how to deliver compound presentation

• 2022 New Pearls of Exxcellence Articles

Management of Brow, Face, and Compound Malpresentations

Author: Meera Kesavan, MD

Mentor: Lisa Keder MD Editor: Daniel JS Martingano DO MBA PhD

Registered users can also download a PDF or listen to a podcast of this Pearl. Log in now , or create a free account to access bonus Pearls features.

Fetal malpresentation, including brow, face, or compound presentations, complicates around 3-4% of all term births. Because these abnormal fetal presentations still are cephalic, many such cases result in vaginal deliveries, yet there are increased risks for adverse outcomes, including cesarean delivery resultant surgical complications, persistent malpresentation precluding vaginal delivery, and abnormal labor resulting in arrest of dilation or descent.

These fetal malpresentation are differentiated in the following ways:

• In face presentations, the presenting part is the mentum, which is further divided based on its position, including mentum posterior, mentum transverse or mentum anterior positions. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Mentum anterior malpresentations can potentially achieve vaginal deliveries, whereas mentum posterior malpresentations cannot.
• In brow presentations, there is less extension of the fetal neck as in face presentations making the leading fetal part being the area between the anterior fontanelle and the orbital ridges. These presentations are uncommon and are managed similarly to face presentations. Brow presentation can be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.
• Compound presentation is defined as the leading fetal part, including a fetal extremity, alongside a cephalic or breech presentation. Management of compound presentations is expected (and often incidentally noted following delivery) because the extremity will often either retract as the head descends or will feasibly allow for delivery in its current position, with manipulation attempts to reduce the compound presentation usually avoided.

Risk factors for brow and face presentations include fetal CNS malformations, congenital or chromosomal anomalies, advanced maternal age, low birthweight, abnormal maternal pelvic anatomy (e.g. contracted pelvis, cephalopelvic disporotion, platypelloid pelvis, etc.) and nulliparity. non-Hispanic White women have the highest risk for malpresentation, whereas non-Hispanic Black women have the lowest risk.

Diagnosis usually is made during the second stage of labor while performing routine vaingla examinations and involves palpation of the abnormal leading fetal part (forehead, orbital ridge, orbits, nose, etc.) Obstetric ultrasound can additionally provide complimentary information to support these diagnoses and distinguish from other fetal malpresentations or malpositions. In face presentation, the mentum (chin) and mouth are palpable.

Management considerations for face, brow, and compounds presentations are unique with compound presentations having higher rates of vaginal delivery and lower complications as compared to either brow or face presentations.

• For brow presentations, approximately 30-40% of brow presentations will convert to a face presentation, and about 20% will convert to a vertex presentation. Anterior positions have the possibility of vaginal deliveries and can be managed by usual labor management principles, whereas mentum posterior positions are indications for cesarean delivery.
• For face presentations, the likelihood of vaginal delivery depends on the orientation of the mentum, with mentum anterior being most suitable for vaginal delivery. If the fetus is mentum posterior, flexion of the neck is precluded and results in the inability of fetal descent.
• For compound presentations, management is expectant and manipulation of the leading extremities should be avoided. Most cases of compound presentation result in vaginal deliveries. For term deliveries, compound presentations with parts other than the hand are unlikely to result in safe vaginal delivery.

Labor management for brow and face presentation overall involves continuous fetal heart rate monitoring and repeat clinical assessments, given the increased potential of fetal complications as noted. Caution should be used with internal monitoring devices, which can cause ophthalmic injury or trauma to the presenting fetal parts, with the use of fetal scalp electrodes discouraged and intrauterine pressure catheters acceptable with appropriate clinical judgment and feasibility.

Midforceps, breech extraction, and manual manipulation are not recommended and increase the risk of maternal and neonatal morbidity. 

Neonatal outcomes for both face and brow presentations include facial edema, bruising, and soft tissue trauma. Complications of compound presentation specifically include umbilical cord prolapse and injury to the presenting limb. With appropriate management, neonatal and maternal morbidity for face, brow, and compound presentations are low.

Further Reading:

Bar-El L, Eliner Y, Grunebaum A, Lenchner E, et al. Race and ethnicity are among the predisposing factors for fetal malpresentation at term. Am J Obstet Gynecol MFM. 2021 Sep;3(5):100405. doi: 10.1016/j.ajogmf.2021.100405. Epub 2021 Jun 4. PMID: 34091061.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol. 2017 Dec;217(6):633-641. doi: 10.1016/j.ajog.2017.07.025. Epub 2017 Jul 22. PMID: 28743440 . 

Pilliod RA, Caughey AB. Fetal Malpresentation and Malposition: Diagnosis and Management. Obstet Gynecol Clin North Am. 2017 Dec;44(4):631-643. doi: 10.1016/j.ogc.2017.08.003. PMID: 29078945 .

Zayed F, Amarin Z, Obeidat B, et al. Face and brow presentation in northern Jordan, over a decade of experience. Arch Gynecol Obstet. 2008 Nov;278(5):427-30. doi: 10.1007/s00404-008-0600-0. Epub 2008 Feb 19. PMID: 18283473 . 

Initial Approval: August 2013; Revised: 11/2016; Revised July 2018; Reaffirmed January 2020; Revised September 2021. Revised July 2023.

This site uses cookies.

This feature is only available for registered users.

Log in here:, not a registered user.

Becoming a registered user gives you access to special features like PDF downloads and podcast episodes of each SASGOG Pearl of Exxcellence.

Create a Free Account

Are you sure you want to remove this Pearl from your favorites list?

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 27:  Compound Presentations

George Tawagi

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

Prolapse of hand and arm or foot and leg.

• MANAGEMENT OF COMPOUND PRESENTATIONS
• Full Chapter
• Supplementary Content

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

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

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

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

Classification of Compound Presentation

Upper limb (arm–hand), one or both

Lower limb (leg–foot), one or both

Arm and leg together

Breech presentation with prolapse of the hand or arm

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

FIGURE 27-1.

Compound presentation: head and hand.

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

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

The condition is suspected when:

There is delay of progress in the active phase of labor

Engagement fails to occur

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

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

Mechanism of Labor

Get free access through your institution, pop-up div successfully displayed.

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

Baby’s hand below head in labour

• Labour & Delivery

I assessed her cervix at 37 weeks gestation. Her cervix was already 3cm dilated and the baby’s head was engaged and well applied to the cervix. I advised her that an induction should be straightforward and she could anticipate a good labour and delivery, as had been the case previously. This proved not to be the case this time.

The patient was almost 39 week’s gestation when she was admitted for an ARM and Syntocinon infusion induction of labour.

Progress in labour was slower than I anticipated. I was phoned by the midwife. The midwife said she estimated her cervix was 5cm dilated. She also said there was a compound presentation apparent, with the baby’s hand being below the head. She said the contractions were in-coordinate. That would explain the slower progress in labour. The contractions would not be optimal because the baby’s head was not well applied to the cervix, with the baby’s hand between the head and cervix.

The midwife tried to push the hand out of the way so the head could be better applied to the cervix but wasn’t able to do so.

I attended. The patient’s cervix was now 8cm dilated. I could easily touch the baby’s fingers when I examined her. The baby’s hand was below the baby’s head.

Between contractions, I was able to push the baby’s hand up and out the way. Fortunately, the baby decided to cooperate and keep its hand away and so the baby’s head was now better applied to the cervix.  The patient had an epidural for the labour so my examination to push the hand away was not uncomfortable to her.

The contractions became more coordinated and efficient with the baby’s head now well applied to the cervix.  Soon the patient’s cervix was fully dilated. She went on to have a normal vaginal delivery with a very small perineal tear. Her son was born in good condition and had a birth weight of 3.6kg.

It was a good outcome but with an interesting unexpected development of a compound presentation in labour. I explained to her that this labour took longer than usual as uterine contractions were not as efficient because of the compound presentation.

It is common to see the baby’s hand in front of the baby’s face and indeed over the forehead when doing ultrasound scans during pregnancy, including in very advanced pregnancy. But to have a compound presentation during labour is uncommon. Compound presentation is reported to occur in 1 in 700 to 1 in 1,000 deliveries.

A compound presentation is usually the baby’s hand or arm presenting with the head but the definition includes the presentation of any foetal extremity alongside the presenting part. It may involve one or more extremities (e.g. hand, arm, foot) with the head or buttocks (if breech presentation).

• Pregnancy Care
• Pregnancy Tests
• Your Pregnancy Journey
• Patient stories
• contraception
• Costs: How much will it cost to have a baby?
• Caesarean Section
• Latest Posts
• Infections in Pregnancy
• Uncategorized
• Medical Conditions in Pregnancy
• Staying Healthy in Pregnancy
• Pregnancy Concerns and Questions
• Miscarriage
• Pregnancy Complications
• Calculating EDC
• Pregnancy and Childbirth Stories
• Pregnancy Loss
• Breast Feeding
• Private Vs public
• Dr Gary Sykes

Recent Posts

• Caesarean Section – what to expect
• Public hospital would not give high risk patient an initial antenatal clinic appointment
• Self-funding private pregnancy care
• “Private pregnancy care was not possible because she was not insured”

Book an appointment now

• Email This field is for validation purposes and should be left unchanged.
• Monday all day 9.00am to 4.30pm
• Tuesday all day 9.00am to 4.30pm
• Wednesday all day 9.00am to 4.30pm
• Thursday morning 9.00am to 12.30pm
• Thursday alternate afternoons 2.00pm to 4.30pm
• Friday alternate mornings 9.00am to 1.00pm
• Friday afternoon 2.00pm to 4.30pm
• Saturday mornings 9.30am to 12.00 midday*

*Saturday morning appointments are not available for initial antenatal visit.

Suite 2-06, Norwest Central 12 Century Circuit Norwest , NSW 2153

Obstetrician Norwest | Obstetrician Bella Vista | Obstetrician  Hills District | Obstetrician Castle Hill | Obstetrician Parramatta

Compound Presentations

• Author: Richard P Perkins, MD; Chief Editor: Carl V Smith, MD  more...
• Sections Compound Presentations
• Compound Presentations: Rare Obstetric Events

Compound presentations are rare obstetric events and often engender much anxiety in the care team. Such concerns are usually unjustified, but considering the unlikely possibility of a problem delivery is valuable. Although in an average delivery service of 2500 births annually such an event might be expected to occur only about once a year, providers should know strategies for managing this situation if intervention becomes necessary. [ 1 , 2 ]

Compound presentations may be observed more commonly after premature rupture of membranes, with preterm labor, with pelvic masses displacing the main fetal pole, or after inductions of labor involving floating presenting parts. Compound presentations are more likely with obstetric interventions than with spontaneous events. [ 3 , 4 , 5 ] This type of presentation involves the prolapse of an extremity along with the more traditional presenting part, almost always the fetal vertex. Usually, the misplaced part is a hand or arm. Less commonly, a foot can present with the vertex if the baby is extended at the knee and flexed at the hip, or a hand or arm may present along the side of the breech. Management of these individual events differs according to the finding and the circumstances. If intact membranes are found, leaving them intact while resolution of the compound presentation is attempted may be wise.

The discovery of a hand beside the head is the most common presentation irregularity and is the least worrisome of the possibilities. In general, if left unattended, the hand will retract or the arm will extend further as labor progresses. Although the presence of an extremity usually does not create prohibitive dystocia, its absence is preferable in principle; this avoids circulatory compromise that could occur if the extremity is in place too long. [ 6 ] Also, the bruising to which the limb is prone adds undue concern for the parents until it disappears. If the hand has not prolapsed beyond the presenting part, causing the hand to retract often is accomplished, if necessary. In contrast, if the hand or arm has prolapsed past the presenting part, abandoning vaginal delivery and proceeding to cesarean delivery is wise.

