cephalic presentation causes

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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• 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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Fetal Position in the Womb

• Risks and Complications
• Altering Fetal Position

Most fetuses are nestled inside the uterus (womb), curled up tight. This cozy position, knees to chest, is known as the fetal position. During pregnancy, the fetal position also refers to the direction a fetus faces in the uterus and is especially important as you approach delivery.

This article reviews the fetal position and how you and your providers change the fetal position before delivery when necessary.

Illustration by Zoe Hansen for Verywell Health

Fetal Position (or Presentation) In Utero

The ideal fetal position for birth is head down, spine parallel to the pregnant person's spine, face toward the back of the pregnant person's body with the chin tucked and arms folded across the chest. However, there are variations to the fetal position in utero that can affect delivery.

• Cephalic : The fetus is head down, with its chin tucked in and facing the pregnant person's spine.
• Breech : The fetus's buttocks or feet are toward the opening of the womb.
• Transverse : The fetus is sideways, at a 90-degree angle, to the pregnant person's spine.

Healthcare providers describe the fetal position in the uterus in terms of the fetal lie, position, and presentation.

Fetal lie refers to how the fetus's spine aligns with the gestational carrier's spine. Healthcare providers describe it as:

• Longitudinal : Parallel with the pregnant person's spine
• Transverse : Perpendicular to the pregnant person's spine
• Oblique : At an angle to the pregnant person's spine

Fetal Position

"Fetal position" refers to the direction the fetus is facing. The occipital bone is at the back of the fetus's head. Healthcare providers use this bone as a point of reference when describing fetal position, as follows: It is described as:

• Occiput anterior : The occipital bone is at the front of the birthing person's body, so the fetus is facing backward.
• Occiput posterior : The occipital bone is at the back of the birthing person's body, so the fetus is facing forward.

Fetal Presentation

Fetal presentation indicates the body part closest to the birth canal, also called the presenting part. The ideal presentation is the cephalic or vertex position. This when the fetus's head is down and the chin is tucked in and facing the spine. However, in some cases, the fetus can present with one of the following body parts closest to the birth canal:

• Buttocks (also known as the breech position)
• Face or brow

Positions and Risk of Delivery Complications 

Fetuses move, kick, and roll throughout pregnancy. However, during the third trimester, as space in the uterus gets tight, most fetuses naturally reposition into the cephalic fetal position, which is ideal for delivery.

However, some settle into breech or transverse positions. You can still deliver the baby in the following positions, but it can prolong labor and increase the risk of the following complications, which can restrict the baby’s oxygen supply:

• Shoulder dystocia : Occurs when the fetus's shoulder gets stuck in your pelvis
• Head entrapment : Occurs when the fetus's head is stuck inside a partially dilated cervix
• Umbilical cord compression or prolapse : Occurs when the umbilical cord is compressed and restricts oxygen and blood flow to the baby

How to Alter Fetal Position Before Delivery

When a healthcare provider performs an ultrasound and vaginal exam near the end of pregnancy , they may find that the fetus isn't in the ideal head-down position. They can help you explore options to alter the fetal position before delivery.

At home, you can try playing music by placing headphones or a speaker at the bottom of your uterus to encourage the fetus to turn. You can also put something cool on the top of your stomach and something warm (not hot) at the bottom to promote movement.

Specific exercises and yoga poses can help relax your pelvis and uterus, creating more room for the fetus and nudging it into the head-down position. Talk with your healthcare provider before attempting these techniques:  

• Cat-cow stretch : Get on your hands and knees and alternate between arching your back upward (like a cat) and dipping it downward (like a cow). 
• Pelvic circles : Gently make circles with your pelvis while standing.
• Child’s pose : Kneel on the ground, sit back on your heels, and stretch your arms forward, lowering your chest towards the ground. You can rest your forehead on the floor or on a cushion. Rest in this pose for 10-15 minutes. 
• Pelvic tilts : Lie on your back with your knees bent and your feet flat on the floor. Slowly tilt your hips upward, then release, returning to a neutral position. You can do this exercise for 10 to 20 minutes three times daily. 

Alternative options include seeing a chiropractor or acupuncturist that your healthcare provider recommends. Chiropractors align your hips and spine. Acupuncture is an Eastern medicine practice that involves inserting tiny needles in certain areas to balance your body’s energy. 

