemented and was found to be normal. The ovary was gently untwisted, after which it gradually started regaining its color. Taking into consideration the young age and nulliparity of the patient, ultrasound features of dermoid and no suspicious features of malignancy on inspection, we decided to go for laparoscopic cystectomy. After cyst aspiration, cystectomy was carried out in a large endo bag and the procedure was completed with minimal spillage of cheesy material. At extraction, a large bony part was felt significantly with sharp edges. So one lateral port was extended to 4 - 5 cm ( Fig. 2 ) and cyst was completely extracted, which revealed a partly formed fetus. Reconstruction of the ovary was done with trimming of ovarian tissue and suturing using 2-0 poliglecaprone 25 (Ethicon Monocryl). Intraoperative blood loss was minimal (around 50 mL). The patient was discharged the next day with uneventful and fast recovery as expected from laparoscopic surgeries.

Gross specimen analysis, radiography and microscopic analysis in histopathology department were undertaken and a final diagnosis of FIF with teratoma was rendered. The presence of fetal skull, rudimentary limbs with digits, malformed trunk with vertebral column, gluteal region with central cleft and a polypoid structure resembling external genitalia support the FIF entity ( Figs. 3 - 7 ).

The present case is the ninth reported case of adult FIF (89% occurring before 18 months) and the third case in an adult female ( Table 1 ) [ 2 - 9 ]. To our knowledge, this is the only known case of FIF reported in an adult ovary. Furthermore, this is the only reported case which has been managed laparoscopically and an acute presentation has so far not been described. Although benign, malignant recurrence has been recorded with FIF [ 10 ].

The term FIF was first described by Friedrich Meckel. There is controversy as to whether this is a distinct entity or a highly organised teratoma. The most accepted theory is the twin theory which states that FIF is a monochorionic, diamniotic twin which becomes incorporated in the body of host twin after anastomosis of vitelline circulation [ 11 ]. According to Willis in 1953, identification of vertebral column ensures the diagnosis of FIF and differentiates this from teratoma. Identification of vertebral column indicates that fetal evolution must have advanced at least to a primitive streak stage to develop notochord [ 12 ]. Some investigators like Prescher et al hypothesized that FIF represents a well-differentiated and highly organized teratoma [ 13 ]. Our case supports the twin theory of origin of FIF due to the high level of organization of tissues and not a cluster of primitive tissues.

The common presentation of FIF is a mass in the abdomen, almost 80% in the retroperitoneum [ 2 ], although it has been reported at various sites right from the cranial cavity to the scrotum. Different organs can be seen in FIF, including vertebral column (91%), limbs (82.5%), central nervous system (55.8%), gastrointestinal tract (45%), vessels (40%) and genitourinary tract (26.5%) [ 14 ]. The mass may compress the surrounding organs leading to symptoms such as abdominal distension, feeding difficulty, vomiting, jaundice or pressure effects on the renal or respiratory system. A presumptive diagnosis can be made by ultrasound, plain radiography, CT scan or MRI which will reveal the presence of axial skeleton and vertebral column. Nevertheless, this should not lead to diagnostic exclusion as an underdeveloped spinal column may not be visualized by radiography [ 15 ]. Molecular analysis using a genetic marker for uniparental isodisomy of chromosomes 14 and 15 has been described [ 16 ]. Treatment of FIF is surgical. Although majority of the cases are benign, complete excision of FIF together with the capsule is crucial as malignant recurrence has been reported rarely, especially if part of the tissue is not completely excised [ 10 ]. A few authors have advocated follow-up for tumor recurrence using tumor markers like AFP, with some of them suggesting 2 years as the ideal time frame, especially when FIF and teratoma are considered as part of the same spectrum [ 13 ].

Conclusions

Although FIF is a rare entity with a chronic course, the possibility should be kept in mind while dealing with an emergency like a twisted ovarian cyst, in spite of the unusual location and sex predilection. The operation to remove FIF can be challenging if the mass is highly vascular with multiple feeding vessels and has been traditionally performed by laparotomy. The aforementioned case proves that laparoscopy is a feasible option in the management of FIF and other partly solid adnexal masses in expert hands. Postoperative follow-up with screening using tumor markers, especially AFP is mandatory if initial levels are raised to rule out malignant recurrence.

