fetal presentation is defined as

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• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fetal presentation and position

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

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

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

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

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

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

Head down, facing up (posterior position)

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

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

Frank breech

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

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

Complete breech

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

Incomplete breech

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

Single footling breech

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

Double footling breech

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

Transverse lie

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

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

Oblique lie

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

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

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

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

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

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

Where to go next

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

• Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

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

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

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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]

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

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

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

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• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2024] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2024 Mar; 230(3S):S890-S900. Epub 2023 May 19.
• 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.

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What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

Breech concerns the position of the fetus before labor . Typically, the fetus comes out headfirst, but in a breech delivery, the buttocks or feet come out first. This type of delivery is risky for both the pregnant person and the fetus.

This article discusses the different types of breech presentations, risk factors that might make a breech presentation more likely, treatment options, and complications associated with a breech delivery.

Verywell / Jessica Olah

Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

• Complete : The fetus’s knees are bent, and the buttocks are presenting first.
• Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
• Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

• Previous pregnancies
• Multiple fetuses in the uterus
• An abnormally shaped uterus
• Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
• Placenta previa, a condition in which the placenta covers the opening to the uterus
• Preterm labor or prematurity of the fetus
• Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
• Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery. 

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

• Pregnant person is carrying more than one fetus
• Placenta is in the wrong place
• Healthcare provider has concerns about the health of the fetus
• Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

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

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

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

Breech presentation

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

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

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

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

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

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

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

History and exam

Key diagnostic factors.

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

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

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

Diagnostic tests

1st tests to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

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

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

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

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

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

Differentials

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

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Malpresentation

8-minute read

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

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

What are presentation and malpresentation?

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

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

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

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

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

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

Breech presentation

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

Breech presentation is the most common type of malpresentation.

Face presentation

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

Transverse lie

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

Oblique lie

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

Unstable lie

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

Cord presentation

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

What is malposition?

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

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

Why might my baby be in the wrong position?

Malpresentation may be caused by:

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

Often no cause is found.

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

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

You are more likely to have a malpresentation if:

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

How is malpresentation diagnosed?

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

Can my baby’s position be changed?

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

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

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

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

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

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

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

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

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

Vaginal breech birth

Risks to your baby can include:

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

Risks to you include:

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

Risks to your baby include:

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

Will I have a malpresentation in my future pregnancies?

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

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Labour complications.

• Interventions during labour
• Giving birth - stages of labour

Breech pregnancy

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• Foetal Version

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When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

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

Read more on NSW Health website

Presentation and position of baby through pregnancy and at birth

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

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

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• Tuesday, August 27, 2024
• Nursing Article

4 Key Steps of the Leopold Maneuver for Accurate Fetal Positioning

 The Leopold Maneuver is a fundamental examination technique used to assess fetal presentation, position, and size during pregnancy . It has been widely employed as a routine prenatal assessment tool by obstetricians and midwives for over a century. The technique involves a series of four maneuvers that allow the examiner to palpate the maternal abdomen and identify the fetal presentation and position.

In this article, we will explore the history, purpose, benefits, and limitations of the Leopold Maneuver , as well as provide a step-by-step guide on how to perform the examination. We will also discuss the importance of the Leopold Maneuver in prenatal care, common issues that may arise during the examination , and the role of the procedure in diagnosing fetal position.

Table of Contents

Definition of the Leopold Maneuver

The Leopold maneuver is a four-step procedure used by healthcare professionals to assess the fetal presentation, fetal lie, and fetal position . This technique involves feeling the abdomen, identifying the location of the fetal back, and palpating the fetal head, buttocks, and limbs to determine their position within the uterus .

History of the Leopold Maneuver

The Leopold maneuver was first described in 1899 by Christian Gerhard Leopold , a German obstetrician. Since then, it has become a standard procedure in obstetrics worldwide. Over the years, the technique has undergone several modifications to make it more accurate and reliable.

Importance of Leopold Maneuver in Obstetrics

The Leopold maneuver is a vital tool in assessing fetal presentation, lie, and position. The information obtained from this technique helps healthcare professionals determine the best mode of delivery and anticipate potential complications during labor and delivery. It also assists in identifying multiple gestations and abnormal fetal presentations , ensuring the safe delivery of the baby.

Purpose and Benefits of the Leopold Maneuver

Assessment of fetal presentation.

The Leopold maneuver is used to determine fetal presentation, which refers to the part of the fetus that enters the maternal pelvis first. The most common fetal presentation is the cephalic presentation, where the baby is head-down. However, other presentations, such as breech or transverse, require special attention during labor and delivery. The Leopold maneuver helps healthcare professionals determine the fetal presentation to prepare for the most optimal delivery for both the mother and baby.

