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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.
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.
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 .
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.
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.
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.
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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What to know if your baby is breech
What's a sunny-side up baby?
What happens to your baby right after birth
Nesting during pregnancy
BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .
Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]
Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]
Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70. https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]
Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]
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Abnormal Position and Presentation of the Fetus
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Position refers to whether the fetus is facing rearward (toward the woman’s back—that is, face down when the woman lies on her back) or forward (face up).
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 or a shoulder leads the way.
The most common and safest combination consists of the following:
Head first (called vertex or cephalic presentation)
Face and body angled toward the right or left
Neck bent forward
Chin tucked in
Arms folded across the chest
If the fetus is in a different position or presentation, labor may be more difficult, and delivery through the vagina may not be possible.
Position and Presentation of the Fetus
There are several abnormal presentations.
Occiput posterior presentation
In occiput posterior presentation (also called sunny-side up), the fetus is head first but is facing up (toward the mother's abdomen). It is the most common abnormal position or presentation.
In breech presentation, the buttocks or sometimes the feet present first. Breech presentation occurs in 3 to 4% of full-term deliveries. It is the second most common type of abnormal presentation.
When delivered vaginally, babies that present buttocks first are more likely to be injured than those that present head first. Such injuries may occur before, during, or after birth. The baby may even die. Complications are less likely when breech presentation is detected before labor or delivery.
Breech presentation is more likely to occur in the following circumstances:
Labor starts too soon ( preterm labor Preterm Labor Labor that occurs before 37 weeks of pregnancy is considered preterm. Babies born prematurely can have serious health problems. The diagnosis of preterm labor is usually obvious. Measures such... read more ).
The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .
Sometimes the doctor can turn the fetus to present head first by pressing on the woman’s abdomen before labor begins, usually after 37 weeks of pregnancy. Some women are given a drug (such as terbutaline ) to prevent labor from starting too soon. If labor begins and the fetus is in breech presentation, problems may occur.
The passageway made by the buttocks in the birth canal may not be large enough for the head (which is wider) to pass through. In addition, when the head follows the buttocks, it cannot be molded to fit through the birth canal, as it normally is. Thus, the baby’s body may be delivered and the head may be caught inside the woman. When the baby’s head is caught, it 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 babies presenting buttocks first than among those presenting head first.
In a first delivery, these problems may occur more frequently because the woman’s tissues have not been stretched by previous deliveries. Because the baby could be injured or die, cesarean delivery is preferred when the fetus is in breech presentation unless the doctor is very experienced with and skilled at delivering breech babies.
In face presentation , the neck arches back so that the face presents first.
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. They often correct themselves. If they do not, forceps, vacuum extractor, or cesarean delivery may be used.
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.
Shoulder dystocia occurs when one shoulder of the fetus lodges against the woman’s pubic bone, and the baby is therefore caught in the birth canal.
In shoulder dystocia, the fetus is positioned normally Abnormal Position and Presentation of the Fetus Position refers to whether the fetus is facing rearward (toward the woman’s back—that is, face down when the woman lies on her back) or forward (face up). It’s important to check the baby’s... read more (head first) for delivery, but the fetus’s shoulder becomes lodged against the woman’s pubic bone as the fetus’s head comes out. (The two pubic bones are part of the pelvic bone. They are joined together by cartilage at the bottom of the pelvis, behind the vaginal opening.) Consequently, the head is pulled back tightly against the vaginal opening. The baby cannot breathe because the chest and umbilical cord are compressed by the birth canal. As a result, oxygen levels in the baby’s blood decrease.
Shoulder dystocia is not common, but it is more common when any of the following is present:
A large fetus Large-for-Gestational-Age (LGA) Newborns A newborn who weighs more than 90% of newborns of the same gestational age at birth (above the 90th percentile) is considered large for gestational age. Newborns may be large because the parents... read more is present.
Labor is difficult, long, or rapid.
A vacuum extractor or forceps Operative Vaginal Delivery Operative vaginal delivery is delivery using a vacuum extractor or forceps. A vacuum extractor consists of a small cup made of a rubberlike material that is connected to a vacuum. It is inserted... read more is used because the fetus’s head has not fully moved down (descended) in the pelvis.
Women are obese.
Women have diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Symptoms of diabetes may... read more .
Women have had a previous baby with shoulder dystocia.
Shoulder dystocia increases the risk of problems and of death in the newborn. The newborn's bones may be broken during delivery, and the brachial plexus Plexus Disorders Plexuses (networks of interwoven nerve fibers from different spinal nerves) may be damaged by injury, tumors, pockets of blood (hematomas), or autoimmune reactions. Pain, weakness, and loss... read more (the network of nerves that sends signals from the spinal cord to the shoulders, arms, and hands) may be injured. The woman is also more likely to have problems such as
Excessive bleeding at delivery (postpartum hemorrhage)
Tears in the area between the vaginal opening and the anus
Injury of muscles in the genital area and nerves in the groin
Separation of the pubic bones.
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- Continuing Education Activity
Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. This activity reviews the cause and pathophysiology of breech presentation and highlights the role of the interprofessional team in its management.
- Describe the pathophysiology of breech presentation.
- Review the physical exam of a patient with a breech presentation.
- Summarize the treatment options for breech presentation.
- Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by breech presentation.
Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended).   
Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.   These are discussed in more detail in the pathophysiology section.
Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.
Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.
As mentioned previously, the most common clinical conditions or disease processes that result in the breech presentation are those that affect fetal motility or the vertical polarity of the uterine cavity.  
Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:
- Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus
- Placentation: Placenta previa as the placenta is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
- Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement of the presenting part.
- Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively
- Congenital anomalies: Fetal sacrococcygeal teratoma, fetal thyroid goiter
- Polyhydramnios: Fetus is often in unstable lie, unable to engage
- Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
- Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to engage in the pelvis.
The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, while complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.
- History and Physical
During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.
During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex.
Any of these findings should raise suspicion and ultrasound should be performed.
Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.
On ultrasound, the fetal lie and presenting part should be visualized and documented. If breech presentation is diagnosed, specific information including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously) should be documented.
- Treatment / Management
Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, there was no significant difference in maternal morbidity or mortality between the two groups. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered.    
Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria.
The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.
Despite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.
Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.
- Differential Diagnosis
- Face and brow presentation
- Fetal anomalies
- Fetal death
- Grand multiparity
- Multiple pregnancies
- Pelvis Anatomy
- Preterm labor
- Uterine anomalies
- Pearls and Other Issues
In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.
- Enhancing Healthcare Team Outcomes
A breech delivery is usually managed by an obstetrician, labor and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery.   
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Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.
Disclosure: Meaghan Shanahan declares no relevant financial relationships with ineligible companies.
This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.
- Cite this Page Gray CJ, Shanahan MM. Breech Presentation. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
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- [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. [Z Geburtshilfe Neonatol. 1997] [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. Krause M, Fischer T, Feige A. Z Geburtshilfe Neonatol. 1997 Jul-Aug; 201(4):128-35.
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Normal labor and delivery
Childbirth begins with the onset of labor , which consists of contractions that lead to progressive cervical dilation and effacement, eventually resulting in the birth of the infant and expulsion of the placenta . The process of normal childbirth depends on a high degree of anatomical and physiological compatibility between the mother and child. The birth canal is the passage consisting of the mother's bony pelvis and soft tissues through which a fetus passes during vaginal delivery. Fetal orientation during childbirth is described in terms of lie, presenting part, position, attitude of the presenting part, and station. The clinical status of the mother and fetus should be consistently monitored during labor and delivery and prophylaxis for neonatal GBS infection given during labor when indicated. While vaginal delivery is typically preferred, cesarean delivery may be indicated under certain circumstances. Complications of normal vaginal delivery include perineal lacerations , hemorrhage, nerve injuries, and coccydynia .
See “ Abnormal labor and delivery ” for intrapartum complications and their management.
Orientation in utero
- Definition : relation of the fetal long axis to the long axis of the maternal uterus
- Longitudinal lie : fetus is in the same axis (most common)
- Transverse lie : fetus is at a 90° angle
- Oblique lie : fetus is at a 45° angle
- Definition : part of the fetus that overlies the maternal pelvic inlet
- Cephalic presentation : head (most common)
- Frank breech : flexed hips and extended knees (buttocks presenting)
- Complete breech : thighs and legs flexed (cannonball position)
- Single Footling breech : hip of one leg is flexed and the knee of the other is extended (one foot presenting)
- Double Footling breech : both thighs and legs are extended (feet presenting)
- Compound presentation : ≥ 1 anatomical presenting part (e.g., cephalic or breech presentation with presentation of an extremity)
- Shoulder presentation : shoulder presentations combined with a transverse or oblique lie
- Definition : relationship and orientation (i.e., fetal occiput pointing towards maternal left or right) of the presenting fetal part to the maternal pelvis
- Left occiput anterior ( LOA ): Fetal back faces the maternal left, anterior fontanelle faces the maternal right, sagittal suture lies in the right oblique diameter (most common position).
- Right occiput anterior (ROA): Fetal back faces the maternal right, anterior fontanelle faces the maternal left, sagittal suture lies in the left oblique diameter .
- Occiput posterior position : Fetal occiput points towards the maternal sacral promontory with face to pubis symphysis ; the fetus faces upward
- Sacrum in breech presentation
- Mentum (chin) in extended cephalic (face) presentation
Fetal attitude 
- Definition : degree of extension/ flexion of the fetal head during cephalic presentation
- Vertex presentation (maximally flexed); most common attitude
- Brow presentation (partially extended)
- Mentum anterior face presentation : Spontaneous vaginal delivery is possible .
- Mentum posterior face presentation
- Forehead presentation (partially flexed; military attitude): Spontaneous vaginal delivery is possible .
Station (Obstetrics) 
- When the widest transverse diameter of the head (presenting part) passes through the pelvic inlet
- Use the rule of fifths: engagement is clinically identified when ≤ 2/5 of the fetal head are felt above the symphysis pubis through the maternal abdomen
- Definition: parallelism between the pelvic plane and the plane of the fetal head
- The sagittal suture is positioned towards the sacral promontory
- Spontaneous vaginal delivery possible
- The sagittal suture is positioned towards the symphysis pubis
- Normal vaginal delivery is impossible. → premature cesarean delivery
Normal spontaneous labor
Obstetric contractions (uterine muscle contractions)  .
False labor only requires reassurance.
Rupture of membranes ( ROM )
- Definition : the rupture of the amniotic sac followed by the release of amniotic fluid
- Spontaneous rupture of membranes : ROM that usually occurs at the onset of labor and is unprovoked by health practitioners
- Artificial rupture of membranes ( amniotomy ): A procedure in which the amniotic sac is ruptured in order to release amniotic fluid .