Resolution is best accomplished by the baby itself. Although people sometimes forget that unborn children have all their reflexes in utero, unborn babies are fully capable, within the limitations of the space available, of reacting as they would as newborns. The simplest approach, therefore, may be to apply a benign noxious stimulus, such as a gentle pinch to a fingertip of the advancing hand. By applying a benign noxious stimulus (between contractions, of course), the hand may withdraw and never appear in the undesired position again. Less often, gentle pressure upward also may displace it successfully. If these maneuvers do not succeed in solving the abnormal situation, it can be ignored as long as labor is progressing normally. Excessive force applied to the extremity can injure it, or it may displace the head and convert the benign situation into an undeliverable shoulder presentation with entrapment of the fetus. [ 7 ]

An intrusive foot beside the head is a more complicated event because it has more bulk than a hand and may retract less readily. Although it will not prolapse further, it may persist, increasing the diameter of the presenting part. Resolving this also involves trying a noxious stimulus, but this succeeds less often because of the complexity of the withdrawal response within available space. Forceful upward displacement also may not succeed if, for any reason, the knee does not readily bend or the hip does not flex further. An experienced operator may find that external manipulation of the leg may be achieved if it is the anterior one, but it is unreachable if it is the posterior limb. With fortuitous fetopelvic proportionality, delivery can still occur, but prudence precludes labor stimulation or difficult operative pelvic maneuvers. If vaginal birth is planned, it should occur spontaneously. Compound presentations preclude forceps applications orvacuum extraction.

Compound presentation with breech birth is less common, and management is less controversial. In general, unless readily resolved by benign maneuvers as described above, abdominal delivery is chosen even if it was not planned already for the breech presentation. An arm presenting with the breech may preclude descent of the breech into the pelvis, may add unduly to the increasing diameters presented as labor progresses, and may influence the baby to rotate into an arm or shoulder presentation. [ 8 ]

A case of a child with isolated lower brachial plexus palsy (Klumpke) and Horner syndrome who had a vertex compound arm presentation at birth has been reported. [ 9 ]  Cases of neonatal compartment syndrome associated with compound presentation have also been described. [ 10 , 11 ]

As suggested, in most cases, these events need not greatly influence the plans already made for the route of management of the birth process. Simple stimuli designed to get the child to withdraw the abnormal part may succeed. Management of labor and delivery after discovery of the intrusive part should be conservative and compatible with otherwise traditional obstetric principles.

Cunningham FG, MacDonald PC, Gant NF, et al, eds. Williams Obstetrics . 19th ed. Norwalk, Conn: Appleton & Lange; 1993. 507.

Goplerud J, Eastman NJ. Compound presentation; a survey of 65 cases. Obstet Gynecol . 1953 Jan. 1(1):59-66. [QxMD MEDLINE Link] .

Brost BC, Calhoun BC, Van Dorsten JP. Compound presentation resulting from the forward-roll technique of external cephalic version: a possible mechanism. Am J Obstet Gynecol . 1996 Mar. 174(3):884-5. [QxMD MEDLINE Link] .

Vezina Y, Bujold E, Varin J. Cesarean delivery after successful external cephalic version of breech presentation at term: A comparative study. Am J Obstet Gynecol . 2004 Mar. 190(3):763-8. [QxMD MEDLINE Link] .

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins--Obstetrics. Practice Bulletin No. 161 Summary: External Cephalic Version. Obstet Gynecol . 2016 Feb. 127 (2):412-3. [QxMD MEDLINE Link] .

Tebes CC, Mehta P, Calhoun DA, et al. Congenital ischemic forearm necrosis associated with a compound presentation. J Matern Fetal Med . 1999 Sep-Oct. 8(5):231-3. [QxMD MEDLINE Link] .

Hill MG, Cohen WR. Shoulder dystocia: prediction and management. Womens Health (Lond) . 2016. 12 (2):251-61. [QxMD MEDLINE Link] . [Full Text] .

Ojumah N, Ramdhan RC, Wilson C, Loukas M, Oskouian RJ, Tubbs RS. Neurological Neonatal Birth Injuries: A Literature Review. Cureus . 2017 Dec 12. 9 (12):e1938. [QxMD MEDLINE Link] . [Full Text] .

Buchanan EP, Richardson R, Tse R. Isolated lower brachial plexus (Klumpke) palsy with compound arm presentation: case report. J Hand Surg Am . 2013 Aug. 38(8):1567-70. [QxMD MEDLINE Link] .

Manini N, Unno H. Delayed onset of neonatal compartment syndrome associated with compound fetal presentation. BMC Pediatr . 2024 Apr 1. 24 (1):224. [QxMD MEDLINE Link] . [Full Text] .

Shen AH, Tevlin R, Kwan MD, Ho OH, Fox PM. Neonatal Compartment Syndrome and Compound Presentation at Birth. J Hand Surg Glob Online . 2020 May. 2 (3):166-70. [QxMD MEDLINE Link] . [Full Text] .

Contributor Information and Disclosures

Richard P Perkins, MD Perinatologist Richard P Perkins, MD is a member of the following medical societies: Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , American College of Obstetricians and Gynecologists Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Council of University Chairs of Obstetrics and Gynecology , Nebraska Medical Association Disclosure: Nothing to disclose.

What would you like to print?

• Print this section
• Print the entire contents of
• Print the entire contents of article

• HIV in Pregnancy
• Pulmonary Disease and Pregnancy
• Kidney Disease and Pregnancy
• Vaccinations/Immunizations During Pregnancy
• Common Pregnancy Complaints and Questions
• Cardiovascular Disease and Pregnancy
• Shock and Pregnancy
• Is immunotherapy for cancer safe in pregnancy?
• The Pregnancy Challenges of Women With Chronic Conditions
• Labetalol, Nifedipine: Outcome on Pregnancy Hypertension

• Drug Interaction Checker
• Pill Identifier
• Calculators

• 2020/viewarticle/immunotherapy-cancer-safe-pregnancy-2024a100083dnews news Is immunotherapy for cancer safe in pregnancy?

• 2002261369-overviewDiseases & Conditions Diseases & Conditions Postterm Pregnancy

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

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].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

• Continuing Education Activity

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

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

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

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

• Anatomy and Physiology

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

Planes and Diameters of the Pelvis

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

Fetal Skull Diameters

There are 6 distinguished longitudinal fetal skull diameters:

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

Cardinal Movements of Normal Labor

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

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

• Indications

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

• Contraindications

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

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

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

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

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

• Technique or Treatment

Mechanism of Labor in Face Presentation

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

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

Mechanism of Labor in Brow Presentation

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

• Complications

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

• Clinical Significance

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

• Enhancing Healthcare Team Outcomes

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

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

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

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

In this Page

Bulk download.

• Bulk download StatPearls data from FTP

Related information

• PubMed Links to PubMed

Similar articles in PubMed

• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2024] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2024 Mar; 230(3S):S890-S900. Epub 2023 May 19.
• Leopold Maneuvers. [StatPearls. 2024] Leopold Maneuvers. Superville SS, Siccardi MA. StatPearls. 2024 Jan
• Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. [Am J Obstet Gynecol. 2021] Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. Dall'Asta A, Rizzo G, Masturzo B, Di Pasquo E, Schera GBL, Morganelli G, Ramirez Zegarra R, Maqina P, Mappa I, Parpinel G, et al. Am J Obstet Gynecol. 2021 Aug; 225(2):171.e1-171.e12. Epub 2021 Mar 4.
• Review Labor with abnormal presentation and position. [Obstet Gynecol Clin North Am. ...] Review Labor with abnormal presentation and position. Stitely ML, Gherman RB. Obstet Gynecol Clin North Am. 2005 Jun; 32(2):165-79.

Recent Activity

• Delivery, Face and Brow Presentation - StatPearls Delivery, Face and Brow Presentation - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

iCliniq Cope

For doctors and hospitals

Ask a Doctor Online Now

Compound Presentations- Causes, Effects on Labor, Complications, and Management

Compound presentation occurs when one extremity emerges concurrently with the part of the fetus that is closest to the birth canal. Read to know the details.

Dr. Ankita Balar

Medically reviewed by

Dr. Richa Agarwal

By subscribing, I agree to iCliniq's Terms & Privacy Policy.

What Are Compound Presentations?

Compound presentations are rare obstetric occurrences that frequently cause the care team to become quite anxious. A prenatal presentation known as a compound presentation occurs when one extremity develops concurrently with the part of the fetus that is closest to the birth canal. A fetal hand or arm typically presents with the head during compound presentations.

A presentation is considered compound when one or more limbs prolapse together with the head or breech, both of which enter the pelvis simultaneously. This group excludes footling breech or shoulder presentations. In 15 % to 20 % of instances, the umbilical cord prolapses along with the condition.

Compound Presentations Are Classified As,

Cephalic presentation with prolapse of,

One or both upper limbs (arm and hand).

One or both lower limbs (leg and foot).

Arms together with legs.

Breech presentation accompanied by an arm or hand prolapse.

The head with the hand or arm combination is by far the most common. On the other hand, the head-foot and breech-arm groups are relatively infrequent. It is unusual for a hand or foot to prolapse alongside the head. The prolapse of the umbilical cord might complicate any combination, which makes it the main issue.

What Causes Compound Presentations?

Different mechanisms can result in compound presentation from several clinical contexts. The causes of compound presentations include any circumstances that prevent the presenting component from completely filling and occluding the pelvic entrance.

Instances of compound presentation include,

Due to early gestational age, multiple gestations , polyhydramnios (excessive amniotic fluid accumulation), or a large maternal pelvis in comparison to fetal size, the fetus does not fully occupy the pelvis, which leaves an opportunity for a fetal extremity to prolapse.

When the presenting part is still high, the membranes rupture, allowing the amniotic fluid to flow and carry a fetal extremity, the umbilical cord, or both to the birth canal.

Preterm labor .

External Cephalic Version (ECV)- A fetal limb (often the hand or arm, but occasionally the foot) may become "trapped" before the fetal head during the external version process and end up being the component that gives birth when labor starts.

How Are Compound Presentations Diagnosed?

A vaginal examination  is used to make the diagnosis, and in many cases, the problem is not discovered until labor has progressed significantly and the cervix is fully dilated.

One suspects the condition when,

The active phase of labor is moving more slowly than it should.

Engagement does not take place- In any situation where the fetal head does not engage during labor, but there is no cephalo-pelvic disproportion, the compound presentation diagnosis should be considered.

Even after the membranes have ruptured, the fetal head continues to be elevated and off-center during labor.

What Is the Effect of Compound Presentation on Labor?

The size of the fetus and the size of the mother's pelvis affect how compound presentation affects labor.

There are three possible perspectives on this,

The fetal head may not enter the pelvic brim in cases where the fetus is large and the pelvis is narrow due to a compound presentation. If it is not fixed, it will cause obstructed labor.

A complex presentation will delay the second stage of labor when the fetus and the pelvis are of average size. This delay results from the prolapsed limb interfering with the fetal head's normal internal and external flexion and rotation mechanisms. Correction is frequently required.

A complex presentation will not change the course of labor if the fetus is small and the pelvis is large; the baby will still be born with the hand prolapsed.

What Are the Complications of Compound Presentation?

The two complications likely to occur are prolapse of the umbilical cord and uterine inertia.

They are as follows,

Prolapse of the Umbilical Cord- The same factors that lead to limb prolapse can cause cord prolapse. Most of the time, it will call for immediate delivery.

Inertia- Inertia may complicate any malpresentation. Its exact cause is unknown, but it may be due to the malposition of the fetus interfering with the normal mechanism of labor. The uterus reacts to this interference by diminishing its action. Treatment of inertia usually first necessitates replacement of the prolapsed limb, except early in the first stage, when it is sometimes better to treat inertia by recognized methods and later replace the limb.

What Is the Treatment and Management of Compound Presentation?

As in all cases of malpresentation, the first essential is to determine whether the pelvis is large enough to allow vaginal delivery. A cesarean section will have to be performed if there is a mechanical obstruction.

If there is no obstruction, a vaginal delivery will be possible following one of the undermentioned methods,

Treatment of the presentation of an arm aims at preventing its prolapse into the vagina when the membranes rupture. Initially, the patient is placed in the genupectoral or high Trendelenburg position for 30 minutes. This allows the limb, aided by gravity, to slip back above the head. The patient is then placed in the dorsal position. The fetal head is pushed into the pelvic brim by abdominal palpation, and an abdominal binder is applied. This method is not always successful. A vaginal examination should be performed as soon as the membranes rupture.

The prolapse of an arm or foot is best treated by replacing the limb above the head. The head is then pressed down by pressure on the abdomen. It is advisable not to remove the hand from the vagina until the head has been pushed into the pelvis.

When a prolapsed arm is discovered during the second stage of labor, it is sometimes possible to deliver by forceps without replacing the arm. During the application of the forceps, care must be taken not to include the arm within the forceps blades.

The internal version is now rarely used because of the dangers involved. The method may cause separation of the placenta and death of the features, rupture of the uterus, and probable death of the mother.