At the Hospital 

At the hospital, your provider may try an external cephalic version (ECV), in which they apply pressure to your belly to turn the fetus's head down.

Providers typically perform ECVs around 37 to 39 weeks' gestation, when the fetal size and the amount of amniotic fluid are ideal. An ECV is generally safe, but there are some risks, including fetal distress and preterm labor (rare).

The success rate of an ECV is about 60%. If an ECV is unsuccessful, your provider may recommend a surgical delivery known as a cesarean section (C-section). Before this surgical procedure, you will receive spinal anesthesia (numbing medicine), and your provider will make incisions in your belly to deliver the baby.

The fetal position indicates fetal alignment and presentation in the uterus. The cephalic (head-down) position is ideal for delivery. While it is possible to vaginally deliver a baby in other fetal positions, the risk of complications increases. There are ways to try to move the fetus at home or in the hospital; however, discuss these options with a healthcare provider before trying them at home.

Merck Manuals Consumer Version. Fetal presentation, position, and lie (including breech presentation) .

Yang L, Yi T, Zhou M, Wang C, Xu X, Li Y, Sun Q, Lin X, Li J, Meng Z. Clinical effectiveness of position management and manual rotation of the fetal position with a U-shaped birth stool for vaginal delivery of a fetus in a persistent occiput posterior position . J Int Med Res . 2020;48(6):300060520924275. doi:10.1177/0300060520924275

American Academy of Family Physicians. What can I do if my baby is breech ? 

Felemban AS, Arab K, Algarawi A, Abdulghaffar SK, Aljahdali KM, Alotaifi MA, Bafail SA, Bakhudayd TM. Assessment of the successful external cephalic version prognostic parameters effect on final mode of delivery . Cureus. 2021;13(7):e16637. doi:10.7759/cureus.16637

Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action . Health Sci Rep . 2023;6(5):e1274. doi: 10.1002/hsr2.1274

By Brandi Jones, MSN-ED RN-BC Jones is a registered nurse and freelance health writer with more than two decades of healthcare experience.

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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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If Your Baby Is Breech

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Frequently Asked Questions Expand All

In the last weeks of pregnancy, a fetus 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 fetus’s buttocks, feet, or both are in place to come out first during birth. This happens in 3–4% of full-term births.

It is not always known why a fetus is breech. Some factors that may contribute to a fetus being in a breech presentation include the following:

You have been pregnant before.

There is more than one fetus in the uterus (twins or more).

There is too much or too little amniotic fluid .

The uterus is not normal in shape or has abnormal growths such as fibroids .

The placenta covers all or part of the opening of the uterus ( placenta previa )

The fetus is preterm .

Occasionally fetuses with certain birth defects will not turn into the head-down position before birth. However, most fetuses in a breech presentation are otherwise normal.

Your health care professional may be able to tell which way your fetus is facing by placing his or her hands at certain points on your abdomen. By feeling where the fetus's head, back, and buttocks are, it may be possible to find out what part of the fetus is presenting first. An ultrasound exam or pelvic exam may be used to confirm it.

External cephalic version (ECV) is an attempt to turn the fetus so that he or she is head down. ECV can improve your chance of having a vaginal birth. If the fetus is breech and your pregnancy is greater than 36 weeks your health care professional may suggest ECV.

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 )

ECV can be considered if you have had a previous cesarean delivery .

The health care professional performs ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the fetus rolls into a head-down position. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning.

The fetus's heart rate is checked with fetal monitoring before and after ECV. If any problems arise with you or the fetus, ECV will be stopped right away. ECV usually is done near a delivery room. If a problem occurs, a cesarean delivery can be performed quickly, if necessary.

Complications may include the following:

Prelabor rupture of membranes

Changes in the fetus's heart rate

Placental abruption

Preterm labor

More than one half of attempts at ECV succeed. However, some fetuses who are successfully turned with ECV move back into a breech presentation. If this happens, ECV may be tried again. ECV tends to be harder to do as the time for birth gets closer. As the fetus grows bigger, there is less room for him or her to move.

Most fetuses that are breech are born by planned cesarean delivery. A planned vaginal birth of a single breech fetus may be considered in some situations. Both vaginal birth and cesarean birth carry certain risks when a fetus is breech. However, the risk of complications is higher with a planned vaginal delivery than with a planned cesarean delivery.

