fetal presentation on breech

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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• 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.

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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INTRODUCTION

This topic will provide an overview of major issues related to breech presentation, including choosing the best route for delivery. Techniques for breech delivery, with a focus on the technique for vaginal breech delivery, are discussed separately. (See "Delivery of the singleton fetus in breech presentation" .)

TYPES OF BREECH PRESENTATION

● Frank breech – Both hips are flexed and both knees are extended so that the feet are adjacent to the head ( figure 1 ); accounts for 50 to 70 percent of breech fetuses at term.

● Complete breech – Both hips and both knees are flexed ( figure 2 ); accounts for 5 to 10 percent of breech fetuses at term.

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Breech Births

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

What are the different types of breech birth presentations?

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

What causes a breech presentation?

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

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

How is a breech presentation diagnosed?

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

Can a breech presentation mean something is wrong?

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

Can a breech presentation be changed?

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

Medical Techniques

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

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

ECV will not be tried if:

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

Complications of EVC include:

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

Vaginal delivery versus cesarean for breech birth?

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

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

What are the risks and complications of a vaginal delivery?

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

When is a cesarean delivery used with a breech presentation?

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

Want to Know More?

• Creating Your Birth Plan
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Compiled using information from the following sources:

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

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Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

• Complete : The fetus’s knees are bent, and the buttocks are presenting first.
• Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
• Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

• Previous pregnancies
• Multiple fetuses in the uterus
• An abnormally shaped uterus
• Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
• Placenta previa, a condition in which the placenta covers the opening to the uterus
• Preterm labor or prematurity of the fetus
• Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
• Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery. 

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

• Pregnant person is carrying more than one fetus
• Placenta is in the wrong place
• Healthcare provider has concerns about the health of the fetus
• Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

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

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

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What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

• The fetus may have abnormalities involving the muscular or central nervous system
• The uterus may have abnormal growths or fibroids
• There might be insufficient amniotic fluid in the uterus (too much or too little)
• This isn’t your first pregnancy
• You have a history of premature delivery
• You have placenta previa (the placenta partially or fully covers the cervix)
• You’re pregnant with multiples
• You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

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What to know if your baby is breech

Find out what breech position means, how to turn a breech baby, and what having a breech baby means for your labor and delivery.

What does it mean when a baby is breech?

Signs of a breech baby, why are some babies breech, how to turn a breech baby: is it possible, will i need a c-section if my baby is breech, how to turn a breech baby naturally.

Breech is a term used to describe your baby's position in the womb. Breech position means your baby is bottom-down instead of head-down.

Babies are often active in early pregnancy, moving into different positions. But by around 8 months, there's not much room in the uterus. Most babies maximize their cramped quarters by settling in head down, in what's known as a cephalic or vertex presentation. But if you have a breech baby, it means they're poised to come out buttocks and/or feet first. At 28 weeks or less, about a quarter of babies are breech, and at 32 weeks, 7 percent are breech. By the end of pregnancy, only 3 to 4 percent of babies are in breech position. At term, a baby in breech position is unlikely to turn on their own.

There are several types of breech presentations:

• Frank breech (bottom first with feet up near the head)
• Complete breech (bottom first with legs crossed)
• Incomplete or footling breech (one or both feet are poised to come out first)

(In rare cases, a baby will be sideways in the uterus with their shoulder, back, or arm presenting first – this is called a transverse lie.)

See what these breech presentations look like .

If your baby is in breech position, you may feel them kicking in your lower belly. Or you may feel pressure under your ribcage, from their head.

By the beginning of your third trimester , your practitioner may be able to tell what position your baby is in by feeling your abdomen and locating the baby's head, back, and bottom.

If your baby's position isn't clear during an abdominal exam at 36 weeks, your caregiver may do an internal exam to try to feel what part of the baby is in your pelvis. In some cases, they may use ultrasound to confirm the baby's position.

We don't usually know why some babies are breech – in most cases it seems to be chance. While sometimes a baby with certain birth defects may not turn to a head-down position, most babies in breech position are perfectly fine. Here are some things that might increase the risk of a breech presentation:

• You're carrying multiples
• You've been pregnant before
• You've had a breech presentation before
• There's too much amniotic fluid or not enough amniotic fluid
• You have placenta previa (the placenta is covering all of part of the opening of the uterus)
• Your baby is preterm
• Your uterus is shaped abnormally or has growths, such as fibroids
• The umbilical cord is short
• You were a breech delivery, or your sibling or parent was a breech delivery
• Advanced maternal age (especially age 45 and older)
• Your baby is a low weight at delivery
• You're having a girl

There is a procedure for turning a breech baby. It's called an external cephalic version (ECV). An ob/gyn turns your baby by applying pressure to your abdomen and manually manipulating the baby into a head-down position. Some women find it very uncomfortable or even painful.