- Delayed rupture of membranes : ROM that occurs during fetal expulsion, after cervical dilation and effacement
- Premature rupture of membranes ( PROM )
- Preterm premature rupture of membranes ( PPROM )
- Prolonged rupture of membranes
- Clinical features : sudden “gush” of pale yellow or clear fluid from the vagina (may also be a constant leaking sensation)
- Consider sterile speculum examination if the diagnosis is uncertain.
- Suggestive findings include pooling, positive litmus test or nitrazine test , and ferning .
Stages of labor   
Management of labor by stage.
- Analgesia upon request
- Fetal heart rate monitoring
- If the fetal position cannot be determined by examination, perform ultrasound .
- Regular assessment of cervical dilation and descent of the fetal head
- In case of heavier bleeding but normal maternal vital signs and fetal heart tracing (e.g., increased bloody show ), delivery should proceed as planned with frequent observation.
- Help the mother to find comfortable and safe positions.
- Guide the delivery of the fetus through the vaginal canal (See “ Mechanics of childbirth ” for expected fetal movements).
- Clamp the umbilical cord after no less than 30–60 seconds . 
- See “Delivery of the infant ” in “ Manually assisted vaginal delivery ” for detailed instructions.
- Oxytocin reduces blood loss by inducing stronger uterine contractions.
- Controlled cord traction ( Brandt-Andrews maneuver ) if placenta is not delivered spontaneously
- See “Delivery of the placenta ” in “ Manually assisted vaginal delivery ” for detailed instructions.
- Examine the placenta to confirm completeness (regular surface with complete cotyledons), which should also consist of the umbilical cord , complete amniotic membranes , and three blood vessels (one vein , two arteries ).
- Repair any obstetric lacerations .
- Fourth stage of labor : Monitoring to rule out postpartum hemorrhage or preeclampsia
Normal mechanics of childbirth 
Adaptation to the different forms of the pelvic region requires a great deal of rotation.
- The head engages below the plane of the pelvic inlet .
- The presenting part begins to descend into the birth canal .
- The chin of the fetus moves towards its chest.
- Internal rotation : The fetal head rotates by 90° (two 45° steps) in the midpelvis, from a transverse to anterior - posterior position.
- Extension : The fetal head, lying behind the symphysis pubis bone and the pelvic floor , acts upwards and forwards.
- Restitution : The fetal head rotates 45° in the opposite direction as it passes through the pelvic outlet .
- External rotation : The anterior shoulder rotates 45° anteriorly as it meets the maternal pelvic floor . This action is transmitted to the head which also rotates 45°, placing the head in its original transverse position.
- Expulsion : Delivery of the head, anterior shoulder followed by the posterior shoulder, and the body
Manually assisted vaginal delivery
The following describes the uncomplicated delivery of an infant in the occiput anterior position , the most common fetal presentation . Begin active management of labor as soon as crowning occurs.   
- Help the mother into the most comfortable position. 
- Cleanse the vulvar and perineal area.
Delivery of the infant
Delivery of the head.
- Support the perineum with a warm compress. 
- Once the vaginal introitus is distended ≥ 5 cm , apply gentle pressure to the fetal occiput with one hand.
- Lift the fetal chin by applying upward pressure through the perineum with the other hand.
- Support the head during passage through the vaginal introitus.
- Check for a nuchal umbilical cord and, if present, slip it over the fetal head.
Delivery of the shoulders
- Assist delivery of the shoulders, if not delivered spontaneously.
- Hold the fetal head with both hands and apply gentle downward traction.
- Once the anterior shoulder appears below the symphysis pubis , apply gentle upward traction until the posterior shoulder is free.
Delivery of the body and immediate care of the newborn
- Apply gentle long-axis traction, if necessary, without placing fingers under the axillae .
- Once delivered, wipe the face and mouth to clear the airway .   
- Quickly dry the infant to prevent hypothermia and stimulate crying. 
- If necessary, initiate neonatal resuscitation .
- Initiate skin -to- skin contact, e.g., by placing the infant on the mother's abdomen.
Clamping the umbilical cord
- Delay clamping by at least 30–60 seconds after delivery (unless immediate neonatal resuscitation is required).  
- Place two Kelly clamps 6–8 cm from the abdominal insertion and cut the cord between them.
Delivery of the placenta
- Palpate the uterine fundus and monitor for signs of placental separation .
- Once placental separation occurs, ask the patient to bear down to expel the placenta .
- If the placenta is not expelled with maternal effort, apply controlled umbilical cord traction .
- Administer oxytocin to prevent postpartum hemorrhage .   
Never apply forceful traction to the umbilical cord , as this may result in uterine inversion or separation of the cord from the placenta . 
Immediate postpartum care 
- Palpate the fundus regularly to assess uterine tone.
- Check maternal blood pressure and pulse every 15 minutes for the first two hours after birth .
- Assess the placenta , membranes, and umbilical cord for completeness and anomalies.
- Inspect for and repair perineal lacerations .
Intrapartum fetal monitoring
Electronic fetal heart rate monitoring  .
- Description : widely used diagnostic tool during 3 rd trimester and labor to detect signs of fetal distress
- Determination of the fetal heart rate ( FHR ), presence of acceleration or deceleration by Doppler ultrasound , recording beats per minute (bpm) in the upper curve (cardiogram)
- Rupture of the membranes must have occurred or an amniotomy performed
- Used when external monitoring is difficult (e.g., maternal obesity , polyhydramnios , multiple gestations )
- Mechanoelectrical measurement of uterine contractions via a pressure transducer, recording in the lower curve in kPa (tocodynagraph)
- During labor
- Admission in the labor ward
- In every case of complication during pregnancy or delivery, such as impending preterm birth , abnormalities of the fetal heart , multiple pregnancy , suspected placental insufficiency , uterine bleeding , tocolysis
Fetal heart rate   
- In CTG , the FHR is designated as the baseline or basal heart rate and is normally 110–160 bpm .
- Mild tachycardia : FHR of 160–180 bpm for > 10 minutes
- Severe tachycardia : FHR of ≥180 bpm for > 10 minutes
- Causes: stress, hypotension , maternal fever ; , medication (e.g., betamimetics for the treatment of tocolysis ), chorioamnionitis , fetal arrhythmias , fetal anemia , hypoxia
- Mild bradycardia : FHR of for > 3 minutes
- Severe bradycardia : FHR of for > 3 minutes
- Causes: supine hypotensive syndrome , fetal heart defects ; , central nervous system anomalies, severe hypoxia
- Methods to assess FHR : Nonstress test ( NST ) and contraction stress test ( CST ) ; are performed during the third trimester of pregnancy to measure FHR reactivity to fetal movements and FHR reactivity in response to uterine contractions respectively. See nonstress test and contraction stress test in “ Prenatal care ” for details.
Fetal heart rate (FHR) tracing
Fetal heart rate variability .
On CTG , variability of FHR is represented by the oscillation of the FHR around the baseline and is determined by measuring the amplitude between the highest and lowest turning point of the FHR curve.
Acceleration (CTG) 
- Description : a normal temporal increase in the FHR from the baseline by > 15 bpm for more than 15 seconds but less than 10 minutes if the gestational age is > 32 weeks , or by > 10 bpm for more than 10 seconds if the gestational age is
- The presence of > 2 accelerations within a span of 20 minutes indicates a reactive fetal heart rate tracing .
- If the acceleration lasts longer than 10 minutes , it should be considered a baseline change in the fetal heart rate .
Decelerations (CTG)     
- Description : a temporary decline in the FHR of > 15 bpm for a maximum duration of 3 minutes
Consider umbilical cord compression or umbilical cord prolapse in patients with recurrent variable decelerations ( ≥ 50% of contractions) .
- Fetal tachycardia ( FHR > 160–180/min )
- Fetal bradycardia ( FHR )
- Loss of baseline variability
- Recurrent variable decelerations and/or late decelerations
- A nonreassuring tracing requires intrauterine resuscitation and/or immediate delivery (cesarean or, if imminent, vaginal delivery).
- A fetal heart tracing that shows a good beat to beat variability ( > 6 bpm ), > 2 accelerations within a 20 minute period, and no evidence of fetal distress (e.g., fetal bradycardia , fetal tachycardia , late or variable decelerations , sinusoidal pattern)
- Indicates fetal well-being .
See “ Intrauterine resuscitation ” for details.
- Initial management includes repositioning of the mother, supplemental O 2 , fluids , and delayed active pushing in the second stage of labor .
- Consider amnioinfusion , tocolytics , and emergency cesarean delivery if initial measures are unsuccessful.
Complications of delivery
- Prolonged second stage of labor
- Obstructed labor , e.g., due to shoulder dystocia
- Umbilical cord complications , including nuchal umbilical cord
- Uterine rupture
- Uterine inversion
- Postpartum hemorrhage
- Amniotic fluid embolism
- See also “ Abnormal labor and delivery .”
- Definition : tear of the perineal area due to significant or rapid stretching forces during labor and delivery
- Epidemiology : most common obstetric injury of the pelvic floor
- Forceps delivery
- No previous delivery
- Occiput posterior delivery
- Rapid delivery of head in breech presentation
- Head extension before crowning
- Lack of perineal elasticity (e.g., perineal edema )
- First degree: cutaneous to subcutaneous tissue tear ( skin , fourchette, posterior vaginal wall) with no involvement of the perineal muscles
- Second degree: first-degree lacerations plus laceration of the perineal muscles without involvement of the anal sphincter
- A: of the external anal sphincter is torn.
- B: > 50% of the external anal sphincter is torn.
- C: external and internal anal sphincters are torn.
- Fourth degree: third-degree lacerations plus lacerations of the anterior wall of the anal canal or rectum
- Perineal edema / hematoma , dysuria
- Symptoms of pelvic floor dysfunction (e.g., fecal/flatus incontinence, pelvic organ prolapse )
- Signs of infection (e.g., foul-smelling discharge, fever , persisting pain )
- A palpable defect
- Decreased anal sphincter tone and/or asymmetric sphincter contractions
- Endoanal ultrasonography : to evaluate the integrity of the internal and external anal sphincter
- Conservative: e.g., NSAIDs , sitz baths
- Suture : local anesthesia and laceration closure using surgical glue or continuous sutures
- Regional or general anesthesia may be used.
- Reconstructive surgery to repair the anal sphincters and mucosa
- Reconstruction of the distal rectovaginal septum and the perineal body
- Primarily associated with third- and fourth-degree lacerations .
