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Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Illustration of the head-down, face-up position

Frank breech

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

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

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

Illustration of the frank breech position

Complete and incomplete breech

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

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

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

Illustration of a complete breech presentation

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

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

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

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

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

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

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

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

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

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

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

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

Why It's Best

Risks of Other Positions

Determining Position
Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

Frank breech: The legs are up with the feet near the head.
Footling breech: One or both legs is lowered over the cervix.
Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

Go into early labor before you're full term
Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
Are pregnant with multiples
Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

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

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

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

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios . Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

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

Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

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Variation in fetal presentation

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Delivery presentations
Variation in delivary presentation
Abnormal fetal presentations

There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os . This includes:

cephalic presentation : fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations which include

left occipito-anterior (LOA)

left occipito-posterior (LOP)

left occipito-transverse (LOT)

right occipito-anterior (ROA)

right occipito-posterior (ROP)

right occipito-transverse (ROT)

straight occipito-anterior

straight occipito-posterior

breech presentation : fetal rump presenting towards the internal cervical os, this has three main types

frank breech presentation (50-70% of all breech presentation): hips flexed, knees extended (pike position)

complete breech presentation (5-10%): hips flexed, knees flexed (cannonball position)

footling presentation or incomplete (10-30%): one or both hips extended, foot presenting

other, e.g one leg flexed and one leg extended

shoulder presentation

cord presentation : umbilical cord presenting towards the internal cervical os

1. Fox AJ, Chapman MG. Longitudinal ultrasound assessment of fetal presentation: a review of 1010 consecutive cases. Aust N Z J Obstet Gynaecol. 2006;46 (4): 341-4. doi:10.1111/j.1479-828X.2006.00603.x - Pubmed citation
2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon

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Determining Normal Fetal Situs (Situs Solitus)

One of the first steps in obtaining cardiac views is to determine how the fetus is oriented within the uterus and to determine the right and left side of the abdominal contents versus the right and left side of the heart and thoracic contents. This is not as easy as it might seem since the fetal left side can be on the maternal right and the opposite can be true.

In summary, situs refers to the right and left orientation of fetal organs. For example situs solitus is the normal left to right axis arrangement in the fetus with the stomach and spleen on the left side of the body, and the liver and gallbladder on the right side.

Visual Summary of Normal Fetal Situs

Below are steps required to determine situs related to cephalic or breech presentation, and whether the spine or back is up (anterior) or down (posterior).

1. Determine the lie of the fetus:

A. Is the fetus head first with the head in front of the ultrasound screen? This could also be termed cephalic or vertex presentation. B. Is the fetal feet or bottom first with the head behind the screen? This could also be termed footling or breech presentation. C. Determine whether the spine or back is anterior (back up) or posterior (back down).

2. Obtain a transverse cut of the thorax to demonstrate a 4-chamber view. The left atrium is nearest the spine and the cardiac axis points to the left.

Detailed Method to Determine Fetal Situs

1. Define within the uterus the presentation of the fetus (generally vertex or breech; less often the presentation is oblique or transverse.).

2. Determine whether the fetal spine is parallel or transverse to the maternal spine. In sagittal view, if the fetal and maternal spine are parallel, the fetus is in longitudinal lie. When the fetal spine is perpendicular to the maternal spine, the fetus is in a transverse lie.

3. Determine the position of the fetal left side. The fetal left side will be as follows: A. With respect to the maternal abdomen, the fetal left side is anterior and near to the ultrasound transducer. B. With respect to the posterior uterine wall, the fetal left side is posterior and farthest from the transducer. C. With respect to the right uterine wall, the fetal left side will be on the maternal right. D. With respect to the left uterine wall, the fetal left side will be on the maternal left.

4. Obtain a transverse view of the abdomen and define the fetal stomach which is positioned in the left side of the fetal abdomen.

5. Obtain a 4-chamber view of the heart by obtaining a transverse view of the thorax. The left atrium and descending aorta are nearest to the spine and the cardiac axis points to the left.

6. Finally, ascertain if the stomach and heart are in their correct respective locations, i.e., the stomach is on the left side and the cardiac axis points to the left.

7. Place a transverse image of the fetal abdomen and heart side by side and validate that the left side of the fetal abdomen (stomach near to the spine) is concordant with the left side of the fetal heart (left atrium and descending aorta near to the spine). This is done by displaying a side by side comparison of a transverse view through the fetal stomach and a 4-chamber cardiac view.

