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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

, MD, Children's Hospital of Philadelphia

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Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

Progress may arrest in the second phase of labor. Operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more is often required.

Position and Presentation of the Fetus

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

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

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

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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

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

Read more on breech presentation .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resources and support

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

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

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

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Last reviewed: October 2023

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INTRODUCTION

PATHOGENESIS AND RISK FACTORS

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

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

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How your twins’ fetal positions affect labor and delivery

Twin fetal presentation – also known as the position of your babies in the womb – dictates whether you'll have a vaginal or c-section birth. Toward the end of pregnancy, most twins will move in the head-down position (vertex), but there's a risk that the second twin will change position after the first twin is born. While there are options to change the second twin's position, this can increase the risk of c-section and other health issues. Learn about the six possible twin fetal presentations: vertex-vertex, vertex-breech, breech-breech, vertex-transverse, breech-transverse, and transverse-transverse – and how they'll impact your delivery and risks for complications.

What is fetal presentation and what does it mean for your twins?

As your due date approaches, you might be wondering how your twins are currently positioned in the womb, also known as the fetal presentation, and what that means for your delivery. Throughout your pregnancy, your twin babies will move in the uterus, but sometime during the third trimester – usually between 32 and 36 weeks – their fetal presentation changes as they prepare to go down the birth canal.

The good news is that at most twin births, both babies are head-down (vertex), which means you can have a vaginal delivery. In fact, nearly 40 percent of twins are delivered vaginally.

But if one baby has feet or bottom first (breech) or is sideways (transverse), your doctor might deliver the lower twin vaginally and then try to rotate the other twin so that they face head-down (also called external cephalic version or internal podalic version) and can be delivered vaginally. But if that doesn't work, there's still a chance that your doctor will be able to deliver the second twin feet first vaginally via breech extraction (delivering the breech baby feet or butt first through the vagina).

That said, a breech extraction depends on a variety of factors – including how experienced your doctor is in the procedure and how much the second twin weighs. Studies show that the higher rate of vaginal births among nonvertex second twins is associated with labor induction and more experienced doctors, suggesting that proper delivery planning may increase your chances of a vaginal birth .

That said, you shouldn't totally rule out a Cesarean delivery with twins . If the first twin is breech or neither of the twins are head-down, then you'll most likely have a Cesarean delivery.

Research also shows that twin babies who are born at less than 34 weeks and have moms with multiple children are associated with intrapartum presentation change (when the fetal presentation of the second twin changes from head-down to feet first after the delivery of the first twin) of the second twin. Women who have intrapartum presentation change are more likely to undergo a Cesarean delivery for their second twin.

Here's a breakdown of the different fetal presentations for twin births and how they will affect your delivery.

Head down, head down (vertex, vertex)

This fetal presentation is the most promising for a vaginal delivery because both twins are head-down. Twins can change positions, but if they're head-down at 28 weeks, they're likely to stay that way.

When delivering twins vaginally, there is a risk that the second twin will change position after the delivery of the first. Research shows that second twins change positions in 20 percent of planned vaginal deliveries. If this happens, your doctor may try to rotate the second twin so it faces head-down or consider a breech extraction. But if neither of these work or are an option, then a Cesarean delivery is likely.

In vertex-vertex pairs, the rate of Cesarean delivery for the second twin after a vaginal delivery of the first one is 16.9 percent.

Like all vaginal deliveries, there's also a chance you'll have an assisted birth, where forceps or a vacuum are needed to help deliver your twins.

Head down, bottom down (vertex, breech)

When the first twin's (the lower one) head is down, but the second twin isn't, your doctor may attempt a vaginal delivery by changing the baby's position or doing breech extraction, which isn't possible if the second twin weighs much more than the first twin.

The rates of emergency C-section deliveries for the second twin after a vaginal delivery of the first twin are higher in second twins who have a very low birth weight. Small babies may not tolerate labor as well.

Head down, sideways (vertex, transverse)

If one twin is lying sideways or diagonally (oblique), there's a chance the baby may shift position as your labor progresses, or your doctor may try to turn the baby head-down via external cephalic version or internal podalic version (changing position in the uterus), which means you may be able to deliver both vaginally.

Bottom down, bottom down (breech, breech)

When both twins are breech, a planned C-section is recommended because your doctor isn't able to turn the fetuses. Studies also show that there are fewer negative neonatal outcomes for planned C-sections than planned vaginal births in breech babies.

As with any C-section, the risks for a planned one with twins include infection, loss of blood, blood clots, injury to the bowel or bladder, a weak uterine wall, placenta abnormalities in future pregnancies and fetal injury.

Bottom down, sideways (breech, transverse)

When the twin lowest in your uterus is breech or transverse (which happens in 25 percent of cases), you'll need to have a c-section.