Estimating Fetal Weight

During the Leopold maneuver, healthcare professionals can estimate fetal weight by palpating the mother’s abdomen. This information is crucial in assessing fetal growth and development and determining the need for intervention or delivery in cases where the fetus is too large or too small.

Identifying Fetal Lie and Attitude

The Leopold maneuver also helps healthcare professionals identify fetal lie and attitudes. Fetal lie refers to the orientation of the fetus in the uterus , while fetal attitude refers to the position of the fetus’s head and limbs in relation to its body . Accurate identification of fetal lie and attitudes is essential in preparing for safe and successful delivery.

Step-by-Step Guide on Performing the Leopold Maneuver

Preparing the Patient for the Examination

Before beginning the Leopold maneuver, the mother should empty her bladder, lie down, and relax her abdominal muscles. The healthcare professional should wash their hands and warm them before beginning the examination.

Step 1: Identification of the Fundus

Palpation of the fundus: The first maneuver is also called Fundal Grip . The healthcare professional palpates the uppermost part of the uterus (fundus) to determine the fetal lie, presentation, and engagement . The healthcare professional should identify the position of the fundus, which is the top of the uterus, by palpating the abdomen with both hands. The fundus is usually located near the navel.

Your Findings Should Be Recorded as, Head : round, more mobile Breach : Large, nodular mass

Step 2: Identification of the Fetal Back

Palpation of the sides of the uterus : The second maneuver is also called Umbilical Grip . The healthcare professional palpates the sides of the uterus to determine the fetal presentation and position . The healthcare professional should identify the location of the fetal back by feeling a smooth, firm, and long surface on one side of the uterus.

Your Findings Should Be Recorded as,

Back : Hard, resistant structure, directed anteriorly, posteriorly, or transversely Fetal Extremities : Numerous small irregular mobile parts

Step 3: Identification of the Fetal Part occupying the Pelvic Inlet

Palpation of the fetal parts : This maneuver is also known as the first Pawlik Grip . The healthcare professional palpates the fetal parts to determine the fetal position and engagement . The healthcare professional should identify the fetal part occupying the pelvic inlet by palpating the lower abdomen . Depending on the fetal presentation, this could be the fetal head or buttocks.

When the head has descended, can feel the anterior shoulder or the space created by the neck from the head.

• Palpate the lower abdomen to identify the presenting part of the fetus (e.g., “The fetal buttocks are presenting at the inlet.”)
• Note the position of the presenting part in relation to the mother’s pelvis (e.g., “The presenting part is in a transverse lie.”)

Step 4: Identification of the Fetal Part in the Pelvic Cavity

Palpation of the pelvic inlet : This maneuver is also known as the second Pawlik Grip . The healthcare professional palpates the pelvic inlet to determine fetal engagement . Finally, the healthcare professional should identify the fetal part in the pelvic cavity . This could be the fetal head, buttocks, or limbs.

Not engaged: Movable mass is felt

Engaged : Fixed mass is felt

Importance of the Leopold Maneuver in Prenatal Care

Identification of abnormal fetal presentation.

The Leopold maneuver is crucial in identifying abnormal fetal presentations , such as breech or transverse, which require special attention during labor and delivery to ensure the safety of both the mother and baby.

Assessment of Fetal Growth and Development

The Leopold maneuver provides healthcare professionals with vital information about fetal growth and development and helps them anticipate potential complications during labor and delivery.

Identification of Multiple Gestations

The Leopold maneuver is an essential tool in identifying multiple gestations to ensure appropriate prenatal care and delivery planning for mothers carrying more than one baby.

Common Issues and Solutions During the Leopold Maneuver

The Leopold maneuver is an obstetric examination technique used to assess fetal presentation, position, and engagement. However, performing this maneuver can be challenging due to various factors. Here are some common issues and solutions during the Leopold maneuver.

Difficulty in Assessing the Fetal Presentation

One common issue during the Leopold maneuver is difficulty in identifying fetal presentation . This can happen when the fetal presentation is not well defined or when there are multiple fetuses. To solve this issue, the examiner should carefully palpate the abdomen and try to differentiate between the fetal parts.

Difficulties in Identifying the Fetal Parts

Another common issue during the Leopold maneuver is difficulty in identifying fetal parts . This can happen when the fetus is in an atypical position or when there are fetal anomalies. To solve this issue, the examiner should use various techniques such as ultrasound or auscultation to guide them in identifying the fetal parts.

Confounding Factors that May Affect the Examination

There are confounding factors that may affect the accuracy of the Leopold maneuver, including obesity, polyhydramnios, fetal anomalies, and fetal movements . These factors can make it more challenging to perform the Leopold maneuver accurately. To solve this issue, examiners should try to minimize these factors or use additional examination techniques to confirm fetal presentation and position.