Above. Normal ultrasound orientation for situs solitus.

Right Hand Rule of Thumb: Introduction

In their article “Sonographic definition of the fetal situs,” Bronshtein, Gover, and Zimmer [ 1 ] describe a “right hand rule of thumb” to define fetal situs during transabdominal scanning, and a “left hand rule of thumb” for transvaginal scanning.

Right Hand Rule of Thumb: Cephalic, supine, back down

Left. The sonographer’s right hand represents the fetus with the thumb pointing to the fetal left. The palm of the hand is anterior, or represents the ventral or face surface of the fetus. The fetus is therefore face up, back down, and the thumb points to the fetal left.

Right. Again, the imaginary fetus is back down with the stomach and cardiac axis pointing to the left. (Ignore color scheme of fetal heart and vessels.)

Right Hand Rule of Thumb: Cephalic, prone, back up

Left. The sonographer’s right hand represents the fetus with the thumb pointing to the fetal left. The top of the hand (dorsal surface or prone position) represents back up.

Right. The imaginary fetus is back up with the stomach and cardiac axis pointing to the fetal left.

Right Hand Rule of Thumb: Breech, supine, back down

Left. The sonographer’s right hand represents the fetus with the thumb pointing to the fetal left. The palm of the sonographer’s hand is anterior, or represents the ventral surface of the fetus. The fetus is therefore face up, back down, and the thumb points to the fetal left.

Right . The imaginary fetus is back down with the stomach and cardiac axis pointing to the left. (Ignore color scheme of fetal heart and vessels).

Right Hand Rule of Thumb: Breech, prone, back up

Right . The imaginary fetus is back up with the stomach and cardiac axis pointing to the fetal left side.

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External cephalic version.

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Continuing Education Activity

In carefully selected patients, an external cephalic version (ECV) may be an alternative to cesarean delivery for fetal malpresentation at term. ECV is a noninvasive procedure that manipulates fetal position through the abdominal wall of the gravida. With the global cesarean section rate reaching 34%, fetal malpresentation ranks as the third most common indication for cesarean delivery, accounting for nearly 17% of cases. Studies suggest a 60% mean success rate for ECV, emphasizing its cost-effectiveness and potential to decrease cesarean delivery rates significantly. While particularly crucial in resource-limited settings where access to medical services during labor is constrained or cesarean delivery is unavailable or unsafe, ECV presents a viable option to improve rates of vaginal delivery in singleton gestations in all settings.

This activity reviews the indications, contraindications, necessary equipment, preferred personnel, procedural technique, risks, and benefits of ECV and highlights the role of the interprofessional team in caring for patients who may benefit from this procedure.

Select suitable candidates for an external cephalic version based on their clinical history and presentation.
Screen patients effectively regarding the risks and benefits of an external cephalic version.
Apply best practices when performing an external cephalic version.
Develop and implement effective interpersonal team strategies to improve outcomes for patients undergoing external cephalic version.
Introduction

The global cesarean section rate has increased from approximately 23% to 34% in the past decade. Fetal malpresentation is now the third-most common indication for cesarean delivery, encompassing nearly 17% of cases. Almost one-fourth of all fetuses are in a breech presentation at 28 weeks gestational age; this number decreases to between 3% and 4% at term. In current clinical practice, most pregnancies with a breech fetus are delivered by cesarean section.

Individual and institutional efforts are increasing to reduce the overall cesarean delivery rate, particularly for nulliparous patients with term, singleton, and vertex gestations. [1] [2] An alternative to cesarean delivery for fetal malpresentation at term is an external cephalic version (ECV), a procedure to correct fetal malpresentation. ECV may be indicated when the fetus is breech or in an oblique or transverse lie after 37 0/7 weeks gestation. [3] The overall success rate for ECV approaches 60%, is cost-effective, and can lead to decreased cesarean delivery rates. [4] ECV is of particular importance in resource-poor environments, where patients may have limited access to medical services during labor and delivery or where cesarean delivery is unavailable or unsafe.