Sideways, sideways (transverse, transverse)

This fetal presentation is rare with less than 1 percent of cases. If both babies are lying horizontally, you'll almost definitely have a C-section.

Learn more:

• Twin fetal development month by month
• Your likelihood of having twins or more
• When and how to find out if you’re carrying twins or more

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

Cleveland Clinic. Fetal Positions for Birth: https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth Opens a new window [Accessed July 2021]

Mayo Clinic. Fetal Presentation Before Birth: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615?s=7 Opens a new window [Accessed July 2021]

NHS. Giving Birth to Twins or More: https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

Science Direct. Breech Extraction: https://www.sciencedirect.com/topics/medicine-and-dentistry/breech-extraction Opens a new window [Accessed July 2021]

Obstetrics & Gynecology. Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

American Journal of Obstetrics and Gynecology. Fetal presentation and successful twin vaginal delivery: https://www.ajog.org/article/S0002-9378(04)00482-X/fulltext [Accessed July 2021]

The Journal of Maternal-Fetal & Neonatal Medicine. Changes in fetal presentation in twin pregnancies https://www.tandfonline.com/doi/abs/10.1080/14767050400028592 Opens a new window [Accessed July 2021]

Reviews in Obstetrics & Gynecology. An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252881/ Opens a new window [Accessed July 2021]

Nature. Neonatal mortality and morbidity in vertex–vertex second twins according to mode of delivery and birth weight: https://www.nature.com/articles/7211408 Opens a new window [Accessed July 2021]

Cochrane. Planned cesarean for a twin pregnancy: https://www.cochrane.org/CD006553/PREG_planned-caesarean-section-twin-pregnancy Opens a new window [Accessed July 2021]

Kids Health. What Is the Apgar Score?: https://www.kidshealth.org/Nemours/en/parents/apgar0.html Opens a new window [Accessed July 2021]

American Journal of Obstetrics & Gynecology. Neonatal mortality in second twin according to cause of death, gestational age, and mode of delivery https://pubmed.ncbi.nlm.nih.gov/15467540/ Opens a new window [Accessed July 2021]

Lancet. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group https://pubmed.ncbi.nlm.nih.gov/11052579/ Opens a new window [Accessed July 2021]

Cleveland Clinic. Cesarean Birth (C-Section): https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section Opens a new window [Accessed July 2021]

St. Jude Medical Staff. Delivery of Twin Gestation: http://www.sjmedstaff.org/documents/Delivery-of-twins.pdf Opens a new window [Accessed July 2021]

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Acute presentation of the pregnant patient

Francesca neuberger.

A Guy's and St Thomas’ Foundation Trust, London, UK;

Catherine Nelson-Piercy

B Guy's and St Thomas’ Foundation Trust and Imperial College Health Care Trust, London, UK

Three-quarters of maternal deaths are in women with coexisting medical complications. It can be challenging to differentiate symptoms of normal pregnancy from pathological symptomatology, and physicians need to be mindful of special considerations in assessing and managing acute medical problems in pregnancy. This article focuses on women presenting with shortness of breath, chest pain and palpitations.

• Symptoms of normal pregnancy can be difficult to differentiate from symptoms secondary to medical problems, and a careful history, examination and selected investigations are required
• Three-quarters of maternal deaths are in women with coexisting medical complications
• The vast majority of investigations and treatments should not be withheld in pregnancy
• Women with medical problems in pregnancy should be managed with a multidisciplinary team approach

Introduction

Physicians participating in the acute medical take are likely to encounter pregnant women on the acute medical unit, or may be asked to give an opinion on the obstetric ward. Pregnancy does not usually alter acute presentations but there are some special considerations in clinical assessment and differential diagnosis.

The MBRACCE report into UK maternal deaths from 2009–2012 1 showed a decrease in mortality from obstetric causes. However, mortality rates from indirect causes (medical and psychiatric) have not altered over the past ten years. Nearly three-quarters of all women who died had a coexisting medical complication. The report recommends that physicians are appropriately trained in the care of pregnant women, and that women with medical disorders in pregnancy have access to coordinated obstetric and medical input.

This review discusses the approach to pregnant women presenting with common symptoms of shortness of breath, chest pain and palpitations.

Shortness of breath

A degree of breathlessness is a feature of normal pregnancy. The challenge for the clinician is identifying pathological symptomatology (Fig ​ (Fig1). 1 ). From the history, women with physiological breathlessness of pregnancy typically describe an ‘air hunger’ at rest and particularly when talking, which may be relieved by activity.

Common and important causes of symptoms in pregnancy. 2 ACS = acute coronary syndrome; GORD = gastro–oesophageal reflux disease; PE = pulmonary embolism; PPCM = peripartum cardiomyopathy; SVT = supraventricular tachycardia.