An EVC has about a 58 percent success rate, and it's more likely to work if this isn't your first baby. It's not for everyone – you can't have the procedure if you're carrying multiples or if you have too little amniotic fluid or placental abruption , for example. Your provider also won't attempt to turn your breech baby if your baby has any health problems.

The procedure is done after 36 weeks and in the hospital, where your baby can be monitored and where you'll be near a delivery room should any complications arise.

It depends, and it's something you'll want to talk with your caregiver about ahead of time. Discuss your preferences, the advantages and risks of each option ( vaginal and cesarean delivery of a breech presentation), and their experience. The biggest risk of a breech delivery is when the body delivers but the head stays entrapped within the cervix.

In the United States, most breech babies are delivered via cesarean. You may wind up having a vaginal breech delivery if your labor is so rapid that you arrive at the hospital just about to deliver. Another scenario is if you have a twin pregnancy where the first baby is in the head-first position and the second baby is not. A baby who delivers head-first will make room for the breech baby.

However, the vast majority of babies who remain breech arrive by c-section. If a c-section is planned, it will usually be scheduled at 39 weeks. To make sure your baby hasn't changed position in the meantime, you'll have an ultrasound at the hospital to confirm their position just before the surgery.

If you go into labor or your water will break s before your planned c-section, be sure to call your provider right away and head for the hospital.

In rare circumstances, if you're at low risk of complications and your caregiver is experienced delivering breech babies vaginally, you may choose to have what is called a "trial of vaginal birth." This means that you can attempt to deliver vaginally but should be prepared to have a cesarean delivery if labor isn't progressing well. You and your baby will be closely monitored during labor.

In addition to ECV, there are some alternative, natural ways to try to turn your baby. There's no proof that any of them work – or that all of them are safe. Consult your practitioner before trying them.

There's no conclusive proof that the mother's position has any effect on the baby's position, but the idea is to employ gravity to help your baby somersault into a head-down position. A few tips:

• Get into one of the following positions twice a day, starting at around 32 weeks.
• Be sure to do these moves on an empty stomach, lest your lunch comes back up.
• Make sure there's someone around to help you get up if you start feeling lightheaded.
• If you find these positions uncomfortable, stop doing them.

Position 1: Lie flat on your back and raise your pelvis so that it's 9 to 12 inches off the floor. Support your hips with a pillow and stay in this position for five to 15 minutes. Position 2: Kneel down, with your forearms on the floor in front of you, so that your bottom sticks up in the air. Stay in this position for five to 15 minutes. Sleeping position

Many women wonder if there are sleeping positions to turn a breech baby. But the positions you use to try to coax your baby head down for a short time shouldn't be used while you're sleeping. (It's not safe to sleep flat on your back in late pregnancy, for example, because the weight of your baby may compress the blood vessels that provide oxygen and nutrients to them.)

The best position for sleeping during pregnancy is on your side. Placing a pillow between your legs in this position may help open your pelvis, giving your baby room to move more easily. Support your back with plenty of pillows, too. Again, there's no proof that this works, but since it's the best sleeping position for you and your baby, you may as well give it a try.

Moxibustion

This ancient Chinese technique burns herbs to stimulate key acupressure points. To help turn a breech baby, an acupuncturist or other practitioner burns mugwort near the acupressure point of your pinky toes. According to Chinese medicine, this should stimulate your baby's activity enough that they may change position on their own. Some studies show that moxibustion in combination with acupuncture and/or positioning methods may be of some benefit. Others show moxibustion to provide no help in coaxing a baby into cephalic position. If you've discussed it with your caregiver and want to give it a try, contact your state acupuncture or Chinese medicine association and ask for the names of licensed practitioners.

One small study found that women who are regularly hypnotized into a state of deep relaxation at 37 to 40 weeks are more likely to have their baby turn than other women. If you're willing to try this technique, look for a licensed hypnotherapist with experience working with pregnant women.