Anatomy and Physiology

ECV can be attempted when managing breech presentations or fetuses with a transverse or oblique lie. Three types of breech presentation are established concerning fetal attitude: complete, frank, and incomplete, which is sometimes referred to as footling breech. In complete breech, the fetal pelvis engages with the maternal pelvic inlet, and the fetal hips and knees are flexed. In frank breech, the fetal pelvis engages with the maternal pelvic inlet, the fetal hips are flexed, the knees are extended, and the feet are near the head. In incomplete or footling breech, one (single footling) or both (double footling) feet are extended below the level of the fetal pelvis.

A fetus with a transverse lie is positioned with their long axis, defined as the spine, at a right angle to the long axis of the gravida. The fetal head may be to the right or left side of the maternal spine. The fetus may be facing up or down. The long axis of the fetus characterizes an oblique lie at any angle to the maternal long axis that is not 90°. An oblique fetus is usually positioned with their head in the right or left lower quadrants, although this is not universal.

Indications

ECV may be indicated in carefully selected patients. The fetus must be at or beyond 36 0/7 weeks of gestation with malpresentation, and there must be no absolute contraindications to vaginal delivery, such as placenta previa, vasa previa, or a history of classical cesarean delivery. Fetal status must be reassuring, and preprocedural nonstress testing is recommended. While ECV may be performed as early as 36 0/7 weeks gestation, many practitioners will delay ECV until 37 0/7 weeks gestation to ensure delivery of a term fetus.

ECV is more successful in multigravidas, those with a complete breech or transverse or oblique presentation, an unengaged presenting part, adequate amniotic fluid, and a posterior placenta. Nulliparous patients and those with an anterior, lateral, or cornual placenta have lower success rates. Patients with advanced cervical dilatation, obesity, oligohydramnios, or ruptured membranes also have lower success rates. Additionally, if the fetus weighs less than 2500 g, is at a low station with an engaged presenting part, is frank breech, or the spine is posterior, the success of ECV is decreased. [5]

Evidence supports the use of parenteral tocolysis, most often with the beta-2-agonist medication terbutaline, to improve the success of ECV; most studies evaluating the various aspects of ECV aspects include using a tocolytic agent. [6] [7] [8] [9] Data regarding the improved success of ECV incorporating regional anesthesia is inconsistent.

Contraindications

Any contraindication to vaginal delivery would also be a contraindication to ECV. These contraindications include but are not limited to placenta previa, vasa previa, active genital herpes outbreak, or a history of classical cesarean delivery. A history of low transverse cesarean delivery is not an absolute contraindication to ECV. [10] The overall success rate of ECV in patients with a previous cesarean birth ranges from 50% to 84%; no cases of uterine rupture during ECV were reported in the four trials evaluating this outcome in patients with a prior cesarean delivery. [11] [12] [13] [14]

Antepartum ECV is contraindicated in multiple gestations, although it can be utilized for twin gestations that would otherwise be suitable candidates for breech extraction. [15] [16]

Patients with severe oligohydramnios, nonreassuring fetal monitoring, a hyperextended fetal head, significant fetal or uterine anomaly, fetal growth restriction, and maternal hypertension carry a low likelihood of successful ECV and a significantly increased risk of poor fetal outcomes; ECV in such situations requires careful consideration.

If a gravida who is otherwise a suitable candidate for ECV presents in early labor with fetal malpresentation, ECV may be a reasonable option if the presenting part is unengaged, the amniotic fluid index is within the normal range, and there are no contraindications to ECV or vaginal delivery. Data from the Nationwide Inpatient Sample from 1998 to 2011 noted a success rate of 65% for ECV performed in carefully selected patients during the admission for delivery. [17] ECV performed in this circumstance resulted in a significantly lower cesarean birth rate and hospital stay of greater than 7 days compared to patients with a persistent breech presentation at the time of delivery. [17]

External cephalic versions should be attempted only in settings where cesarean delivery services are readily available. Therefore, the required equipment for ECV includes all such requirements for cesarean delivery, including anesthesia services. Access to tocolytic agents, bedside ultrasonography, and external fetal heart rate monitoring equipment is also required. Following ECV, fetal status must be assessed; nonstress testing is preferred. If nonstress testing is unavailable, Doppler indices of the umbilical artery, middle cerebral artery, and ductus venosus may be performed. [18]

The personnel typically required to perform an ECV include:

Obstetrician
Labor and delivery nurse.

