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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.

Definitions

• 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.

Risk Factors

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
• Primiparity

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

Presentation

• 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.

Investigations

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.

Malpresentation

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

Malposition

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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Fetal Presentation: Baby’s First Pose

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Occiput Anterior

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.

Breech Presentation

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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What Is a Transverse Baby?

Although rare, a baby can be in a transverse lie position in the third trimester. Here's what that means and how it impacts delivery.

What Does Transverse Lie Mean?

What are the causes of a transverse lie position, what are the possible risks and complications, how can the transverse lie position affect pregnancy, what about delivery, can you turn a transverse baby.

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During pregnancy, the fetus moves around into different fetal positions , but most end up in the optimal head down, face down (cephalic occiput anterior) position in the last few weeks. When the fetus doesn’t move into the cephalic position for birth, it’s called fetal malpresentation.

One of the rarest positions is the transverse lie, where the fetus lies horizontally, often with one shoulder down or pressing against the birth canal. If you have a transverse baby at term, the provider will intervene because a vaginal delivery is not possible.

Here’s all you need to know about transverse lie causes and how it may affect pregnancy and delivery.   

The transverse lie position is when the fetus lies across the pregnant person’s abdomen horizontally. Because the shoulder is often in the pelvic inlet, it is also sometimes called shoulder presentation. But the fetus can also have its back facing the birth canal or with feet and hands facing it.

The chances of the baby being in the sideways position at term are only around 1 in 300. But before term, at 32 weeks gestation, it’s as high as 1 in 50.

“Transverse lie is normal in the first trimester, common in the second, unusual in the third, and it’s not a position where vaginal birth is possible,” says Gail Tully, CPM, creator of Spinning Babies, a website which offers ways to ease a baby’s rotation through the pelvis based on its position. 

Often, a clear cause or risk factor for a transverse lie position is unknown. “But two of the most common risk factors for transverse lie at term include having extra amniotic fluid —often associated with diabetes but can be found on its own—and multiple gestation , such as twins or triplets,” says Layan Alrahmani, MD , maternal and fetal medicine specialist and assistant professor in obstetrics and gynecology at Loyola University Medical Center. 

Other possible risk factors for transverse lie include: 

• Multiparity (previous births may lead to lax abdominal muscles)
• Premature labor
• Low amniotic fluid
• Placenta previa (placenta is covering the pregnant person’s cervix)
• Pelvic, uterine, or fetal abnormalities (the latter is more common in primiparity, or first time births)

“Sometimes the baby is in the position for a reason,” says Karolyn Zambrotta, CNM , an obstetrics and gynecology specialist. “And after the doctor does the C-section you’ll find the problem, like a short or tight umbilical cord.” 

Transverse lie at term can be risky for both the pregnant person and baby. 

“The transverse lie is frequently found early in the pregnancy. But if the baby does not change position, then a vaginal delivery cannot occur and we have to plan differently,” says Carolina Bibbo, MD , maternal-fetal medicine specialist at Brigham and Women’s Hospital. “If the water were to break when the baby is in a transverse lie position, the cord could prolapse which is an obstetrical emergency.”  

Other possible complications include:

• Obstructed labor
• Uterine rupture
• Birth trauma
• Postpartum hemorrhage
• Birth defects 

Some pregnant people feel abdominal and back pain during pregnancy when the fetus is in the sideways position. This is related to the uterus being stretched in different ways and can cause tightening in the ribs and cramping lungs. If your health care provider approves, you can try deep breathing and gentle yoga exercises at home to help relieve pain and encourage the fetus to turn. 

If the health care provider still suspects the fetus is lying horizontal at 36 weeks, an ultrasound will be performed to confirm. Because a baby in the transverse lie position cannot be delivered vaginally, your providers will develop an alternate birth plan which can include a procedure called external cephalic version (ECV) to try and turn the fetus for vaginal delivery, or a C-section.

In the case of multiples, triplets are almost always delivered via C-section. But for twins, if the first is head down, the second may drop into the cephalic position for normal delivery having more room after the first one comes out. “You could also try ECV or internal podalic version (IPV) on the second twin if needed,” says Dr. Alrahmani. “It’s really case by case and depends on the provider’s experience and preference too.” 

After 34 weeks, it is very unlikely for a fetus in transverse lie to spontaneously change to the optimal head down position. But, in some cases, it is possible to turn a transverse baby.

Natural methods

If the fetus is not head down by 32 weeks, and there are no health concerns, midwives like Zambrotta might first recommend trying some natural techniques. As Dr. Bibbo notes, the data is limited for different approaches but yoga positions can help in some cases. 

Low-risk methods to encourage transverse babies to turn include sound or light (putting music or a bright light near the bottom of the uterus), temperature (placing something cold like frozen peas behind the head and something warm like a rice-filled sock at the bottom of the stomach), and Traditional Chinese Medicine (TCM) like moxibustion , which involves heating acupuncture points with a stick of mugwort.

Small studies have shown that the Webster technique, a gentle chiropractic approach that aligns the pelvis, can help correct fetal malpresentation. And the forward leaning inversion, also developed by a chiropractor, is the most effective position for transverse lie babies, according to Tully, who trains labor and delivery nurses on body balance techniques. 