In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily. There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord . It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

Although a planned cesarean birth is the most common way that breech fetuses are born, there may be reasons to try to avoid a cesarean birth.

A cesarean delivery is major surgery. Complications may include infection, bleeding, or injury to internal organs.

The type of anesthesia used sometimes causes problems.

Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications with the placenta.

With each cesarean delivery, these risks increase.

If you are thinking about having a vaginal birth and your fetus is breech, your health care professional will review the risks and benefits of vaginal birth and cesarean birth in detail. You usually need to meet certain guidelines specific to your hospital. The experience of your health care professional in delivering breech babies vaginally also is an important factor.

Amniotic Fluid : Fluid in the sac that holds the fetus.

Anesthesia : Relief of pain by loss of sensation.

Breech Presentation : A position in which the feet or buttocks of the fetus would appear first during birth.

Cervix : The lower, narrow end of the uterus at the top of the vagina.

Cesarean Delivery : Delivery of a fetus from the uterus through an incision made in the woman’s abdomen.

External Cephalic Version (ECV) : A technique, performed late in pregnancy, in which the doctor attempts to manually move a breech baby into the head-down position.

Fetus : The stage of human development beyond 8 completed weeks after fertilization.

Fibroids : Growths that form in the muscle of the uterus. Fibroids usually are noncancerous.

Oxygen : An element that we breathe in to sustain life.

Pelvic Exam : A physical examination of a woman’s pelvic organs.

Placenta : Tissue that provides nourishment to and takes waste away from the fetus.

Placenta Previa : A condition in which the placenta covers the opening of the uterus.

Placental Abruption : A condition in which the placenta has begun to separate from the uterus before the fetus is born.

Prelabor Rupture of Membranes : Rupture of the amniotic membranes that happens before labor begins. Also called premature rupture of membranes (PROM).

Preterm : Less than 37 weeks of pregnancy.

Ultrasound Exam : A test in which sound waves are used to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus.

Umbilical Cord : A cord-like structure containing blood vessels. It connects the fetus to the placenta.

Uterus : A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus.

Vagina : A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

Vertex Presentation : A presentation of the fetus where the head is positioned down.

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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.

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• Childbirth Problems

Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study

Robyn schafer.

1 Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, NJ, United States of America

2 Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States of America

Marit L. Bovbjerg

3 Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States of America

Melissa Cheyney

4 Department of Anthropology, Oregon State University, Corvallis, OR, United States of America

Julia C. Phillippi

5 School of Nursing, Vanderbilt University, Nashville, TN, United States of America

Associated Data

MANA Stats data are available to researchers with an approved data use agreement. Researchers can apply for access to use MANA Stats data by emailing gro.statsanam@snoitacilppahcraeser .

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling)

Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats)

Planned community birth (homes and birth centers), United States

Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset

Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes

Main outcome measures

Maternal : intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture

Neonatal : transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death

One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7–10.4 and OR 18.6, 95% CI 15.9–21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4–16.3), even after congenital anomalies were excluded.

Conclusions

All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Introduction

There has been a recent increase in breech birth in community settings (homes and birth centers) in the United States [ 1 ]. This is despite research demonstrating increased risk of intrapartum or neonatal death (16.8/1000 adjusted odds ratio [aOR] 8.2, 95% CI, 3.7–18.4) [ 2 ] in breech community births and consensus obstetric and midwifery recommendations that classify breech presentation as a contraindication to home birth [ 3 , 4 ]. Since 2000, planned cesarean has been the standard of care for breech presentation, following a landmark large-scale, randomized controlled trial (the Term Breech Trial) [ 5 ] and subsequent American College of Obstetricians and Gynecologists (ACOG) committee opinion [ 6 ] recommending planned cesarean delivery for all singleton term breech fetuses. However, more recent research has called those recommendations into question [ 7 – 12 ], concluding that although risk of adverse outcomes is higher in planned vaginal breech birth than planned cesarean, the absolute risk is quite low [ 13 – 16 ]. Internationally, support for vaginal breech birth is increasing [ 17 – 20 ], but nearly all breech fetuses (95.5%) in the US are born via cesarean [ 1 , 13 , 14 , 21 ]. ACOG committee opinion now recommends that for a term, singleton fetus, planned vaginal breech birth “may be reasonable under hospital-specific protocol guidelines for eligibility and labor management” [ 22 ]. However, hospital-based care for planned vaginal breech birth in the US is very difficult to obtain, in part due to a lack of skilled providers and medicolegal concerns [ 22 – 24 ], leading some individuals to seek care in community-based settings (homes and birth centers) [ 25 – 27 ].