ECV may only be performed in a setting where cesarean delivery services are readily available. Personnel typically required for cesarean delivery include:

Surgical first assistant
Anesthesia personnel
Surgical technician or operating room nurse
Circulating or operating room nurse
Pediatric personnel
Note: for cesarean delivery, labor and delivery nurses may serve as surgical technicians, circulating, or operating room roles.
Preparation

Before attempting ECV, informed consent must be obtained; this should include tocolysis and neuraxial analgesia if those procedures will be performed. Some clinicians will obtain consent from the patient for potential emergency cesarean delivery at this time, although this practice is not universal. Additionally, an ultrasound examination should be performed to verify fetal presentation, exclude fetal and uterine anomalies, locate the placental position, and evaluate the amniotic fluid index. Many clinicians will evaluate preprocedural fetal status with a nonstress test.

The current evidence supports the administration of terbutaline 0.25mg subcutaneously 15 to 30 minutes before the ECV but does not support using calcium channel blockers or nitroglycerin for preprocedural tocolysis. [19] While multiple studies report the increased success of ECV in patients who are administered epidural or spinal neuraxial anesthesia, overall data is insufficient to warrant a universal recommendation; neuraxial anesthesia may improve success rates for ECV in situations where tocolysis alone was unsuccessful. [20]

Technique or Treatment

The gravida should be supine with a leftward tilt using a wedge support to relieve pressure on the great vessels. ECV is best performed using a 2-handed approach.

If the fetal presentation is breech, lift the breech out of the pelvis with one hand and apply downward pressure to the posterior fetal head to attempt a forward roll. If a forward roll is unsuccessful, a backward roll can be attempted. If the fetus is in either a transverse or oblique presentation, similar manipulation of the fetus is used to try to move the fetal head to the pelvis. [21]

Fetal well-being should be evaluated intermittently with Doppler or real-time ultrasonography during ECV. ECV should be abandoned if there is significant fetal bradycardia, patient discomfort, or if a version is not achieved easily. After a successful or unsuccessful ECV, external fetal heart rate monitoring should be performed for 30 to 60 minutes. If the gravida is Rh negative, anti-D immune globulin should be administered.

Immediate induction of labor to minimize reversion is not recommended. If the initial attempt at ECV is unsuccessful, additional attempts can be made during the same admission or at a later date.

Complications

Complications of ECV are rare and occur in only 1% to 2% of attempts. The most common complication associated with ECV is fetal heart rate abnormalities, particularly bradycardia, occurring at a rate of 4.7% to 20%; these abnormalities usually are transient and improve upon completion or abandonment of the procedure.

More severe complications of ECV occur at a rate of less than 1% and include premature rupture of membranes, cord prolapse, vaginal bleeding, placental abruption, fetomaternal hemorrhage, emergent cesarean delivery, and stillbirth. Many of these rare complications require emergent cesarean delivery; some clinicians choose to perform ECV in the operating room, although this is neither necessary nor universal. [22]

ECV is associated with changes in Doppler indices that may reflect decreased placental perfusion. It appears these changes are short-lived and have no detrimental effects on the outcomes of uncomplicated pregnancies. A recent prospective study investigating the effects of ECV on fetal circulation in the antepartum period noted no differences in the Doppler evaluation of the middle cerebral artery or ductus venosus; all studied patients remained stable and were discharged home after the procedure. [18]

Clinical Significance

Some data indicate that only 20% to 30% of eligible candidates are offered ECV. [23] Patients who undergo a successful ECV procedure have a lower cesarean delivery rate than patients who do not but are still at a higher risk of cesarean delivery than patients with cephalic fetuses who do not require ECV. ECV is cost-effective if the probability of a successful ECV exceeds 32%. Overall, ECV is successful in 58% of attempts, reduces the risk for CS by two-thirds, and enables 80% of these patients to deliver vaginally. [24]

Enhancing Healthcare Team Outcomes

ECV is not a benign procedure and is most successful when performed under the care of an interprofessional team. Labor and delivery nurses play an integral role in the success of ECV as they frequently assist in the procedure, prepare the patient for ECV, and implement external fetal monitoring before, during, and after the procedure. Additionally, the support of emergent operating room staff promotes the safe delivery of a healthy fetus should complications arise during the ECV procedure. Clear and concise anticipatory interprofessional communication improves safety and outcomes for the gravida and the fetus should complications occur.

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Disclosure: Meaghan Shanahan declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Martingano declares no relevant financial relationships with ineligible companies.

Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Shanahan MM, Martingano DJ, Gray CJ. External Cephalic Version. [Updated 2023 Dec 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

The head is tucked down to the chest.
The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

A complete breech is when the buttocks present first and both the hips and knees are flexed.
A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

This is when the widest part of your baby's head has entered the pelvis.
Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
This is when your baby's head moves down (descends) further through your pelvis.
Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
During descent, the baby's head is flexed down so that the chin touches the chest.
With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
Usually, the baby will be face down toward your spine.
Sometimes, the baby will rotate so it faces up toward the pubic bone.
As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
After the head is delivered, the top shoulder is delivered under the pubic bone.
After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

How your twins’ fetal positions affect labor and delivery

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

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

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

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

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

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

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

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

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

Head down, head down (vertex, vertex)

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

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

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

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

Head down, bottom down (vertex, breech)

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

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

Head down, sideways (vertex, transverse)

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

Bottom down, bottom down (breech, breech)

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

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

Bottom down, sideways (breech, transverse)

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

Sideways, sideways (transverse, transverse)

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

Learn more:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Mammary Glands
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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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An unusual case of severe asphyxia with the fetal position unexpectedly inverted in a malformed uterus: a case report

Jiro Abe ORCID: orcid.org/0000-0002-3977-2679 1 , 2 , 3 ,
Takashi Nasu 1 ,
Ayumu Noro 1 &
Junko Tsubaki 1

Journal of Medical Case Reports volume 18 , Article number: 209 ( 2024 ) Cite this article

Metrics details

We present a severe neonatal consequence due to the unexpected and crucial inversion of the fetal position after sudden termination of tocolysis during early labor of a woman with congenital uterine anomaly. It has been reported that congenital uterine anomalies latently affect the fetal position. The clinical pitfalls in childbirth with uterine anomalies are discussed here on the basis of clinical evidence.

Case presentation

At a perinatal medical center in Japan, a 29-year-old Japanese mother who had a history of bicornuate uterus, received tocolysis to prolong her pregnancy for 5 days during the late preterm period after preterm-premature rupture of the membrane. She gave birth to a 2304 g male neonate of the gestational age of 35 weeks and 5 days with severe asphyxia by means of crash cesarean section for fetal sustained bradycardia after sudden termination of tocolysis. We found the fetal position to reverse from cephalic to breech position during early labor. He ended up having severe cerebral palsy after brain cooling against hypoxic-ischemic encephalopathy for 3 days. The mechanism of inversion from cephalic to breech position without amnionic fluid remains unclear, although women with a known diagnosis of a uterine anomaly have higher risk of adverse outcomes such as malpresentation.

Conclusions

When considering the clinical course of this case on the basis of the medical reports, we suspected that uterine anomalies and changes in intrauterine pressure could cause fetal malpresentation and adverse neonatal outcomes.

Peer Review reports

Uterine abnormalities may be overlooked in women with successful reproductive outcomes, but one study estimated that, even in women with normal pregnancy outcomes, the incidence of congenital uterine anomalies is approximately 3%. The likelihood of fetal malpresentation at the time of delivery is notably increased by the presence of uterine anomalies [ 1 ]. A case is presented where a mother with bicornuate uterus received tocolytic treatment with β-stimulants after surpassing 35 weeks of gestation. Following the discontinuation of tocolysis associated with the onset of labor, the fetus experienced distress and malpresentation, ultimately resulting in severe cerebral palsy in the child. There are no existing case reports that show a change in fetal presentation during labor with uterine anomalies resulting in fetal asphyxia.