Always speak with your health care professional before trying any methods to turn the fetus.

Intervention

If natural methods have not helped by 36 weeks, your provider will likely want to try an ECV in which they use their hands to put pressure on your belly to try and turn the fetus head down. This procedure should be done in a hospital setting to monitor the fetal heart rate, and for the rare case where an emergency C-section is needed. Possible complications include placental abruption, fetal heart rate abnormalities (FHR), premature rupture of the membranes , preterm labor, fetal distress, and vaginal bleeding. 

ECV may not be safe if you have placenta previa, a low amount of amniotic fluid, a significant uterine abnormality, vaginal bleeding, high blood pressure, multiples (before delivery of the first twin), or fetal distress.

“In general, the success rate for external cephalic version is 60% of babies,” explains Dr. Bibbo. “But there’s a greater chance for ECV to turn a fetus in transverse lie than in a breech position.”

A baby in the transverse lie position cannot fit through the pregnant person’s pelvis. If gentle exercises, chiropractic techniques, or other natural methods don’t help your baby turn by 36 weeks, you may be a candidate for ECV to move the baby into the optimal head down position for birth. But if ECV doesn’t work, then the health care provider will schedule a C-section.

Whatever ends up being needed to ensure the safety of both parent and fetus, it's always important to ask any questions you may have. That includes information on postpartum recovery should you need a C-section.

Chapter 26: Transverse Lie . Oxorn-Foote Human Labor & Birth, 7e . 2023.

Effectiveness and Safety of Acupuncture and Moxibustion in Pregnant Women with Noncephalic Presentation: An Overview of Systematic Reviews . Evidence-Based Complementary and Alternative Medicine . 2019.

The Webster Technique: a chiropractic technique with obstetric implications . J Manipulative Physiol Ther . 2002.

External Cephalic Version . StatPearls. 2022.

External Cephalic Version . Obstetrics: Normal and Problem Pregnancies (Seventh Edition) , 2017.

External Cephalic Version: A Dying Art Worth Reviving . J Obstet Gynaecol India . 2018.

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• Nursing Article

4 Key Steps of the Leopold Maneuver for Accurate Fetal Positioning

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

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

Table of Contents

Definition of the Leopold Maneuver

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

History of the Leopold Maneuver

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

Importance of Leopold Maneuver in Obstetrics

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

Purpose and Benefits of the Leopold Maneuver

Assessment of fetal presentation.

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

Estimating Fetal Weight

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

Identifying Fetal Lie and Attitude

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

Step-by-Step Guide on Performing the Leopold Maneuver

Preparing the Patient for the Examination

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

Step 1: Identification of the Fundus

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

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

Step 2: Identification of the Fetal Back

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

Your Findings Should Be Recorded as,

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

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

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

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

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

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

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

Not engaged: Movable mass is felt

Engaged : Fixed mass is felt

Importance of the Leopold Maneuver in Prenatal Care

Identification of abnormal fetal presentation.

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

Assessment of Fetal Growth and Development

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

Identification of Multiple Gestations

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

Common Issues and Solutions During the Leopold Maneuver

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

Difficulty in Assessing the Fetal Presentation

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

Difficulties in Identifying the Fetal Parts

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

Confounding Factors that May Affect the Examination

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

The Role of the Leopold Maneuver in Diagnosing Fetal Position

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

Importance of Diagnosing Fetal Position

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

Accuracy of Leopold Maneuver in Diagnosing Fetal Position

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

Limitations of the Leopold Maneuver in Diagnosing Fetal Position

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

Complications

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

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

Nurse’s Responsibilities

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

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

What is the Leopold Maneuver?

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

How is the Leopold Maneuver performed?

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

What is the purpose of the Leopold Maneuver?

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

Can the Leopold Maneuver be performed at home?

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

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

Variations in fetal presentations include face, brow, breech, and shoulder. Occiput posterior position (facing forward, toward the mother's pubic bone) is less common than occiput anterior position (facing backward, toward the mother's spine).

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What Is Fetal Station?

Dorling Kindersley / Getty Images

Fetal station is something your doctor may check as your pregnancy delivery date nears. The fetal station is a measurement of how far the baby has descended in the pelvis, measured by the relationship of the fetal head to the ischial spines (sit bones). The ischial spines are approximately 3 to 4 centimeters inside the vagina and are used as the reference point for the station score.

Station is a measurement of fetal descent in labor and is measured using vaginal exams . It usually isn't measured until the last few weeks of pregnancy or you may not hear it discussed until you are in labor.

Why It’s Important

The station number is one of the signs of progression in labor. When labor begins, some women will have a baby who is fairly high in the pelvis with a station of -2. Other women start labor with a baby that is engaged at a 0 station, or lower. In the case of fetal station, lower in the pelvis (and closer to the vaginal opening) means a positive number.

You might hear someone say the baby is coming down, which is a positive change in station of your baby. The station of your baby really starts to change once you are pushing.