- Pain and dyspareunia
- Rectovaginal fistulae
- Wound dehiscence
- Prevention : application of warm compress to perineum during delivery
Complications of fourth-degree lacerations include rectovaginal fistulae .
Obstetric nerve injuries 
Acute nerve injury can occur during childbirth due to compression, transection, traction, or vascular injury to the nerve.
- Etiology : injury to the coccyx during childbirth as a result of internal and external pressure on the coccyx during labor and delivery
- Pain and tenderness of the coccyx , esp. when sitting or leaning back
- Pain may suddenly increase when the patient is changing from a sitting to a standing position.
- Pain may also occur during defecation or sexual intercourse.
- Physical examination : palpation of the coccyx elicits pain
- Diagnosis : clinical
- Protection (e.g., sitting on Donut or wedge cushions)
- Analgesics (e.g., NSAIDs )
- Local heat or cooling according to patient preference
- Exacerbating factors (e.g., sitting on hard surfaces, cycling) should be avoided if possible.
- Prognosis : resolves spontaneously in the majority of patients ( > 90% ) 
Postpartum retroperitoneal hematoma
- Epidemiology : rare ( ∼ 1:1000 ) 
- Laceration of a uterine artery during hysterotomy or uterine rupture
- Extension of a paravaginal hematoma into the retroperitoneal space
- Other: pelvic or abdominal injury, anticoagulation, rupture of an aneurysm of the abdominopelvic vasculature
- Signs of hemodynamic instability (e.g., tachycardia , hypotension )
- Usually painless (unless caused by pelvic or abdominal injury)
- Diagnostics : imaging (e.g., sonography , CT)
- Prompt laparotomy
- Alternatively: selective arterial embolization
Planned home birth
- In the US, approx. 1% of births per year are home births.
- 75% of these home births are planned.
- There is insufficient evidence to determine what makes a good candidate for a home birth .
- Home births can be considered in individuals with no contraindications .
- Patients who would like to plan a home birth should be advised about the benefits and risks of home birth compared to hospital delivery in order to make an informed decision .
- Lower risk of maternal interventions (e.g., induction or augmentation of labor , episiotomy , cesarean delivery )
- Lower risk of certain maternal complications (e.g., vaginal or perineal lacerations , peripartum or postpartum infections)
- Lower costs
- Familiar environment for the mother
- Higher risk of perinatal death for both the mother and fetus
- Higher risk of neurological complications for the newborn
- Fetal malpresentation (e.g., breech presentation )
- Multiple gestation pregnancy
- Previous cesarean delivery
- Any other risk factor for a complicated pregnancy (see “ High-risk pregnancies ”)
- No means for safe and timely transport to a nearby hospital or accredited birth center
- Lack of access to home- birth provider services (e.g., certified professional midwife, certified nurse midwife, obstetrician , family medicine physician)
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Fetal Presentation: Baby’s First Pose
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Occiput posterior, transverse position, complete breech, frank breech, changing fetal presentation, baby positions.
The position in which your baby develops is called the “fetal presentation.” During most of your pregnancy, the baby will be curled up in a ball – that’s why we call it the “fetal position.” The baby might flip around over the course of development, which is why you can sometimes feel a foot poking into your side or an elbow prodding your bellybutton. As you get closer to delivery, the baby will change positions and move lower in your uterus in preparation. Over the last part of your pregnancy, your doctor or medical care provider will monitor the baby’s position to keep an eye out for any potential problems.
In the occiput anterior position, the baby is pointed headfirst toward the birth canal and is facing down – toward your back. This is the easiest possible position for delivery because it allows the crown of the baby’s head to pass through first, followed by the shoulders and the rest of the body. The crown of the head is the narrowest part, so it can lead the way for the rest of the head.
The baby’s head will move slowly downward as you get closer to delivery until it “engages” with your pelvis. At that point, the baby’s head will fit snugly and won’t be able to wobble around. That’s exactly where you want to be just before labor. The occiput anterior position causes the least stress on your little one and the easiest labor for you.
In the occiput posterior position, the baby is pointed headfirst toward the birth canal but is facing upward, toward your stomach. This can trap the baby’s head under your pubic bone, making it harder to get out through the birth canal. In most cases, a baby in the occiput posterior position will either turn around naturally during the course of labor or your doctor or midwife may help it along manually or with forceps.
In a transverse position, the baby is sideways across the birth canal rather than head- or feet-first. It’s rare for a baby to stay in this position all the way up to delivery, but your doctor may attempt to gently push on your abdomen until the baby is in a more favorable fetal presentation. If you go into labor while the baby is in a transverse position, your medical care provider will likely recommend a c-section to avoid stressing or injuring the baby.
If the baby’s legs or buttocks are leading the way instead of the head, it’s called a breech presentation. It’s much harder to deliver in this position – the baby’s limbs are unlikely to line up all in the right direction and the birth canal likely won’t be stretched enough to allow the head to pass. Breech presentation used to be extremely dangerous for mothers and children both, and it’s still not easy, but medical intervention can help.
Sometimes, the baby will turn around and you’ll be able to deliver vaginally. Most healthcare providers, however, recommend a cesarean section for all breech babies because of the risks of serious injury to both mother and child in a breech vaginal delivery.
A complete breech position refers to the baby being upside down for delivery – feet first and head up. The baby’s legs are folded up and the feet are near the buttocks.
In a frank breech position, the baby’s legs are extended and the baby’s buttocks are closest to the birth canal. This is the most common breech presentation .
By late in your pregnancy, your baby can already move around – you’re probably feeling those kicks! Unfortunately, your little one doesn’t necessarily know how to aim for the birth canal. If the baby isn’t in the occiput anterior position by about 32 weeks, your doctor or midwife will typically recommend trying adjust the fetal presentation. They’ll use monitors to keep an eye on the baby and watch for signs of stress as they push and lift on your belly to coax your little one into the right spot. Your doctor may also advise you to try certain exercises at home to encourage the baby to move into the proper position. For example, getting on your hands and knees for a few minutes every day can help bring the baby around. You can also put cushions on your chairs to make sure your hips are always elevated, which can help move things into the right place. It’s important to start working on the proper fetal position early, as it becomes much harder to adjust after about 37 weeks when there’s less room to move around.
In many cases, the baby will eventually line up properly before delivery. Sometimes, however, the baby is still in the wrong spot by the time you go into labor. Your doctor or midwife may be able to move the baby during labor using forceps or ventouse . If that’s not possible, it’s generally safer for you and the baby if you deliver by c-section.
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- Delivery presentations
- Variation in delivary presentation
- Abnormal fetal presentations
There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os . This includes:
cephalic presentation : fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations which include
left occipito-anterior (LOA)
left occipito-posterior (LOP)
left occipito-transverse (LOT)
right occipito-anterior (ROA)
right occipito-posterior (ROP)
right occipito-transverse (ROT)
breech presentation : fetal rump presenting towards the internal cervical os, this has three main types
frank breech presentation (50-70% of all breech presentation): hips flexed, knees extended (pike position)
complete breech presentation (5-10%): hips flexed, knees flexed (cannonball position)
footling presentation or incomplete (10-30%): one or both hips extended, foot presenting
other, e.g one leg flexed and one leg extended
cord presentation : umbilical cord presenting towards the internal cervical os
- 1. Fox AJ, Chapman MG. Longitudinal ultrasound assessment of fetal presentation: a review of 1010 consecutive cases. Aust N Z J Obstet Gynaecol. 2006;46 (4): 341-4. doi:10.1111/j.1479-828X.2006.00603.x - Pubmed citation
- 2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon
- Obstetric curriculum
- Cord presentation
- Footling presentation
- Normal obstetrics scan (third trimester singleton)
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Abnormal Fetal lie, Malpresentation and Malposition
Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12
- 1 Definitions
- 2 Risk Factors
- 3.2 Presentation
- 3.3 Position
- 4 Investigations
- 5.1 Abnormal Fetal Lie
- 5.2 Malpresentation
- 5.3 Malposition
The lie, presentation and position of a fetus are important during labour and delivery.
In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.
- Longitudinal, transverse or oblique
- Cephalic vertex presentation is the most common and is considered the safest
- Other presentations include breech, shoulder, face and brow
- Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
- Other positions include occipito-posterior and occipito-transverse.
Note: Breech presentation is the most common malpresentation, and is covered in detail here .
Fig 1 – The two most common fetal presentations: cephalic and breech.
The risk factors for abnormal fetal lie, malpresentation and malposition include:
- Multiple pregnancy
- Uterine abnormalities (e.g fibroids, partial septate uterus)
- Fetal abnormalities
- Placenta praevia
Identifying Fetal Lie, Presentation and Position
The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.
For more information on the obstetric examination, see here .
- Face the patient’s head
- Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side
- Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
- You may be able to gently push the fetal head from side to side
The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .
During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.
Fig 2 – Assessing fetal lie and presentation.
Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.
Abnormal Fetal Lie
If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.
ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.
It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.
Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.
ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .
Fig 3 – External cephalic version.
The management of malpresentation is dependent on the presentation.
- Breech – attempt ECV before labour, vaginal breech delivery or C-section
- Brow – a C-section is necessary
- If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
- If the chin is posterior (mento-posterior) then a C-section is necessary
- Shoulder – a C-section is necessary
90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.
- Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth
If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.
- Breech - attempt ECV before labour, vaginal breech delivery or C-section
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Australian Government Department of Health and Aged Care
Identifying fetal presentation and discussing management options with women who have a malpresentation late in pregnancy enables informed planning for the birth.
Fetal presentation refers to the part of the baby that is overlying the maternal pelvis. Fetal lie refers to the relationship between the longitudinal axis of the baby with respect to the longitudinal axis of the mother (longitudinal lie, transverse lie, oblique lie).
Most babies present with the crown of the head at the cervix (vertex presentation). Less optimal situations are when the presenting part is the face or brow; the buttocks (breech presentation); or foot or feet (footling presentation). Babies that are in a transverse lie may present the fetal back or shoulders, arms or legs, or the umbilical cord (funic presentation). In an oblique lie, generally no palpable fetal part is presenting. This lie is usually transitory and occurs as the baby is moving.
Fetal presentation can be identified by palpation of the maternal abdomen, and confirmed by ultrasound if there is any doubt.
61.1.1 Fetal presentation at birth
Among women who gave birth in Australia in 2010, most fetal presentations were vertex (94.4%). Malpresentations included breech (3.9%), face or brow presentation (0.2%) and shoulder/transverse and compound presentations (0.7%) ( Li et al 2012 ) .