A 29-year-old Japanese mother who had a history of bicornuate uterus gave birth to a 2304 g male neonate of the gestational age of 35 weeks and 5 days with severe asphyxia. She was a primigravida without health issues, and her pregnancy course, including changes in maternal body mass index (BMI) and gestational weight gain, was smooth. She was admitted to our hospital to receive tocolysis treatments using ritodrine hydrochloride because of preterm premature rupture of membrane at 35 weeks’ gestation, receiving antibiotics, no antenatal corticosteroids, and no magnesium sulfate. The ultrasound examinations revealed overall fetal growth, reduced amniotic fluid, and a fetal vertex position. A total of 3 hours before the birth, the administration of the tocolytic agent, by ritodrine hydrochloride using the maximum dose of 200 µg per minute, was terminated to promote vaginal delivery, and she was transferred to a delivery room. Non-reassuring patterns repetitively emerged at 1 hour prior to the birth, which were only confirmed by cardiotocography without an ultrasound examination performed at that time (Fig. 1 A). General fetal resuscitation such as maternal oxygen administration and intravenous infusion of a liter of non-glucose crystalloid without acute tocolysis was used as part of the obstetric management of labor, while preparing for cesarean delivery for fetal distress. Quick pelvic examinations ensured the fetus’s cephalic position while observing the mother in preparation for an emergency cesarean operation, although the fetal position during delivery was not confirmed by ultrasound. Half an hour before the birth, fetal bradycardia was sustained while the pelvic examination indicated that the fetal head was unexpectedly floating (Fig. 1 A). A crash cesarean section was performed, where he was found to be in a breech presentation. We found quite little amniotic fluid without the evidence of meconium-stained amniotic fluid or cord coiling. The pathological findings of the placenta and umbilical cord proved only mild chorioamnionitis without any evidence of delivery injury or anomaly afterward.

(A) Cardiotocography immediately before birth. Non-reassuring patterns repetitively emerged 1 hour prior to birth. Pelvic examinations revealed a fixed cephalic position. At half an hour, fetal bradycardia was sustained while the pelvic examination indicated that the fetal head was unexpectedly floating. (B) Sequential brain magnetic resonance imaging (MRI). According to sequential brain MRI findings, his lesions post hypoxic-ischemic encephalopathy (HIE) were mainly located in the basal ganglia and the brain stem

After delivery he presented with bradycardia and deep cyanosis without breathing, muscle movements, and reflections. Because his asphyxia turned out to be refractory to routine resuscitation, he was intubated after 1 minute. His skin color rapidly became pink, and the heart rate returned to a normal range without the recovery of muscle movements and reflex actions. He received an appearance, pulse, grimace, activity, and respiration (APGAR) score of 1 at 1 minute and 3 at 5 minutes; the arterial cord blood sample was not available, because of technical difficulty in sampling umbilical cord blood. He needed special care that included mechanical ventilation and correction of mixed acidosis (pH 6.85, pvCO2 77 mmHg, HCO 3 − 12.6 mmol/l at 15 minutes after birth), and then he was given phenobarbital. At 1.5 hours after birth, he was transferred to another tertiary care hospital where he received therapeutic hypothermia for hypoxic-ischemic encephalopathy; the Sarnat grade was moderate, and the Thompson score was calculated as 16 points [ 2 ]. He was a late preterm and low-birth-weight newborn with no congenital anomalies or other problems that would be predictive of neonatal asphyxia through newborn screening especially focusing on the brain, heart, or metabolism. We could not find clinical and pathological evidence of his severe asphyxia in the end. Chromosomal testing was not conducted. He ended up having severe cerebral palsy after brain cooling for 3 days. His sequential brain MRI findings supported the severity of the encephalopathy that mainly affected the basal ganglia and brain stem (Fig. 1 B). He is now 9 months of age and remains in bed with special healthcare requirements that include tube feeding, while presenting with dystonia with severe mental developmental retardation.

Discussion and conclusions

The mother had some delivery risks as follows: a uterine anomaly, absent amniotic fluid after preterm-premature rupture of membrane, and threatened late-preterm labor. The placental blood flow in mothers with congenital uterine anomalies is reduced, and there is a predicted decrease in the reserve capacity for blood supply to the fetus, particularly during delivery. When a mother has congenital uterine anomalies, there is a 5-fold increased risk of preterm birth and a 20-fold increased risk of placental abruption [ 3 ]. This case is believed to be caused by circulatory insufficiency between the mother and fetus, with the influence of congenital uterine anomaly likely playing a background role. Increased intrauterine pressure might have occurred by abrupt termination of tocolysis with the lack of amniotic fluid, which would make the fetal status worse, although there was no evidence of excessively rapid uterine contractions in the tocography (Fig. 1 A).