Measurement of fetal station is important when a forceps delivery is being considered. The baby must have progressed to an appropriate station for forceps delivery, as defined by the American College of Obstetricians and Gynecologists.

How It's Determined

The measurement of fetal station by a vaginal exam is somewhat subjective and there can be variation between practitioners. The doctor feels for the baby's head and determines where it is relative to the ischial spines. Ultrasound might also be used to help determine the fetal station.

The difference between numbers in the score is equivalent to the length in centimeters. Moving from +1 to +2 is a movement of about 1 centimeter.

Fetal Station Numbers

Fetal station is stated in negative and positive numbers.

• -5 station is a floating baby
• -3 station is when the head is above the pelvis
• 0 station is when the head is at the bottom of the pelvis, also known as being fully engaged 
• +3 station is within the birth canal
• +5 station is crowning

Fetal Station and Bishop Score

Fetal station is also one of the five components of the Bishop score, which used to evaluate the cervix's readiness for labor and to predict whether you will need to have labor induced. The other factors in the score are also determined by the vaginal examination. They include cervical dilation , cervical effacement , cervical consistency, and cervical position .

A Bishop score of 10 (out of a possible 13) or more indicates the cervix is ripe and you are likely to have spontaneous labor and delivery. A score of 8 or more indicates you are a good candidate for induction, while a score of under 6 indicates you are less likely to go into labor soon and induction is less favorable. A score of 3 or less denotes a cervix that is unfavorable for an induction unless a cervical ripening agent is used.

A commonly used modified Bishop score uses just station, dilation, and effacement instead. With this more simplified scoring system, a score of 5 or more (out of 9) indicates cervical ripeness. Preference of the doctor, the specifics of your pregnancy and medical history, and other factors will determine which scoring method is used.

A Word From Verywell

Fetal station is just one of the factors that indicate progress in childbirth. It always helps to have more information and understand the terminology of labor, but know that every delivery is different and that your baby's station can shift quickly. If you have questions or concerns, ask your doctor or midwife.

National Collaborating Centre for Women's and Children's Health (UK). Induction of Labour . London: RCOG Press; 2008 Jul. (NICE Clinical Guidelines, No. 70.) Appendix B, Bishop score.

American College of Obstetricians and Gynecologists. Assisted vaginal delivery .

Wormer KC, Bauer A, Williford AE. Bishop Score. StatPearl.

Takeda S, Takeda J, Koshiishi T, Makino S, Kinoshita K. Fetal station based on the trapezoidal plane and assessment of head descent during instrumental delivery. Hypertension Research in Pregnancy . 2014;2(2):65-71. doi:10.14390/jsshp.2.65.

By Robin Elise Weiss, PhD, MPH Robin Elise Weiss, PhD, MPH is a professor, author, childbirth and postpartum educator, certified doula, and lactation counselor.

Labour and Delivery Care Module: 9. Obstructed Labour

Study session 9.  obstructed labour, introduction.

Obstructed labour is a totally preventable labour complication. One of your major roles as a skilled birth attendant is to prevent the occurrence of obstructed labour in women in your community. It is highly prevalent in the rural areas of Ethiopia, particularly among women who are in labour at home for a long time.

Obstructed labour is associated with a high perinatal mortality and morbidity (fetal and newborn deaths, and disease and disability occurring around the time of the birth). It contributes to 22% of the maternal mortality in Ethiopia. This shocking figure is certainly an underestimation of the problem, because deaths due to obstructed labour are often classified under other complications (such as sepsis, postpartum haemorrhage or ruptured uterus).

In this session, you will learn how to identify the clinical signs of prolonged and obstructed labours and determine the best management. Delayed management of obstructed labour often causes fistula in surviving women, which if not treated, may make them outcasts from their community for the rest of their lives.

Learning Outcomes for Study Session 9

When you have studied this session, you should be able to:

9.1 Define and use correctly all of the key words printed in bold . (SAQs 9.2 and 9.3)

9.2 List the main causes of obstructed labour and describe how each factor contributes to the development of this complication. (SAQ 9.1)

9.3 Describe the clinical signs of obstructed labour and the common maternal and fetal complications that result from uterine obstruction. (SAQ 9.3)

9.4 Describe the management of obstructed labour and ways of preventing it through your actions. (SAQ 9.3)

9.5 Explain how social changes at community level could affect the risk of obstructed labour occurring. (SAQ 9.4)

9.1  Defining obstructed labour

Obstructed labour is the failure of the fetus to descend through the birth canal, because there is an impossible barrier (obstruction) preventing its descent despite strong uterine contractions. The obstruction usually occurs at the pelvic brim, but occasionally it may occur in the pelvic cavity or at the outlet of the pelvis. When labour is prolonged because of failure to progress, there is a high risk that the descent of the fetus will become obstructed. There is no single definition of prolonged labour , because what counts as ‘too long’ varies with the stage of labour (see Box 9.1).

Box 9.1  When is labour classed as prolonged in the different stages of labour?

• Prolonged latent phase of labour : when true labour lasts for more than about 8 hours without entering into the active first stage.
• Prolonged active phase of labour : when true labour takes more than about 12 hours without entering into the second stage.
• Multigravida mother: when it lasts for more than 1 hour.
• Primigravida mother: when it lasts for more than 2 hours.