Acknowledgments

None to declare.

Financial Disclosure

Conflict of Interest

Informed Consent

Written informed consent was obtained from the patient for publication of this case report.

Author Contributions

Vandana Menon performed surgery and postoperative follow-up, and manuscript preparation. Bedaya Amro performed surgery and manuscript preparation. Tasnim E. V. Keloth contributed to histopathology examination and manuscript preparation. Arnaud Wattiez contributed to manuscript supervision. Maan Haachmi contributed to radiology examination and diagnosis.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.

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• Daga BV, Chaudhary VA, Ingle AS, Dhamangaokar VB, Jadhav DP, Kulkarni PA. Double fetus-in-fetu: CT scan diagnosis in an adult. Indian J Radiol Imaging. 2009;19(3):216-218. doi pubmed
• Hopkins KL, Dickson PK, Ball TI, Ricketts RR, O'Shea PA, Abramowsky CR. Fetus-in-fetu with malignant recurrence. J Pediatr Surg. 1997;32(10):1476-1479. doi
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• Willis RA. The borderland of embryology and pathology. 2nd edn. Washington, DC: Butterworths. 1962:44.
• Prescher LM, Butler WJ, Vachon TA, et al. Fetus in fetu: Review of the literature over the past 15 years. J Pediatr Surg Case Rep. 2015;3:554-562. doi
• Ji Y, Chen S, Zhong L, Jiang X, Jin S, Kong F, Wang Q, et al. Fetus in fetu: two case reports and literature review. BMC Pediatr. 2014;14:88. doi pubmed
• Hoeffel CC, Nguyen KQ, Phan HT, Truong NH, Nguyen TS, Tran TT, Fornes P. Fetus in fetu: a case report and literature review. Pediatrics. 2000;105(6):1335-1344. doi pubmed
• Miura S, Miura K, Yamamoto T, Yamanaka M, Saito K, Hirabuki T, Kurosawa K, et al. Origin and mechanisms of formation of fetus-in-fetu: two cases with genotype and methylation analyses. Am J Med Genet A. 2006;140(16):1737-1743. doi pubmed