Uterine anomalies are known to significantly elevate the chances of fetal malpresentation during delivery. According to the meta-analysis by Chan, the likelihood of fetal malpresentation was found to be higher in cases of arcuate uterus, unification defects, and canalization defects, with the odds being 2.53 [95% confidence interval (CI) 1.54–4.18; p < 0.001], 3.87 (95% CI 2.42–6.18; p < 0.001), and 6.24 (95% CI 4.05–9.62; p < 0.001) times, respectively [ 4 ]. Furthermore, a retrospective study by Hua and colleagues, which encompassed all types of uterine anomalies (including uterine septum, unicornuate uterus, bicornuate uterus, and uterine didelphys), revealed that women with these anomalies were 8.6 times more likely to experience breech presentation of the fetus compared with women with standard uterine anatomy (95% CI 6.2–12.0; p < 0.01) [ 5 ]. Additionally, a comprehensive retrospective cross-sectional study, examining a total of 109,736 singleton infants (both preterm and full-term), of which 4535 were breech at birth, determined that women with any form of uterine malformation had an almost 10-fold increase in the likelihood of breech fetal presentation (odds ratio, 9.47; 95% CI 6.77–13.25) [ 6 ]. Possible causes are thought to be changes in intrauterine and external pressure, for example, the effects of uterine malformations, the sudden discontinuation of uterine contraction inhibiting drugs, and the transfer from the delivery table to the bed. The unexpected inversion of the fetal position with very little amniotic fluid during early labor would have led to the poor consequence, causing the umbilical cord to twist and consequently leading to the interruption of placental blood flow.

It may have been unavoidable, but we can suggest two preventive plans for this case. One plan would be ongoing expectant management with or without tocolysis. The issue of whether to suppress or allow progressive labor to proceed during the late-preterm period remains controversial [ 7 ]. If waiting for labor while inhibiting uterine contractions, it is necessary to carefully monitor changes in intrauterine pressure when stopping tocolytic agents. The other one would be planned earlier delivery including elective cesarean operation. Bicornuate uterus has been reported to be a risk factor for unsuccessful vaginal delivery [ 8 ]. A major meta-analysis discovered that the likelihood of undergoing a primary cesarean delivery was 2.6 times higher for women with congenital uterine anomalies (adjusted odds ratio [aOR], 2.6; 95% CI 1.7–4.0; p < 0.01) [ 5 ]. Additionally, a retrospective cohort study over a decade at a French university hospital assessed women known to have uterine malformations, focusing on the baby’s presentation and the method of delivery. In this group, women with uterine abnormalities showed a significantly increased incidence of breech presentations (36.51% as opposed to 4.52%; p < 0.01) and cesarean deliveries (55.26% compared with 18.70%; p < 0.01), in contrast to women with normally formed uteri [ 9 ].

Women with congenital uterine anomalies face significantly higher risks of preterm birth, placental abruption, fetal malpresentation, and breech presentation. Several studies highlight the increased odds of complications such as fetal malpresentation and breech births, indicating a need for careful monitoring and possibly alternative delivery plans, including elective cesarean operations. Our report concludes with suggestions for managing such high-risk cases, emphasizing the importance of careful monitoring or possibly opting for an earlier planned delivery to mitigate risks.

Availability of data and materials

The approval from the parent allowed us to use the patient’s data and report this case with data anonymization.

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Acknowledgements

We appreciate clinical support from Asuka Takahata, Tetsuo Onda, Naho Fuseya.

We all declare no financial support or relationships that may pose a conflict of interest by disclosing any financial arrangements we have with a company whose product figures prominently in the submitted manuscript or with a company making a competing product, or any conflict relating to technology or methodology.

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Department of Pediatrics, JCHO Hokkaido Hospital, 3-18, Nakanoshima 1 Jyou 8 Tyoume, Sapporo, Japan

Jiro Abe, Takashi Nasu, Ayumu Noro & Junko Tsubaki

Department of Pediatrics, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi 7, Kita-Ku, Sapporo, 060-8638, Japan

Mitochondrial Redox Biology, Medical Research Council Mitochondrial Biology Unit and Department of Medicine, University of Cambridge, The Keith Peters Building, Cambridge Biomedical Campus Hills Road, Cambridge, CB2 0XY, UK

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Contributions

Jiro Abe designed and prepared the manuscript; Takashi Nasu, Ayumu Noro, and Junko Tsubaki provided technical support and conceptual advice. All of the authors read and approved the final version of the manuscript.

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Correspondence to Jiro Abe .