61.2 Abdominal palpation
Abdominal palpation is accurate in identifying presentation, especially if carried out by an experienced health professional ( Webb et al 2011 ) . In Australia, it is recommended that all health professionals providing antenatal care be experienced in palpation of the pregnant abdomen including identification of the presenting part RANZCOG 2009. While the positive effects of abdominal palpation are difficult to quantify, no risks have been identified and it provides a point of engagement with the mother and baby. Assessment of presentation by abdominal palpation before 36 weeks is not always accurate.
Assess fetal presentation by abdominal palpation at 36 weeks or later, when presentation is likely to influence the plans for the birth.
Approved by NHMRC in June 2014; expires June 2019
Where there is any doubt as to the presenting part, obstetric ultrasound should be used to confirm the palpation findings. Ultrasound can also exclude fetal anomaly, low-lying placenta, hyperextension of the baby’s head and the presence of umbilical cord around the fetal neck RANZCOG 2009.
- Practice point
Suspected non-cephalic presentation after 36 weeks should be confirmed by an ultrasound assessment.
61.3 Breech presentation
Breech presentation is common in mid pregnancy, with incidence decreasing as the pregnancy approaches term. Turning the baby (eg using external cephalic version [ ECV ]) reduces the number of babies who are breech at term, thereby improving the chance of a vaginal birth.
The optimal mode of birth for women who have a baby in the breech position is the subject of much controversy. Following the initial findings of the Term Breech Trial of fewer adverse outcomes among babies following planned caesarean section than planned vaginal birth ( Hannah et al 2000 ) , breech birth is now more likely to occur by caesarean section. Rates of singleton vaginal breech births in Australia fell from 23.1% in 1991 ( Sullivan et al 2009 ) to 4.0% in 2010 ( Li et al 2012 ) .
However, several studies have shown that with careful selection criteria and involvement of experienced health professionals in centres that are supportive, vaginal breech birth can be successful in 49–83% of women, with rates of morbidity equal to that of birth by caesarean section and higher success rates among multiparous women Sibony et al 2003, Alarab et al 2004, Kumari & Grundsell 2004, Oboro et al 2004, Ulander et al 2004, Krupitz et al 2005, Uotila et al 2005, Goffinet et al 2006, Daskalakis et al 2007, Hopkins et al 2007, Jadoon et al 2008.
Evidence into neonatal or maternal outcomes associated with mode of breech birth is inconsistent:
- Risks to the infant : Some cohort studies Kumari & Grundsell 2004, Doyle et al 2005, Molkenboer et al 2007 found no differences in mortality and morbidity between vaginal births and caesarean sections, while others found higher rates of morbidity following vaginal birth Gilbert et al 2003, Herbst 2005, Rietberg et al 2005, Daskalakis et al 2007, Hopkins et al 2007, Toivonen et al 2012 and one found a higher risk of neonatal mortality among babies of 1,000–1,500 g following vaginal birth but no significant difference in neonatal mortality above these weights ( Demirci et al 2012 ) . An observational study found that the risk of adverse perinatal outcomes following vaginal birth was increased among babies with a birthweight below the 10th percentile and a gestational age of less than 39 weeks ( Azria et al 2012 ) . A systematic review of cohort studies found a lower risk of developmental dysplasia of the hip following caesarean section compared with vaginal birth ( Panagiotopoulou et al 2012 ) . Importantly, the follow-up study from the babies born in the Term Breech Trial showed that risk of death or developmental delay at 2 years of age did not differ with mode of birth ( Whyte et al 2004 ) .
- Risks to the mother : Some studies have found lower rates of maternal morbidity following vaginal birth Kumari & Grundsell 2004, Oboro et al 2004, Hopkins et al 2007, Toivonen et al 2012, while another found a lower risk of maternal complications following caesarean section ( Krebs & Langhoff-Roos 2003 ) .
Identifying breech presentation at around 36 weeks gestation enables timely discussion of ECV and referral as required (eg to a health professional with expertise in ECV ) or referral to a health professional and centre with expertise in vaginal breech birth.
61.4 External cephalic version
Offering ECV when clinically appropriate is recommended in the United Kingdom RCOG 2010, the United States ACOG 2006 and Australia RANZCOG 2009.
The reported success rate of ECV is in the range of 36.7–72.3% Hutton et al 2003, Fok et al 2005, Nor Azlin et al 2005, Nassar et al 2006, El-Toukhy et al 2007, Weiniger et al 2007, Grootscholten et al 2008, Kok et al 2008c, Rijnders et al 2010, Buhimschi et al 2011, Burgos et al 2011, Gottvall & Ginstman 2011, Obeidat et al 2011, Bogner et al 2012, Cho et al 2012, Cluver et al 2012.
A spontaneous reversion rate of 3–14% has been reported after 36 weeks Nassar et al 2006, El-Toukhy et al 2007, Buhimschi et al 2011, Cho et al 2012.
61.4.2 Benefits and risks
Successful ECV reduces the rate of caesarean sections, with vaginal birth following ECV being successful in 71–84% of women El-Toukhy et al 2007, Buhimschi et al 2011, Gottvall & Ginstman 2011, Bogner et al 2012, Reinhard et al 2013.
ECV is a safe procedure when performed in a setting where an urgent caesarean section can be performed Nassar et al 2006, Grootscholten et al 2008, Gottvall & Ginstman 2011, Bogner et al 2012, Cho et al 2012. In a systematic review, the most frequently reported complications of ECV were transient abnormal cardiotocography patterns (5.7%), persisting pathological cardiotocography (0.37%), vaginal bleeding (0.47%) and placental abruption (0.12%) ( Collaris & Oei 2004 ) . Caesarean section was performed in 0.43% of all procedures and perinatal mortality was 0.16%.
Small studies have shown that the moderate degree of pain associated with ECV is well tolerated by the majority of women because of its short duration ( Fok et al 2005 ) and that most women rate ECV as a good experience, whether it is successful (94%) or unsuccessful (71%) ( Rijnders et al 2010 ) .
61.4.3 Factors influencing success of ECV
Factors predicting successful ECV include posterior placental location, complete breech position, amniotic fluid index >10, unengaged presenting part, maternal weight <65 kg and thicker fundal myometrium on ultrasound Hutton et al 2008, Kok et al 2008b, Kok et al 2009, Buhimschi et al 2011, Burgos et al 2011, Obeidat et al 2011, Bogner et al 2012, Burgos et al 2012, Cho et al 2012. ECV is also more successful in multiparous (57–78% than primiparous (27–53%) women Nassar et al 2006, El-Toukhy et al 2007, Kok et al 2008c, Rijnders et al 2010, Burgos et al 2011, Cho et al 2012, and if the health professional performing the ECV is experienced. ECV at 34–35 weeks versus ≥37 weeks increased the likelihood of cephalic version but did not decrease the rate of caesarean section ( Hutton et al 2011 ) .
The use of tocolytics (uterine relaxants) to facilitate ECV has been shown to increase cephalic presentations ( RR : 1.38; 95% CI : 1.03–1.85) and reduce the rate of caesarean sections ( RR : 0.82; 95% CI : 0.71–0.94) in both nulliparous and multiparous women ( Cluver et al 2012 ) . The available evidence supports the use of beta mimetics for tocolysis Kok et al 2008a, Wilcox et al 2011, Cluver et al 2012.
A small non-randomised study suggested that clinical hypnosis combined with tocolysis before ECV may increase success rates ( Reinhard et al 2012 ) .
Offer external cephalic version to women with uncomplicated singleton breech pregnancy after 37 weeks of gestation.
Relative contraindications for external cephalic version include a previous caesarean section, uterine anomaly, vaginal bleeding, ruptured membranes or labour, oligohydramnios, placenta praevia and fetal anomalies or compromise.
External cephalic version should be performed by a health professional with appropriate expertise.
61.4.4 Other interventions
- Acupoint stimulation : The evidence for the effectiveness and safety of moxibustion (a Chinese medicine treatment that involves burning of Artemisia argyi close to the skin at an acupuncture point) is inconsistent and largely based on small studies, many of which are of poor quality with high heterogeneity. Some systematic reviews van den Berg et al 2008, Li et al 2009, Vas et al 2009, RCT s Habek et al 2003, Neri et al 2004 and a cohort study ( Grabowska & Manyande 2009 ) have reported a higher rate of cephalic version with moxibustion and other acupuncture point stimulation methods, while others have found no beneficial effect Cardini et al 2005, Guittier et al 2009. Although small studies have not observed significant maternal or fetal side effects associated with moxibustion Neri et al 2007, Guittier et al 2008, a recent Cochrane review identified a need for further evidence on its safety and effectiveness ( Coyle et al 2012 ) .
- Posture : A Cochrane review (n=417) found insufficient evidence to support the use of posture management to turn a breech baby ( Hofmeyr & Kulier 2011 ) . Combined with moxibustion, postural techniques may reduce the number of non-cephalic presentations at birth ( RR : 0.73; 95% CI : 0.57–0.94) ( Coyle et al 2012 ) .
61.5 Discussing fetal presentation
If a woman has a baby that is in the breech position, she should be given information in a calm, reassuring manner using appropriate terminology so that she can decide which options are most suitable to her situation. Points for discussion include that:
- for babies in the breech position, ECV may be offered (this involves a health professional using his or her hands on the woman’s abdomen to gently turn the breech baby and is successful in approximately half of women, with success more likely if medications to relax the uterus are used)
- ECV is not appropriate in some situations (eg when there is vaginal bleeding, a low level of amniotic fluid or fetal or uterine anomalies)
- ECV has low complication rates but should be carried out where there are facilities for emergency caesarean section
- other interventions to turn a breech baby (posture and acustimulation) are less effective than ECV and the evidence on their safety is limited
- if a woman chooses not to have ECV , the procedure is unsuccessful or the baby returns to breech position, vaginal birth may still be possible depending on the individual situation.
61.6 Practice summary: fetal presentation
At around 36 weeks gestation.
- Aboriginal and Torres Strait Islander Health Practitioner
- Aboriginal and Torres Strait Islander Health Worker
- multicultural health worker.
- Discuss the risks associated with malpresentation Explain that, while most babies turn to present with the crown of the head before labour, the birth process can be complicated if this does not occur.
- Discuss ECV with women with a breech baby Explain that turning the baby before the birth reduces the need for caesarean section. Discuss the benefits and risks of the procedure and where it would take place.
- Discuss plans for the birth Explain the risks and benefits associated with planned vaginal birth and caesarean section.
- Take a holistic approach Encourage women to attend with family members to discuss plans for ECV and birthing options.
- ACOG (2018) Mode of term singleton breech delivery . ACOG Committee Opinion No. 745. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132: e60–3.