Chiropractic care

There's a technique – called The Webster Breech Technique – that aims to reduce stress on the pelvis by relaxing the uterus and surrounding ligaments. The idea is that a breech baby can turn more naturally in a relaxed uterus, but research is limited as to the risks and benefits of this technique. If you're interested, talk with your provider about working with a chiropractor who's experienced with the technique.

This is a safe – and again, unproven – method based on the fact that your baby can hear sounds outside the womb. Simply play music close to the lower part of your abdomen (some women use headphones) to encourage your baby to move in the direction of the sound.

Learn more:

• C-section recovery
• Third trimester pregnancy guide and checklist
• Hospital bag checklist

Was this article helpful?

Breech, posterior, transverse lie: What position is my baby in?

C-section recovery: Timeline, aftercare tips, and expectations

Too much amniotic fluid (polyhydramnios)

Hospital bag checklist: What to pack for labor and postpartum

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

ACOG. 2019. If your baby is breech. FAQ. The American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/if-your-baby-is-breech Opens a new window [Accessed November 2021]

ACOG. 2018. Mode of term singleton breech delivery. Committee opinion number 745. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/08/mode-of-term-singleton-breech-delivery Opens a new window [Accessed November 2021]

Brici P et al. 2019. Turning foetal breech presentation at 32-35 weeks of gestational age by acupuncture and moxibustion. Evidence-based Complementary and Alternative Medicine https://www.hindawi.com/journals/ecam/2019/8950924/ Opens a new window [Accessed November 2021]

Ekeus C et al. 2019. Vaginal breech delivery at term and neonatal morbidity and mortality — a population-based cohort study in Sweden. Journal of Maternal Fetal Neonatal Medicine 32(2):265. https://pubmed.ncbi.nlm.nih.gov/28889774/ Opens a new window [Accessed November 2021]

Fruscalzo A et al 2014. New and old predictive factors for breech presentation: our experience in 14433 singleton pregnancies and a literature review. Journal of Maternal Fetal Neonatal Medicine 27(2): 167-72. https://pubmed.ncbi.nlm.nih.gov/23688372/ Opens a new window [Accessed November 2021]

Garcia MM et al. 2019 Effectiveness and safety of acupuncture and moxibustion in pregnant women with noncephalic presentation: An overview of systematic reviews. Evidence Based Complementary Alternative Medicine 7036914. https://pubmed.ncbi.nlm.nih.gov/31885661/ Opens a new window [Accessed November 2021]

Gray C. 2021. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed November 2021]

Meaghan M et al. 2021. External cephalic version. NCBI StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482475/ Opens a new window [Accessed November 2021]

MedlinePlus. 2020. Breech - series - Types of breech presentation. https://medlineplus.gov/ency/presentations/100193_3.htm Opens a new window [Accessed November 2020]

Noli SA et al. 2019. Preterm birth, low gestational age, low birth weight, parity, and other determinants of breech presentation: Results from a large retrospective population-based study. Biomed Research International https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766171/ Opens a new window [Accessed November 2021]

Pistolese RA. 2002. The Webster Technique: A chiropractic technique with obstetric implications. Journal of Manipulative and Physiological Therapeutics 25(6): E1-9. https://pubmed.ncbi.nlm.nih.gov/12183701/ Opens a new window [Accessed November 2021]

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

• Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the role of the interprofessional team in managing delivery safely for both the mother and the baby.

• Describe the mechanism of labor in the face and brow presentation.
• Summarize potential maternal and fetal complications during the face and brow presentations.
• Review different management approaches for the face and brow presentation.
• Outline some interprofessional strategies that will improve patient outcomes in delivery cases with face and brow presentation issues.
• Introduction

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. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

Face presentation – an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]

In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6]  The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor. [7]

• Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements. 

Planes and Diameters of the Pelvis

The three most important planes in the female pelvis are the pelvic inlet, mid pelvis, and pelvic outlet. 

Four diameters can describe the pelvic inlet: anteroposterior, transverse, and two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three different anteroposterior diameters, named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5cm and is the widest distance between the innominate line on both sides. 

The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. 

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

• Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the presenting diameter in vertex presentation. 
• Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm 
• Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm 
• Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation. 

Cardinal Movements of Normal Labor

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (Restitution)
• Expulsion (delivery of anterior and posterior shoulders)

Some of the key movements are not possible in the face or brow presentations.  

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery will be explained in later sections.

• Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

• Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations. 

Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous.

Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully. 

People who are usually involved in the delivery of face/ brow presentation are:

• Experienced midwife, preferably looking after laboring woman 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (e.g., epidural)
• Theatre team  - in case of failure to progress and an emergency cesarean section will be required.
• Preparation

No specific preparation is required for face or brow presentation. However, it is essential to discuss the labor options with the mother and birthing partner and inform members of the neonatal, anesthetic, and theatre co-ordinating teams.

• Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery, if the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] Fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot take place. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

• Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]

However, there are still some complications associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor.

Prolonged labor itself can provoke foetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications.

Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

• Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to vertex presentation.

Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descend through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section.

Manual attempts to change face presentation to vertex, manual or forceps rotation to mentum anterior are considered dangerous and are discouraged.

• Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf 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 Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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

• Variations in Fetal Position and Presentation |

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

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

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

Occiput posterior position

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

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

Breech presentation

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

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

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

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

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

Labor starts too soon (preterm labor).

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

Other presentations

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

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

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

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

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Variation in fetal presentation

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At the time the article was created The Radswiki had no recorded disclosures.

At the time the article was last revised Yuranga Weerakkody had no financial relationships to ineligible companies to disclose.

• 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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NeoQuest June 2024: Cutaneous Nodules on a Term Newborn

A late preterm infant was born by uncomplicated spontaneous vaginal delivery. Fetal ultrasonography at 20 weeks’ gestation revealed swelling of the right forearm that persisted on repeat ultrasounds. Fetal ultrasonography at 35 weeks’ gestation also demonstrated an increased abdominal circumference. At birth, the infant was noted to have nodular lesions of the upper extremity (Figure 1A) and abdomen (Figure 1B). The remainder of the physical examination was unremarkable.

Figure 1. Nodular lesions of the (A) right upper extremity and (B) abdomen of the infant in the case vignette. Image adapted from: Velagala S, Heiden E, Lisse S, Wu H, Prior D, Chen G, Christison-Lagay E,Provini L, Antaya R, Spencer-Manzon M, Johnston L. A unique presentation of nodular masses in infancy. Neoreviews . 2024.25(6): e370–e374. 1

Of the following, the infant’s underlying diagnosis is most likely associated with:

• Café au lait spots
• Hypercalcemia
• Positive S-100 staining
• Spindle cell proliferation

Answer: D. Spindle cell proliferation

Explanation:

Soft tissue masses in neonates encompass a wide variety of diagnoses. Differentiation of these masses is imperative, as the evaluation and management vary based on the underlying diagnosis.

The masses seen in the infant in the case vignette are most consistent with infantile myofibromatosis (IM), also known as infantile fibromatosis or hemangiopericytoma. 2 This rare tumor is of mesenchymal origin, affecting approximately 1 per 150,000-400,000 live births. 1,3 Affected patients have rubbery, firm, skin-colored, or vascular-appearing lesions (resembling hemangiomas) known as fibromatoses. 1,2   These lesions are most commonly located in the skin, soft tissues, and muscle, and they contain proliferations of spindle cells (Figure 2) that are locally invasive (Option D). 1,2 Though these masses have a high rate of recurrence, they do not metastasize. 2 The fibromatoses in patients with IM can take one of three forms: solitary, multicentric, or generalized. 1-3 Solitary lesions are the most common and are usually located in the head and neck. Because these lesions do not tend to recur, they typically have a good prognosis. 2,4 Multicentric lesions tend to involve the skin, soft tissues, and infrequently, bone. 2,4 Multicentric lesions usually have a good prognosis and can spontaneously regress over time. 2 The generalized form is the most severe as a result of visceral involvement and can be fatal. 2

Café au lait spots (CALs) ( Option A ) are hyperpigmented areas of skin that can be found in healthy newborns, as well as in association with syndromes such as neurofibromatosis type 1 (NF1) (Figure 3). 5 The presence of six or more CALs in a child less than one year of age should raise suspicion for NF1. 5 NF1 is due to a germline mutation in the NF1 gene that encodes neurofibromin, a tumor suppressor gene. 5 Early identification of NF1 is advantageous, as screening for optic gliomas and learning disabilities can begin as early as possible. 5 Cutaneous neurofibromas seen in patients with NF1 do not develop until later in childhood or even adolescence, making this diagnosis unlikely for the infant in the vignette.