In the examination, features such as tachycardia may be within normal limits (see Box 1). A useful bedside test is to monitor oxygen saturations with a pulse oximeter on exercise, for example climbing stairs. This allows the clinician to evaluate the degree of breathlessness with gentle exertion, and monitor oxygen saturations. While there is no widely accepted formal protocol for this, it is a reassuring feature if oxygen saturations do not decrease on exercise.

Normal results of commonly requested investigations in pregnancy are detailed in Table 1. Asthma is common and has a variable course in pregnancy. Acute severe asthma should be managed vigorously with the same drug treatments, including magnesium, steroids and theophyllines, as outside of pregnancy. There are extensive safety data for all these drugs in pregnancy, and guidelines stress the importance of not withholding steroids, in particular, 5 chest X-rays (CXR) should not be withheld where indicated. Continuous fetal monitoring should be used for women over 24-weeks gestation with acute severe asthma. Intensivists should be involved early. Acute asthma attacks are very rare in labour, perhaps due to higher circulating levels of endogenous steroids. 5

Bacterial pneumonia is no more common in pregnancy, but there is an increased susceptibility to viral pneumonias including Varicella zoster and influenza. CXR should not be withheld if pneumonia is suspected, and treatment with antivirals should be initiated for women with pneumonia secondary to flu viruses. The flu vaccine is recommended for all pregnant women. In the most recent MBRACCE report, influenza was the cause of death in 1 in 11 maternal mortalities. More than half of these deaths could have been prevented by vaccination.

Pulmonary embolism (PE) remains the commonest direct cause of maternal mortality and should be suspected in women with sudden-onset breathlessness and pleuritic pain or collapse. It should be investigated, as outlined in Fig ​ Fig2. 2 . It is notoriously difficult to diagnose or exclude on clinical grounds alone, and many women will undergo imaging. The prevalence of ultimately diagnosed PE in pregnant women undergoing imaging for suspected PE is low at 1.4–4.2%. 7 D-dimer is not validated in pregnancy, 6 therefore it is unhelpful in enabling clinicians to target their imaging appropriately. However, the presence of risk factors is helpful in risk stratifying pregnant women with suspected PE. Those with pre-existing risk factors (age >35 years, raised body mass index, previous venous thromboembolism (VTE), varicose veins, cardiac disease or recent hospital admission) and pregnancy-related risk factors (multiparity, in vitro fertilisation, pre-eclampsia, antenatal/postpartum haemorrhage, caesarean section or hyperemesis gravidarum) are more likely to develop VTE in pregnancy or postpartum. 7 A V/Q scan should be requested in preference to a computed tomography pulmonary angiography (CTPA) in women with a normal CXR, because the radiation dose to maternal lung and breast is reduced. The fetal radiation exposure associated with CTPA and V/Q is approximately 0.1 mGy and 0.5 mGy respectively, although quoted figures vary depending on the imaging protocol used. 6 These doses are well below the 50 mGy maximum recommended exposure in pregnancy. 2

Algorithm for the investigation and initial management of suspected PE in pregnancy and the puerperium. Reproduced with permission. 6 CTPA = computerised tomography pulmonary angiogram; CXR = chest X-ray; DVT = deep vein thrombosis; ECG = electrocardiogram; FBC = full blood count; LFT = liver function test; LMWH = low-molecular-weight heparin; PE = pulmonary embolism; U&E = urea and electrolytes.

In women diagnosed with massive PE in pregnancy, intravenous unfractionated heparin is the first-line treatment of choice. In those with massive PE associated with circulatory collapse and risk of imminent arrest, thrombolysis should be considered. It is potentially life-saving, and should not be withheld. Thrombolysis is increasingly used for submassive PE with high clot burden to reduce the risk of chronic pulmonary hypertension. There is no increased risk of haemorrhage compared with outside pregnancy. 8 The approach to thrombolysing a pregnant woman should be multidisciplinary, with involvement of obstetrics, intensivists, experienced physicians and radiologists. Alternative therapeutic options used successfully in pregnancy include catheter-directed thrombolytic therapy, or thoracotomy and surgical embolectomy.

An echocardiogram is key in diagnosing valvular heart disease. While many women will have pre-existing diagnoses, they may only become symptomatic in the latter stages of pregnancy. First presentation of valvular heart disease is seen most in the migrant population. Women have a poorer pregnancy outcome if they fall into New York Heart Association class III and IV, regardless of the nature of the lesion. 2 Women with regurgitant lesions and normal left ventricular function are low risk. Those with stenotic lesions and impaired left ventricular function are higher risk. Women with pre-existing heart disease should be offered pre-pregnancy counseling and be monitored closely through their pregnancy. Those with mechanical heart valves need expert management of their anticoagulation.

Box 1.  Normal cardiorespiratory examination findings in pregnancy.