- RANZCOG (2016) Management of Term Breech Presentation (C-obs 11) . Melbourne: RANZCOG .
- RCOG (2017) External Cephalic Version and Reducing the Incidence of Breech Presentation. Guideline no. 20a . London: Royal College of Obstetricians and Gynaecologists.
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- Alarab M, Regan C, O’Connell MP et al (2004) Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 103(3): 407–12.
- Azria E, Le Meaux JP, Khoshnood B et al (2012) Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery. Am J Obstet Gynecol 207(4): 285 e1–9.
- Bogner G, Xu F, Simbrunner C et al (2012) Single-institute experience, management, success rate, and outcome after external cephalic version at term. Int J Gynaecol Obstet 116(2): 134–37.
- Buhimschi CS, Buhimschi IA, Wehrum MJ et al (2011) Ultrasonographic evaluation of myometrial thickness and prediction of a successful external cephalic version. Obstet Gynecol 118(4): 913–20.
- Burgos J, Melchor JC, Pijoan JI et al (2011) A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term. Int J Gynaecol Obstet 112(1): 48–51.
- Burgos J, Cobos P, Rodriguez L et al (2012) Clinical score for the outcome of external cephalic version: a two-phase prospective study. Aust N Z J Obstet Gynaecol 52(1): 59–61.
- Cardini F, Lombardo P, Regalia AL et al (2005) A randomised controlled trial of moxibustion for breech presentation. BJOG 112(6): 743–47.
- Cho LY, Lau WL, Lo TK et al (2012) Predictors of successful outcomes after external cephalic version in singleton term breech pregnancies: a nine-year historical cohort study. Hong Kong Med J 18(1): 11–19.
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- Daskalakis G, Anastasakis E, Papantoniou N et al (2007) Cesarean vs. vaginal birth for term breech presentation in 2 different study periods. Int J Gynaecol Obstet 96(3): 162–66.
- Demirci O, Tugrul AS, Turgut A et al (2012) Pregnancy outcomes by mode of delivery among breech births. Arch Gynecol Obstet 285(2): 297–303.
- Doyle NM, Riggs JW, Ramin SM et al (2005) Outcomes of term vaginal breech delivery. Am J Perinatol 22(6): 325–28.
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- Grabowska C & Manyande A (2009) Management of breech presentation with the use of moxibustion in the UK: A preliminary study. Eur J Orient Med 6(1): 38–42.
- Grootscholten K, Kok M, Oei SG et al (2008) External cephalic version-related risks: a meta-analysis. Obstet Gynecol 112(5): 1143–51.
- Guittier MJ, Klein TJ, Dong H et al (2008) Side-effects of moxibustion for cephalic version of breech presentation. J Altern Complement Med 14(10): 1231–33.
- Guittier MJ, Pichon M, Dong H et al (2009) Moxibustion for breech version: a randomized controlled trial. Obstet Gynecol 114(5): 1034–40.
- Habek D, Cerkez Habek J, Jagust M (2003) Acupuncture conversion of fetal breech presentation. Fetal Diagn Ther 18: 418–21.
- Hannah ME, Hannah WJ, Hewson SA et al (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 356(9239): 1375–83.
- Herbst A (2005) Term breech delivery in Sweden: mortality relative to fetal presentation and planned mode of delivery. Acta Obstet Gynecol Scand 84(6): 593–601.
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- Kumari AS & Grundsell H (2004) Mode of delivery for breech presentation in grandmultiparous women. Int J Gynaecol Obstet 85(3): 234–39.
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- Molkenboer JF, Vencken PM, Sonnemans LG et al (2007) Conservative management in breech deliveries leads to similar results compared with cephalic deliveries. J Matern Fetal Neonatal Med 20(8): 599–603.
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What Is Breech?
When a fetus is delivered buttocks or feet first
- Types of Presentation
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. Christine Zink, MD, is a board-certified emergency medicine with expertise in the wilderness and global medicine. She completed her medical training at Weill Cornell Medical College and residency in emergency medicine at New York-Presbyterian Hospital. She utilizes 15-years of clinical experience in her medical writing.
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Labor and Birth
Labor and Birth Just the facts In this chapter, you’ll learn: types of fetal presentations and positions ways in which labor can be stimulated signs and symptoms of labor stages and cardinal movements of labor nursing responsibilities during labor and birth, including ways to provide comfort and support. A look at labor and birth Labor and birth is physically and emotionally straining for a woman. As the patient’s body undergoes physical changes to help the fetus pass through the cervix, she may also feel discomfort, pain, panic, irritability, and loss of control. To ensure the safest outcome for the mother and child, you must fully understand the stages of labor as well as the factors affecting its length and difficulty. With an understanding of the labor and birth process, you’ll be better able to provide supportive measures that promote relaxation and help increase the patient’s sense of control. Fetal presentation Fetal presentation is the relationship of the fetus to the cervix. It can be assessed through vaginal examination, abdominal inspection and palpation, sonography, or auscultation of fetal heart tones. By knowing the fetal presentation, you can anticipate which part of the fetus will first pass through the cervix during delivery. How long and how hard Fetal presentation can affect the length and difficulty of labor as well as how the fetus is delivered. For example, if the fetus is in a breech presentation (the fetus’s soft buttocks are presenting first), the force exerted against the cervix by uterine contractions is less than it would be if the fetus’s firm head presented first. The decreased force against the cervix decreases the effectiveness of the uterine contractions that help open the cervix and push the fetus through the birth canal. Presenting difficulties Sometimes, the fetus’s presenting part is too large to pass through the mother’s pelvis or the fetus is in a position that’s undeliverable. In such cases, cesarean birth may be necessary. In addition to the usual risks associated with surgery, an abnormal fetal presentation increases the risk of complications for the mother and fetus. Factors determining fetal presentation The primary factors that determine fetal presentation during birth are fetal attitude, lie, and position. Fetal attitude Fetal attitude (degree of flexion) is the relationship of the fetal body parts to one another. It indicates whether the presenting parts of the fetus are in flexion (complete or moderate) or extension (partial or full). What’s in an attitude? Complete flexion Moderate flexion Partial extension Full extension In complete flexion, the head of the fetus is tucked down onto the chest, with the chin touching the sternum. Moderate flexion (aka military position or sinciput), the head of the fetus is slightly flexed but held straighter than in complete flexion. The chin doesn’t touch the chest. In partial extension, the head of the fetus is extended, with the head pushed slightly backward so that the brow becomes the first part of the fetus to pass through the pelvis during birth. In complete extension, the head and neck of the fetus are hyperextended and the occiput touches the fetus’s upper back. The back is usually arched, which increases the degree of hyperextension. This position is commonly called the fetal position. Many fetuses assume this attitude early in labor but convert to complete flexion as labor progresses. This is an uncommon fetal position and a vaginal birth is unlikely. Commonly, this skull diameter is too large to pass through the pelvis. The occiput is the presenting part. The top of the head is the presenting part. The brow or forehead is the presenting part. The mentum (chin) is the presenting part. Fetal lie The relationship of the fetal spine to the maternal spine is referred to as fetal lie. Fetal lie can be described as longitudinal, transverse, or oblique. Fetal position Fetal position is the relationship of the presenting part of the fetus to a specific quadrant of the mother’s pelvis. It’s important to define fetal position because it influences the progression of labor and whether surgical intervention is needed. Spelling it out Fetal position is defined using three letters. The first letter designates whether the presenting part is facing the woman’s right (R) or left (L) side. The second letter or letters refer to the presenting part of the fetus: the occiput (O), mentum (M), sacrum (Sa), or scapula or acromion process (A). The third letter designates whether the presenting part is pointing to the anterior (A), posterior (P), or transverse (T) section of the mother’s pelvis. The most common fetal positions are left occiput anterior (LOA) and right occiput anterior (ROA). (See Fetal position abbreviations , page 298 .) Duration determinant Commonly, the duration of labor and birth is shortest when the fetus is in the LOA or ROA position. When the fetal position is posterior, such as left occiput posterior (LOP), labor tends to be longer and more painful for the woman because the fetal head puts pressure on her sacral nerves. (See Determining fetal position .) Which way do I Lie? Longitudinal Transverse Oblique The fetal spine is parallel to the maternal spine. The fetal spine is at a 90-degree angle to the maternal spine. The fetal spine is at a 45-degree angle to the maternal spine. Approximately 99% of all fetuses are in this position. The presenting part can be either vertex or breech. Occurs in less than 1% of all deliveries and is considered abnormal. The presenting part can be a shoulder, an iliac crest, a hand, or an elbow. Also considered abnormal and is rare. The presenting part can also be a shoulder, an iliac crest, a hand, or an elbow. Fetal position abbreviations Here’s a list of presentations that are used when documenting vertex presentations. Although it is possible to apply the same abbreviation system to breech (sacrum), face (mentum) and shoulder (acromion process) presentation, it is rarely done due to those presentations precipitating a cesarean section delivery. Vertex presentations (occiput) LOA, left occipitoanterior ROA, right occipitoanterior LOP, left occipitoposterior ROP, right occipitoposterior LOT, left occipitotransverse ROT, right occipitotransverse Types of fetal presentation Fetal presentation refers to the part of the fetus that presents into the birth canal first. It’s determined by fetal attitude, lie, and position. Fetal presentation should be determined in the early stages of labor in case an abnormal presentation endangers the mother and the fetus. (See Classifying fetal presentation , pages 300 and 301.) The four main types of fetal presentation are: cephalic breech shoulder compound. Cephalic presentation When the fetus is in cephalic presentation, the head is the first part to contact the cervix and expel from the uterus during delivery. About 95% of all fetuses are in cephalic presentation at birth. The four types of cephalic presentation are vertex, brow, face, and mentum (chin). Determining fetal position Fetal position is determined by the relationship of a specific presenting part (occiput, sacrum, mentum [chin], or sinciput [deflected vertex]) to the four quadrants (anterior, posterior, right, or left) of the maternal pelvis. For example, a fetus whose occiput (O) is the presenting part and who’s located in the right (R) and anterior (A) quadrant of the maternal pelvis is identified as ROA. These illustrations show the possible positions of a fetus in vertex presentation. Vertex In the vertex cephalic presentation, the most common presentation overall, the fetus is in a longitudinal lie with an attitude of complete flexion. The parietal bones (between the two fontanels) are the presenting part of the fetus. This presentation is considered optimal for fetal descent through the pelvis. Classifying fetal presentation Fetal presentation may be broadly classified as cephalic, shoulder, compound, or breech. Almost all births are cephalic presentations. Breech births are the second most common type. Cephalic In the cephalic, or head-down, presentation, the position of the fetus may be further classified by the presenting skull landmark, such as vertex, brow, sinciput, or mentum (chin). Shoulder Although a fetus may adopt one of several shoulder presentations, examination can’t differentiate among them; thus, all transverse lies are considered shoulder presentations. Compound In compound presentation, an extremity prolapses