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) ) recommendations for manuscripts submitted to biomedical journals, the Committee on Publication Ethics ( ) guidelines, and the of Transparency and Best Practice in Scholarly Publishing. website: www.jcgo.org   editorial contact: [email protected] Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada © Elmer Press Inc. All Rights Reserved. : The views and opinions expressed in the published articles are those of the authors and do not necessarily reflect the views or opinions of the editors and Elmer Press Inc. This website is provided for medical research and informational purposes only and does not constitute any medical advice or professional services. The information provided in this journal should not be used for diagnosis and treatment, those seeking medical advice should always consult with a licensed physician.         179 IMAGES presentation fetal presentations & positions Fetal Presentation and Positioning Premium Vector Cureus Embryo Development VIDEO Introduction to mass com presentation Section 5 Foetal Attitude Foetus development stages 🤰🥺#3Danimation #shortvideo #knowledge #share #easylearning #medico foetus live "mighty whity" Manually change foetus presentation✨#shortvideo Fetus week 24 COMMENTS Fetal presentation before birth 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. Fetal Presentation, Position, and Lie (Including Breech Presentation 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 ... Cephalic Position: Understanding Your Baby's Presentation at Birth Cephalic occiput anterior. Your baby is head down and facing your back. Almost 95 percent of babies in the head-first position face this way. This position is considered to be the best for ... Fetal Positions For Birth: Presentation, Types & Function Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left. This is called left occiput anterior or right ... Fetal Presentation, Position, and Lie (Including Breech Presentation) Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse. Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position. Abnormal fetal lie, presentation, or position may occur with. Fetopelvic disproportion (fetus too large for the pelvic inlet) Fetal presentation: Breech, posterior, transverse lie, and more 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 ... Position and Presentation of the Fetus Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant patient's spine) with the face and body angled to one side and the neck flexed. Abnormal presentations include face, brow, breech, and shoulder. Occiput ... Normal Labor Breech Presentation. When the fetus presents as a breech, the three general configurations are frank, complete, and footling presentations and are described in Chapter 28 ... As a rule, the fetus forms an ovoid mass that corresponds roughly to the shape of the uterine cavity. The fetus becomes folded or bent upon itself in such a manner that ... Fetal Positions for Labor and Birth 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. Tips to Reduce Discomfort Figure: Position and Presentation of the Fetus Position and Presentation of the Fetus. Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the position of a fetus is facing rearward (toward the woman's back) with the face and body angled to one side and the neck flexed, and presentation is head first. Presentation and Mechanisms of Labor The fetus undergoes a series of changes in position, attitude, and presentation during labor. This process is essential for the accomplishment of a vaginal delivery. The presence of a fetal malpresentation or an abnormality of the maternal pelvis can significantly impede the likelihood of a vaginal delivery. The contractile aspect of the uterus ... Obstetric Examination Lie. Facing the patient's head, place hands on either side of the top of the uterus and gently apply pressure. Move the hands and palpate down the abdomen. One side will feel fuller and firmer - this is the back. Fetal limbs may be palpable on the opposing side. Fig 2 - Assessing fetal lie and presentation. Presentation and position of baby through pregnancy and at birth If your baby is headfirst, the 3 main types of presentation are: anterior - when the back of your baby's head is at the front of your belly. lateral - when the back of your baby's head is facing your side. posterior - when the back of your baby's head is towards your back. Top row: 'right anterior — left anterior'. Abnormal Fetal Lie and Presentation 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. 14.5: Maternal Changes During Pregnancy, Labor, and Birth The fetus faces the maternal spinal cord and the smallest part of the head (the posterior aspect called the occiput) exits the birth canal first. In fewer than 5 percent of births, the infant is oriented in the breech presentation, or buttocks down. PDF Step 1 Determining fetal lie, position, presentation and attitude Step 5 presentation. Double-head fetoscope and traditional Pinard Horn Follow Step 5 - a complementary diagnostic procedure after performing the Leopold Maneuver Fetus in breech presentation In breech presentation, the fetal heart rate will be found around or above the mothers' navel. A fetal heart rate found at this spot can confirm the suspicion of Fetal position Breech presentation refers to when the fetus is in a longitudinal lie with its buttocks as the lowest part. The document discusses the different types of breech presentations as well as their incidence, classifications, positions, etiology, diagnosis, and management both during pregnancy and delivery. ... the fetus forms an ovoid mass that ... Leopold Maneuvers |Steps Leopold maneuvers are a systematic four-step physical examination performed to evaluate the fetal lie, presentation, and position of the fetus in the uterus. ... If you feel broad, firm, irregular soft mass indicates fetal buttocks is in the fundus. It means presentation is cephalic and the lie is longitudinal. This is the normal findings which ... Variation in fetal presentation There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os. This includes: cephalic presentation: fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations ... What you need to know about fetal abdominal masses Management is conservative and depends on mass size, symptoms, and presence of complications. Masses greater than 4 cm to 5 cm are associated with a risk of torsion approaching 50% to 78% and typically warrant postnatal surgical resection. 3-5 Neonatal cyst aspiration is generally not recommended because of recurrence risk and the need to ... Malpresentation and Malposition of the Fetus By: Amos Grünebaum. Updated on March 25, 2019. A malpresentation or malposition of the fetus is when the fetus is in any abnormal position, other than vertex (head down) with the occiput anterior or posterior. The following are considered malpresentations or malpositions: Unstable lie. Breech. Rare Presentation of Fetus in Fetu The common presentation of FIF is a mass in the abdomen, almost 80% in the retroperitoneum [2], ... Kanhaiya C, Sadhna M, Sabiha M. Fetus in fetu: a rare presentation in an adult female. Oman Med J. 2010;25. doi; Sharma N, Verma P, Pathak P. 27 cm fetus in fetu presenting in a 36-year-old man: report of a rare case and brief review of ... assignment essay homework paper phd report resume review speech thesis