Although labour can be classed as ‘prolonged’ at any stage, you should note that obstructed labour most commonly develops after the labour has entered into the second stage.

9.2  Causes of obstructed labour

As indicated above, obstructed labour is generally a second stage phenomenon, in women whose labour is prolonged. Why labour becomes prolonged or obstructed may be due to one of the ‘Ps’ (as midwives and obstetricians call them): ‘powers’, ‘passenger’ and ‘passage’.

• Powers : Inadequate power, due to poor or uncoordinated uterine contractions, is a major cause of prolonged labour. Either the uterine contractions are not strong enough to efface and dilate the cervix in the first stage of labour, or the muscular effort of the uterus is insufficient to push the baby down the birth canal during the second stage.
• Passenger: The fetus is the ‘passenger’ travelling down the birth canal. Prolonged labour may occur if the fetal head is too large to pass through the mother’s pelvis, or the fetal presentation is abnormal.
• Passage: The birth canal is the passage, so labour may be prolonged if the mother’s pelvis is too small for the baby to pass through or the pelvis has an abnormal shape, or if there is a tumour or other physical obstruction in the pelvis.

Table 9.1 summarises the mechanical causes of ‘passenger’ and ‘passage’ failure.

The mechanical causes of prolonged and obstructed labour shown in Table 9.1 can be grouped into various categories: cephalopelvic disproportion; malpresentations and malpositions; or an abnormality in the fetus or the mother which obstructs the birth canal. We will look at each of these in turn in more detail.

9.2.1  Cephalopelvic disproportion (CPD)

Cephalic (pronounced ‘seff-ah-lik’) is from a Greek word meaning ‘the head’. Disproportion tells you that the size of the fetal head is different from the size of the mother’s pelvic brim.

C ephalopelvic disproportion (CPD) means it is difficult or impossible for the fetus to pass safely through the mother’s pelvis due either to a maternal pelvis that is too narrow for that fetal head, or a large fetal head relative to that mother’s pelvis (see Figure 9.1, and think back to the anatomy of the maternal pelvis and fetal skull which you learned in Study Session 6 of the Antenatal Care Module). The small (or contracted) pelvis in developing countries like Ethiopia is generally due to malnutrition in childhood persisting into adult life. Cephalopelvic disproportion cannot usually be diagnosed before the 37th week of pregnancy because before then the baby’s head has not reached birth size.

9.2.2  Abnormal presentations and multiple pregnancies

Persistent malpresentation or malposition are other major causes of obstructed labour.

Can you distinguish between these two terms and recall some abnormal fetal presentations and malpositions from Study Session 8?

Malpresentation is any presentation other than vertex (the top of the baby’s skull is the presenting part). The most common malpresentations are breech (the baby’s buttocks and/or its feet present first), and shoulder when it engages ‘shoulder first’. Malposition is when the baby is ‘head down’ (cephalic presentation), but the vertex is in the wrong position relative to the mother’s pelvis. Two of the most common malpositions result in face and brow presentations.

You also learned about multiple pregnancies in Study Session 8. Labour can be obstructed by locked twins (the two babies are ‘locked’ together at their necks when the first twin is in breech presentation and the second twin is in cephalic presentation), or conjoined twins (twins fused at the chest, head or any other site).

9.2.3 Fetal abnormalities

Some fetal abnormalities result in a fetus with an abnormally large head diameter, for example, hydrocephalus, which is due to excessive accumulation of fluid around the baby’s brain.

9.2.4  Abnormalities of the reproductive tract

A possible cause of obstructed labour is if the mother has a tumour (growth or swelling of tissue) in her pelvic cavity, or a scarred birth canal due to a severe type of female genital mutilation (‘female circumcision’). Or she may have a tight perineum (the area between the vulva and the anus), which does not stretch in order to allow the baby to pass through.

Female genital mutilation is the subject of Study Session 5 in the Module on Adolescent and Youth Reproductive Health .

9.3  Clinical signs of obstructed labour

A key sign of an obstructed labour is if the widest diameter of the fetal skull remains stationary above the pelvic brim because it is unable to descend. You should be able to detect this by careful palpation of the mother’s abdomen as the uterus relaxes and softens between contractions. However, if the uterus has gone into tonic contraction (it is continuously hard) and sits tightly moulded around the fetus, it will be very difficult to feel whether the fetus is making any progress in the birth canal. Palpation will also be very painful for the woman . In this case you will have to rely more on other signs for your diagnosis, listed below.

9.3.1  Assessment of clinical signs of obstruction

Obstructed labour is more likely to occur if:

• The labour has been prolonged (lasting more than 12 hours)
• The mother appears exhausted, anxious and weak
• Rupture of the fetal membranes and passing of amniotic fluid was premature (several hours before labour began)
• The mother has abnormal vital signs: fast pulse rate, above 100 beats/minute; low blood pressure; respiration rate above 30 breaths/minute; possibly also a raised temperature.