alongside the major presenting part so that two presenting parts appear in the pelvis at the same time. Breech In the breech, or head-up, presentation, the position of the fetus may be further classified as frank, where the hips are flexed and knees remain straight; complete, where the knees and hips are flexed; kneeling, where the knees are flexed and the hips remain extended; and incomplete, where one or both hips remain extended and one or both feet or knees lie below the breech; or footling, where one or both feet extend below the breech. Brow In brow presentation, the fetus’s brow or forehead is the presenting part. The fetus is in a longitudinal lie and exhibits an attitude of partial flexion. Although this isn’t the optimal presentation for a fetus, few suffer serious complications from the delivery. In fact, many brow presentations convert to vertex presentations during descent through the pelvis. Face The face type of cephalic presentation is unfavorable for the mother and the fetus. In this presentation, the fetus is in a longitudinal lie and exhibits an attitude of complete extension. Because the face is the presenting part of the fetal head, severe edema and facial distortion may occur from the pressure of uterine contractions during labor. Faced with potential complications If labor is allowed to progress, careful monitoring of both the fetus and the mother is necessary to reduce the risk of compromise. Labor may be prolonged and ineffective in some instances, and vaginal birth may not be possible because the presenting part has a larger diameter than the pelvic outlet. Attempts to manually convert the face presentation to a more favorable position are rarely successful and are associated with high perinatal mortality and maternal morbidity. Mentum The mentum, or chin, type of cephalic presentation is also unfavorable for the mother and the fetus. In this presentation, the fetus is in a longitudinal lie with an attitude of complete extension. The presenting part of the fetus is the chin, which may lead to severe edema and facial distortion from the pressure of the uterine contractions during labor. The widest diameter of the fetal head is presenting through the pelvis because of the extreme extension of the head. If labor is allowed to progress, careful monitoring of both the fetus and the mother is necessary to reduce the risk of compromise. Labor is usually prolonged and ineffective. Vaginal delivery is usually impossible because the fetus can’t pass through the ischial spines. Breech presentation Although 25% of all fetuses are in breech presentation at week 30 of gestation, most turn spontaneously at 32 to 34 weeks’ gestation. However, breech presentation occurs at term in about 3% of births. Labor is usually prolonged with breech presentation because of ineffective cervical dilation caused by decreased pressure on the cervix and delayed descent of the fetus. It gets complicated In addition to prolonging labor, the breech presentation increases the risk of complications. In the fetus, cord prolapse; anoxia; intracranial hemorrhage caused by rapid molding of the head; neck trauma; and shoulder, arm, hip, and leg dislocations or fractures may occur. Complications that may occur in the mother include perineal tears and cervical lacerations during delivery and infection from premature rupture of the membranes. How will I know? A breech presentation can be identified by abdominal and cervical examination. The signs of breech presentation include: fetal head is felt at the uterine fundus during an abdominal examination fetal heart tones are heard above the umbilicus soft buttocks or feet are palpated during a cervical examination. Once, twice, three types more The three types of breech presentation are complete, frank, and incomplete. Complete breech In a complete breech presentation, the fetus’s buttocks and the feet are the presenting parts. The fetus is in a longitudinal lie and is in complete flexion. The fetus is sitting crossed-legged and both legs are drawn up (hips flexed) with the anterior of the thighs pressed tightly against the abdomen; the lower legs are crossed with the calves pressed against the posterior of the thighs; and the feet are tightly flexed against the outer aspect of the posterior thighs. Although considered an abnormal fetal presentation, complete breech is the least difficult of the breech presentations. Frank breech In a frank breech presentation, the fetus’s buttocks are the presenting part. The fetus is in a longitudinal lie and is in moderate flexion. Both legs are drawn up (hips flexed) with the anterior of the thighs pressed against the body; the knees are fully extended and resting on the upper body with the lower legs stretched upward; the arms may be flexed over or under the legs; and the feet are resting against the head. The attitude is moderate. Incomplete breech In an incomplete breech presentation, also called a footling breech, one or both of the knees or legs are the presenting parts. If one leg is extended, it’s called a single-footling breech (the other leg may be flexed in the normal attitude); if both legs are extended, it’s called a double-footling breech. The fetus is in a longitudinal lie. At least one of the thighs and one of the lower legs are extended with little or no hip flexion. Perhaps expect prolapse A footling breech is the most difficult of the breech deliveries. Cord prolapse is common in a footling breech because of the space created by the extended leg. A cesarean birth may be necessary to reduce the risk of fetal or maternal mortality. Shoulder presentation Although common in multiple pregnancies, the shoulder presentation of the fetus is an abnormal presentation that occurs in less than 1% of deliveries. In this presentation, the shoulder, iliac crest, hand, or elbow is the presenting part. The fetus is in a transverse lie, and the attitude may range from complete flexion to complete extension. Lacking space and support In the multiparous woman, shoulder presentation may be caused by the relaxation of the abdominal walls. If the abdominal walls are relaxed, the unsupported uterus falls forward, causing the fetus to turn horizontally. Other causes of shoulder presentation may include pelvic contraction (the vertical space in the pelvis is smaller than the horizontal space) or placenta previa (the low-lying placenta decreases the vertical space in the uterus). Early identification and intervention are critical when the fetus is in a shoulder presentation. Abdominal and cervical examination and sonography are used to confirm whether the mother’s abdomen has an abnormal or distorted shape. Attempts to turn the fetus may be unsuccessful unless the fetus is small or preterm. A cesarean delivery may be necessary to reduce the risk of fetal or maternal death. Compound presentation In a compound presentation, an extremity presents with another major presenting part, usually the head. In this type of presentation, the extremity prolapses alongside the major presenting part so that they present simultaneously. Engagement Engagement occurs when the presenting part of the fetus passes into the pelvis to the point where, in cephalic presentation, the biparietal diameter of the fetal head is at the level of the midpelvis (or at the level of the ischial spines). Vaginal and cervical examinations are used to assess the degree of engagement before and during labor. A good sign Because the ischial spines are usually the narrowest area of the female pelvis, an engagement indicates that the pelvic inlet is large enough for the fetus to pass through (because the widest part of the fetus has already passed through the narrowest part of the pelvis). Floating away In the primipara, nonengagement of the presenting part at the onset of labor may indicate a complication, such as cephalopelvic disproportion, abnormal presentation or position, or an abnormality of the fetal head. The nonengaged presenting part is described as floating. In the multipara, nonengagement is common at the onset of labor; however, the presenting part quickly becomes engaged as labor progresses. Station Station is the relationship of the presenting part of the fetus to the mother’s ischial spines. If the fetus is at station 0, the fetus is considered to be at the level of the ischial spines. The fetus is considered engaged when it reaches station 0. Grand central stations Fetal station is measured in centimeters. The measurement is called minus when it’s above the level of the ischial spines and plus when it’s below that level. Station measurements range from — 1 to — 3 cm (minus station) and + 1 to + 4 cm (plus station). A crowning achievement When the station is measured at + 4 cm, the presenting part of the fetus is at the perineum—commonly known as crowning. (See Assessing fetal engagement and station , page 306 .) Advice from the experts Assessing fetal engagement and station During a cervical examination, you’ll assess the extent of the fetal presenting part into the pelvis. This is referred to as fetal engagement. After you have determined fetal engagement, palpate the presenting part and grade the fetal station (where the presenting part lies in relation to the ischial spines of the maternal pelvis). If the presenting part isn’t fully engaged into the pelvis, you won’t be able to assess station. Station grades range from —3 (3 cm above the maternal ischial spines) to +4 (4 cm below the maternal ischial spines, causing the perineum to bulge). A zero grade indicates that the presenting part lies level with the ischial spines. A look at labor stimulation For some patients, it’s necessary to stimulate labor. The stimulation of labor may involve induction (artificially starting labor) or augmentation (assisting a labor that started spontaneously). Although induction and augmentation involve the same methods and risks, they’re performed for different reasons. Many high-risk pregnancies must be induced because the safety of the mother or fetus is in jeopardy. Medical problems that justify induction of labor include preeclampsia, eclampsia, severe hypertension, diabetes, Rh sensitization, prolonged rupture of the membranes (over 24 hours), and a postmature fetus (a fetus that’s 42 weeks’ gestation or older). Augmentation of labor may be necessary if the contractions are too weak or infrequent to be effective. Conditions for labor stimulation Before stimulating labor, the fetus must be: in longitudinal lie (the long axis of the fetus is parallel to the long axis of the mother) at least 39 weeks’ gestation or have fetal lung maturity established The ripe type In addition to the above fetal criteria, the mother must have a ripe cervix before labor is induced. A ripe cervix is soft and supple to the touch rather than firm. Softening of the cervix allows for cervical effacement, dilation, and effective coordination of contractions. Using Bishop score, you can determine whether a cervix is ripe enough for induction. (See Bishop score , page 308 .) When it isn’t so great to stimulate Stimulation of labor should be done with caution in women age 35 and older and in those with grand parity or uterine scars. Labor should not be stimulated if, but not limited to: transverse fetal position umbilical cord prolapse active genital herpes infections women who have had previous myomectomy (fibroid removal) from the inside of the uterus stimulation of the uterus increases the risk of such complications as placenta previa, abruptio placentae, uterine rupture, and decreased fetal blood supply caused by the increased intensity or duration of contractions. Methods of labor stimulation If labor is to be induced or augmented, one method or a combination of methods may be used. Methods of labor stimulation include breast stimulation, amniotomy, oxytocin administration, and ripening agent application. Breast stimulation In breast stimulation, the nipples are massaged to induce labor. Stimulation results in the release of oxytocin, which causes contractions that sometimes result in labor. The patient or her partner can help with breast stimulation by: applying a water-soluble lubricant to the nipple area (to prevent irritation) gently rolling the nipple through the patient’s clothing. Too much, too soon? One drawback of breast stimulation is that the amount of oxytocin being released by the woman’s body can’t be controlled. In some cases (rarely), too much oxytocin leads to excessive uterine stimulation (tachysystole or tetanic contractions), which impairs fetal or placental blood flow, causing fetal distress. Bishop score Bishop score is a tool that you can use to assess whether a woman