Breech presentation affects approximately 3–4% of term pregnancies, and community births currently comprise about 2% of US births [ 28 , 29 ]. Based on birth certificate data from the National Center for Health Statistics, rates of US community births rose 33.2% from 2019 to 2022, including a 61.7% increase in breech births (n = 423 in 2019, n = 684 in 2022), in tandem with a decrease in hospital births [ 1 ]. In 2022, 12.5% (n = 488) of all reported singleton, term (greater than or equal to 37 + 0/7 weeks’ gestation) vaginal breech births in the US occurred in a community birth setting [ 1 ]. Research has established that intrapartum and neonatal death rates are higher in breech birth than cephalic births [ 2 ], but little is known about neonatal and maternal outcomes associated with breech presentation managed in community birth settings.

Data is also limited about maternal and neonatal outcomes based on type of breech presentation. Breech presentation is classified based on the position of the lower fetal extremities (see Table 1 ). Breech presentation nomenclature has been applied inconsistently in research and clinical practice recommendations, and there is ambiguity about variations of presentation types (such as partial flexion, location of feet alongside or just below the buttocks, or dynamic presentations that change during labor) [ 5 , 15 , 18 , 30 – 32 ]. Alternative nomenclatures have been proposed, but none have gained widespread acceptance [ 33 , 34 ]. Footling or kneeling breech presentation is generally considered a contraindication to vaginal birth due to increased risk of perinatal morbidity from umbilical cord prolapse or head entrapment leading to hypoxic injury [ 17 – 19 , 22 ]. However, there is limited evidence to support this recommendation since, with rare exceptions [ 30 , 35 ], vaginal breech trials historically have excluded (or not reported data regarding) footling or kneeling presentations [ 5 , 15 , 16 , 36 , 37 ]. Research that examines potential differences in community birth outcomes associated with type of breech presentation is needed to guide informed decision-making and optimize perinatal outcomes [ 2 ]. The purpose of this study was to analyze associations between breech birth and maternal and neonatal outcomes compared to cephalic presentations in planned community births and assess differences in outcomes associated with type of breech presentation.

* There is not a consensus definition for position of the fetal feet in a complete presentation, which either (a) cannot be below the fetal buttocks [ 5 ] or (b) may be palpable at or just below the buttocks [ 16 , 18 ].

† The term “incomplete” is inconsistently defined in the literature as either (a) both hips flexed with one knee flexed and one knee extended [ 18 , 30 ] or (b) one or both hips not completely flexed, regardless of attitude at the knee (in essence, an umbrella term for footling and kneeling presentations) [ 38 , 39 ].

Materials and methods

This cohort study used registry data (birth years 2012–2018) from the Midwives Alliance of North America Statistics Project (MANA Stats). MANA Stats includes extensive prenatal, birth, and postpartum data from individuals who received care from midwives in community birth settings in the United States. Individuals are prospectively enrolled in the registry at the onset of care in pregnancy with informed consent, and midwives enter data throughout perinatal care. MANA Stats development, data collection protocols, and evidence of reliability and validity are described elsewhere [ 40 , 41 ]. Ethical approval was received from Oregon State University’s IRB. All pregnant persons and midwives gave informed consent for research participation.

MANA data were accessed July 1, 2019. The study sample (N = 71,943) included all singleton, term births for individuals who planned community birth at the onset of labor and had a documented fetal presentation at birth ( Fig 1 ). Pregnancies missing information on fetal presentation at birth were excluded, as were persons who changed their intended site of birth to a hospital setting prior to onset of labor. Both vaginal and cesarean births were included. The main exposure of interest was breech presentation at birth (n = 695) in comparison to cephalic presentation, subdivided by type of breech presentation as defined by the data set variable “breech presentation at birth” as frank, complete, footling, kneeling, or unknown. No formal definitions of breech types were provided to midwives entering data into the registry; those who were uncertain could contact MANA Stats support staff for assistance.

