Abnormal Position and Presentation of the Fetus

By Julie S. Moldenhauer, MD, Children's Hospital of Philadelphia

Last full review/revision June 2018 by Julie S. Moldenhauer, MD 

 

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Position refers to whether the fetus is facing rearward (toward the woman’s back—that is, face down when the woman lies on her back) or forward (face up).

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

The most common and safest combination consists of the following:

• Head first (called vertex or cephalic presentation)
• Facing rearward
• Face and body angled toward the right or left
• Neck bent forward
• Chin tucked in
• Arms folded across the chest

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

Position and Presentation of the Fetus

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the position of a fetus is facing rearward (toward the woman’s back) with the face and body angled to one side and the neck flexed, and presentation is head first. An abnormal position is facing forward, and abnormal presentations include face, brow, breech, and shoulder.

Abnormal Presentations

There are several abnormal presentations.

Occiput posterior presentation

In occiput posterior presentation (also called sunny-side up), the fetus is head first but is facing up (toward the mother's abdomen). It is the most common abnormal position or presentation.

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

Breech presentation

The buttocks or sometimes the feet present first. Breech presentation occurs in 3 to 4% of full-term deliveries. It is the second most common type of abnormal presentation.

When delivered vaginally, babies that present buttocks first are more likely to be injured than those that present head first. Such injuries may occur before, during, or after birth. The baby may even die. Complications are less likely when breech presentation is detected before labor or delivery.

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

• Labor starts too soon (preterm labor).
• The uterus is abnormally shaped or contains abnormal growths such as fibroids.
• The fetus has a birth defect.

Sometimes the doctor can turn the fetus to present head first by pressing on the woman’s abdomen before labor begins, usually after 37 weeks of pregnancy. However, if labor begins and the fetus is in breech presentation, problems may occur.

The passageway made by the buttocks in the birth canal may not be large enough for the head (which is wider) to pass through. In addition, when the head follows the buttocks, it cannot be molded to fit through the birth canal, as it normally is. Thus, the baby’s body may be delivered and the head may be caught inside the woman. When the baby’s head is caught, it puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among babies presenting buttocks first than among those presenting head first.

In a first delivery, these problems may occur more frequently because the woman’s tissues have not been stretched by previous deliveries. Because the baby could be injured or die, cesarean delivery is preferred when the fetus is in breech presentation unless the doctor is very experienced with and skilled at delivering breech babies.

Other presentations

In face presentation, the neck arches back so that the face presents first.

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

Usually, fetuses do not stay in a face or brow presentation. They often correct themselves. If they do not, forceps, vacuum extractor, or cesarean delivery may be used.

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

Shoulder Dystocia

Shoulder dystocia occurs when one shoulder of the fetus lodges against the woman’s pubic bone, and the baby is therefore caught in the birth canal. 

The fetus is positioned normally (head first) for delivery, but the fetus’s shoulder becomes lodged against the woman’s pubic bone as the fetus’s head comes out. Consequently, the head is pulled back tightly against the vaginal opening. The baby cannot breathe because the chest and umbilical cord are compressed by the birth canal. As a result, oxygen levels in the baby’s blood decrease.

Shoulder dystocia is not common, but it is more common when any of the following is present:

• A large fetus is present.
• Labor is difficult, long, or rapid.
• A vacuum extractor or forceps is used because the fetus’s head has not fully moved down (descended) in the pelvis.
• Women are obese.
• Women have diabetes.
• Women have had a previous baby with shoulder dystocia.

When this complication occurs, the doctor quickly tries various techniques to free the shoulder so that the baby can be delivered vaginally. Sometimes when these techniques are tried, the nerves to the baby’s arm are damaged or the baby’s arm bone or collarbone may be broken. An episiotomy (an incision that widens the opening of the vagina) may be done to help with delivery.

If these techniques are unsuccessful, the baby may be pushed back into the vagina and delivered by cesarean. If all of these techniques are unsuccessful, the baby may die.

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