You should assess a woman with this labour history b y doing a vaginal examination. Any of the following additional signs would suggest the presence of obstruction:

• Foul-smelling meconium draining from the mother’s vagina.
• Concentrated urine, which may contain meconium or blood.
• Oedema (swelling due to collection of fluid in the tissues) of the vulva (female external genitalia, including the labias), especially if the woman has been pushing for a long time. Vagina feels hot and dry to your gloved examining finger because of dehydration.
• Oedema of the cervix.
• A large swelling over the fetal skull can be felt ( caput , Study Session 4).
• Malpresentation or malposition of the fetus.
• Poor cervical effacement (look back at Figure 1.1 in the first study session); as the result the cervix feels like an ‘empty sleeve’.
• Bandl’s ring may be seen ( Figure 9.2 ).

9.3.2  Bandl’s ring

Bandl’s ring is the name given to the depression between the upper and lower halves of the uterus, at about the level of the umbilicus. It should not be seen or felt on abdominal examination during a normal labour (Figure 9.2a), but when it becomes visible and/or palpable (Figure 9.2b) Bandl’s ring is a late sign of obstructed labour. Above this ring is the grossly thickened, upper uterine segment which is pulled upwards (retracted) towards the mother’s ribs. Below the Bandl’s ring is the distended (swollen), dangerously thinned, lower uterine segment. The lower abdomen can be further distended by a full bladder and gas in the intestines.

9.3.3  Evidence from the partograph

You will remember from Study Session 4 that the partograph is a key tool in detecting an abnormal or prolonged labour. Obstructed labour is revealed by recordings on the partograph of the rate of cervical dilatation (which, as you know, should progress at a rate of at least 1 cm per hour) and the rate of fetal he ad descent. Figure 9.3(a) shows a partograph record of a normal labour with progressive cervical dilatation and fetal head descent. However in Figure 9.3(b) you can quickly see that there is evidence of a prolonged first or second stage of labour because:

• the cervical dilatation measurement has crossed the ‘Alert line’ and if no action is taken it will cross the Action line, despite strong uterine contractions; the fetal head is not descending.

In Figure 9.3(b), how many hours after recordings began on the partograph did cervical dilation stop progressing?

The cervix stopped dilating 4 hours after the partograph record began.

In the partograph shown in Figure 9.3(b), how much time has passed since there was any sign of cervical dilatation?

The partograph shows that there was no increase in cervical diameter for the previous two and a half hours.

9.4  Management of obstructed labour

There are several things that you can do to try to relieve the obstruction if the record of cervical dilatation reaches the Alert line on the partograph, and before it approaches the Action line. The details of these procedures were taught in the Antenatal Care Module (Study Session 22) and your practical skills training, so we will only refer briefly to them here.

• If the woman has signs of shock (fast pulse and low blood pressure), prepare to give her an intravenous infusion of N ormal Saline or Ringer’s L actate to rehydrate her. Use a large (No. 18 or 20) cannula. Infuse her with 1 litre of fluids, with the flow rate running as quickly as possible, then repeat 1 litre every 20 minutes until her pulse slows to less than 90 beats per minute, and her diastolic blood pressure (when the heart relaxes after a beat) is 90 mmHg or higher.
• If you think the obstruction may be due to a very full bladder, prepare to drain it by inserting a catheter. Clean the perineal area and catheteri s e the mother’s bladder to drain the urine into a closed container. Relieving this obstruction may be enough to allow the baby to be born. Note that catheteri s ation of the bladder in a woman with obstructed labour is usually very difficult, because the urethra is also obstructed by the deeply engaged baby’s head.

9.5  Complications resulting from obstructed labour

The complications of uterine obstruction for the mother and for the fetus or newborn can be very serious. Remember that uterine obstructions happen mainly because of a prolonged labour at home that was not well managed and which was not referred quickly enough. The commonest complication affecting the mother is the formation of a fistula.

9.5.1  Fistula

Fistula is an abnormal opening (usually as a result of ruptured tissues) between the:

• Vagina and the urinary bladder
• Vagina and rectum
• Vagina and urethra (the tube bringing urine from the bladder to the opening in the vulva)
• Vagina and ureter (the tube bringing urine from each kidney to the bladder).

As a result of the fistula, urine or faeces get into the vagina and exit in an uncontrolled way. A woman with a fistual can leak urine or faeces while walking, or doing any daily activities, and the waste stains her clothes and creates a bad smell (Figure 9.5). Because of these effects, her husband and family may stigmatise her or make her an outcast. You can also imagine what continuously leaking urine or faeces means at a personal level. Other consequences of fistula may include constant depression, and many physical illnesses and infections of the reproductive tract, bladder and kidneys, which may even result in the woman taking her own life.

Obstructed labour is responsible for about 20% of all cases of fistula formation (see the research study reported in Figure 9.6).

Other rare causes of fistula are congenital malformation (abnormal communication, usually between the rectum and vagina, found at birth), infection (specifically tuberculosis), trauma, forceful sexual intercourse (rape), and early age sexual intercourse.