We explored associations between breech presentations at time of birth and multiple perinatal outcomes including durations of labor stages and membrane rupture. Labor stages were defined in the MANA Stats system as follows: first stage as the interval between frequent, intense contractions and onset of pushing; second stage as the start of active pushing efforts until birth of the neonate; and third stage as time from birth of the neonate until placental expulsion, as described in prior publications [ 42 ]. The management of impossible or improbable duration values are described in supplemental materials ( S1 Table ). Because this was a cohort of planned community births, intrapartum or postpartum transfer to hospital within six hours after birth was assessed, along with the reason(s) for transfer and urgency. Determination of indication(s) for transfer and associated urgency were based on assessment of the transferring midwife. We also analyzed maternal hospitalization in the first six weeks postpartum, including new admissions following community birth and postpartum readmissions. Finally, we evaluated adverse maternal outcomes, including severe (i.e., third- or fourth-degree) perineal laceration, retained placenta, and obstetric hemorrhage (defined as ≥1000 mL and/or diagnosed hemorrhage regardless of estimated blood loss) [ 43 ].

Neonatal outcomes included transfer to hospital in the first six hours of life (including indications and urgency), hospitalization (any) and/or NICU admission in the first six weeks of life (whether primary or readmission), umbilical cord prolapse, birth injury (defined as “skeletal fracture, peripheral nerve injury, and soft tissue or solid organ hemorrhage requiring intervention”), and intrapartum or neonatal death up to six weeks. Because term breech presentation is associated with congenital anomalies [ 44 – 46 ], we also assessed the presence of congenital anomalies (diagnosed antenatally or in the first six weeks of life) and explored deaths associated with anomalies separately. For every intrapartum or neonatal death, we explored free-text data entered by the community birth midwives describing the clinical course and circumstances surrounding care and provided brief case summaries.

Statistical analyses were performed using SPSS V 24.0.0.0 (IBM Corporation, Armonk, NY, USA) and R version 3.3.2 (R Foundation for Statistical Computing, Vienna, Austria). Initial analysis compared all types of breech presentation, collectively, to cephalic presentation. Analyses were then repeated to compare outcomes by presentation type. Medians and interquartile range are reported for labor durations and frequencies for all other outcomes. Because multivariable models were not possible due to low event counts for adverse outcomes, bivariable analyses were performed. We reported counts and proportions, including odds ratios (ORs) and confidence intervals (CI) for outcomes with five or more events in both comparison groups. Standard bivariable statistics were used to explore associations. We used unadjusted logistic regression models to calculate ORs and 95% CIs for categorical outcomes and the Kruskal-Wallis test to assess associations between breech presentation and labor duration, stratified by parity.

To contextualize our study sample, we compared the overall proportion of breech presentation to the expected proportion in the general US childbearing population based on vital statistics data (2016–2021) [ 47 ]. With the understanding that maternity care policies related to breech birth care may affect access to care and health outcomes [ 48 ], we also explored the two most frequent outcomes (cesarean and intrapartum transfer) for both cephalic and breech presentation stratified by covariables of planned site of community birth (i.e., home or birth center) and region of the country. Finally, since there is evidence that the level of integration of community birth providers into regional health systems affects maternal and neonatal birth outcomes [ 49 ], we explored associations state-level midwifery care integration scores (defined by Vedam et al., 2018) as an additional covariable in this analysis.

In this sample of 71,943 individuals, 1% (n = 695) gave birth to a term, singleton, breech neonate. Incidence of breech births in this low-risk sample of planned community births was, predictably, lower than the rate of 2.8% found the general US childbearing population (based on term, singleton births with known presentation from 2016–2021). As shown in Table 2 , demographic characteristics of individuals in this sample who experienced breech birth were generally similar to those with a cephalic birth, except for increased likelihood of being nulliparous (48.7% breech, 32.6% cephalic) and not eligible for low-income public health insurance (19.5% breech, 23.2% cephalic). Of the 695 breech neonates in this sample, the majority presented frank breech at birth (57.0%, n = 396), followed by complete (19.3%, n = 134), footling (17.7%, n = 123), and kneeling (0.7%, n = 5) presentations. Type of breech presentation was unknown in 5.3% (n = 37) of births.

a For maternal age, the p-value is from a t-test assuming equal variances

b Denominator is multiparas

c Other types of providers included student midwives under supervision, clinicians with other credentials (e.g., ND, DO, lay midwives), and unknown or missing provider credential information.