This method should only be used in the following cases,

An arm prolapses again after replacement.

A foot resists all attempts at replacement.

Occasionally when the compound presentation is complicated by prolapse of the cord.

Prolapse of the cord necessitates rapid treatment if the fetus is to be saved. In the first stage of labor, a cesarean section is the treatment of choice. During the second stage of labor, forceps delivery is indicated, preferably if conditions permit, without replacement of the limb. The internal version is indicated solely when these procedures are not practical because of a lack of equipment.

Conclusion:

In the majority of situations, compound presentation events need not significantly alter the arrangements already made for the method of managing the birth process. Simple stimuli that are intended to encourage the baby to reject the abnormal component may be successful. Following the identification of the invasive portion, labor and delivery should be managed conservatively and in accordance with other established obstetrical standards.

Frequently Asked Questions

How is compound presentation treated, how is compound breech clinically seen, what does icd code 10 in compound presentation represent, is compound presentation normal/vertex, what is meant by cephalic presentation, and is it considered good, how are compound presentation patients delivered, is a cephalic presentation considered ideal in cases of c section, what are the complications of breech position, and can patients with the same have a normal delivery.

Compound Presentation

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1823738/

Compound presentations

https://pubmed.ncbi.nlm.nih.gov/13774261/

Management of Brow, Face, and Compound Malpresentations

https://exxcellence.org/list-of-pearls/management-of-brow-face-and-compound-malpresentations/

Obstetrics and Gynecology

Rate this article

Related topics

Dengue Fever? Do Not Panic! | Home Remedies for Dengue

Impacts on Pregnancy and Lactation After a Bariatric Surgery

Acute Purulent Conjunctivitis - Causes, Types, Symptoms, Diagnosis, and Management

Peripheral Odontogenic Fibroma of the Jaw - A Diagnostic Challenge

Trying for Pregnancy During the COVID Era

Negative Blood Group and Pregnancy Rh Incompatibility

Source Article Arrow Most popular articles

Ovulation and Safe Period: What is the Safe Period to Have Sex?

Dr. Sabita Laskar

Unwanted 72 - Uses, Dosage, Side Effects, Drug Warnings, and Precautions

Dr. Veena Madhan Kumar

Jelqing - Penis Enlargement Exercise

Dr. Ramchandra Lamba

Dolo 650 MG Tablet

Dr. Anshul Varshney

I-Pill - Uses, Dosage, Side Effects, Drug Warnings, and Precautions

Ask your health query to a doctor online

*guaranteed answer within 4 hours

Disclaimer: No content published on this website is intended to be a substitute for professional medical diagnosis, advice or treatment by a trained physician. Seek advice from your physician or other qualified healthcare providers with questions you may have regarding your symptoms and medical condition for a complete medical diagnosis. Do not delay or disregard seeking professional medical advice because of something you have read on this website. Read our Editorial Process to know how we create content for health articles and queries.

This website uses cookies to ensure you get the best experience on our website. iCliniq privacy policy

Uptodate Reference Title

Compound fetal presentation.

INTRODUCTION  —  Compound presentation is a fetal presentation in which an extremity presents alongside the part of the fetus closest to the birth canal. The majority of compound presentations consist of a fetal hand or arm presenting with the head [ 1 ]. This topic will review the pathogenesis, clinical manifestations, diagnosis, and management of this uncommon intrapartum scenario.

INCIDENCE  —  Compound presentation has been reported to occur in 1 in 250 to 1 in 1500 births [ 2-5 ]. This is a crude, wide estimate because transient cases are not consistently recognized, documented, or reported.

PATHOGENESIS AND RISK FACTORS  —  A variety of clinical settings can lead to compound presentation via different pathways. Compound presentation may occur when:

● The fetus does not fully occupy the pelvis, thus allowing a fetal extremity room to prolapse. Predisposing factors include early gestational age, multiple gestation, polyhydramnios, or a large maternal pelvis relative to fetal size [ 2,3 ].

● Membrane rupture occurs when the presenting part is still high, which allows flow of amniotic fluid to carry a fetal extremity, umbilical cord, or both toward the birth canal.

● During external version, a fetal limb (commonly the hand/arm, but occasionally the foot) becomes "trapped" below the fetal head and thus becomes the presenting part when labor ensues [ 6-8 ].

● The head of the first twin and an extremity of the second twin present together within the birth canal, but this is rare.

CONSEQUENCES  —  The large irregular presenting part of a compound presentation can result in:

● Dystocia.

● Cord prolapse, which was reported in 15 and 23 percent of patients in two series [ 2,9 ].

CLINICAL PRESENTATION

● Compound presentation may present as an incidental finding on ultrasound examination [ 10 ].

● Antepartum or intrapartum digital examination through a partially dilated or effaced cervix may detect an irregular shape beside or in advance of the head or breech.

● Intrapartum, the head may remain persistently unengaged after membrane rupture and deviated from the midline [ 9 ]. Active phase protraction or arrest of labor may occur. In the second stage, arrest of descent may be associated with a variant of compound presentation in which the fetal hand fills the space between the head and the maternal sacrum [ 11 ].

DIAGNOSIS  —  The diagnosis of compound presentation is based on identification of one or more fetal extremities presenting alongside or in front of the head or buttocks on physical or ultrasound examination [ 10 ].

On physical examination, a foot can be distinguished from a hand by its three bony protuberances (calcaneus, lateral and medial malleolus), the angle at the level of the calcaneus, and the toes, which are short and lie in the same line with no opposing thumb.

Differential diagnosis  —  When a fetal extremity is the presenting part on physical examination, differential diagnosis includes:

● Compound presentation

● Transverse lie with prolapse of an extremity

● Footling breech presentation

An accurate diagnosis is easily made by ultrasound examination or more thorough abdominal and vaginal examinations.

Antepartum management  —  Antepartum identification of compound presentation usually does not require any interventions or monitoring.

If noted on ultrasound examination immediately following an otherwise successful external cephalic version, the compound presentation will usually resolve spontaneously. In this setting, if a foot or hand is preventing the head from settling into the inlet, vibroacoustic stimulation can prompt fetal movement sufficient to resolve the problem.

If a compound presentation is identified on ultrasound examination in a patient with polyhydramnios, the patient should be counseled on the risks of a prolapsed umbilical cord and fetal extremity when membranes rupture. (See "Umbilical cord prolapse", section on 'Anticipation and prevention of cord prolapse' .)

Intrapartum management  —  Approaches to intrapartum management are based on patient-specific factors, clinical experience, and insights from case reports and small series, given the infrequent occurrence of this problem. High-quality data to guide management are not available.

For patients with normally progressing labor, we favor observation alone. Some authorities suggest attempting to gently reposition the fetal extremity, while others discourage this practice [ 3-5,9,12 ]. We favor expectant management because sometimes the presenting part will push the extremity aside or the fetus will retract the extremity as labor progresses, allowing a large majority of compound presentations to deliver vaginally. A compound presentation involving the arm is more likely to resolve than one involving the foot [ 4 ]. We choose to not pinch the presenting part in an attempt to provoke the fetus into withdrawing the presenting part, although this practice is not likely to be harmful.

If the compound presentation persists, descent of the presenting part in the second stage could slow or stop, unless the fetus is extremely small. Manipulation is reasonable in this setting. The author gently pushes the small part up into the uterine cavity with his dominant hand while simultaneously applying gentle fundal pressure to effect descent of the head with his other hand. If this gentle maneuver does not resolve the compound presentation and abnormal progress of labor, the author has a low threshold for proceeding to cesarean birth because of the increased risk for obstructed labor and an adverse outcome (see 'Outcome' below). Oxytocin augmentation should be avoided as it may lead to uterine rupture [ 2,7 ]. Forceps- or vacuum-assisted vaginal birth should also be avoided, with possible rare exceptions in which clinical judgment suggests this approach would be faster and safer than an urgent cesarean birth.

OUTCOME  —  In most cases managed by contemporary standards, labor results in an uncomplicated vaginal birth. Historically, however, high mortality rates were reported and were related to prolonged obstructed labor, internal podalic version and extraction, uterine rupture, prolapsed cord, and complications of preterm birth.

No large contemporary series of compound presentation have been published. The following case reports, and others, underscore the need for cesarean birth if the compound presentation does not resolve spontaneously or with gentle pressure in cases of protracted labor. However, it should be noted that only complicated cases prompt publication of a case report [ 13-15 ].

● One case report of a patient with a compound presentation and protracted labor described ischemic necrosis of the arm, which was attributed to entrapment of the fetal arm between the head and bony pelvis; limb amputation was required [ 13 ].

● Another case report described a similar occurrence with a dramatic appearance of limb ischemia ( picture 1 ), but recovery occurred without the need for amputation [ 15 ].

● A third case report described a vacuum-assisted birth in which an unrecognized compound presentation resulted in a maternal rectal laceration; the fetal hand was found to be protruding through the anus as the head was crowning [ 14 ].

If neonatal compartment syndrome occurs, some authorities recommend urgent fasciotomy, which may salvage the limb. (See "Pathophysiology, classification, and causes of acute extremity compartment syndrome", section on 'Birth injury' .)

SOCIETY GUIDELINE LINKS  —  Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor" .)

SUMMARY AND RECOMMENDATIONS

● Clinical findings and diagnosis – Compound presentation may be an incidental finding on an antepartum ultrasound examination or it may be palpated as an irregular shape beside or in advance of the vertex or breech during digital cervical examination. The diagnosis is based on identification of one or more fetal extremities presenting alongside or in front of the head or buttocks. (See 'Clinical presentation' above and 'Diagnosis' above.)

● Epidemiology – Persistent compound presentation is rare once active labor is established. Predisposing factors include preterm birth, multiple gestation, polyhydramnios, a large maternal pelvis, external cephalic version, and rupture of membranes at high station. (See 'Incidence' above and 'Pathogenesis and risk factors' above.)

● Management

• Antepartum – Antepartum identification of compound presentation usually does not require any interventions or monitoring other than patient education about the finding. (See 'Antepartum management' above.)

• Intrapartum – For compound presentations with normal progress of labor, we suggest expectant management rather than intervention ( Grade 2C ). Most cases will resolve spontaneously or will have vaginal births even without resolution. (See 'Intrapartum management' above.)

A persistent compound presentation can result in dystocia. If descent of the presenting part in the second stage becomes protracted or arrests, we gently push the small part up into the uterine cavity with the dominant hand while simultaneously applying fundal pressure with the other hand to effect descent of the vertex. If the compound presentation and labor abnormality do not resolve after this gentle maneuver, we have a low threshold for proceeding to cesarean birth. Oxytocin augmentation should be avoided as it may lead to uterine rupture. (See 'Intrapartum management' above.)

ACKNOWLEDGMENTS  —  The UpToDate editorial staff acknowledges Edward R Yeomans, MD, and Clint M Cormier, MD, who contributed to earlier versions of this topic review.

• Cruikshank DP, White CA. Obstetric malpresentations: twenty years' experience. Am J Obstet Gynecol 1973; 116:1097.
• GOPLERUD J, EASTMAN NJ. Compound presentation; a survey of 65 cases. Obstet Gynecol 1953; 1:59.
• Breen JL, Wiesmeier E. Compound presentation: a survey of 131 patients. Obstet Gynecol 1968; 32:419.
• Weissberg SM, O'Leary JA. Compound presentation of the fetus. Obstet Gynecol 1973; 41:60.
• QUINLIVAN WL. Compound presentation. Can Med Assoc J 1957; 76:633.
• Brost BC, Calhoun BC, Van Dorsten JP. Compound presentation resulting from the forward-roll technique of external cephalic version: a possible mechanism. Am J Obstet Gynecol 1996; 174:884.
• Ang LT. Compound presentation following external version. Aust N Z J Obstet Gynaecol 1978; 18:213.
• KING JM, MITCHELL AP. Compound presentation of the foetus following external version. J Obstet Gynaecol Br Emp 1953; 60:555.
• CHAN DP. A study of 65 cases of compound presentation. Br Med J 1961; 2:560.
• Dall'Asta A, Volpe N, Galli L, et al. Intrapartum Sonographic Diagnosis of Compound Hand-Cephalic Presentation. Ultraschall Med 2017; 38:558.
• Vacca A. The 'sacral hand wedge': a cause of arrest of descent of the fetal head during vacuum assisted delivery. BJOG 2002; 109:1063.
• SWEENEY WJ 3rd, KNAPP RC. Compound presentations. Obstet Gynecol 1961; 17:333.
• Tebes CC, Mehta P, Calhoun DA, Richards DS. Congenital ischemic forearm necrosis associated with a compound presentation. J Matern Fetal Med 1999; 8:231.
• Byrne H, Sleight S, Gordon A, et al. Unusual rectal trauma due to compound fetal presentation. J Obstet Gynaecol 2006; 26:174.
• Kwok CS, Judkins CL, Sherratt M. Forearm Injury Associated with Compound Presentation and Prolonged Labour. J Neonatal Surg 2015; 4:40.