Pregnant women are more susceptible to pulmonary oedema. Clinicians need to look for and address underlying causes such as underlying cardiac disease, pregnancy-induced hypertension and fluid overload. 9

Chest pain is not part of normal pregnancy, although symptoms such as ankle swelling, breathlessness and tachycardia may be normal. The differential diagnosis for chest pain in pregnancy is outlined in Table 1.

On examination, many healthy pregnant women will have ejection systolic murmurs (see Box 1). Diastolic murmurs should always be considered pathological. The interpretation of common investigations for chest pain in pregnancy is outlined in Table 1.

Gastro-oesophageal reflux is diagnosed on the basis of the history and is very common, affecting two-thirds of women, particularly in the third trimester. It is due to the effect of progesterone on the lower oesophageal sphincter and the mechanical effect of the enlarging uterus. 10 If symptoms are associated with vomiting or abdominal tenderness, then the diagnosis should be questioned. Treatment with antacids, H 2 -receptor antagonists and proton pump inhibitors is safe in pregnancy, following lifestyle advice.

Normal findings in pregnancy for common investigations for breathlessness, chest pain and palpitations. 3,4

Pneumothorax can occur at any gestation, but should be considered as a cause of chest pain following a vaginal delivery. Management is the same as outside pregnancy.

Cardiac disease is the single most common cause of maternal death in the UK and a high index of suspicion is needed. 1 The incidence of acquired heart disease is increasing due to older age at first pregnancy and a higher prevalence of cardiovascular risk factors, such as hypertension, diabetes and obesity. 11 Acute coronary syndromes are predominantly due to atherosclerotic disease, but there is an increased incidence of coronary artery dissection and thrombosis compared with the non-pregnant population. Percutaneous coronary intervention should not be withheld in pregnancy.

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction (left ventricular ejection fraction <45%) towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. 12 Ejection fraction is less than 45% and no alternative cause of cardiomyopathy is identified. PPCM is more prevalent in women who are older, multiparous, hypertensive and Afro-Caribbean. The mainstay of treatment for PPCM is conventional pharmacological therapy for heart failure, such as diuretics, vasodilators and beta-blockers, and delivery of the baby. Anticoagulation is given to women with severely impaired left ventricular function, and some require antiarrhythmics. In the postpartum period, angiotensin-converting enzyme inhibitors are given. Many women recover within three to six months of diagnosis, but the prognosis is variable.

Aortic dissection is characterised by severe ‘tearing’ chest pain, often associated with systolic hypertension. This can be diagnosed with a chest CT scan.

Palpitations

Pregnant women may become more aware of their own heart beating in pregnancy due to sinus tachycardia and increased cardiac output. An increase in pulse rate of 10–20 bpm, particularly by the third trimester, is within normal limits. Women may experience a ‘thump’ from normal beats after a compensatory pause that follows ventricular ectopics. 13 Those who report persistent or severe symptoms should be investigated.

The approach to identifying arrhythmias in pregnancy is to correctly diagnose the arrhythmia, check for underlying heart disease associated with the arrhythmia, then exclude systemic disease. 14 If a woman with palpitations has a history or examination suggesting previous heart surgery, family history of sudden cardiac death or valvular heart disease, then this places her in a higher risk group.

Supraventricular tachycardias are common. Management is the same as outside of pregnancy, and vagotonic manoevres and adenosine can be used to reveal the underlying rhythm. Calcium channel blockers, such as verapamil and beta-blockers, are safe. Direct-current cardioversion can be performed with fetal monitoring and obstetric anaesthetic input.

Thyrotoxicosis should be excluded as a cause of tachycardia, because untreated hyperthyroidism can cause fetal complications, such as growth restriction, prematurity and stillbirth, as well as maternal complications of pre-eclampsia, congestive cardiac failure and thyroid storm. 15 When interpreting thyroid function tests, clinicians should use trimester-specific reference ranges (see Table 1). Severe hyperemesis gravidarum (HG) can cause transient biochemical hyperthyroidism due to the thyroid-stimulating hormone (TSH)-like effects of the beta subunits of human chorionic gonadotropin. This occurs in over 60% of pregnancies with severe HG. Differentiation from first presentation of Graves’ disease requires thorough clinical assessment. Negative TSH-receptor antibodies also support a diagnosis of HG.

Phaeochromocytoma should be considered in women with palpitations associated with severe atypical hypertension, headache, glucose intolerance and anxiety. A high index of suspicion is needed to make the diagnosis. Phaeochromocytoma is associated with maternal mortality of up to 50% at the time of labour or induction of general anaesthesia, 16 and fetal mortality of approximately 26% in undiagnosed cases and 11% in diagnosed cases. 17 In the last MBRRACE triennium, there were two deaths caused by phaeochromocytoma. Investigation is the same as outside pregnancy.