9.5.2  Other common complications of obstructed labour

To summarise briefly, unless it is well managed, obstructed labour can also lead to the following complications in the mother:

• Postpartum haemorrhage (you will learn about this in Study Session 11 in this Module)
• Slow return of the uterus to its pre-pregnancy size
• Shock (low blood pressure and fast pulse rate)
• The small intestine becomes paralyzed and stops movement (paralytic ileus)
• Sepsis (widespread infection throughout the body)

Complications of obstructed labour for the newborn can include:

You will learn in detail about complications affecting the newborn in the Modules on Postnatal Care and Integrated Management of Newborn and Childhood Illness

• Neonatal sepsis
• Convulsions (fits)
• Facial injury
• Severe asphyxia (life-threatening lack of oxygen)

9.6  Prevention of obstructed labour

There are several things that a skilled birth attendant can do to prevent a prolonged labour from becoming obstructed. Additionally, certain cultural changes would also make a significant difference to the circumstances that increase the risk of obstructed labour. We now look briefly at these factors.

9.6.1  Skilled birth attendance

As we said at the beginning, obstructed labour is a major cause of maternal death worldwide, and especially in developing countries like Ethiopia. The most important intervention that could prevent this toll of death and disability is having the services of a skilled attendant at the birth. So a really important part of your role as a rural health worker is to teach the people in your community (men as well as women) about the importance of getting skilled care at every delivery. Encourage the women to come to you for advice and maintain close links with the health centres or hospital (if there is one) in your area to facilitate quick and efficient referral in cases of emergency.

9.6.2  Using the partograph

The best diagnostic tool for identifying prolonged labour is to plot the stages of labour on the partograph, at the same time as regularly assessing fetal and maternal condition (see also Study Session 4). The partograph record will give you an early warning if labour may be prolonged to the point where an obstructed uterus seems likely and referral is essential. So always remember to use it when attending any delivery.

What are the two things you must do to minimise the chances of a woman who is in labour developing a fistula?

The two things you should do are:

• Closely monitor the progress of labour using the partograph to check that the record of cervical dilatation stays on or to the left of the Alert line.
• Urgently refer the mother to a health facility if she has an obstruction (the record of cervical dilatation is approaching the Action line on the partograph), with pre-referral IV fluid infusion or bladder catheteri s ation if appropriate.

9.6.3  Birth preparedeness and complication readiness

As you learned in the Antenatal Care Module (Study Session 13), birth preparedness and complication readiness are the pillars of safer labour and delivery. So assist your community to organise themselves into birth preparedness teams, which have the leadership, knowledge, funding and transport to transfer mothers to the nearest health facility if there is an emergency such as obstructed labour.

9.6.4  Nutritional education

It is also important to intervene in the underlying factors that increase the risk of obstructed labour. As we said earlier, a major cause of obstructed labour is a small pelvis, which is mostly the result of poor nutrition during childhood persisting into adult life. Thus it is important to improve childhood nutrition through health education, especially for girls, to reduce the risk of prolonged and obstructed labour in later life.

9.6.5  Delaying early marriage

Early marriage is the subject of a study session in the Module on Adolescent and Youth Reproductive Health.

Another issue is early marriage. Researches in Ethiopia have shown that 50% of women, especially rural women, get married on average at around 16 years, and most of them rapidly become pregnant. This group of very young mothers is at especially high risk of obstructed labour because the pelvis has not grown sufficiently to accommodate the baby’s head. In your discussions with women, their partners and community leaders you can point out these risks of early marriage, and try to persuade them of the importance of delaying the first birth until after the woman is 18. As part of this, you will need to promote contraception (family planning methods) as a way of delaying the first pregnancy among these very young women. If unwanted pregnancy occurs, it is also important to counsel about safe abortion services (as described in the Antenatal Care Module, Part 2, Study Session 20).

Summary of Study Session 9

In Study Session 9 you have learned that:

• Obstructed labour is failure of descent of the fetus through the birth canal (pelvis) because there is an impossible barrier (obstruction) preventing its descent in spite of strong uterine contractions.
• Causes of obstructed labour are c ephalopelvic disproportion (CPD), abnormal presentations, fetal abnormalities and abnormalities of the maternal reproductive tract.
• Causes of prolonged labour are abnormali ty in one or more of the three ‘P s ’ : p ower, p assenger and p assage.
• The best diagnostic tool for you to identify prolonged labour is the partograph.
• The clinical features of obstructed labour include mother stay in labour for more than 12 hours, exhausted and unable to support herself, deranged vital signs, dehydrated, Bandl’s ring formation in the abdomen, bladder f ull above the symphysis pubis, big caput and big moulding, may be edematous vaginal opening.
• Common maternal complications of obstructed labour include sepsis, paralytic ileus, postpartum haemorrhage, fistula formation.
• Common fetal complications of obstructed labour are severe asphyxia, neonatal sepsis and death.
• Early referral can save the life of the woman and the baby in case of obstructed labour.

Self-Assessment Questions (SAQs) for Study Session 9

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 9.1 (tests Learning Outcome 9.2)

Write down what you understand by the three ‘Ps’ and how they cause obstructed labour.

The three ‘Ps’ (powers, passenger and passage) are a shorthand way of describing the main causes of obstructed labour. After you have checked your answers with ours (below), re-read Section 9.2 for more detail about the causes.