1 : Obstetric malpresentations: twenty years' experience.

2 : Compound presentation; a survey of 65 cases.

3 : Compound presentation: a survey of 131 patients.

4 : Compound presentation of the fetus.

5 : Compound presentation.

6 : Compound presentation resulting from the forward-roll technique of external cephalic version: a possible mechanism.

7 : Compound presentation following external version.

8 : Compound presentation of the foetus following external version.

9 : A study of 65 cases of compound presentation.

10 : Intrapartum Sonographic Diagnosis of Compound Hand-Cephalic Presentation.

11 : The 'sacral hand wedge': a cause of arrest of descent of the fetal head during vacuum assisted delivery.

12 : Compound presentations.

13 : Congenital ischemic forearm necrosis associated with a compound presentation.

14 : Unusual rectal trauma due to compound fetal presentation.

15 : Forearm Injury Associated with Compound Presentation and Prolonged Labour.

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟

اضافه کردن مدیلیب به صفحه اصلی

• PREMIUM SIGN UP

Press ESC to close

Nuchal hand & compound presentations.

A nuchal hand is one of several compound presentations where an extremity is alongside the presenting part of your baby at birth.  With a vertex baby, the presenting part is their head, and with a breech baby, it is their bottom. A nuchal hand means that their hand is up by their face when they are born, which is the most common presentation irregularity.  Ideally, your baby retracts their arm and comes out headfirst.  A nuchal hand doesn’t automatically mean a C-section, but it does have the possibility to bring up some complications. This episode answers several questions about a nuchal hand, how it affects your birth, and whether you can do anything during pregnancy or labor to prevent it.

Become a Pregnancy Podcast Premium member or log in to access all articles and episodes ad-free.

This Content is Only Available to Premium Members.

Share article:, circumcision, anterior placenta.

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

• Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

• Cookie Preferences

Achieve Mastery of Medical Concepts

Study for medical school and boards with lecturio.

• USMLE Step 1
• USMLE Step 2
• COMLEX Level 1
• COMLEX Level 2

Advertisement

Fetal Malpresentation and Malposition

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

Last updated: Feb 14, 2023

Fetal Lie and Presentation

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

Share this concept:

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

Clinical relevance

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

Risk factors for fetal malpresentation

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

Epidemiology

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

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

Related videos

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

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

Presentation

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

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

Cephalic presentations

Cephalic presentations can be categorized as:

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

Vertex presentation

Face presentation (mentum anterior position)

Brow presentation (mentum posterior position)

Breech presentations

Breech presentations can be categorized as:

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

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

Transverse and compound presentations

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

Shoulder presentation (transverse lie)

Neglected shoulder presentation resulting in arm prolapse during labor

Vertex presentation with a compound hand

Fetal malpresentation

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

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

Vertex positions

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

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

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

Face and brow positions

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

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

Face presentation (mentum posterior position)

Breech and shoulder positions

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

Dorso-inferior shoulder presentation

Dorso-superior shoulder presentation

Attitude and asynclitism

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

Fetal malposition

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

Diameters of the fetal head

Comparison of presentation, attitude, and presenting diameter

How to establish lie, presentation, and position

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

Leopold’s maneuvers

Ultrasonography.

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

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

Vaginal and cervical examination

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

Vertex presentations

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

Compound presentations

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

Brow presentations

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

Face presentations

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

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

Natural history of breech presentations

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

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

Fetal risks associated with breech presentations

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

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

Fetal risks associated with vaginal breech delivery

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

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

Vaginal breech delivery

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

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

External cephalic version

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

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

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

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

Management of transverse presentations

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

Study with Lecturio for

Medical School

Nursing School

• Data Privacy
• Terms and Conditions
• Legal Information

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Create your free account or log in to continue reading!

Sign up now and get free access to Lecturio with concept pages, medical videos, and questions for your medical education.

Log in to your account​

User Reviews

Get Premium to test your knowledge

Lecturio Premium gives you full access to all content & features

Get Premium to watch all videos

Verify your email now to get a free trial.

Create a free account to test your knowledge

Lecturio Premium gives you full access to all contents and features—including Lecturio’s Qbank with up-to-date board-style questions.

Fastest Obstetric, Gynecology and Pediatric Insight Engine

• Abdominal Key
• Anesthesia Key
• Basicmedical Key
• Otolaryngology & Ophthalmology
• Musculoskeletal Key
• Obstetric, Gynecology and Pediatric
• Oncology & Hematology
• Plastic Surgery & Dermatology
• Clinical Dentistry
• Radiology Key
• Thoracic Key
• Veterinary Medicine
• Gold Membership