is ready for labor. A score ranging from 0 to 3 is given for each of five factors: cervical dilation, length (effacement), consistency, position, and station. If the woman’s score exceeds 8, the cervix is considered suitable for induction. Factor Score Cervical dilation • Cervix dilated <1 cm 0 • Cervix dilated 1 to 2 cm 1 • Cervix dilated 2 to 4 cm 2 • Cervix dilated >4 cm 3 Cervical length (effacement) • Cervical length >4 cm (0% effaced) 0 • Cervical length 2 to 4 cm (0% to 50% effaced) 1 • Cervical length 1 to 2 cm (50% to 75% effaced) 2 • Cervical length <1 cm (>75% effaced) 3 Cervical consistency • Firm cervical consistency 0 • Average cervical consistency 1 • Soft cervical consistency 2 Cervical position • Posterior cervical position 0 • Middle or anterior cervical position 1 Zero station notation (presenting part level) • Presenting part at ischial spines —3 cm 0 • Presenting part at ischial spines —1 cm 1 • Presenting part at ischial spines +1 cm 2 • Presenting part at ischial spines +2 cm 3 Modifiers Add 1 point to score for: Preeclampsia Each prior vaginal delivery Subtract 1 point from score for: Postdates pregnancy Nulliparity Premature or prolonged rupture of membranes Adapted with permission from Bishop, E. H. (1964). Pelvic scoring for elective induction. Obstetrics and Gynecology, 24, 266-268. Amniotomy Amniotomy (artificial rupturing of the membranes) is performed to augment or induce labor when the membranes haven’t ruptured spontaneously. This procedure allows the fetal head to contact the cervix more directly, thus increasing the efficiency of contractions. Amniotomy is virtually painless for both the mother and the fetus because the membranes don’t have nerve endings. System requirements To perform amniotomy, the fetus must be in the vertex presentation with the cervix dilated to at least 2 cm; additionally, the head should be well applied to the cervix to help prevent umbilical cord prolapse. Nurse need to be aware of the potential for umbilical cord prolapse during an amniotomy if the head is not fully engaged into the pelvis at zero station. Let it flow, let it flow, let it flow During amniotomy, the woman is placed in a dorsal recumbent position. An amniohook (a long, thin instrument similar to a crochet hook) is inserted into the vagina to puncture the membranes. If puncture is properly performed, amniotic fluid gushes out. Advice from the experts Complications of amniotomy Umbilical cord prolapse—a life-threatening complication of amniotomy—is an emergency that requires immediate cesarean birth to prevent fetal death. It occurs when amniotic fluid, gushing from the ruptured sac, sweeps the cord down through the cervix. Prolapse risk is higher if the fetal head isn’t engaged in the pelvis before rupture occurs. Cord prolapse can lead to cord compression as the fetal presenting part presses the cord against the pelvic brim. Immediate action must be taken to relieve the pressure and prevent fetal anoxia and fetal distress. Here are some options: Insert a gloved hand into the vagina and gently push the fetal presenting part away from the cord. Place the woman in Trendelenburg position to tilt the presenting part backward into the pelvis and relieve pressure on the cord. Administer oxygen to the mother by face mask to improve oxygen flow to the fetus. If the cord has prolapsed to the point that it’s visible outside the vagina, don’t attempt to push the cord back in. This can add to the compression and may cause kinking. Cover the exposed portion with a compress soaked with sterile saline solution to prevent drying, which could result in atrophy of the umbilical vessels. Persevere if it isn’t clear Normal amniotic fluid is clear. Bloody or meconium-stained amniotic fluid is considered abnormal and requires careful, continuous monitoring of the mother and fetus. Bloody amniotic fluid may indicate a bleeding problem. Meconium-stained amniotic fluid may indicate fetal distress. If the fluid is meconium-stained, note whether the staining is thin, moderate, thick, or particulate. Take a whiff Amniotic fluid has a scent described as either a sweet smell or odorless. A foul smell indicated the presence of an infection and the patient needs further evaluation. Prolapse potential Amniotomy increases the risk to the fetus because there’s a possibility that a portion of the umbilical cord will prolapse with the amniotic fluid. Fetal heart rate (FHR) should be monitored during and after the procedure to make sure that umbilical cord prolapse didn’t occur. (See Complications of amniotomy , page 309 .) Oxytocin administration Synthetic oxytocin (Pitocin) is used to induce or augment labor. It may be used in patients with gestational hypertension, prolonged gestation, maternal diabetes, Rh sensitization, premature or prolonged rupture of membranes, and incomplete or inevitable abortion. Oxytocin is also used to evaluate for fetal distress after 31 weeks’ gestation and to control bleeding and enhance uterine contractions after the placenta is delivered. Oxytocin is always administered I.V. with an infusion pump. Throughout administration, FHR and uterine contractions should be assessed, monitored, and documented according to National Institutes of Child Health and Human Development (NICHD) criteria. First things first Prior to the start of an infusion you should have at least a 15-minute strip of both FHR and uterine activity to establish a reassuring FHR. There also should be a Bishop score documented as a measure of ensuring the cervix is ripe for labor. Additionally, a set of maternal vital signs should also be obtained. Nursing interventions Here’s how to administer oxytocin: Start a primary I.V. line. Insert the tubing of the administration set through the infusion pump, and set the drip rate to administer the oxytocin at a starting infusion rate of 0.5 to 2 mU/minute. The maximum dosage of oxytocin is 20 mU/minute. Typically, oxytocin is diluted 10 units in 500 ml or 20 units in 1,000 ml of an isotonic solution; lactated Ringer is the most common. This dilution results in a dosage of 2 mU/minute for every 3 ml/hour of I.V. fluid infused. An alternative dosing is 30 units diluted in 500 ml and the dosage becomes 1 mU/minute for every 1 ml/hour of I.V. fluid infused. Piggyback ride The oxytocin solution is then piggybacked to the primary I.V. line, through the lowest possible access point on the I.V. tubing. If a problem occurs, such as a nonreassuring FHR pattern or uterine tachysystole, stop the piggyback infusion immediately and resume the primary line. Immediate action Because oxytocin begins acting immediately, be prepared to start monitoring uterine contractions. Increase the oxytocin dosage as ordered—but never increase the dose more than 1 to 2 mU/minute every 15 to 60 minutes. Typically, the dosage continues at a rate that maintains a regular pattern (uterine contractions occur every 2 to 3 minutes lasting less than 2 minutes duration). If more is in store Before each increase, be sure to assess contractions, maternal vital signs, fetal heart rhythm, and FHR. If you’re using an external fetal monitor, the uterine activity strip or grid should show contractions occurring every 2 to 3 minutes. The contractions should last for about 60 seconds and be followed by uterine relaxation. If you’re using an internal uterine pressure catheter (IUPC), look for an optimal baseline value ranging from 5 to 15 mm Hg. Your goal is to verify uterine relaxation between contractions. Assist with comfort measures, such as repositioning the patient on her other side, as needed. Following through Continue assessing maternal and fetal responses to the oxytocin. Maternal assessment should include blood pressure, pulse, and a pain assessment Review the infusion rate to prevent uterine tachysystole. To manage tachysystole, discontinue the infusion and administer oxygen. (See Complications of oxytocin administration , page 312 .) To reduce uterine irritability, try to increase uterine blood flow. Do this by changing the patient’s position and increasing the infusion rate of the primary I.V. line. After tachysystole resolves, resume the oxytocin infusion per your facility’s policy. Advice from the experts Complications of oxytocin administration Oxytocin can cause uterine tachysystole. This, in turn, may progress to tetanic contractions, which last longer than 2 minutes. Signs of tachysystole include contractions that are less than 2 minutes apart and last 90 seconds or longer, uterine pressure that doesn’t return to baseline between contractions, and intrauterine pressure that rises over 75 mm Hg. What else to watch for Other potential complications include fetal distress, abruptio placentae, uterine rupture, and water intoxication. Water intoxication, which can cause maternal seizures or coma, can result because the antidiuretic effect of oxytocin causes decreased urine flow. Stop signs Watch for the following signs of oxytocin administration complications. If any indication of any potential complications exists, stop the oxytocin administration, administer oxygen via face mask, and notify the doctor immediately. Fetal distress Signs of fetal distress include: late decelerations bradycardia. Abruptio placentae Signs of abruptio placentae include: sharp, stabbing uterine pain pain over and above the uterine contraction pain heavy bleeding hard, boardlike uterus. Also watch for signs of shock, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils. Uterine rupture Signs of uterine rupture include: sudden, severe pain during a uterine contractions tearing sensation absent fetal heart sounds. Also watch for signs of shock, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils. Water intoxication Signs and symptoms of water intoxication include: headache and vomiting (usually seen first) hypertension peripheral edema shallow or labored breathing dyspnea tachypnea lethargy confusion change in level of consciousness. Ripening agent application If a woman’s cervix isn’t soft and supple, a ripening agent may be applied to it to stimulate labor. Drugs containing prostaglandin E 2 —such as dinoprostone (Cervidil, Prepidil, Prostin E2)—are commonly used to ripen the cervix. These drugs initiate the breakdown of the collagen that keeps the cervix tightly closed. The ripening agent can be: applied to the interior surface of the cervix with a catheter or suppository applied to a diaphragm that’s then placed against the cervix inserted vaginally. Additional doses may be applied every 3 to 6 hours; however, two or three doses are usually enough to cause ripening. The woman should remain flat after application to prevent leakage of the medication. Success half the time The success of this labor stimulation method varies with the agent used. After just a single application of a ripening agent, about 50% of women go into labor spontaneously and deliver within 24 hours. Those women who don’t go into labor require a different method of labor stimulation. Prostaglandin should be removed before amniotomy. Use this drug with caution in women with asthma, glaucoma, and renal or cardiac disease. Not to be ignored Prior to application of the ripening agent, a 15-minute strip of FHR and uterine activity should be completed as a baseline. Although the ripening agent is applied, carefully monitor the patient’s uterine activity. If uterine tachysystole occurs or if labor begins, the prostaglandin agent should be removed. The patient should also be monitored for adverse effects of prostaglandin application, including headache, vomiting, fever, diarrhea, and hypertension. FHR and uterine activity should be monitored continuously between 30 minutes and 2 hours after vaginal insertion, dependent upon the agent used. Onset of labor True labor begins when the woman has bloody show, her membranes rupture, and she has painful contractions of the uterus that cause effacement and dilation of the cervix. The actual mechanism that triggers this process is unknown. Before the onset of true labor, preliminary signs appear that indicate the beginning of the birthing process. Although not considered to be a true stage of labor, these signs signify that true labor isn’t far away. Preliminary signs and symptoms of labor Preliminary signs and symptoms of labor include lightening, increased level of activity, Braxton Hicks contractions, and ripening of the cervix. Subjective signs, such as restlessness, anxiety, and sleeplessness, may also occur. (See Labor: True or false?) Lightening Lightening is the descent of the fetal head into the pelvis. The uterus lowers and moves into a more anterior position, and the contour of the abdomen