Women with pre-existing medical conditions who become pregnant and those who develop medical complications in pregnancy require a coordinated approach involving senior physicians and obstetricians. Physicians are experienced in assessing patients with chest pain, palpitations and/or breathlessness, and can make a valuable contribution to the care of pregnant women presenting with them provided they avoid errors of omission.

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Preeclampsia: Pathophysiology and Clinical Presentations

The following are key points to remember from this JACC state-of-the-art review on preeclampsia—pathophysiology and clinical presentations:

• Preeclampsia is a hypertensive disorder of pregnancy that occurs in 2-8% of pregnancies and causes substantial morbidity and mortality.
• Preeclampsia is defined as new-onset hypertension and new-onset end-organ damage after 20 weeks’ gestation. Proteinuria is no longer required for the diagnosis.
• The complex pathophysiology of preeclampsia begins with abnormal placental development, endothelial dysfunction, and immunologic aberrations, possibly related to genetic susceptibility. Clinical features of preeclampsia include hypertension, proteinuria, renal dysfunction, neurological abnormalities, eclampsia, cardiac dysfunction, pulmonary edema, hepatic dysfunction, hematologic dysfunction, and fetal growth restriction.
• Hypertension is necessary for the diagnosis of preeclampsia, defined as systolic blood pressure (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg on two occasions ≥4 hours apart after 20 weeks’ gestation in a woman with previously normal BP; or SBP ≥160 mm Hg or DBP ≥110 mm Hg on one occasion.
• Proteinuria: The imbalance between proangiogenic and antiangiogenic factors likely causes podocyte injury leading to increased risk of hypertension and chronic kidney disease. Proteinuria can take up to 2 years to resolve after preeclampsia.
• Renal dysfunction in preeclampsia is defined as serum creatinine >1.1 mg/dl or a doubling of baseline creatinine. Inflammatory cytokines lead to endothelial dysfunction and thrombotic microangiopathy of the kidneys, and decreased intravascular volumes in preeclampsia increases sodium and free-water retention.
• Neurologic dysfunction includes headaches, visual disturbances, seizure, posterior reversible encephalopathy syndrome, and hemorrhagic stroke. The classic preeclampsia headache is progressive, bilateral, pulsating/throbbing, associated with visual changes, worse with higher BP, worsened by physical activity, and not relieved by over-the-counter medications.
• Eclampsia is defined as new-onset tonic-clonic, focal or multifocal seizures in the setting of pregnancy-related hypertension. Magnesium reduces the risk of eclampsia by 59%.
• Cardiac dysfunction: Impaired placentation in preeclampsia causes increased vascular resistance and higher afterload, resulting in mild-to-moderate left ventricular diastolic dysfunction with concentric left ventricular hypertrophy. Preeclampsia is also a risk factor for peripartum cardiomyopathy (defined as left ventricular systolic function <45%).
• Pulmonary edema is rare in preeclampsia and is related to: 1) increased vascular permeability, 2) cardiac dysfunction, 3) corticosteroids/tocolytics, and 4) iatrogenic volume overload.
• Hepatic dysfunction is defined as transaminases ≥2x the upper limit of normal (AST typically < ALT) with right upper quadrant or epigastric tenderness.
• Hematologic disturbances in preeclampsia include thrombocytopenia (due to increased platelet activation, aggregation, and consumption) and disseminated intravascular coagulopathy (due to consumption coagulopathy, hepatic injury and decreased clotting factors, and/or inflammatory response).
• Fetal growth restriction (defined as an estimated fetal weight <10th percentile for gestational age) occurs commonly in pregnancies complicated by preeclampsia. Several mechanisms of uterine and placental dysfunction contribute to intrauterine growth restriction.
• Low-dose aspirin is recommended for prevention of preeclampsia in high-risk women. Possible benefits of exercise, pravastatin, and metformin are being investigated. The definitive treatment for preeclampsia is delivery.
• Further research to understand the link between preeclampsia and subsequent short- and long-term cardiovascular disease is needed.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Acute Heart Failure, Hypertension

Keywords: Aspirin, Cardiomyopathies, Eclampsia, Fetal Growth Retardation, Headache, Hypertension, Hypertension, Pregnancy-Induced, Hypertrophy, Left Ventricular, Pre-Eclampsia, Kidney Diseases, Pregnancy, Primary Prevention, Proteinuria, Pulmonary Edema, Renal Insufficiency, Seizures, Stroke, Thrombocytopenia, Vascular Diseases

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Baby Your Baby- What to Know About Vitamins in Pregnancy

by Utah Department of Health and Human Services

It is very common for moms to ask questions about vitamins during pregnancy and breastfeeding. Nurse Al Romeo with MotherToBaby Utah at the Utah Department of Health and Human Services is here today to talk about why it is important to get the right amounts of different vitamins and minerals.

Why do pregnant and breastfeeding people need to pay attention to getting the right amounts of vitamins and minerals?