Subcutaneous fat necrosis in the newborn (SCFN) consists of indurated nodules, with or without erythema, that are typically localized to bony prominences, including the upper back, buttocks, thighs, shoulders, and occiput. 6 SCFN can occur following therapeutic hypothermia treatment for hypoxic-ischemic encephalopathy, which is not consistent with the infant in this case vignette. 6 Therapeutic hypothermia induces hypoperfusion, leading to granulomatous inflammation and subsequent necrosis of fat tissue. Hypercalcemia is a complication of 80% of cases of SCFN ( Option B ) and is thought to be due to the release of 1,25-dihydroxyvitamin D (1,25(OH) 2 D), causing an increased uptake of calcium from the intestine. 6,7 In contrast to the infant in the case vignette, lesions in SCFN do not develop antenatally and are not present at birth; however, following development, the majority will slowly resolve by 6 months of age. 6

Langerhans cell histiocytosis (LCH), previously known as histiocytosis X, is a rare disorder of histiocytes, an antigen-presenting cell of the innate immune system found in connective tissue. 8,9 Infants with LCH can present with single or multiple isolated skin lesions, including nodules (Figure 4A), or have disseminated multiorgan system involvement. 8,9 The associated lesions most often involve bone (80%), skin (33%), and the pituitary (25%). 8,9 Other, less common organs include the liver, spleen, lungs, and central nervous system (excluding the pituitary). 8 Immunohistochemistry staining of tissue is positive for S-100 ( Option C ) and CD1a (Figure 4B and 4C) antigens. 8,9 There are several variants of LCH that range from benign to life-threatening disseminated forms. 9 While the lesions that occur with LCH can be numerous and look similar to those seen in infantile myofibromatosis, LCH most commonly involves bone, whereas IM most commonly involves the skin.

Did you know? Bone tumors from IM spontaneously regress with complete healing within the first few years of age. 4

While café au lait spots can be seen in otherwise healthy neonates, what genetic conditions other than NF1 are associated with these skin lesions?

For a review of common neonatal pigmentary lesions, refer to: Habeshian KA, Kirkorian AY. Congenital pigmentary anomalies in the newborn. Neoreviews . 2021:22(10)e660-e670. 5

NeoQuest June 2024 Authors :

Allison N. J. Lyle, MD, MA, University of Louisville School of Medicine Lila S. Nolan, MD, Washington University School of Medicine in St. Louis

References:

• Velagala S, Heiden E, Lisse S, Wu H, Prior D, Chen G, Christison-Lagay E,Provini L, Antaya R, Spencer-Manzon M, Johnston L. A unique presentation of nodular masses in infancy. Neoreviews . 2024;25(6);e370–e374
• Fernandez KS. Solid tumors in the neonatal period. Neoreviews . 2014;15(2):e56-e68
• Wu W, Chen J, Cao X, Yang M, Zhu J, Zhao G. Solitary infantile myofibromatosis in the bones of the upper extremities: two rare cases and a review of the literature. Oncology Letters . 2013;6(5);1406-1408
• Eichenfield LF, Frieden IJ (Eds). Neonatal and Infant Dermatology (3 rd ed). Elsevier; 2015
• Habeshian KA, Kirkorian AY. Congenital pigmentary anomalies in the newborn. Neoreviews . 2021:22(10);e660-e670
• Vali P, Lakshminrushimha S. Case 2: Beware of lumps and bumps after cooling! Neoreviews . 2017.18(7);e441-444
• Pavlek LR, Braswell E. Case 1: An infant with arm swelling and nodules. Neoreviews . 2019;20(2);e86-e89
• Liberman MR, Virmani P, Chotikanatis K, Glick SA. Birthmarks of medical significance. Neoreviews . 2015;16(1);e26-e35
• Dokania G, Agrawal H, Niklinski W, Pyati S, Giordano L. Solitary foot nodule in a newborn. Neoreviews . 2016;17(12);e733-e757

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Ý nghĩa của breech presentation trong tiếng Anh

• Until about the 32nd week , most babies are breech presentations , after which time the great majority somersault round with heads down.
• Breech presentation in itself is associated with increased complication , whatever the mode of delivery .
• You noted breech presentation by physical exam , which was subsequently confirmed by ultrasound .
• antenatally
• Apgar score
• birth centre
• birth pangs
• contraction
• gas and air
• vacuum extraction

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