Malpresentations

Key Abbreviations Abdominal diameter AD American College of Obstetricians and Gynecologists ACOG Amniotic fluid index AFI Anteroposterior AP Biparietal diameter BPD Cerebral palsy CP Combined spinal-epidural CSE Computed tomography CT Confidence interval CI External cephalic version ECV Ex utero intrapartum treatment  EXIT Fetal heart rate FHR Internal podalic version IPV Magnetic resonance imaging MRI Occipitofrontal diameter OFD Odds ratio OR Perinatal mortality rate PMR Periventricular leukomalacia PVL Preterm premature rupture of the membranes PPROM Relative risk RR Term breech trial TBT Near term or during labor, the fetus normally assumes a vertical orientation, or lie, and a cephalic presentation, with the flexed fetal vertex presenting to the pelvis ( Fig. 17-1 ). However, in about 3% to 5% of singleton gestations at term, an abnormal lie, presentation, or flexed attitude occurs; such deviations constitute fetal malpresentations. The word malpresentation suggests the possibility of adverse consequences, and malpresentation is often associated with increased risk to both the mother and the fetus. In the early twentieth century, mal­presentation often led to a variety of maneuvers intended to facilitate vaginal delivery, including destructive operations lead­ing, predictably, to fetal death. Later, manual or instrumented attempts to convert the malpresenting fetus to a more favorable orientation were devised. Internal podalic version (IPV) followed by a complete breech extraction was once advocated as a solution to many malpresentation situations. However, like with most manipulative efforts to achieve vaginal delivery, IPV was associated with high fetal and maternal morbidity and mortality rates and has been largely abandoned. In contemporary practice, cesarean delivery has become the recommended mode of delivery in the malpresenting fetus. FIG 17-1 Frontal view of a fetus in a longitudinal lie with fetal vertex flexed on the neck. Clinical Circumstances Associated with Malpresentation Generally, factors associated with malpresentation include (1) diminished vertical polarity of the uterine cavity, (2) increased or decreased fetal mobility, (3) obstructed pelvic inlet, (4) fetal malformation, and (5) prematurity. The association of great parity with malpresentation is presumably related to laxity of maternal abdominal musculature and resultant loss of the normal vertical orientation of the uterine cavity. Placentation either high in the fundus or low in the pelvis ( Fig. 17-2 ) is another factor that diminishes the likelihood of a fetus assuming a longitudinal axis. Uterine myomata, intrauterine synechiae, and müllerian duct fusion abnormalities such as a septate uterus or uterine didelphys are similarly associated with a higher than expected rate of malpresentation. Because both prematurity and polyhydramnios permit increased fetal mobility, the probability of a noncephalic presentation is greater if preterm labor or rupture of the membranes occurs. Furthermore, preterm birth involves a fetus that is small relative to the maternal pelvis; therefore engagement and descent with labor or rupture of the membranes can occur despite a malpresentation. In contrast, conditions such as chromosomal aneuploidies, congenital myotonic dystrophy, joint contractures from various etiologies, arthrogryposis, oligohydramnios, and fetal neurologic dysfunction that result in decreased fetal muscle tone, strength, or activity are also associated with an increased incidence of fetal malpresentation. Finally, the cephalopelvic disproportion associated with severe fetal hydrocephalus or with a contracted maternal pelvis may be implicated as an etiology of malpresentation because normal engagement of the fetal head is prevented. FIG 17-2 Either the high fundal or low implantation of the placenta, as illustrated here, would normally be in the vertical orientation of the intrauterine cavity and increase the probability of a malpresentation. Abnormal Axial Lie The fetal lie indicates the orientation of the fetal spine relative to the spine of the mother. The normal fetal lie is longitudinal and by itself does not indicate whether the presentation is cephalic or breech. If the fetal spine or long axis crosses that of the mother, the fetus may be said to occupy a transverse or oblique lie ( Fig. 17-3 ), which may cause an arm, foot, or shoulder to be the presenting part ( Fig. 17-4 ). The lie may be termed unstable if the fetal membranes are intact and fetal mobility is increased, which results in frequent changes of lie and/or presentation. FIG 17-3 A fetus may lie on a longitudinal, oblique, or transverse axis, as illustrated. The lie does not indicate whether the vertex or the breech is closest to the cervix. FIG 17-4 This fetus lies in an oblique axis with an arm prolapsing. Abnormal fetal lie is diagnosed in approximately 1 in 300 cases, or 0.33% of pregnancies at term. Prematurity is often a factor, with abnormal lie reported to occur in about 2% of pregnancies at 32 weeks’ gestation—six times the rate found at term. Persistence of a transverse, oblique, or unstable lie beyond 37 weeks’ gestation requires a systematic clinical assessment and a plan for management; this is because rupture of the membranes without a fetal part filling the inlet of the pelvis poses an increased risk of cord prolapse, fetal compromise, and maternal morbidity if neglected. As noted, great parity, prematurity, contraction or deformity of the maternal pelvis, and abnormal placentation are the most commonly reported clinical factors associated with abnormal lie; however, it often happens that none of these factors are present. In fact, any condition that alters the normal vertical polarity of the intrauterine cavity will predispose to abnormal lie. Diagnosis of the abnormal lie may be made by palpation using Leopold maneuvers or by vaginal examination verified by ultrasound. Whereas routine use of Leopold maneuvers may be helpful, Thorp and colleagues found the sensitivity of Leopold maneuvers for the detection of malpresentation to be only 28%, and the positive predictive value was only 24% compared with immediate ultrasound verification. Others have observed prenatal detection in as few as 41% of cases before labor. Adaptations have been made to the Leopold maneuvers that may improve detection of an abnormal lie or presentation. The Sharma modified Leopold maneuver and the Sharma right and left lateral maneuvers in the original report demonstrated improved diagnostic accuracy; they detected vertex presenting occipitoanterior (95% vs. 84.4%, P = .04), posterior presentations (96.3% vs. 66.6%, P = .00012), and breech presentations correctly more often than with traditional Leopold maneuvers. These maneuvers use the forearms in addition to the hands and fingers. As with any abdominal palpation technique, limitations on accuracy are to be expected in the obese patient and in a patient with uterine myomata. The ready availability of ultrasound in most clinical settings is of benefit, and its use can obviate the vagaries of the abdominal palpation techniques. In all situations, early diagnosis of malpresentation is of benefit . A reported fetal loss rate of 9.2% with an early diagnosis, versus a loss rate of 27.5% with a delayed diagnosis, indicates that early diagnosis improves fetal outcome. Reported perinatal mortality rates for unstable or transverse lie (corrected for lethal malformations and extreme prema­turity) vary from 3.9% to 24%, with maternal mortality as high as 10%. Maternal deaths are usually related to infection after premature rupture of membranes (PROM), hemorrhage secondary to abnormal placentation, complications of operative intervention for cephalopelvic disproportion, or traumatic delivery. Fetal loss of phenotypically and chromosomally normal gestations at ages considered to be viable is primarily associated with delayed interventions, prolapsed cord, or traumatic delivery. Cord prolapse occurs 20 times as often with abnormal lie as it does with a cephalic presentation. Management of a Singleton Gestation Safe vaginal delivery of a fetus from an abnormal axial lie is not generally possible. A search for the etiology of the malpresentation is always indicated. A transverse/oblique or unstable lie late in the third trimester necessitates ultrasound examination to exclude a major fetal malformation and abnormal placentation. Fortunately, most cases of major fetal anomalies or abnormal placentation can now be diagnosed long before the third trimester. Phelan and colleagues reported 29 patients with transverse lie diagnosed at or beyond 37 weeks’ gestation and managed expectantly, and 83% (24 of 29) spontaneously converted to breech (9 of 24) or vertex (15 of 24) before labor; however, the overall cesarean delivery rate was 45%, with two cases of cord prolapse, one uterine rupture, and one neonatal death. External cephalic version (ECV) is recommended at 36 to 37 weeks to help diminish the risk of adverse outcome. In cases of an abnormal lie, the risk of fetal death varies with the obstetric intervention. Fetal mortality should approach zero for cesarean birth but has been reported to be as high as 10% in older reports and between 25% and 90% when IPV and breech extraction are performed. ECV has been found to be safe and relatively efficacious and is further discussed later in this chapter. If external version is unsuccessful or unavailable, if spontaneous rupture of the membranes occurs, or if active labor has begun with an abnormal lie, cesarean delivery is the treatment of choice for the potentially viable infant. There is no place for IPV and breech extraction in the management of transverse or oblique lie or in an unstable presentation in a singleton pregnancy because of the unacceptably high rate of fetal and maternal complications. A persistent abnormal axial lie, particularly if accompanied by ruptured membranes, also alters the choice of uterine incision at cesarean delivery. A low transverse (Kerr) uterine incision has many surgical advantages and is generally the preferred approach for cesarean delivery for an abnormal lie (see Chapter 19 ). Because up to 25% of transverse incisions may require vertical extension for delivery of an infant from an abnormal lie, and the lower uterine segment is often poorly developed and insufficiently broad such that a traumatic delivery of the presenting part is made more difficult, other uterine incisions may be considered. A “J” or “T” extension of the low transverse incision results in a uterine scar that is more susceptible to subsequent rupture due to poor vascularization. Therefore in the uncommon case of a transverse or oblique lie with a poorly developed lower uterine segment, when a transverse incision is deemed unfeasible or inadequate, a vertical incision (low vertical or classical) may be a reasonable alternative. Intraoperative cephalic version may allow the use of a low transverse incision, but ruptured membranes or oligohydramnios may make this difficult. Uterine relaxing agents such as inhalational anesthetics or intravenous (IV) nitroglycerin may improve success of these maneuvers if the difficulty is attributable to a contracted uterine fundus. Deflection Attitudes Attitude refers to the position of the fetal head in relation to the neck. The normal attitude of the fetal head during labor is one of full flexion with the fetal chin against the upper chest. Deflexed attitudes include various degrees of deflection or even extension of the fetal neck and head ( Fig. 17-5 ), leading to, for example, face or brow presentations. Spontaneous conversion to a more normal, flexed attitude or further extension of an intermediate deflection to a fully extended position commonly occurs as labor progresses owing to resistance exerted by the bony pelvis and soft tissues. Although safe vaginal delivery is possible in many cases, experience indicates that cesarean delivery may be the most appropriate alternative when arrest of progress is observed. FIG 17-5 The normal “attitude” ( top ) shows the fetal vertex flexed on the neck. Partial deflexion ( middle ) shows the fetal vertex intermediate between flexion and extension. Full deflexion ( lower ) shows the fetal vertex completely extended with the face presenting. Face Presentation A face presentation is characterized by a longitudinal lie and full extension of the fetal neck and head with the occiput against the upper back ( Fig. 17-6 ). The fetal chin (mentum) is chosen as the point of designation during vaginal examination. For example, a fetus presenting by the face whose chin is in the right posterior quadrant of the maternal pelvis would be called a right mentum posterior ( Fig. 17-7 ). The reported incidence of face presentation ranges from 0.14% to 0.54% and averages about 0.2%, or 1 in 500 live births overall. The reported perinatal mortality rate, corrected for nonviable malformations and extreme prematurity, varies from 0.6% to 5% and averages about 2% to 3%. FIG 17-6 This fetus with the vertex completely extended on the neck enters the maternal pelvis in a face presentation. The cephalic prominence would be palpable on the same side of the maternal abdomen as the fetal spine. FIG 17-7 The point of designation from digital examination in the case of a face presentation is the fetal chin relative to the maternal pelvis. Left, right mentum posterior (RMP); middle, mentum anterior (MA); right, left mentum transverse (LMT). All clinical factors known to increase the general rate of malpresentation have been implicated in face presentation; many infants with a face presentation have malformations. Anencephaly, for instance, is found in about one third of cases of face presentation. Fetal goiter and tumors of the soft tissues of the head and neck may also cause deflexion of the head. Frequently observed maternal factors include a contracted pelvis or cephalopelvic disproportion in 10% to 40% of cases. In a review of face presentation, Duff found that one of these etiologic factors was found in up to 90% of cases. Early recognition of the face presentation is important, and the diagnosis can be suspected when abdominal palpation finds the fetal cephalic prominence on the same side of the maternal abdomen as the fetal back ( Fig. 17-8 ); however, face presen­tation is more often discovered by vaginal examination. In practice, fewer than 1 in 20 infants with face presentation is diagnosed by abdominal examination. In fact, only half of these infants are found by any means to have a face presentation before the second stage of labor, and half of the remaining cases are undiagnosed until delivery. However, perinatal mortality may be higher with late diagnosis. FIG 17-8 Palpation of the maternal abdomen in the case of a face presentation should find the fetal cephalic prominence on the side away from the fetal small parts, instead of on the same side, as in the case of a normally flexed fetal neck and head. Mechanism of Labor Knowledge of the early mechanism of labor for face presentation is incomplete. Many infants with a face presentation probably begin labor in the less extended brow position. With descent into the pelvis, the forces of labor press the fetus against maternal tissues; subsequent flexion (to a vertex presentation) or full extension of the head on the spine (to a face presentation) then occurs. The labor of a face presentation must include engagement, descent, internal rotation generally to a mentum anterior position, and delivery by flexion as the chin passes under the symphysis ( Fig. 17-9 ). However, flexion of the occiput may not always occur, and delivery in the fully extended attitude may be common. FIG 17-9 Engagement, descent, and internal rotation remain cardinal elements of vaginal delivery in the case of a face presentation, but successful vaginal delivery of a term-size fetus presenting a face generally requires delivery by flexion under the symphysis from a mentum anterior position, as illustrated here. The prognosis for labor with a face presentation depends on the orientation of the fetal chin. At diagnosis, 60% to 80% of infants with a face presentation are mentum anterior, 10% to 12% are mentum transverse, and 20% to 25% are mentum posterior. Almost all average-sized infants presenting mentum anterior with adequate maternal pelvic dimensions will achieve spontaneous or assisted vaginal delivery. Furthermore, most mentum transverse infants will rotate to the mentum anterior position and will deliver vaginally, and even 25% to 33% of mentum posterior infants will rotate and deliver vaginally in the mentum anterior position. In a review of 51 cases of persistent face presentation, Schwartz and colleagues found that the mean birthweight of those infants in a mentum posterior position who did rotate and deliver vaginally was 3425 g, compared with 3792 g for those infants who did not rotate and deliver vaginally. Persistence of the mentum posterior position with an infant of normal size, however, makes safe vaginal delivery less likely. Overall, 70% to 80% of infants with a face presenting can be delivered vaginally, either spontaneously or by low forceps in the hands of a skilled operator, whereas 12% to 30% require cesarean delivery. Manual attempts to convert the face to a flexed attitude or to rotate a posterior position to a more favorable mentum anterior position are rarely successful and increase both maternal and fetal risks. Again, IPV and breech extraction for face presentation historically are associated with unacceptably high fetal loss rates. Maternal deaths from uterine rupture and trauma have also been documented. Thus contemporary management through spontaneous delivery and cesarean delivery for other obstetric indications as necessary are the preferred routes for both maternal and fetal safety. Prolonged labor is a common feature of face presentation and has been associated with an increased number of intrapartum deaths; therefore prompt attention to an arrested labor pattern is recommended. In the case of an average or small fetus, an adequate pelvis, and hypotonic labor, oxytocin may be considered. No absolute contraindication to oxytocin augmentation of hypotonic labor in face presentations exists, but an arrest of progress despite adequate labor should call for cesarean delivery. Worsening of the fetal condition in labor is common. Salzmann and colleagues observed a tenfold increase in fetal compromise with face presentation. Several other observers have also found that abnormal fetal heart rate (FHR) patterns occur more often with face presentation. Continuous intrapartum electronic FHR monitoring of a fetus with face presentation is considered mandatory, but extreme care must be exercised in the placement of an electrode because ocular or cosmetic damage is possible. If external Doppler heart rate monitoring is inadequate and an internal electrode is recommended, placement of the electrode on the fetal chin is often preferred. Contraindications to vaginal delivery of a face presentation include macrosomia, nonreassurance of FHR monitoring even without arrested or protracted labor, or an inadequate maternal pelvis; cesarean delivery has been reported in as many as 60% of cases of face presentation for these reasons. If cesarean delivery is warranted, care should be taken to flex the head gently, both to accomplish elevation of the head through the hysterotomy incision as well as to avoid potential cervical nerve damage to the neonate. Forced flexion may also result in fetal injury, especially with fetal goiter or neck tumors. Fetal laryngeal and tracheal edema that results from the pressure of the birth process might require immediate nasotracheal intubation. Nuchal tumors or simple goiters, fetal anomalies that might have caused the malpresentation, require expert neonatal management, including the possibility of an ex utero intrapartum treatment (EXIT) procedure, which establishes a fetal/neonatal airway before the umbilical cord is clamped. Identification of and planning for these particular circumstances in the prelabor setting are ideal. Brow Presentation A fetus in a brow presentation occupies a longitudinal axis with a partially deflexed cephalic attitude midway between full flexion and full extension ( Fig. 17-10 ). The frontal bones are the point of designation. If the anterior fontanel is on the mother’s left side, with the sagittal suture in the transverse pelvic axis, the fetus would be in a left frontum transverse position ( Fig. 17-11 ). The reported incidence of brow presentation varies widely, from 1 in 670 to 1 in 3433, averaging about 1 in 1500 deliveries. Brow presentation is detected more often in early labor before flexion occurs to a normal attitude. Less frequently, further extension results in a face presentation. FIG 17-10 This fetus is in a brow presentation in a frontum anterior position. The head is in an intermediate deflexion attitude. FIG 17-11 In brow presentation, the anterior fontanel (frontum) relative to the maternal pelvis is the point of designation. Left, fetus in left frontum transverse (LFT); middle, frontum anterior (FA); right, left frontum anterior (LFA). In 1976, the perinatal mortality rate corrected for lethal anomalies and very low birthweight varied from 1% to 8%. In a study of 88,988 deliveries, corrected perinatal mortality rates for brow presentations depended on the mode of delivery; a loss rate of 16%, the highest in this study, was associated with manipulative vaginal birth. In general, factors that delay engagement are associated with persistent brow presentation. Cephalopelvic disproportion, prematurity, and high parity are often found and have been implicated in more than 60% of cases of persistent brow presentation. Detection of a brow presentation by abdominal palpation is unusual in practice. More often, a brow presentation is detected on vaginal examination. As in the case of a face presentation, diagnosis in labor is more likely. Fewer than 50% of brow presentations are detected before the second stage of labor, and most of the remainder are undiagnosed until delivery. Frontum anterior is reportedly the most common position at diagnosis, occurring about twice as often as either transverse or posterior positions. Although the initial position at diagnosis may be of limited prognostic value, the cesarean delivery rate is higher with frontum transverse or frontum posterior than with frontum anterior positioning. A persistent brow presentation requires engagement and descent of the largest (mento-occipital) diameter of the fetal head. This process is possible only with a large pelvis or a small infant, or both. However, most brow presentations convert spontaneously by flexion or further extension