It is important for mom to get the right amounts of vitamins and minerals for her health and the health of baby. For example, iron (about 27 milligrams per day) is needed to make additional blood cells so baby gets enough oxygen. Calcium (about 1,000 milligrams per day) is needed to make baby’s bones and the right amount is needed so baby doesn’t steal calcium from mom’s bones. Today we’ll look at some examples of where too little or too much of some vitamins can cause problems.

What vitamins can cause problems if you don’t get enough of them?

Folic acid is a great example. If mom doesn’t have enough folic acid in her system (at least 400 micrograms per day) when she gets pregnant, baby has an increased chance of having spinal cord problems, called spina bifida, where the spine doesn’t finish closing in the first several weeks of pregnancy. That is why we fortify bread and cereal and ask moms to take a prenatal vitamin before pregnancy.

What vitamins can cause problems if you get too much of them?

Vitamins A is one where we want to make sure mom isn’t getting too much during pregnancy. If mom gets too much of a type of Vitamin A, retinoids, by taking too many supplements with large doses (over 10,000 International Units per day), it can have the same effect as Accutane, isotretinoin, which causes birth defects for the ears, heart, mouth, and other problems. Some Vitamin A products contain 25,000 International Units so taking 1 a day is almost 3 times as much as the upper limit.

We are happy for moms to contact us at mothertobaby.utah.gov and ask about any vitamins and minerals that they have questions about.

Links to websites or resources: See the fact sheet about herbals at https://mothertobaby.org/fact-sheets/herbal-products-pregnancy/ .

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How can physical activity help manage my diabetes, what can i do to reach or maintain a healthy weight, should i quit smoking, how can i take care of my mental health, clinical trials for healthy living with diabetes.

Healthy living is a way to manage diabetes . To have a healthy lifestyle, take steps now to plan healthy meals and snacks, do physical activities, get enough sleep, and quit smoking or using tobacco products.

Healthy living may help keep your body’s blood pressure , cholesterol , and blood glucose level, also called blood sugar level, in the range your primary health care professional recommends. Your primary health care professional may be a doctor, a physician assistant, or a nurse practitioner. Healthy living may also help prevent or delay health problems  from diabetes that can affect your heart, kidneys, eyes, brain, and other parts of your body.

Making lifestyle changes can be hard, but starting with small changes and building from there may benefit your health. You may want to get help from family, loved ones, friends, and other trusted people in your community. You can also get information from your health care professionals.

What you choose to eat, how much you eat, and when you eat are parts of a meal plan. Having healthy foods and drinks can help keep your blood glucose, blood pressure, and cholesterol levels in the ranges your health care professional recommends. If you have overweight or obesity, a healthy meal plan—along with regular physical activity, getting enough sleep, and other healthy behaviors—may help you reach and maintain a healthy weight. In some cases, health care professionals may also recommend diabetes medicines that may help you lose weight, or weight-loss surgery, also called metabolic and bariatric surgery.

Choose healthy foods and drinks

There is no right or wrong way to choose healthy foods and drinks that may help manage your diabetes. Healthy meal plans for people who have diabetes may include

• dairy or plant-based dairy products
• nonstarchy vegetables
• protein foods
• whole grains

Try to choose foods that include nutrients such as vitamins, calcium , fiber , and healthy fats . Also try to choose drinks with little or no added sugar , such as tap or bottled water, low-fat or non-fat milk, and unsweetened tea, coffee, or sparkling water.

Try to plan meals and snacks that have fewer

• foods high in saturated fat
• foods high in sodium, a mineral found in salt
• sugary foods , such as cookies and cakes, and sweet drinks, such as soda, juice, flavored coffee, and sports drinks

Your body turns carbohydrates , or carbs, from food into glucose, which can raise your blood glucose level. Some fruits, beans, and starchy vegetables—such as potatoes and corn—have more carbs than other foods. Keep carbs in mind when planning your meals.

You should also limit how much alcohol you drink. If you take insulin  or certain diabetes medicines , drinking alcohol can make your blood glucose level drop too low, which is called hypoglycemia . If you do drink alcohol, be sure to eat food when you drink and remember to check your blood glucose level after drinking. Talk with your health care team about your alcohol-drinking habits.

Find the best times to eat or drink

Talk with your health care professional or health care team about when you should eat or drink. The best time to have meals and snacks may depend on

• what medicines you take for diabetes
• what your level of physical activity or your work schedule is
• whether you have other health conditions or diseases

Ask your health care team if you should eat before, during, or after physical activity. Some diabetes medicines, such as sulfonylureas  or insulin, may make your blood glucose level drop too low during exercise or if you skip or delay a meal.

Plan how much to eat or drink

You may worry that having diabetes means giving up foods and drinks you enjoy. The good news is you can still have your favorite foods and drinks, but you might need to have them in smaller portions  or enjoy them less often.