The Role of the Leopold Maneuver in Diagnosing Fetal Position

The Leopold maneuver is a crucial examination technique for diagnosing fetal position, and it plays a significant role in obstetric care. Here are some important factors to consider when using the Leopold maneuver to diagnose fetal position.

Importance of Diagnosing Fetal Position

Diagnosing fetal position is essential for obstetricians and midwives to ensure safe delivery. By knowing the fetal position, they can anticipate any potential complications during delivery and prepare accordingly. This can help minimize the risk of fetal distress, maternal injury, and other delivery-related complications .

Accuracy of Leopold Maneuver in Diagnosing Fetal Position

The Leopold maneuver is an accurate technique for diagnosing fetal position, with a sensitivity of up to 84%. It is a non-invasive and cost-effective method that can be performed by most healthcare providers. Therefore, it is widely used in obstetric care to diagnose fetal position.

Limitations of the Leopold Maneuver in Diagnosing Fetal Position

However, the Leopold maneuver has some limitations in diagnosing fetal position. It may not be accurate in identifying fetal presentation in cases of multiple pregnancies, fetal anomalies, or when the fetus is in an atypical position . Additionally, the examiner’s experience and skill level can also affect the accuracy of the Leopold maneuver.

Complications

The Leopold maneuver is generally considered a safe and non-invasive examination, but as with any medical procedure, there are potential complications that can occur. Some possible complications of the Leopold maneuver include:

• Discomfort: The Leopold maneuver can cause some discomfort or mild pain for the patient, especially if the examiner is pressing too hard or manipulating the fetus in a way that causes discomfort.
• False results: In some cases, the Leopold maneuver can produce false results, which can lead to incorrect decisions about delivery options or interventions. This can occur if the fetus is in an unusual position or if the examiner is inexperienced or unable to accurately interpret the results of the exam.
• Fetal distress: In rare cases, the Leopold maneuver can cause fetal distress or other complications, such as premature labor or rupture of the amniotic sac. This can occur if the examiner is too forceful or aggressive during the exam or if the fetus is in a vulnerable position.
• Infection: While the Leopold maneuver is a non-invasive exam, there is still a small risk of infection if the examiner does not follow proper hygiene protocols, such as washing their hands before and after the exam.

Nurse’s Responsibilities

The Leopold maneuver is a technique used by healthcare professionals, including nurses, to assess the position of a fetus in the mother’s uterus. As a nurse, your responsibilities during Leopold maneuvers include:

• Explaining the procedure to the patient: Before performing the Leopold maneuver, it is important to explain the procedure to the patient and ensure that they understand what will happen during the exam. This can help reduce anxiety and improve the patient’s overall experience.
• Preparing the patient: Before performing the exam, you will need to ensure that the patient is positioned correctly and that their clothing is adjusted to allow access to their abdomen. You may also need to provide a drape or cover for modesty.
• Assisting the healthcare provider: During the Leopold maneuver, you may be asked to assist the healthcare provider by holding the patient’s abdomen or providing support as needed. You may also need to help position the patient to allow for optimal access to the uterus.
• Monitoring the patient: As the Leopold maneuver can cause some discomfort or pain for the patient, it is important to monitor their vital signs and overall comfort level throughout the exam. If the patient experiences any discomfort or pain, you may need to provide comfort measures, such as adjusting their position or providing pain relief medication.
• Documenting the exam: After the Leopold maneuver, it is important to document the results of the exam in the patient’s medical record. This includes noting the fetal presentation, position, and engagement, as well as any other relevant information.
• Providing patient education: Following the exam, you may need to provide the patient with education about the results of the exam, as well as any next steps that may be needed. This can include discussing delivery options, potential complications, and follow-up appointments.

What is the Leopold Maneuver?

The Leopold Maneuver is a manual examination technique used by obstetricians and midwives to assess the fetal presentation, position, and size during pregnancy. The technique involves a series of four maneuvers that allow the examiner to palpate the maternal abdomen and identify the fetal presentation and position.

How is the Leopold Maneuver performed?

The Leopold Maneuver involves four maneuvers, which are performed in sequence. The first maneuver involves palpating the fundus to determine the location of the fetal head or buttocks. The second maneuver involves identifying the location of the fetal back. The third maneuver involves palpating the lower abdomen to identify the presenting part of the fetus. The fourth maneuver involves determining fetal descent and engagement.

What is the purpose of the Leopold Maneuver?

The purpose of the Leopold Maneuver is to assess the fetal presentation, position, and size during pregnancy. The examination can provide valuable information to obstetricians and midwives to ensure the health and safety of both the mother and the baby. The Leopold Maneuver can help identify abnormal fetal presentation, and multiple gestations, and estimate fetal weight.

Can the Leopold Maneuver be performed at home?

No, the Leopold Maneuver is a medical examination technique that should only be performed by trained healthcare professionals, such as obstetricians or midwives. It requires specialized knowledge, training, and experience to perform the examination accurately.