to either a vertex or a face presentation and are then managed accordingly. The earlier the diagnosis is made, the more likely conversion will occur spontaneously. Fewer than half of fetuses with persistent brow presentations undergo spontaneous vaginal delivery, but in most cases, a trial of labor is not contraindicated. Prolonged labors have been observed in 33% to 50% of brow presentations, and secondary arrest is not uncommon. Forced conversion of the brow to a more favorable position with forceps is contraindicated, as are attempts at manual conversion. One unexpected cause of persistent brow presentation may be an open fetal mouth pressed against the vaginal wall, splinting the head and preventing either flexion or extension ( Fig. 17-12 ). Although this is rare in phenotypically normal fetuses, it needs to be considered in anomalous conditions of the fetus such as epignathus, a rare oropharyngeal teratoma. FIG 17-12 The open fetal mouth against the vaginal sidewall may brace the head in the intermediate deflexion attitude as shown here. Similar to face presentations, minimal manipulation yields the best results if the FHR pattern remains reassuring. Expectant management may be justified, preferably with a relatively large pelvis in relation to fetal size and adequate labor progress, according to one large study. If a brow presentation persists with a large baby, successful vaginal delivery is unlikely, and cesarean delivery may be most prudent. Radiographic or computed tomographic (CT) pelvimetry is not used clinically, and one report states that although 91% of cases with adequate pelvimetry converted to a vertex or a face presentation and delivered vaginally, 20% with some form of pelvic contracture did also. Therefore regardless of pelvic dimensions, consideration of a trial of labor with careful monitoring of maternal and fetal condition may be appropriate. As in the case of a face presentation, oxytocin may be used cautiously to correct hypotonic contractions, but prompt resumption of progress toward delivery should follow. Compound Presentation Whenever an extremity, most commonly an upper extremity, is found prolapsed beside the main presenting fetal part, the situation is referred to as a compound presentation ( Fig. 17-13 ). The reported incidence ranges from 1 in 377 to 1 in 1213 deliveries. The combination of an upper extremity and the vertex is the most common. FIG 17-13 The compound presentation of an upper extremity and the vertex illustrated here most often spontaneously resolves with further labor and descent. This diagnosis should be suspected with any arrest of labor in the active phase or failure to engage during active labor. Diagnosis is made on vaginal examination by discovery of an irregular mobile tissue mass adjacent to the larger presenting part. Recognition late in labor is common, and as many as 50% of persisting compound presentations are not detected until the second stage. Delay in diagnosis may not be detrimental because it is likely that only the persistent cases require intervention. Although maternal age, race, parity, and pelvic size have been associated with compound presentation, prematurity is the most consistent clinical finding. The very small premature fetus is at great risk of persistent compound presentation. In late pregnancy, ECV of a fetus in breech position increases the risk of a compound presentation. Older, uncontrolled studies report elevated perinatal mortality rates with a compound presentation, with an overall rate of 93 per 1000. Higher loss rates of 17% to 19% have been reported when the foot prolapses. As with other malpresentations, fetal risk is directly related to the method of management. A fetal mortality rate of 4.8% has been noted if no intervention is required compared with 14.4% with intervention other than cesarean delivery. A 30% fetal mortality rate has been observed with IPV and breech extraction. These figures may demonstrate selection bias because it is possible that more often, the difficult cases were chosen for manipulative intervention. When intervention is necessary, cesarean delivery appears to be the only safe choice. Fetal risk in compound presentation is specifically associated with birth trauma and cord prolapse. Cord prolapse occurs in 11% to 20% of cases, and it is the most frequent complication of this malpresentation. Cord prolapse probably occurs because the compound extremity splints the larger presenting part and results in an irregular fetal aggregate that incompletely fills the pelvic inlet. In addition to the hypoxic risk of cord prolapse, common fetal morbidity includes neurologic and musculoskeletal damage to the involved extremity. Maternal risks include soft tissue damage and obstetric laceration. Again, although laboring is not proscribed, the prolapsed extremity should not be manipulated. However, it may spontaneously retract as the major presenting part descends. Seventy-five percent of vertex/upper extremity combinations deliver spontaneously. Occult or obscured cord prolapse is possible, and therefore continuous electronic FHR monitoring is recommended. The primary indications for surgical intervention (i.e., cesarean delivery) are cord prolapse, nonreassuring FHR patterns, and arrest of labor. Cesarean delivery is the only appropriate clinical intervention for cord prolapse and nonreassuring FHR patterns because both version extraction and repositioning the prolapsed extremity are associated with adverse outcome and should be avoided. From 2% to 25% of compound presentations require cesarean delivery. Protraction of the second stage of labor and dysfunctional labor patterns have been noted to occur more frequently with persistent compound presentations. As in other malpresentations, spontaneous resolution occurs more often, and surgical intervention is less frequently necessary in those cases diagnosed early in labor. Small or premature fetuses are more likely to have persistent compound presentations but are also more likely to have a successful vaginal delivery. Persistent compound presentation with parts other than the vertex and hand in combination in a term-sized infant has a poor prognosis for safe vaginal delivery, and cesarean delivery is usually necessary. However, a simple compound presentation (e.g., hand) may be allowed to labor, if labor is progressing normally with reassuring fetal status. Breech Presentation The infant presenting as a breech occupies a longitudinal axis with the cephalic pole in the uterine fundus. This presentation occurs in 3% to 4% of labors overall, although it is found in 7% of pregnancies at 32 weeks and in 25% of pregnancies of less than 28 weeks’ duration. The three types of breech are noted in Table 17-1 . The infant in the frank breech position is flexed at the hips with extended knees (pike position). The complete breech is flexed at both joints (tuck position), and the footling or incomplete breech has one or both hips partially or fully extended ( Fig. 17-14 ). TABLE 17-1 BREECH CATEGORIES TYPE OVERALL % OF BREECHES RISK OF PROLAPSE (%) † PREMATURE (%) ‡ Frank 48-73 * † ‡ 0.5 38 Complete 4.6-11.5 † ‡ 4-6 12 Footling 12-38 ‡ 15-18 50   * Data from Collea JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. Am J Obstet Gynecol. 1980;137:235-244. † Data from Gimovsky ML, Wallace RL, Schifrin BS, Paul RH. Randomized management of the nonfrank breech presentation at term: a preliminary report. Am J Obstet Gynecol. 1983;146:34-40. ‡ Data from Brown L, Karrison T, Cibils LA. Mode of delivery and perinatal results in breech presentation. Am J Obstet Gynecol. 1994;171:28-34. FIG 17-14 The complete breech is flexed at the hips and flexed at the knees. The incomplete breech shows incomplete deflexion of one or both knees or hips. The frank breech is flexed at the hips and extended at the knees. The diagnosis of breech presentation may be made by abdominal palpation or vaginal examination and confirmed by ultrasound. Prematurity, fetal malformation, müllerian anomalies, and polar placentation are commonly observed causative factors. High rates of breech presentation are noted in certain fetal genetic disorders, including trisomies 13, 18, and 21; Potter syndrome; and myotonic dystrophy. Conditions that alter fetal muscular tone and mobility—such as increased and decreased amniotic fluid, for example—also increase the frequency of breech presentation. The breech head appears dolichocephalic on ultrasound, and for that reason, the biparietal diameter (BPD) appears small. However, the head circumference remains unaffected. This difference may be as much as 16+ days (95% confidence interval [CI], 14.3 to 18.1; P = .001). Whereas the contracted BPD may affect ultrasound-determined weight estimates of the fetus, an occipitofrontal diameter (OFD) to BPD ratio of greater than 1.3 in the absence of other indicators of growth delay signals the deformation characteristic of the breech-presenting fetus. Approximately 80% of breech fetuses will have a dolichocephalic contour, previously termed the “breech head.” The fundus of the uterus assumes a more elongated contour than the bowl-like developed lower uterine segment. Thus it is believed that forces external to the fetus are responsible for this head shape. Because both dolichocephaly and breech may be associated with a genetically and phenotypically anomalous fetus, it behooves the sonologist to perform a detailed survey of the fetal anatomy prior to assuming the presence of the “breech head.” Mechanism and Conduct of Labor and Vaginal Delivery The two most important elements for the safe conduct of vaginal breech delivery are continuous electronic FHR monitoring and noninterference until spontaneous delivery of the breech to the umbilicus has occurred. Early in labor, the capability for immediate cesarean delivery should be established. Anesthesia should be available, the operating room readied, and appropriate informed consent obtained (discussed later). Two obstetricians should be in attendance in addition to a pediatric team. Appropriate training and experience with vaginal breech delivery are fundamental to success. Although experience is becoming infinitely less common, simulation of breech deliveries will help to maintain these skills. The instrument table should be prepared in the customary manner, with the addition of Piper forceps and extra towels. No contraindication exists to epidural analgesia in labor, and many believe epidural anesthesia to be an asset in the control and conduct of the second stage. The infant presenting in the frank breech position usually enters the pelvic inlet in one of the diagonal pelvic diameters ( Fig. 17-15 ). Engagement has occurred when the bitrochanteric diameter of the fetus has progressed beyond the plane of the pelvic inlet, although by vaginal examination, the presenting part may be palpated only at a station of −2 to −4 (out of 5). As the breech descends and encounters the levator ani muscular sling, internal rotation usually occurs to bring the bitrochanteric diameter into the anteroposterior (AP) axis of the pelvis. The point of designation in a breech labor is the fetal sacrum ; therefore when the bitrochanteric diameter is in the AP axis of the pelvis, the fetal sacrum will lie in the transverse pelvic diameter ( Fig. 17-16 ). FIG 17-15 The breech typically enters the inlet with the bitrochanteric diameter aligned with one of the diagonal diameters, with the sacrum as the point of designation in the other diagonal diameter. This illustrates a left sacrum posterior alignment. FIG 17-16 With labor and descent, the bitrochanteric diameter generally rotates toward the anteroposterior axis, and the sacrum rotates toward the transverse axis. If normal descent occurs, the breech will present at the outlet and will begin to emerge, first as sacrum transverse, then rotating to sacrum anterior. This direction of rotation may reflect the greater capacity of the hollow of the posterior pelvis to accept the fetal chest and small parts. Crowning occurs when the bitrochanteric diameter passes under the pubic symphysis. It is important to emphasize that operator intervention is not yet needed or helpful, other than possibly to perform the episiotomy if indicated and to encourage maternal expulsive efforts. Premature or aggressive intervention may adversely affect the delivery in at least two ways. First, complete cervical dilation must be sustained for sufficient duration to retard retraction of the cervix and entrapment of the aftercoming fetal head. Rushing the delivery of the trunk may result in cervical retraction. Second, the safe descent and delivery of the breech infant must be the result of uterine and maternal expulsive forces only in order to maintain neck flexion. Any traction by the provider in an effort to speed delivery would encourage deflexion of the neck and result in the presentation of the larger occipitofrontal fetal cranial profile to the pelvic inlet ( Fig. 17-17 ). Such an event could be catastrophic. Rushed delivery also increases the risk of a nuchal arm, with one or both arms trapped behind the head above the pelvic inlet. Entrapment of a nuchal arm makes safe vaginal delivery much more difficult because it dramatically increases the aggregate size of delivering fetal parts that must egress vaginally. Safe breech delivery of an average-sized infant, therefore, depends predominantly on maternal expulsive forces and patience, not traction, from the provider. FIG 17-17 The fetus emerges spontaneously (A), whereas uterine contractions maintain cephalic flexion. Premature aggressive traction (B) encourages deflexion of the fetal vertex and increases the risk of head entrapment or nuchal arm entrapment. As the frank breech emerges further, the fetal thighs are typically flexed firmly against the fetal abdomen, often splinting and protecting the umbilicus and cord. The Pinard maneuver may be needed to facilitate delivery of the legs in a frank breech presentation. After delivery to the umbilicus has occurred, pressure is applied to the medial aspect of the knee, which causes flexion and subsequent delivery of the lower leg. Simultaneous to this, the fetal pelvis is rotated away from that side ( Fig. 17-18 ). This results in external rotation of the thigh at the hip, flexion of the knee, and delivery of one leg at a time. The dual movement of counterclockwise rotation of the fetal pelvis as the operator externally rotates the right thigh and clockwise rotation of the fetal pelvis as the operator externally rotates the fetal left thigh is most effective in facilitating delivery. The fetal trunk is then wrapped with a towel to provide secure support of the body while further descent results from expulsive forces from the mother. The operator primarily facilitates the delivery of the fetus by providing support and guiding the body through the introitus. The operator is not applying outward traction on the fetus, which might result in deflexion of the fetal head or nuchal arm. FIG 17-18 After spontaneous expulsion to the umbilicus, external rotation of each thigh (A) combined with opposite rotation of the fetal pelvis results in flexion of the knee and delivery of each leg (B). When the scapulae appear at the introitus, the operator may slip a hand over the fetal shoulder from the back ( Fig. 17-19 ); follow the humerus; and, with movement from medial to lateral, sweep first one and then the other arm across the chest and out over the perineum. Gentle rotation of the fetal trunk counterclockwise assists delivery of the right arm, and clockwise rotation assists delivery of the left arm (turning the body “into” the arm). This accomplishes delivery of the arms by drawing them across the fetal chest in a fashion similar to that used for delivery of the legs ( Fig. 17-20 ). These movements cause the fetal elbow to emerge first, followed by the forearm and hand. Once both arms have been delivered, if the vertex has remained flexed on the neck, the chin and face will appear at the outlet, and the airway may be cleared and suctioned ( Fig. 17-21 ). FIG 17-19 When the scapulae appear under the symphysis, the operator reaches over the left shoulder, sweeps the arm across the chest (A), and delivers the arm (B). FIG 17-20 Gentle rotation of the shoulder girdle facilitates delivery of the right arm. FIG 17-21 Following delivery of the arms, the fetus is wrapped in a towel for control and is slightly elevated. The fetal face and airway may be visible over the perineum. Excessive elevation of the trunk is avoided. With further maternal expulsive forces alone, spontaneous controlled delivery of the fetal head often occurs. If not, delivery may be accomplished with a simple manual effort to maximize flexion of the vertex using pressure on the fetal maxilla (not the mandible), the Mauriceau-Smellie-Veit maneuver, using gentle downward traction along with suprapubic pressure (Credé maneuver; Fig. 17-22 ). Although maxillary pressure facilitates flexion, the main force effecting delivery remains the mother. FIG 17-22 Cephalic flexion is maintained by pressure ( black arrow ) on the fetal maxilla, not the mandible. Often, delivery of the head is easily accomplished with continued expulsive forces from above and gentle downward traction. Alternatively, the operator may apply Piper forceps to the aftercoming head. The application requires very slight elevation of the fetal trunk by the assistant, while the operator kneels and applies the Piper forceps from beneath the fetus directly to the fetal head in the pelvis. Delivery of the breech presenting fetus, therefore, should occur on a table/bed capable of allowing the operators to correctly position themselves for the application of forceps. Direct access to the perineum is required. If a delivery bed is used, merely dropping the foot of the bed will be inadequate. The position of the operator for applying the forceps is depicted in Figure 17-23 , which also demonstrates how excessive elevation by the assistant may potentially cause harm to the neonate. Hyperextension of the fetal neck from excessive elevation of the fetal trunk, shown in Figure 17-23 , should be avoided because of the potential for spinal cord injury. FIG 17-23 Demonstration of incorrect assistance during the application of Piper forceps. The assistant hyperextends the fetal neck, a position that increases the risk for neurologic injury. Piper forceps are characterized by absence of pelvic curvature. This modification allows direct application to the fetal head and avoids conflict with the fetal body that would occur with the application of standard instruments from below. The assistant maintains control of the fetal body while the forceps are inserted into the vagina from beneath the fetus by the primary operator. The blade to be placed on the maternal left is held by the handle in the operator’s left hand; the blade is inserted with the operator’s right hand in the vagina along the left maternal sidewall and is placed against the right fetal parietal bone. The handle of the right blade is then held in the operator’s right hand and is inserted by the left hand along the right maternal sidewall and placed against the left fetal parietal bone. At this point, the assistant allows the fetal body to rest on the shank and handles of the forceps. Gentle downward traction on the forceps with the fetal trunk supported on the forceps shanks results in controlled delivery of the vertex ( Fig. 17-24 ). Forceps application controls the fetal head and prevents extension of the head on the neck. Application of Piper forceps to the aftercoming head may be advisable both to ensure control of the delivery and to maintain optimal operator proficiency in anticipation of deliveries that may require their use. FIG 17-24 The fetus may be laid on the forceps and delivered with gentle downward traction, as illustrated here. Arrest of spontaneous progress in labor with adequate uterine contractions necessitates consideration of cesarean delivery. Any evidence of fetal compromise or sustained cord compression on the basis of continuous electronic FHR monitoring also requires consideration of cesarean delivery. Vaginal interventions directed at facilitating delivery of the breech complicated by an arrest of spontaneous progress are discouraged because fetal and maternal morbidity and mortality are both greatly increased. However, if labor is deemed to be hypotonic by internally monitored uterine pressures, oxytocin is not contraindicated. Mechanisms of descent and delivery of the incomplete and the complete breech are not unlike those used for the frank breech described earlier; at least one leg may not require attention. The risk of cord prolapse or entanglement is greater, and hence the possibility of emergency cesarean delivery is increased. Furthermore, incomplete and complete breeches may not be as effective as cervical dilators as either the vertex or the larger aggregate profile of the thighs and buttocks of the frank breech. Thus the risk of entrapment of the aftercoming head is increased, and as a result, primary cesarean delivery is often advocated for nonfrank breech presentations. However, the randomized trial of Gimovsky and colleagues found vaginal delivery of the nonfrank breech to be reasonably safe. Contemporary Management of the Term Breech Debate has largely diminished about the proper management of the term breech. Much of the older data were derived from relatively few studies of varied methodologies, patient populations, and multiple retrospective cohort analyses, which are subject to bias. These reports indicated that the perinatal mortality rate for the vaginally delivered breech appears to be greater than for its cephalic counterpart, but much of the reported perinatal mortality rate associated with breech presentation was largely due to lethal anomalies and complications of prematurity, both of which are found more frequently among breech infants. Excluding anomalies and extreme prematurity, the corrected perinatal mortality reported by some investigators approached zero regardless of the method of delivery, whereas others found that even with exclusion of these factors, the term breech infant has been found to be at higher risk for birth trauma and asphyxia. To date, only three randomized trials have been reported. Although conclusions regarding the safety of breech vaginal delivery from a fetal standpoint may continue to vary, the practical reality today is that intentional vaginal breech delivery is rare. A summary of some of the reported complications is listed in Table 17-2 . Overall, consideration of a potential breech vaginal delivery must be mutually agreed on by the patient and the physician after complete informed consent is obtained. TABLE 17-2