For people who have diabetes, carb counting and the plate method are two common ways to plan how much to eat or drink. Talk with your health care professional or health care team to find a method that works for you.

Carb counting

Carbohydrate counting , or carb counting, means planning and keeping track of the amount of carbs you eat and drink in each meal or snack. Not all people with diabetes need to count carbs. However, if you take insulin, counting carbs can help you know how much insulin to take.

Plate method

The plate method helps you control portion sizes  without counting and measuring. This method divides a 9-inch plate into the following three sections to help you choose the types and amounts of foods to eat for each meal.

• Nonstarchy vegetables—such as leafy greens, peppers, carrots, or green beans—should make up half of your plate.
• Carb foods that are high in fiber—such as brown rice, whole grains, beans, or fruits—should make up one-quarter of your plate.
• Protein foods—such as lean meats, fish, dairy, or tofu or other soy products—should make up one quarter of your plate.

If you are not taking insulin, you may not need to count carbs when using the plate method.

Work with your health care team to create a meal plan that works for you. You may want to have a diabetes educator  or a registered dietitian  on your team. A registered dietitian can provide medical nutrition therapy , which includes counseling to help you create and follow a meal plan. Your health care team may be able to recommend other resources, such as a healthy lifestyle coach, to help you with making changes. Ask your health care team or your insurance company if your benefits include medical nutrition therapy or other diabetes care resources.

Talk with your health care professional before taking dietary supplements

There is no clear proof that specific foods, herbs, spices, or dietary supplements —such as vitamins or minerals—can help manage diabetes. Your health care professional may ask you to take vitamins or minerals if you can’t get enough from foods. Talk with your health care professional before you take any supplements, because some may cause side effects or affect how well your diabetes medicines work.

Research shows that regular physical activity helps people manage their diabetes and stay healthy. Benefits of physical activity may include

• lower blood glucose, blood pressure, and cholesterol levels
• better heart health
• healthier weight
• better mood and sleep
• better balance and memory

Talk with your health care professional before starting a new physical activity or changing how much physical activity you do. They may suggest types of activities based on your ability, schedule, meal plan, interests, and diabetes medicines. Your health care professional may also tell you the best times of day to be active or what to do if your blood glucose level goes out of the range recommended for you.

Do different types of physical activity

People with diabetes can be active, even if they take insulin or use technology such as insulin pumps .

Try to do different kinds of activities . While being more active may have more health benefits, any physical activity is better than none. Start slowly with activities you enjoy. You may be able to change your level of effort and try other activities over time. Having a friend or family member join you may help you stick to your routine.

The physical activities you do may need to be different if you are age 65 or older , are pregnant , or have a disability or health condition . Physical activities may also need to be different for children and teens . Ask your health care professional or health care team about activities that are safe for you.

Aerobic activities

Aerobic activities make you breathe harder and make your heart beat faster. You can try walking, dancing, wheelchair rolling, or swimming. Most adults should try to get at least 150 minutes of moderate-intensity physical activity each week. Aim to do 30 minutes a day on most days of the week. You don’t have to do all 30 minutes at one time. You can break up physical activity into small amounts during your day and still get the benefit. 1

Strength training or resistance training

Strength training or resistance training may make your muscles and bones stronger. You can try lifting weights or doing other exercises such as wall pushups or arm raises. Try to do this kind of training two times a week. 1

Balance and stretching activities

Balance and stretching activities may help you move better and have stronger muscles and bones. You may want to try standing on one leg or stretching your legs when sitting on the floor. Try to do these kinds of activities two or three times a week. 1

Some activities that need balance may be unsafe for people with nerve damage or vision problems caused by diabetes. Ask your health care professional or health care team about activities that are safe for you.

Stay safe during physical activity

Staying safe during physical activity is important. Here are some tips to keep in mind.

Drink liquids

Drinking liquids helps prevent dehydration , or the loss of too much water in your body. Drinking water is a way to stay hydrated. Sports drinks often have a lot of sugar and calories , and you don’t need them for most moderate physical activities.

Avoid low blood glucose

Check your blood glucose level before, during, and right after physical activity. Physical activity often lowers the level of glucose in your blood. Low blood glucose levels may last for hours or days after physical activity. You are most likely to have low blood glucose if you take insulin or some other diabetes medicines, such as sulfonylureas.

Ask your health care professional if you should take less insulin or eat carbs before, during, or after physical activity. Low blood glucose can be a serious medical emergency that must be treated right away. Take steps to protect yourself. You can learn how to treat low blood glucose , let other people know what to do if you need help, and use a medical alert bracelet.