Notes: Data come from the Midwives Alliance of North America Statistics Project (MANA Stats), birth years 2012–2018. Comparison of demographic and pregnancy risk factor variables between births including a breech fetus, compared to births with a cephalic fetus. Sample was limited to singleton, not preterm, and not missing information on presentation.

Associations between breech presentation and maternal and neonatal outcomes are presented in Table 3 , with reasons for transfer detailed and compared in Table 4 . Nearly half (42.4%) of all breech neonates in planned community births were born via cesarean (versus 3.8% for cephalic), and, relatedly, more individuals with a breech fetus transferred from community birth settings to the hospital in the intrapartum period (OR 9.0, 95% CI 7.7–10.4). Midwives classified more breech intrapartum transfers as urgent (46% v. 17%, p < 0.001), with malpresentation/malposition (85%) being the most common reason for intrapartum transfer. Multiple indications for transfer were commonly cited. Other than cord prolapse and fetal malpresentation, all other reasons for transfer were more common among cephalic labors. After intrapartum transfer (n = 344), 50 breech neonates were born vaginally (14.5%, vs. 61.4% of cephalic intrapartum transfers) in hospital settings. Vaginal hospital births included 30 frank breech, 7 complete, 12 footling, and 1 unknown breech type.

a limited to those who completed community birth

b limited to vaginal births; includes third- and fourth-degree lacerations

Notes: Odds Ratios are breech vs. cephalic, so OR > 1 means the outcome is more common in breech labors, and OR < 1 means outcome is less common in breech labors. All ORs are unadjusted because of small sample sizes.

a Multiple item selection permissible on data entry

b P-values are suppressed unless there were at least 5 events in both groups.

c Other reasons were reported as

Medical complications: abnormal vital signs, seizure, stroke, active herpes simplex infection, cardiac condition, excessive nausea, and vomiting

Obstetric complications: prolonged rupture of membranes, precipitous labor (unattended), hypertensive disorders of pregnancy, oligohydramnios, postterm gestation, cervical edema, urinary retention

Situational or environmental factors: poor weather conditions, independent maternal decision to transfer, state regulations, lack of availability of birth attendant

d Postpartum and neonatal transfer include transfers within the first 6 hours after birth.

e Other reasons were reported as

Medical complications: abnormal vital signs, postpartum psychosis, syncope

Obstetric complications: precipitous labor

Situational or environmental factors: maternal intuition (“didn’t feel right”), desire to remain with neonate requiring transfer

f Other reasons were reported as

Neonatal complications: lethargy, cardiac arrythmia, unspecified (baby “didn’t look right”), protocol following resuscitation (not meeting criteria for respiratory distress syndrome)

Situational or environmental factors: precipitous and/or unattended birth, desire for neonate to remain with postpartum person requiring transfer

Maternal postpartum transfers were also more likely to be considered urgent in breech births (OR 2.7, 95% CI 1.5–4.6), even though prevailing maternal indications for transfer (including hemorrhage, laceration repair, and retained placenta) were more common in the cephalic group. Neither postpartum hemorrhage nor maternal hospitalization increased significantly with breech presentation compared to cephalic. There were insufficient events of operative births (i.e., forceps) (n = 4) or retained placenta (n = 7) for analysis.

Distributions of labor duration variables are shown in Fig 2 , stratified by presentation and parity. Median active labor for breech fetuses among nulliparas was shorter than cephalic fetuses (406 vs. 480 minutes), but the opposite was true for multiparous individuals (228 breech vs. 207 cephalic). There were no significant differences in duration of second or third stages based on fetal presentation, although breech labors were associated with significantly longer durations of membrane rupture for both nulliparas (median 336 minutes for breech vs. 268 cephalic) and multiparas (84 breech vs. 31 cephalic).