• Powers refers to the strength of the uterine contractions – too weak or uncoordinated and the baby is not pushed down the birth canal.
• Passenger refers to the baby – if the head is too big or deformed, or if the position or presentation is wrong, the baby will not be able to pass down the birth canal.
• Passage refers to the birth canal – if it is too small or deformed, or has blockages from tumours or scars, the baby will not be able to pass smoothly.

SAQ 9.2 (tests Learning Outcome 9.1)

Write down what you understand by the following terms:

• a. Perinatal mortality and morbidity
• b. Prolonged latent phase of labour
• c. Prolonged second stage of labour
• d. Malposition
• a. Perinatal mortality and morbidity - fetal and newborn deaths, and disease and disability occurring around the time of the birth.
• b. Prolonged latent phase of labour - when true labour lasts for more than about 8 hours without entering into the active first stage.
• c. Prolonged second stage of labour - when it lasts for more than 1 hour (for multigravida mothers) and more than 2 hours (primigravida mothers).
• d. Malposition - when the baby is ‘head down’ but the vertex (the top of the baby’s skull) is in the wrong position relative to the mother’s pelvis.
• e. Caput - a large central swelling on the fetal skull.
• f. Fistula — an abnormal opening (usually resulting from a tear) between the vagina and the urinary bladder (or the rectum or urethra or ureter).

Read Case Study 9.3 and then answer the questions that follow it.

Case Study 9.1  Tadelech’s story

Tadelech lives in Mekit Woreda. The journey from village to city can take days, and she lives far from even a health post. Tadelech is 25 years old and has already delivered two children safely in the village. This is her third pregnancy. Contractions started at 40 weeks of gestation. After two days of labour Tadelech is carried on a home-made stretcher to your health post. When you examine Tadelech, finds two swellings (masses) over the abdomen, with a depression between them at about the level of the woman’s umbilicus (belly button). You also find that the baby’s head is not engaged (it is just above the pelvic brim). On vaginal examination, you estimate that Tadelech’s cervix is 8 cm dilated and the station of the fetal head is –3. Tadelech’s vagina is hot and dry and she has oedema of the vulva.

SAQ 9.3 (tests Learning Outcomes 9.1, 9.3 and 9.4)

• a. From the case study what signs do you find that indicate prolonged or obstructed labour?
• b. How do you manage Tadelech’s condition?
• It is clear that while Tadelech has been in the active first stage of labour for some time (dilated cervix of 8 cm), but she may actually be in a prolonged active phase of labour (when true labour lasts for more than about 8 hours without finally entering the second stage). Since you have not been monitoring her labour up to this point, you cannot be absolutely sure whether her cervix is dilating slowly, or if dilatation has completely ceased and the labour is not progressing at all.
• The two swellings (masses) above and below the depression in her abdomen known as Bandl ’s ring indicate an obstructed labour.
• Furthermore, at -3 the baby’s head is not engaged, and remains above the pelvic brim; this indicates that it is not descending as you would expect it to do after Tadelech has been in labour for two days.
• The hot and dry vagina and oedema (swelling due to collection of fluid in the tissues) of the vulva are further signs of a potential obstruction.
• Explain this calmly to her and her family.
• Activate the birth preparedness plan to get her transferred to a health facility as quickly as possible, together with her birth companion.
• Tadelech’s vital signs suggest she is in shock: she has a fast pulse rate and low blood pressure). Her hot and dry vagina indicates dehydration. You begin treating her for shock and dehydration by giving her an intravenous infusion (see Section 9.4) and keeping it working during the trip to the higher health facility.
• If the obstruction appears partly to be caused by an overfull bladder which the woman cannot empty in the normal way, you drain this using a catheter.

SAQ 9.4 (tests Learning Outcome 9.5)

How can you reduce the risks of a prolonged and obstructed labour for women giving birth at home?

You can reduce the risks of obstructed labour by:

• Teaching the importance of good childhood nutrition to ensure that girls’ pelvic bones have the best chance of developing to the normal size for safe delivery.
• Promoting family planning and discouraging early marriage and especially pregnancy at less than 18 years of age.
• Explaining the importance for the safety of the mother and baby of having a skilled care attendant at all deliveries.
• Assisting your community in organising birth preparedness teams so that in an emergency they can get the mother to the nearest health facility as quickly as possible.
• Always using a partograph to monitor the progress of labour.

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• Second Opinion

Fetal Growth Restriction

What is fetal growth restriction (FGR)?

Fetal growth restriction (FGR) is a condition in which an unborn baby (fetus) is smaller than expected for the number of weeks of pregnancy (gestational age). It is often described as an estimated weight less than the 10th percentile. This means that the baby weighs less than 9 out of 10 babies of the same gestational age. Newborn babies with FGR may be called “small for gestational age.”

FGR can begin at any time during pregnancy. With FGR, the baby does not grow well. FGR may affect the overall size of the baby and the growth of organs, tissues, and cells. This can cause many problems. But many newborns who are small may just be small. They may not have any problems.

What causes FGR?