changes. In primiparas, these changes commonly occur about 2 weeks before birth. In multiparas, these changes can occur on the day labor begins or after labor starts. More pressure here, less pressure there Lightening increases pressure on the bladder, which may cause urinary frequency. In addition, leg pain may occur if the shifting of the fetus and uterus increases pressure on the sciatic nerve. The mother may also notice an increase in vaginal discharge because of the pressure of the fetus on the cervix. However, breathing becomes easier for the woman after lightening because pressure on the diaphragm is decreased. Advice from the experts Labor: True or false? Use this chart to help differentiate between the signs and symptoms of true labor and those of false labor. Signs and symptoms True labor False labor Cervical changes Cervix softens and dilates No cervical dilation or effacement Level of discomfort Intense Mild Location of contractions Start in the back and spread to the abdomen Abdomen or groin Uterine consistency when palpated Hard as a board; can’t be indented Easily indented with a finger Regularity of contractions Regular with increasing frequency and duration Irregular; no discernible pattern; tends to decrease in intensity and frequency with activity Frequency and duration of contractions affected by position or activity No Yes Ruptured membranes Possible No Increased level of activity After having endured increased fatigue for most of the third trimester, it’s common for a woman to experience a sudden increase in energy before true labor starts. This phenomenon is sometimes referred to as “nesting” because, in many cases, the woman directs this energy toward last-minute activities, such as organizing the baby’s room, cleaning and straightening her home, and preparing other children in the household for the new arrival. A built-in energy source The woman’s increase in activity may be caused by a decrease in placental progesterone production (which may also be partly responsible for the onset of labor) that results in an increase in the release of epinephrine. This epinephrine increase gives the woman extra energy for labor. Braxton Hicks contractions Braxton Hicks contractions are mild contractions of the uterus that occur throughout pregnancy. They may become extremely strong a few days to a month before labor begins, which may cause some women, especially a primipara, to misinterpret them as true labor. Several characteristics, however, distinguish Braxton Hicks contractions from labor contractions. Patternless Braxton Hicks contractions are irregular. There’s no pattern to the length of time between them and they vary widely in their strength. They gradually increase in frequency and intensity throughout the pregnancy, but they maintain an irregular pattern. In addition, Braxton Hicks contractions can be diminished by increasing activity or by eating, drinking, or changing position. Labor contractions can’t be diminished by these activities. Painless Braxton Hicks contractions are commonly painless—especially early in pregnancy. Many women feel only a tightening of the abdomen in the first or second trimester. If the woman does feel pain from these contractions, it’s felt only in the abdomen and the groin—usually not in the back. This is a major difference from the contractions of labor. No softening or stretching Probably, the most important differentiation between Braxton Hicks contractions and true labor contractions is that Braxton Hicks contractions don’t cause progressive effacement or dilation of the cervix. The uterus can still be indented with a finger during a contraction, which indicates that the contractions aren’t efficient enough for effacement or dilation to occur. Ripening of the cervix Ripening of the cervix refers to the process in which the cervix softens to prepare for dilation and effacement. It’s thought to be the result of hormone-mediated biochemical events that initiate breakdown of the collagen in the cervix, thus causing it to soften and become flexible. As the cervix ripens, it also changes position by tipping forward in the vagina. Ripening of the cervix doesn’t produce outwardly observable signs or symptoms. The ripeness of the cervix is determined during a pelvic examination, usually in the last weeks of the third trimester. Signs of true labor Signs of true labor include uterine contractions, bloody show, and spontaneous rupture of membranes. Uterine contractions The involuntary uterine contractions of true labor help effacement and dilation of the uterus and push the fetus through the birth canal. Although uterine contractions are irregular when they begin, as labor progresses they become regular with a predictable pattern. Early contractions occur anywhere from 5 to 30 minutes apart and last about 30 to 45 seconds. The interval between the contractions allows blood flow to resume to the placenta, which supplies oxygen to the fetus and removes waste products. As labor progresses, the contractions increase in frequency, duration, and intensity. During the transition phase of the first stage of labor—when contractions reach their maximum intensity, frequency, and duration— they each last 60 to 90 seconds and recur every 2 to 3 minutes.
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What Is Fetal Surgery, and How Is It Changing?
BY CARRIE MACMILLAN December 5, 2023
Being pregnant can be nerve-racking even in the best of circumstances, but any type of complication for the mother or fetus may understandably turn natural jitters into serious concern.
Fortunately, pregnant women with complications today have more treatment options compared to decades ago.
“In many cases, what was untreatable yesterday is treatable today. And it is ever-evolving,” says Mert Ozan Bahtiyar, MD , director of the Yale Fetal Care Center .
Dr. Bahtiyar is a maternal-fetal medicine specialist and a fetal surgeon. Broadly speaking, fetal surgery encompasses procedures “that allow us to change the course of a disease in a baby while it is still in the uterus,” he explains.
That can mean treating a range of conditions earlier than was previously possible, including fetal anemia (when red blood cell volume falls below normal), spina bifida (when the spinal cord doesn’t properly develop), congenital diaphragmatic hernia (in which the diaphragm doesn’t close during development), and other issues, such as twin-to-twin transfusion syndrome (an imbalance in blood flow between identical twins), and various heart conditions. And earlier treatment often means better outcomes.
Improved technology is driving most of the advances. This includes miniaturized surgical instruments, such as the fetoscope, which is inserted through a small hole in the mother’s abdomen to enter the uterus. This allows the medical provider to see the fetus and placenta, and, if needed, treat conditions or take samples.
“We also have better digital imaging, including fast fetal MRI [magnetic resonance imaging] and high-definition, next-generation ultrasounds,” Dr. Bahtiyar says. “We can detect fetal anemia as early as 16 weeks' gestation. This was not something that we treated in utero in the past. But now, it is routine to sample a baby’s blood and get results within 45 seconds."
At the Yale Fetal Care Center, a team of board-certified experts spanning maternal-fetal medicine, neonatology, genetics, pediatric surgery, and perinatal palliative care work together to develop a plan for pregnant patients and their developing babies. A care coordinator guides families through testing, specialist appointments, and anything else that is needed. After a baby is born, any additional Yale Medicine pediatric subspecialists, from pediatric cardiology to pediatric neurology, can provide additional care.
Below, we talked more with Dr. Bahtiyar about advances in fetal surgery for three different conditions.
Fetal surgery for spina bifida—in utero repair
The Yale Fetal Care Center specializes in treating a variety of complex issues that affect mother and baby, including spinal bifida, a rare condition in which a portion of the fetal spinal column doesn’t close as it should.
Of the several types of spina bifida, myelomeningocele is the most severe; a portion of the spinal cord or nerves is exposed in a sac of fluid that bulges through an opening in the baby’s back. This can lead to paralysis, hydrocephalus (a condition in which there is extra cerebrospinal fluid in and around the brain), developmental delays , and/or problems with bowel and bladder control.
Most babies born with myelomeningocele require surgery to close the sac to prevent infection, which should be done within 48 hours of birth. Now, the surgery can sometimes be done in utero.
“For the appropriately chosen cases, we can open the mother’s uterus, perform the surgery on the fetus while it is still attached to the placenta, put the fetus back in and repair the uterus, and the pregnancy continues,” Dr. Bahtiyar explains. “This in utero surgery comes with higher risks, but outcomes are significantly better than waiting and treating the baby after birth.”
When the surgery is done after birth, there is an 80% chance the baby will need to have a shunt (a hollow tube) placed in the brain to remove excess fluid. According to a study published in the New England Journal of Medicine , the in utero repair reduces the odds an infant will require a shunt to about 40%.
Congenital diaphragmatic hernia repair via fetal surgery
Congenital diaphragmatic hernia (CDH) is another condition that historically could be treated only after birth. In CDH, the diaphragm (the muscle that separates the abdomen and the chest) doesn’t fully close during development. As a result, abdominal organs can protrude into the chest cavity, which can affect lung development.
According to Dr. Bahtiyar, severe forms of this condition once carried a relatively poor prognosis, but that is no longer true. “In the past, it might lead to a situation where, after the baby is born, the survival rate was—or was expected to be—very low. It could be severely life-limiting,” he explains. “But now, we can, in utero, place a balloon temporarily in the fetus’s trachea. The fluids that accumulate behind the balloon help the lungs to expand and develop, which, in turn, helps the abdominal cavity to extend because it pushes the bowel down.”
This makes the actual postnatal repair procedure more likely to be successful, Dr. Bahtiyar notes.
Fetal anemia: diagnosis and treatment advances with fetal surgery
Fetal anemia, in which there is an insufficient number of red blood cells, is another area in which important treatment strides have been made. In the most severe cases, fetal anemia can lead to heart failure. Fetal anemia most commonly occurs when the mother and baby have incompatible blood types [also called Rh incompatibility], Dr. Bahtiyar says.
Advances in ultrasound techniques mean that doctors can now detect anemia in the womb before it leads to fetal heart failure. The treatment for this condition is an intrauterine blood transfusion.
“In the past, we would put the blood in the abdominal cavity of the fetus, and it would be absorbed from there slowly. But it was unreliable,” Dr. Bahtiyar says. “We had to use estimates on how much blood to put in, which was crude, and there was a risk of injury to the bowel.”
Now, the solution is to place a needle into the umbilical vein of the fetus. “First, we diagnose the suspected anemia through ultrasound. Then, we confirm it by taking a blood sample, and then we know how much to increase the amount of blood,” he says. “Then, very precisely, we give blood and repeat it as many times as necessary.”
Transfusion, Dr. Bahtiyar explains, corrects anemia temporarily. “This is why we need to do it multiple times during pregnancy,” he says. “The condition corrects itself after birth as the maternal antibodies, which are responsible for the anemia, wash out shortly after the baby is born.”
In some cases, such as with fetal anemia and twin-to-twin transfusion syndrome , fetal procedures can cure a problem, but in other situations, it’s more about improving the medical complication. So, it is important to realize that just because certain surgical procedures can be done while the baby is still in the womb, it is the parents’ choice as to whether one should be done.
“Sometimes, it’s about decreasing the severity of the disease when nothing can completely make it go away,” Dr. Bahtiyar says. “We are not here to make decisions for the patient. We are there to listen and to help them make decisions that are right for them.”
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