For neonates, breech presentation was associated with increased odds of neonatal transfer, NICU admission, and birth injury (OR 4.7, 95% CI 3.1–7.0; OR 2.6, 95% CI 1.9–3.5; and OR 7.9, 95% CI 4.7–13.2, respectively) ( Table 3 ). There was no association between presentation at birth and neonatal hospitalization. Regarding indications for neonatal transfer ( Table 4 ), breech neonates were more likely to transfer for birth injury (18.5% vs. 3.5%) and “other” (not listed) reasons (55.6% vs. 30.9%) and less likely to transfer for respiratory distress (40.7% vs. 60.7%). Breech births were also more likely to experience umbilical cord prolapse (2.2% v. 0.1%, OR 32.2, 95% CI 18.0–57.7).

There was also a substantive increase in odds of intrapartum or neonatal death for the breech fetus (OR 8.5, 95% CI 4.4–16.3). Although based on only ten perinatal deaths (five intrapartum and five neonatal), this association persisted even when deaths related to congenital anomalies were excluded (OR 8.3, 95% CI 4.0–17.1). Deaths (described in S2 Table ) were attributed to congenital anomalies (n = 4), head entrapment (n = 3), cord prolapse (n = 2), and unknown causes (interoperative death, suspected placental abruption) (n = 1). Several intrapartum/neonatal deaths were complicated by late diagnosis of breech presentation and inefficient transfer of care including medical errors by emergency medical services (EMS), delays in hospital assessment and treatment, and conflicts with EMS or hospital staff. It is also worth noting that intrapartum/neonatal deaths included several instances of late onset of community-based care, with the midwives describing assuming responsibility for antepartum care only after hospital providers declined care for planned vaginal birth due to breech presentation in the absence of other risk factors.

Maternal and neonatal outcomes stratified by type of breech presentation are shown in Table 5 . For many outcomes, the small sample size of breech births and correspondingly low event counts preclude firm conclusions; however, a few patterns do emerge from the limited data. Rates of intrapartum transfer and cesarean birth are similar across all breech types, and postpartum hemorrhage was less common with frank breech (3.3% frank vs. 6.0% complete, 7.0% footling/kneeling). Neonatal transfers, hospitalization, and NICU admissions were twice as common in footling/kneeling presentations. Umbilical cord prolapse was also significantly more common, occurring in 7.3% of footling/kneeling breech births (0.8% frank, 2.3% complete); however, perinatal death was half as likely (7.8/1000 footling/kneeling vs. 20/1000 frank, 22/1000 complete)—a finding that should be interpreted with caution given the low incidence of death (n = 1) in the footling/kneeling group.

a limited to those who completed community birth: 64,176 cephalic, 208 frank, 68 complete, 62 footling or kneeling presentations

Data are from planned community births in the USA, 2012–2018, limited to singleton term labors for which fetal presentation at birth was identified. Odds ratios use frank breech as the reference group (i.e., complete vs. frank; footling/kneeling vs. frank). Breech presentations of unknown type (N = 37) were excluded from this analysis.

Odds ratios have been suppressed for any category for which there were <5 events in either the numerator or denominator.

Finally, analysis of contextual variables ( S3 Table ) found higher rates of cesarean and intrapartum transfer for breech labors in the New England region (OR 17.6, 95% CI 7.6–40.9 and OR 47.2, 95% CI 20.1–110.7, respectively) compared to other regions of the country. There were no substantive differences in outcomes based on planned site of community birth (i.e., home or birth center) or level of integration of community birth midwifery services into the healthcare system, as defined by Vedam et al.[ 49 ]

Among this sample of planned community births, breech presentation was associated with high rates of intrapartum transfer and cesarean birth (OR 9.0 and 18.6, respectively) and no increased risk of maternal hospitalization or postpartum hemorrhage. Associations with nearly all assessed adverse neonatal outcomes were increased in breech births, including transfer, NICU admission, and birth injury. Umbilical cord prolapse occurred in 2.2% of breech births (OR 32.2, 95% CI 18.0–57.7). There was a high rate of intrapartum and neonatal death (14.4/1000, OR 8.5, 95% CI 4.4–16.3), which persisted even after excluding congenital anomalies.

All types of breech presentation carry additional risk for adverse neonatal outcomes. Although sample sizes precluded meaningful analysis of perinatal outcomes associated with type of breech presentation, our findings support existing research that increased incidence of umbilical cord prolapse in footling/kneeling breech presentations may not be associated with increased risk of severe complications [ 50 ], though this result should be interpreted with caution. Labor duration was not affected by type of breech presentation, as consistent with prior findings [ 51 ]. Although there was some regional variation in rates of maternal transfer and cesarean, there were no substantive differences in outcomes based on parity, planned site of birth, or level of care integration of community-based midwifery services.