Many things increase the risk for FGR. These include problems with the placenta or umbilical cord. The placenta may not attach well. Or the blood flow through the umbilical cord may be limited. Factors in both the mother and the baby may cause FGR.

Factors in the mother that can cause FGR include:

High blood pressure or other heart and blood vessel disease

Too few red blood cells (anemia)

Long-term lung or kidney conditions

Autoimmune conditions such as lupus

Very low weight

A large amount of excess weight (obese)

Poor nutrition or weight gain

Alcohol or drug use

Cigarette smoking

Factors in the baby that can cause FGR include:

Being one of a twin or triplets

Birth defects, such as heart defects

Problem with genes or chromosomes

What are the symptoms of FGR?

A pregnant woman doesn’t have symptoms of FGR. But a baby with FGR may have certain signs after birth, such as:

Low birth weight

Low blood sugar levels

Lower body temperature

High level of red blood cells

Trouble fighting infections

How is FGR diagnosed?

One of the main reasons for regular prenatal exams is to make sure your baby is growing well. During pregnancy, the size of your baby is estimated in different ways, including:

Fundal height. To check fundal height, your healthcare provider measures from the top of your pubic bone to the top of your uterus (fundus). Fundal height, measured in centimeters (cm), is about the same as the number of weeks of pregnancy after the 20th week. For example, at 24 weeks gestation, your fundal height should be close to 24 cm. If the fundal height is less than expected, it may mean FGR.

If your healthcare provider thinks you have FGR, you will have other tests. These include: 

Fetal ultrasound. Estimating fetal weight with ultrasound is the best way to find FGR. Ultrasound uses sound waves to create images of the baby in the womb. Sound waves will not harm you or the baby. Your healthcare provider or a technician will use the images to measure the baby. A diagnosis of FGR is based on the difference between actual and expected measurements at a certain gestational age.

Doppler ultrasound.   You may also have this special type of ultrasound to diagnose FGR. Doppler ultrasound checks the blood flow to the placenta and through the umbilical cord to the baby. Decreased blood flow may mean your baby has FGR.

You may have repeat ultrasound exams, Doppler studies, and other tests.

How is FGR managed?

Management depends on how serious the FGR is. This is based on the ultrasound (estimated fetal weight) and Doppler ultrasound (blood flow to the baby), as well is risk factors and the number of weeks gestation.

Treatment may include:

Frequent monitoring. This means you will have prenatal visits more often, and ultrasound and Doppler ultrasound exams. You may have other tests.

Tracking fetal movements. Your healthcare provider may also ask you to keep track of fetal movements. If so, he or she will give you instructions.

Corticosteroid medicine

Hospital stay

Early delivery or emergency cesarean

What are possible complications of FGR?

FGR can cause many serious complications. Your baby may need to be delivered early and stay in the hospital. Your baby may have trouble breathing, infections, and other problems. Stillbirths and death may occur. As your child grows, he or she will be at higher risk for heart and blood vessel problems.

How can FGR be prevented?

FGR can happen in any pregnancy. But some factors, like cigarette smoking or alcohol or medicine use, increase the risk for FGR. Regular and early prenatal care and a healthy diet and steady weight gain help to prevent FGR and other problems.

When should I call my healthcare provider?

Make sure your healthcare provider knows your health history. If you are counting fetal movements and find that the number has decreased, let your healthcare provider know. And if you notice other changes or if you have concerns about your pregnancy, call your healthcare provider.

Key points about fetal growth restriction

FGR is a condition in which the baby is smaller than expected for gestational age.  

Many factors increase the risk for FGR. They may be related to the placenta, mother, or baby.

Estimating fetal weight with ultrasound is the best way to identify FGR.

If FGR is diagnosed, you will need to be closely monitored.

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.

Before your visit, write down questions you want answered.

Bring someone with you to help you ask questions and remember what your provider tells you.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

Ask if your condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if you do not take the medicine or have the test or procedure.

If you have a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your provider if you have questions.

Related Links

• Johnson Center
• Fetal and Pregnancy Health
• Small for Gestational Age
• Large for Gestational Age
• Gestational Age Assessment

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Care of the Baby in the Delivery Room

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

• Variations in Fetal Position and Presentation |

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

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

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

Occiput posterior position

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

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

Breech presentation

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

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

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

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

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

Labor starts too soon (preterm labor).

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

Other presentations

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

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

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

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

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What is Stillbirth?

The loss of a baby due to stillbirth remains a sad reality for many families and takes a serious toll on families’ health and well-being. Learn more about stillbirth below.

A stillbirth is the death or loss of a baby before or during delivery. Both miscarriage and stillbirth describe pregnancy loss, but they differ according to when the loss occurs. In the United States, a miscarriage is usually defined as loss of a baby before the 20th week of pregnancy, and a stillbirth is loss of a baby at or after 20 weeks of pregnancy.

Stillbirth is further classified as either early, late, or term.

• An early stillbirth is a fetal death occurring between 20 and 27 completed weeks of pregnancy.
• A late stillbirth occurs between 28 and 36 completed pregnancy weeks.
• A term stillbirth occurs between 37 or more completed pregnancy weeks.

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