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

• Operative Vaginal Delivery
• Placenta Accreta
• Prolonged and Postterm Pregnancy
• Mental Health and Behavioral Disorders in Pregnancy

Stay updated, free articles. Join our Telegram channel

Comments are closed for this page.

Full access? Get Clinical Tree

• ajog-v8-id1166

Case Presentation

Declarations.

Case Report

Austin J Obstet Gynecol. 2021; 8(2): 1166.

Compound Presentation: A Case Report of One of the Rarest Varieties- Vertex, Hand, and Feet Presentation

Sium AF*, Tilahun A, Mersha A and Yihun S

Department of Obstetrics and Gynecology, Saint Paul’s Hospital Millennium Medical College, Ethiopia

*Corresponding author: Abraham Fessehaye Sium, Saint Paul’s Hospital Millennium Medical College, Department of Obstetrics and Gynecology, Addis Ababa, Ethiopia

Received: February 03, 2021; Accepted: February 25, 2021; Published: March 04, 2021

Background: Compound presentation occurs in approximately 1/700 deliveries. Being the rarest type, there is scarce literature about the recommended management for vertex-hand-feet variety of compound presentation. We report a similar type of compound presentation.

Case Summary: A 25 years-old primigravida who claimed to be 9 months ammenorric presented with a history of pushing down pain of 12 hours duration with associated history of passage of liquor of 4 hours duration. Up on physical examination she was in active first of labor at cervical dilation of 5 centimeters and the presentation was compound- a vertex-hand-feet variety. Cesarean delivery was done after two hours of conservative management and the outcome was an alive 2300grams male neonates with no perinatal or maternal complication.

Conclusion: In the rarest variety of compound presentation, which is a vertex, hand, and feet type, spontaneous correction is unusual if the fetus is alive and interference is usually necessary.

Keywords: Compound presentation; Vertex-hand-feet presentation; Malpresenation

Compound presentation occurs in approximately 1/700 deliveries. Vertex, and hand presentation is the commonest type. Being the rarest type, there is scarce literature about the recommended management for vertex-hand-feet variety of compound presentation. We report a similar type of compound presentation.

A 25 years-old primigravida lady who claimed to be 9 months ammenorric presented with a history of pushing down pain of 12 hours duration and associated passage of liquor of four hours duration. She had no history of vaginal bleeding, nor headache, nor blurry of vision. Her medical, surgical, and psychosocial history was unremarkable.

Up on physical examination, her vital signs were normal and the pertinent finding was on pelvic examination. The cervix was 5 centimeters dilated, station was at minus 1, and the presentation was compound, vertex-hand-feet type. Bedside ultrasound was done and the estimated fetal weight was 2400 grams and there was no gross fetal congenital anomaly. Two hours of conservative management was allowed with the hope to achieve spontaneous resolution of the compound presentation, but there was no progress in the cervical dilation.

With an indication of compound presentation plus arrest of cervical dilation, cesarean section was done and the outcome was alive 23000 grams male neonate with Apgar score of 7, and 8 at first and fifth minutes respectively. Intra-operatively, the diagnosis was confirmed and pelvic diameter was assessed. The obstetric conjugate was 11 centimeters. There was no difficulty encountered during extraction of the body and no perinatal complication. The patient had smooth post-operative course and her follow up visit at one week documented no abnormality with good wound healing.

COMPOUND or complex presentation is not very rare in obstetric practice, yet it is not common enough to give an individual obstetrician considerable experience on the condition. The literature on the subject is surprisingly scarce [1]. Compound presentation is defined as presentation of a fetal extremity alongside the presenting part. It may involve one or more extremities (hand, arm and foot) with the vertex or the breech. The majority of compound presentations is represented by the fetal hand or arm presenting with the vertex [2]. Our case is one of the rarest forms of compound presentation-vertex, hand, and feet. In a case series reported in the literature, Lokenath Bhose reported 18 such cases out 91 cases of compound presentation (Table 1). As depicted in (Table 2), Goplerud and Eastman reported only 4 similar cases out of 131 cases in a similar case series, while Donald P.C and Chan reported only 3 cases out of 65 compound presentation cases (Table 3). Preterm delivery and external cephalic version are acknowledged as being among the predisposing factors, although most cases of compound presenation occur in low-risk term cephalic presenting fetuses [2,3]. In our case the gestational age of the pregnancy was unknown but the birth weight of the baby was 2300 grams.

The effects of a compound presentation on labour depends on the size of the fetus and the size of the maternal pelvis. This may be considered in three degrees: 1. Where the fetus is large and the pelvis is small, a compound presentation may prevent the fetal head from entering the pelvic brim. Unless it is corrected, an obstructed labour will result. 2. Where the fetus and the pelvis are of average size, a compound presentation will cause delay in the second stage of labour. This delay is due to the prolapsed limb’s interference with the normal mechanism of flexion and internal rotation of the fetal head. Correction is usually necessary. 3. Where the fetus is small and the pelvis large, a compound presentation will have no effect on the course of labour. The fetus will be born with the hand in the prolapsed position [4]. The second effect explains our case as the baby was of average size-2300 grams and the pelvis was of average size.

The diagnosis of CP involves the palpation of a small part of the limb along with the major presenting part during vaginal examination. In early labor, the fetus may retract the extremity allowing for the spontaneous resolution of this malpresentation. On the other hand, if the extremity fails to retract spontaneously and prolapses below the fetal head, the correction of the malpresentation can be manually attempted by gently pushing the prolapsed arm upward and the head simultaneously downward by fundal pressure [5]. In our case the diagnosis was made intra-partum with one feet and one hand presenting before the vertex.

In general, the management of compound presentation consists of watchful waiting in the hope that the limb will withdraw. Interference in the form of internal version and breech extraction is often accompanied by uterine rupture and high fetal loss. However, the vertex and feet combination often poses problems. It is associated with a fetal mortality more than twice that of the vertex and hand combination. Spontaneous correction of this type of compound presentation is unusual if the fetus is alive and interference is usually necessary. Labour in such cases may become obstructed with consequent rupture of the uterus. On the rare occasion when vaginal delivery becomes possible, difficulty may arise from a nuchal hitch. This is probably due to the lower limbs taking up the space in the pelvis and impeding progress [6,7]. In our case, an attempt was made to achieve spontaneous resolution of the compound presentation and vaginal delivery by allowing two hours of conservative management.