Avoid high blood glucose and ketoacidosis

Taking less insulin before physical activity may help prevent low blood glucose, but it may also make you more likely to have high blood glucose. If your body does not have enough insulin, it can’t use glucose as a source of energy and will use fat instead. When your body uses fat for energy, your body makes chemicals called ketones .

High levels of ketones in your blood can lead to a condition called diabetic ketoacidosis (DKA) . DKA is a medical emergency that should be treated right away. DKA is most common in people with type 1 diabetes . Occasionally, DKA may affect people with type 2 diabetes  who have lost their ability to produce insulin. Ask your health care professional how much insulin you should take before physical activity, whether you need to test your urine for ketones, and what level of ketones is dangerous for you.

Take care of your feet

People with diabetes may have problems with their feet because high blood glucose levels can damage blood vessels and nerves. To help prevent foot problems, wear comfortable and supportive shoes and take care of your feet  before, during, and after physical activity.

If you have diabetes, managing your weight  may bring you several health benefits. Ask your health care professional or health care team if you are at a healthy weight  or if you should try to lose weight.

If you are an adult with overweight or obesity, work with your health care team to create a weight-loss plan. Losing 5% to 7% of your current weight may help you prevent or improve some health problems  and manage your blood glucose, cholesterol, and blood pressure levels. 2 If you are worried about your child’s weight  and they have diabetes, talk with their health care professional before your child starts a new weight-loss plan.

You may be able to reach and maintain a healthy weight by

• following a healthy meal plan
• consuming fewer calories
• being physically active
• getting 7 to 8 hours of sleep each night 3

If you have type 2 diabetes, your health care professional may recommend diabetes medicines that may help you lose weight.

Online tools such as the Body Weight Planner  may help you create eating and physical activity plans. You may want to talk with your health care professional about other options for managing your weight, including joining a weight-loss program  that can provide helpful information, support, and behavioral or lifestyle counseling. These options may have a cost, so make sure to check the details of the programs.

Your health care professional may recommend weight-loss surgery  if you aren’t able to reach a healthy weight with meal planning, physical activity, and taking diabetes medicines that help with weight loss.

If you are pregnant , trying to lose weight may not be healthy. However, you should ask your health care professional whether it makes sense to monitor or limit your weight gain during pregnancy.

Both diabetes and smoking —including using tobacco products and e-cigarettes—cause your blood vessels to narrow. Both diabetes and smoking increase your risk of having a heart attack or stroke , nerve damage , kidney disease , eye disease , or amputation . Secondhand smoke can also affect the health of your family or others who live with you.

If you smoke or use other tobacco products, stop. Ask for help . You don’t have to do it alone.

Feeling stressed, sad, or angry can be common for people with diabetes. Managing diabetes or learning to cope with new information about your health can be hard. People with chronic illnesses such as diabetes may develop anxiety or other mental health conditions .

Learn healthy ways to lower your stress , and ask for help from your health care team or a mental health professional. While it may be uncomfortable to talk about your feelings, finding a health care professional whom you trust and want to talk with may help you

• lower your feelings of stress, depression, or anxiety
• manage problems sleeping or remembering things
• see how diabetes affects your family, school, work, or financial situation

Ask your health care team for mental health resources for people with diabetes.

Sleeping too much or too little may raise your blood glucose levels. Your sleep habits may also affect your mental health and vice versa. People with diabetes and overweight or obesity can also have other health conditions that affect sleep, such as sleep apnea , which can raise your blood pressure and risk of heart disease.

NIDDK conducts and supports clinical trials in many diseases and conditions, including diabetes. The trials look to find new ways to prevent, detect, or treat disease and improve quality of life.

What are clinical trials for healthy living with diabetes?

Clinical trials—and other types of clinical studies —are part of medical research and involve people like you. When you volunteer to take part in a clinical study, you help health care professionals and researchers learn more about disease and improve health care for people in the future.

Researchers are studying many aspects of healthy living for people with diabetes, such as

• how changing when you eat may affect body weight and metabolism
• how less access to healthy foods may affect diabetes management, other health problems, and risk of dying
• whether low-carbohydrate meal plans can help lower blood glucose levels
• which diabetes medicines are more likely to help people lose weight

Find out if clinical trials are right for you .

Watch a video of NIDDK Director Dr. Griffin P. Rodgers explaining the importance of participating in clinical trials.

What clinical trials for healthy living with diabetes are looking for participants?

You can view a filtered list of clinical studies on healthy living with diabetes that are federally funded, open, and recruiting at www.ClinicalTrials.gov . You can expand or narrow the list to include clinical studies from industry, universities, and individuals; however, the National Institutes of Health does not review these studies and cannot ensure they are safe for you. Always talk with your primary health care professional before you participate in a clinical study.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by NIDDK is carefully reviewed by NIDDK scientists and other experts.

NIDDK would like to thank: Elizabeth M. Venditti, Ph.D., University of Pittsburgh School of Medicine.

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