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Abe, J., Nasu, T., Noro, A. et al. An unusual case of severe asphyxia with the fetal position unexpectedly inverted in a malformed uterus: a case report. J Med Case Reports 18 , 209 (2024). https://doi.org/10.1186/s13256-024-04524-0

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Received : 01 February 2022

Accepted : 25 March 2024

Published : 26 April 2024

DOI : https://doi.org/10.1186/s13256-024-04524-0

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Inverted fetal position
Neonatal asphyxia
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Late preterm
Uterine anomalies

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COMMENTS

Fetal Positions For Birth: Presentation, Types & Function
Possible fetal positions can include: Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left.
Fetal presentation before birth
This positioning is called fetal presentation. Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation.
Your Guide to Fetal Positions before Childbirth
Here's your guide to the different positions, or fetal presentations, your baby might be in before birth. ... Head Down, Facing Down (Cephalic Presentation) This is the most common position for babies in-utero. In the cephalic presentation, the baby is head down, chin tucked to chest, facing their mother's back. This position typically ...
Delivery, Face and Brow Presentation
The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin.
Cephalic Position During Labor: Purpose, Risks, and More
Cephalic position is when a fetus is head down when it is ready to enter the birth canal. It is the best and safest position for labor and delivery. Learn why it's best, the risks of other positions, and how to turn a fetus if it is in a noncephalic position.
Fetal presentation: Breech, posterior, transverse lie, and more
Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation).
Fetal Presentation, Position, and Lie (Including Breech Presentation)
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 ...
Cephalic presentation
A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation, where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations ...
Your baby in the birth canal
This is called cephalic presentation. This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries. There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).
Fetal Presentation, Position, and Lie (Including Breech Presentation)
Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse. Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position. Abnormal fetal lie, presentation, or position may occur with. Fetopelvic disproportion (fetus too large for the pelvic inlet)
The evolution of fetal presentation during pregnancy: a retrospective
Introduction. Cephalic presentation is the most physiologic and frequent fetal presentation and is associated with the highest rate of successful vaginal delivery as well as with the lowest frequency of complications 1.Studies on the frequency of breech presentation by gestational age (GA) were published more than 20 years ago 2, 3, and it has been known that the prevalence of breech ...
Variation in fetal presentation
There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os. This includes: cephalic presentation: fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations ...
Fetal Situs
Visual Summary of Normal Fetal Situs. Below are steps required to determine situs related to cephalic or breech presentation, and whether the spine or back is up (anterior) or down (posterior). 1. Determine the lie of the fetus: A. Is the fetus head first with the head in front of the ultrasound screen?
Abnormal Presentation
Cephalic presentation means head first. This is the normal presentation. ... Compound presentation means that a fetal hand is coming out with the fetal head. This is a problem because: The amount of baby that must come through the birth canal at one time is increased. There is increased risk of mechanical injury to the arm and shoulder ...
External Cephalic Version
The global cesarean section rate has increased from approximately 23% to 34% in the past decade. Fetal malpresentation is now the third-most common indication for cesarean delivery, encompassing nearly 17% of cases. Almost one-fourth of all fetuses are in a breech presentation at 28 weeks gestational age; this number decreases to between 3% and 4% at term. In current clinical practice, most ...
Your baby in the birth canal: MedlinePlus Medical Encyclopedia
Learn about the different types of fetal presentation, such as cephalic, breech, and transverse lie, and how they affect the baby's position and movement through the birth canal. Find out what fetal station, fetal lie, and fetal attitude mean, and how they describe the baby's position and movement. See the cardinal movements of labor and delivery, and the terms used to describe them.
Fetal presentation: how twins' positioning affects delivery
Twin fetal presentation - also known as the position of your babies in the womb - dictates whether you'll have a vaginal or c-section birth. ... or your doctor may try to turn the baby head-down via external cephalic version or internal podalic version (changing position in the uterus), which means you may be able to deliver both vaginally.
Abnormal Fetal lie, Malpresentation and Malposition
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.
External cephalic version
External cephalic version (ECV) refers to a procedure in which the fetus is rotated from a noncephalic to a cephalic presentation by manipulation through the mother's abdomen ( figure 1 ). It is typically performed as an elective procedure in nonlaboring patients at or near term to improve their chances of having a vaginal cephalic birth.
An unusual case of severe asphyxia with the fetal position unexpectedly
We found the fetal position to reverse from cephalic to breech position during early labor. He ended up having severe cerebral palsy after brain cooling against hypoxic-ischemic encephalopathy for 3 days. ... determined that women with any form of uterine malformation had an almost 10-fold increase in the likelihood of breech fetal presentation ...