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• Introduction
• Definitions
• Perinatal Morbidity And Mortality
• Complications And Counseling
• Intrapartum Complications And Counseling
• Intrapartum Management
• Management Of Labor And Delivery
• Cesarean Delivery
• Perinatal Outcome

Abnormal Fetal Lie and Presentation

Introduction.

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

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

DEFINITIONS

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

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

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

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

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

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

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

Table 1. Breech presentation by gestational age

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

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

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

Table 2. Anomalies frequently diagnosed in breech fetuses

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

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

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

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

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

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

Table 4. Incidence of breech presentation by birth weight

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

Table 5. Varieties of breech presentation

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

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

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

PERINATAL MORBIDITY AND MORTALITY

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

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

COMPLICATIONS AND COUNSELING

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

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

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

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

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

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

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

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

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

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

INTRAPARTUM COMPLICATIONS AND COUNSELING

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

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

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

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

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

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

Table 7. Spontaneous conversion of breech to cephalic presentation

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

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

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

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

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

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

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

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

Table 8. External cephalic version late in pregnancy

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

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

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

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

INTRAPARTUM MANAGEMENT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MANAGEMENT OF LABOR AND DELIVERY

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

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

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

Table 14. Effect of anesthesia on breech delivery

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

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

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

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

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

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

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

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

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

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

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

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

CESAREAN DELIVERY

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

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

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

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

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

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

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

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

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

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

PERINATAL OUTCOME

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

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

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

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

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

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

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

• Variations in Fetal Position and Presentation |

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

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

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

Occiput posterior position

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

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

Breech presentation

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

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

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

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

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

Labor starts too soon (preterm labor).

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

Other presentations

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

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

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

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

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Fetal Station Maternity Nursing Review

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

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

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

Fetal Station Lecture for Maternity Nursing

Fetal station review.

Fetal means baby and station means location or position.

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

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

How is fetal station measured?

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

Test your knowledge: Fetal Station Quiz

References:

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

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

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Fetal death

Intrauterine death of a fetus before delivery from the mother, regardless of the duration of pregnancy. Fetal deaths do not include induced terminations of pregnancy (abortions). This definition of fetal death, adopted by NCHS as the nationally recommended standard, is based on the definition published by the World Health Organization in 1950 and revised in 1988. The term fetal death encompasses other commonly used terms, including stillbirth, spontaneous abortion, and miscarriage. All U.S. states and registration areas have definitions similar to the standard definition, except for Puerto Rico and Wisconsin, which have no formal definition. Although the majority of fetal deaths occur early in pregnancy, most states in the United States require the reporting of fetal deaths only at 20 weeks of gestation or more. In Health, United States , data are presented for fetal deaths at 20 weeks or more, late fetal deaths at 28 weeks or more, and perinatal deaths. Perinatal deaths refer to a combination of fetal deaths (at least 28 weeks of gestation) and early infant (neonatal) deaths (younger than 7 days). Perinatal death is not a reportable vital event, but the measure is used for statistical purposes because of the implications for both public health and clinical interventions. (Also see Sources and Definitions, National Vital Statistics System, Fetal Death Data Set ; Gestation ; Infant death ; Rate: Death and related rates .)

Harris tries to take centrist track as opponents paint her as extreme

by MATTHEW GALKA | The National Desk

WASHINGTON (TND) — Now that Vice President Kamala Harris has formally accepted her party’s nomination, the race is on to try and define what she’s all about.

It was noticeable at the Democratic National Convention that Harris tried to expand the Democratic umbrella while trying to chart a course that appeals to moderates and independents instead of the extreme progressives in her party. A handful of Republicans tried to make the case that she has broad appeal, too.

I want to let my fellow Republicans in on a little secret. The Democrats are just as patriotic as us," said former Rep. Adam Kinzinger, R-Ill.

Harris preached safety and security when it comes to communities and the border, a far cry from the "Open Borders" and "Defund the Police" tags that have hounded Democrats for years. Her opponents aren't buying the pivot.

"She will never build the wall. She doesn't wanna build a wall. She's only saying if she, if she changes her mind, it's only because she wants to get elected because who wouldn't want to have a strong border?" said former President Donald Trump during a stop at the southern border in Arizona this week.

Trump has been on the campaign trail highlighting Harris' flip-flops. His campaign created a website on past stances she’s taken like diverting funds for law enforcement and giving federal benefits to illegal immigrants. They’re also out with an ad labeling Harris as anything but a centrist, calling her “dangerously liberal.”

The big question over the next two-and-a-half months is if Harris can convince voters she’s a moderate that independents can get on board with. Former Democratic House Speaker Nancy Pelosi said Harris should govern from the center if she were to win, because, as she puts it, "that’s where the public is."