compound presentation of fetus

2022 New Pearls of Exxcellence Articles

Management of Brow, Face, and Compound Malpresentations

Author: Meera Kesavan, MD

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

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

These fetal malpresentation are differentiated in the following ways:

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

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

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

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

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

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

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

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

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Chapter 27: Compound Presentations

George Tawagi

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Prolapse of hand and arm or foot and leg.

MANAGEMENT OF COMPOUND PRESENTATIONS
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Supplementary Content

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

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

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

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

Classification of Compound Presentation

Upper limb (arm–hand), one or both

Lower limb (leg–foot), one or both

Arm and leg together

Breech presentation with prolapse of the hand or arm

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

FIGURE 27-1.

Compound presentation: head and hand.

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

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

The condition is suspected when:

There is delay of progress in the active phase of labor

Engagement fails to occur

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

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

Mechanism of Labor

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Fetal Malpresentation and Malposition

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

Last updated: Feb 14, 2023

Fetal Lie and Presentation

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

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

Clinical relevance

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

Risk factors for fetal malpresentation

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

Epidemiology

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

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

Presentation

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

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

Cephalic presentations

Cephalic presentations can be categorized as:

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

Vertex presentation

Face presentation (mentum anterior position)

Brow presentation (mentum posterior position)

Breech presentations

Breech presentations can be categorized as:

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

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

Transverse and compound presentations

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

Shoulder presentation (transverse lie)

Neglected shoulder presentation resulting in arm prolapse during labor

Vertex presentation with a compound hand

Fetal malpresentation

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

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

Vertex positions

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

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

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

Face and brow positions

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

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

Face presentation (mentum posterior position)

Breech and shoulder positions

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

Dorso-inferior shoulder presentation

Dorso-superior shoulder presentation

Attitude and asynclitism

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

Fetal malposition

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

Diameters of the fetal head

Comparison of presentation, attitude, and presenting diameter

How to establish lie, presentation, and position

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

Leopold’s maneuvers

Ultrasonography.

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

Suprapubic bedside ultrasound confirming a cephalic presentation

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

Vaginal and cervical examination

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

Vertex presentations

Expectant management
All have high chances of successful vaginal delivery.

Compound presentations

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

Brow presentations

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

Face presentations

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

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

Natural history of breech presentations

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

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

Fetal risks associated with breech presentations

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

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

Fetal risks associated with vaginal breech delivery

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

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

Vaginal breech delivery

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

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

External cephalic version

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

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

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

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

Management of transverse presentations

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

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Uptodate Reference Title

Compound fetal presentation.

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

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

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

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

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

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

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

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

● Dystocia.

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

CLINICAL PRESENTATION

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

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

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

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

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

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

● Compound presentation

● Transverse lie with prolapse of an extremity

● Footling breech presentation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SUMMARY AND RECOMMENDATIONS

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

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

● Management

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

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

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

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

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

1 : Obstetric malpresentations: twenty years' experience.

2 : Compound presentation; a survey of 65 cases.

3 : Compound presentation: a survey of 131 patients.

4 : Compound presentation of the fetus.

5 : Compound presentation.

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

7 : Compound presentation following external version.

8 : Compound presentation of the foetus following external version.

9 : A study of 65 cases of compound presentation.

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

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

12 : Compound presentations.

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

14 : Unusual rectal trauma due to compound fetal presentation.

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

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INTRODUCTION

PATHOGENESIS AND RISK FACTORS