In the rarest variety of compound presentation, which is a vertex, hand, and feet type, spontaneous correction of this type of compound presentation is unusual if the fetus is alive and interference is usually necessary. Hence, we recommend cesarean delivery during early labor.

Consent for publication

A verbal informed consent was obtained from the patient for publication of this case.

Availability of Supporting Data

All supporting documents are submitted along with the case report.

Authors’ Contributions

AF and SY contributed the introduction and case summary. AM and AT prepared the discussion and conclusion part.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgement

The authors would like to thank the Department of Obstetrics and Gynecology at Saint Paul’s Hospital millennium Medical College, Addis Ababa, Ethiopia.

• Compound Presentation a Review of 91 Cases by Lokenath Bhose MB. Lecturer Chittaranjan Sevasadan College of Obstetrics, Gynaecology and Child Health, Calcutta, India). 1961; 68: 307-314.
• Cruikshank DP, White CA. Obstetric malpresentations: twenty years’ experience. Am J Obstet Gynecol. 1973; 116: 1097-1104.
• A Study of 65 Cases of Comipound Presentation by Donald PC. Chan MB. Lecturer in Obstetrics and Gynaecology, Honig Konzg University).
• Compound Presentation W. LG. Quinlivan, MB. Woodstock, Ont.
• Labor and delivery. Editors. In: Cunningham FG, Hauth JC, Leveno KJ, et al. Williams Obstetrics (22 nd edition). 414 New York: McGraw-Hill. 2005.
• Ang LT. Compound Presentation Following External Version. 1978; 18: 213- 214.
• James LB, Edward W. Compound Presentation: A Survey of 131 Patients, Obstetrics & Gynecology. 1968; 32: 419-422.

Citation: Sium AF, Tilahun A, Mersha A and Yihun S. Compound Presentation: A Case Report of One of the Rarest Varieties- Vertex, Hand, and Feet Presentation. Austin J Obstet Gynecol. 2021; 8(2): 1166.

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. Abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma .

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 part of the baby’s body that leads out of the birth canal. 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. 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’ position for birth and the lowest-risk presentation for vaginal birth.

In vertex presentation, the baby is positioned head-first with back of the head 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 . If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury.

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

Before vaginal delivery, the baby must be 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, physicians should usually intervene . This may mean simple manual procedures to help reposition the baby or, in many cases, a planned C-section delivery . Healthcare professionals must identify and quickly resolve issues related to fetal size, weight, and presentation. Failing to intervene is medical malpractice .

Numerous complications may result from abnormal weight, size, abnormal position, or abnormal presentation.

Should I contact a lawyer?

Abnormal presentation, if mishandled, can cause birth injuries. If you have any concerns about your baby’s labor and delivery, a consultation with an attorney is completely free. A birth injury lawyer can provide insight about potential medical malpractice.

Compound presentation

In a compound presentation , there are multiple presenting parts. Most commonly,  the baby’s head and an arm come out 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.

Risk factors for compound presentation include:

• Prematurity
• Intrauterine growth restriction (IUGR)
• Multiple gestations ( twins , triplets, etc.)
• Polyhydramnios (too much amniotic fluid)
• 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, a cervical examination finds compound presentation.

If a mother has polyhydramnios, the risk of compound presentation is higher. 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.

If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency. Often, the safest way to deliver a baby with compound presentation is C-section.

Complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy , intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE).

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.

Limb presentation poses a large risk for dystocia, which is a medical emergency.

Occipitoposterior (OP) position

In occipitoposterior (OP) position, the baby is head-first with the back of the head turned towards the mother’s back. This position is also called an occiput posterior position. The baby’s head can be rotated to the right (right occipitoposterior position, or ROP), or to the left (left occipitoposterior position, or LOP).

Approximately 1 out of 19 babies present  in a posterior position rather than an anterior position.

Occipitoposterior position increases the baby’s risk of experiencing:

• prolonged labor
• prolapsed umbilical cord
• forceps and vacuum extractor injuries
• brain bleeds
• a lack of oxygen to the brain
• Hypoxic-ischemic Encephalopathy (HIE)

If a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section.  A C-section can help prevent oxygen deprivation caused by complications with OP position.

A nurse explains posterior position

Breech presentation

Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should change positions 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. During a vaginal delivery, a baby is at increased risk for serious problems with labor.

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:

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

Dealing with a birth injury can be difficult, but our attorneys can help.

Face presentation

A baby usually tucks its chin so they can be born head-first. A face presentation occurs when the face is the presenting part of the baby. In this position, the baby’s neck is extended backward. 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. The baby will often need a breathing tube placed in the airway to maintain airway patency and assist breathing.

Image by healthhand.com

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

W hen face presentation occurs, experts recommend liberal use of C-section.

Complications of Mismanaged Face Presentation

• 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. The brow (forehead) is the part 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
• anencephaly (an absence of major parts of the brain and skull)
• anterior neck mass (a growth on the front of the neck)
• Previous c-section delivery
• Polyhydramnios (excessive amniotic fluid)

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, an ultrasound can show brow presentation.

Warning signs of brow presentation may include signs of fetal distress or lack of labor progression.

Management of brow presentation

Infants in brow presentation early in labor may spontaneously move into a safer position during the delivery process. Safe delivery in brow presentation may be possible if the infant is small and/or the mother’s pelvic opening is 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 watch for signs of fetal distress, such as an abnormal heart rate.  Signs of fetal distress can indicate that a baby is in danger of sustaining serious brain injury. Quick intervention can prevent harm to the baby.

Medical staff should also monitor progression of labor when attempting a vaginal delivery of a baby in brow presentation. Prolonged labor can cause extended periods of fetal oxygen deprivation, which can cause birth asphyxia and permanent injury. 

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. The contractions can put pressure on the infant’s head and cut off their oxygen supply. In cases of brow presentation, usage of Pitocin is risky when the baby is not positioned for safe delivery.

Complications of brow presentation

Physicians can diagnose brow presentation early. When appropriately managed, delivery

can typically occur with 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.

These situations make transverse lie position more likely:

• polyhydramnios (too much amniotic fluid)
• Multiples pregancy
• placenta previa
• a baby with intrauterine growth restriction (IUGR)

Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position. A C-section should ideally be performed before the membranes break. 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.

• Free Case Review
• Available 24/7
• No Fee Unless We Win

Featured Videos

Testimonial from keziah’s family, posterior position, hypoxic-ischemic encephalopathy (hie).

Featured Testimonial

What Our Clients Say…

After the traumatic birth of my son, I was left confused, afraid, and seeking answers. We needed someone we could trust and depend on . ABC Law Centers: Birth Injury Lawyers was just that.

Helpful resources

More about our firm.

• Meet our birth injury attorneys
• Meet our in-house medical staff
• Verdicts and settlements
• Testimonials
• 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 .

Over $350 Million Recovered

In Verdicts, Settlements, & Judgements

$4.75 Million

$3.9 Million

$5.85 Million

Awards & Memberships

• Presentation Collections

How to Communicate With Clients, Using Project Presentation?

Get to know, how project presentations can make client communication easier and lead to successful results. Effective communication with clients is critical to any business relationship. One of the most powerful tools you have at your disposal may be a project presentation.

From updates to pitching a new idea and finally closing the deal, all this will be intensely influenced by a good presentation structure. This blog looks into using project report PPT to enable effective communication with the client and to drive home a point clearly and in line with set objectives.

Get to Know Your Audience

Getting ready for a winning project presentation starts with understanding your audience. The clientele is really very diverse in expertise and expectations. Catering to such needs and preferences really improves communication.

• Ask the Right Questions: Understand your clients as much as possible before you dive in. What are their goals? What level of detail do they want? Where are they having pain? All these questions, when answered, would lead to a presentation that wows them.
• Segment Your Content: Consider segmenting your content if you have both technical and non-technical shareholders in your audience. Retain technical slides for people who will want to know all the details and have separate but simpler visuals for those decision-makers who would rather see an overview.

Structure Your Presentation

A well-structured presentation is one whose message is kept simple. A client should easily follow your narrative, and not get confused in a sea of data or jargon.

Set the agenda upfront

Open your presentation with a statement of what it will cover. Make mention of what points your clients are to look out for; this tells them what to expect. This sets a context for a focused discussion and keeps the presentation on track.

Use the Rule of Three

Try to put related points into threes when giving information. This is because research shows that people are more likely to remember information if it is presented in groups of three. For instance, you could break down your project into three phases: planning, execution, and review.

Visualize Complex Data

If you’re going to present numbers and data, that may be complex, such as the timeline of the project or how the budget is going to break down, then make use of charts, graphs, and infographics. It’s known that chart presentation ideas modify complex information in simple form and bring meaning to difficult texts.

According to a 3M study, visuals are processed at a rate of 60,000 times faster than text , so incorporating them into a presentation increases understanding.

Engage Your Clients through Storytelling

Storytelling is just what you need to engage clients and make your presentation unforgettable. You’ll be able to hook emotionally if you put your project inside a story to connect with an audience.

Success Stories

Share case studies or success stories relating to your project and demonstrate its value. Demonstrate how similar projects solved issues or acquired extraordinarily positive results for other clients. This will not only establish credibility in terms of the services or solutions being offered but will also, from their perspective, show what is possible.

Establish a Narrative Arc

Establish in clear terms what the presentation is about, pointing out the challenges or opportunities that your projects address; then, flow into the main content detailing proposed solutions; and end with expected outcomes or next steps that close out your presentation by giving your clients clarity on the value of your project.

Provide Data to Build Trust

In today’s data-driven environment, clients want to see proof backing up their claims. Effectively utilizing data to provide legitimacy and credibility in your project presentation will portray, demographically, to your clients that your proposals are fact-based.

Include Relevant Statistics: Mention relevant statistics when one speaks about the metrics of a project, timelines, and budgets. For instance, propose a new marketing strategy and mention data about the performance of similar strategies in the past. In one Demand Report survey, 74% of B2B buyers reported that they are more likely to engage with vendors with ROI evidence, so backing it up with data can influence the decision-making process.

Pump up the volume with credible sources: Make sure that every nugget of data you present is from credible and reliable sources. This will not only provide more weight to your arguments but also help your clients relax knowing that your recommendations are based on well-thought-out data.

Encourage Interaction and Obtain Feedback

Communication, in general, is a two-way process. Trying to engage in interaction and feedback during your presentation, might lead you to have a much more efficient discussion and a better client relationship.

Ask Open-Ended Questions

Involve your customers in the sale—ask for their opinions, ideas, and concerns during your presentation. This will not only interest them and keep them intrigued, but also provide you with great insights into their priorities and preferences.

Add Interactive Elements

Make your presentation interactive with the use of polls, quizzes, or Q&A sessions. A large number of people said that, in a study conducted by the Content Marketing Institute, interactive content engages the audience much better than static content. So, it is a very efficient technique to do client presentations.

Recap Key Takeaways

When finishing a presentation, review all the highlights and subsequently always suggest the next steps. The clients should leave having no questions in their minds regarding what has taken place and what needs to be done moving forward.

• Review Main Points: In short, sum up the main elements of the presentation. Highlight what is most important for the client about their goals and problems.
• Suggest Next Steps: Make very clear what the next steps are going to be, and with that, exactly what is expected of your clients. This might include the approval of the proposal, feedback solicited, or even a follow-up meeting scheduled.

An effective project presentation to a client must entail a well-thought-out deliberation to understand their needs, preferences, and expectations. You will make a presentation that not only informs but drives action if you understand your audience, structure the project update template presentation to drive clarity, engage in telling your story, use data to build trust, encourage interaction, and summarise the takeaways.

Spread Love

Related blogs.

Hi there! I'm Akshaya, a dedicated content researcher with 1.5 years of experience. As a passionate PowerPoint enthusiast, I love crafting engaging blogs that empower users to create stunning presentations. Through my work, I aim to provide valuable insights and practical tips that help users make the most of our innovative PowerPoint templates.

Recent Blogs

How to use Google Slides offline and Work Anywhere?

Google Slides is equally a perfect tool that can be used in the creation and sharing of presentations. Use is...

How To Make A Graph In Google Slides

Google Slides is a powerful tool for creating presentations, but it also offers a variety of features for visualizing data....

How to Include Business Report with Infographic Presentation

These days because we live in a data-driven business world, to be able to express complex information concisely and effectively...

SIGNUP FOR NEWSLETTER