Due to logistical and ethical concerns about randomizing individuals to site or mode of birth [ 10 , 52 , 53 ], assessment of outcomes associated with breech presentation relies primarily on observational evidence. This descriptive analysis is useful for guiding decision-making for breech labor and birth. The size and scope of this dataset are a strength of this study, with a large sample of individuals across community birth settings throughout the United States and high rates of participation in data collection from community midwives (>95%) [ 40 ]. Prospective enrollment in pregnancy ensured that all birth outcomes were included, thereby minimizing selection bias and potential underreporting of adverse outcomes [ 40 ]. Additionally, this dataset includes vaginal breech births and footling/kneeling presentations, which are often excluded from research.

Despite these strengths, there are also several limitations to the research based on this dataset. First, because participation in data collection is voluntary, outcomes may differ between providers who participate in data collection and those who do not. Second, as with any dataset, research findings are limited by the existing variables and their definitions. For example, because community birth providers avoid frequent or unnecessary cervical examinations, the dataset defined onset of second stage by initiation of pushing (rather than with onset of full cervical dilation as it is commonly defined). Although these definitions are used elsewhere in the literature [ 42 ], these findings may not correlate exactly to other studies exploring labor durations. Similarly, the lack of variables regarding comprehensive clinical and environmental factors prohibited investigation of predictive factors associated with breech birth outcomes. For example, we could not distinguish between planned and unplanned breech births, assess relationships with external cephalic version, determine when breech presentation was identified or whether a skilled breech attendant was present, or correlate outcomes with regulatory scope of practice restrictions, such as state regulations that limit community birth providers’ care for breech labors.

One additional limitation of this study is the possibility that not all presentation types were classified accurately. In community birth settings, there is rarely access ultrasound technology to confirm presentation, and evidence has demonstrated poor reliability in determining presentation by physical examination alone [ 54 ]. Due to constraints of existing breech nomenclature, there was also potential for unreliable classifications of presentation variants (such as when the hips and knees are incompletely flexed or feet are located alongside or just below the buttocks) or those that changed during labor (such as a complete breech fetus who extends a leg). Finally, because community birth care utilizes low levels of intervention, findings from breech community birth may not be generalizable to high-resource hospital settings [ 14 ].

Interpretation and implications

Findings from this study reinforce existing evidence of increased risk of adverse neonatal outcomes in breech community birth [ 2 , 55 , 56 ]. Although many emergent interventions and technologies are not readily accessible in community births, the physiologic approach exemplified in these settings is widely considered by expert breech clinicians to be optimal for perinatal outcomes [ 57 , 58 ]. However, even physiologic management in a low-risk population does not appear to circumvent risks to the breech neonate.

This research has implications for clinical practice, health care policy, and future research. Pregnant people should be counselled about the increased risk of adverse neonatal outcomes for breech fetuses in planned community births. These risks should be considered in context of the risks and benefits associated with sites and modes of birth, including risks to future pregnancies and individuals’ unique needs, preferences, values, and risk tolerance [ 13 , 17 ]. Care providers in all settings should take steps to identify breech presentation at term and provide evidence-based information about breech birth outcomes to ensure informed choice. Skills in breech assessment and management should be incorporated into midwifery and obstetric training to optimize outcomes. Recognizing that breech community births will inevitably occur, both accidentally and intentionally, community and hospital birth providers should develop guidelines to identify and manage complications and provide timely and efficient transfer when needed [ 59 ].

Community birth is not well integrated into the health care system throughout the United States [ 49 , 60 ], and this lack of coordination of care across birth settings was evident in several intrapartum and neonatal deaths in this sample. In addition, it was noted in a few cases that individuals were late to community-based care after they were declined care for planned hospital vaginal birth due to breech presentation in the absence of other risk factors. Community birth in the presence of high-risk conditions often indicates a failure of the medical system to meet patient’s needs for less interventive care and autonomy in decision-making [ 27 , 61 – 64 ]. Restrictive policies preventing hospital providers from offering care for planned vaginal breech birth to appropriate candidates should be eliminated as they impede patient autonomy and access to care and inadvertently push more medically complex births into community settings [ 24 , 26 , 57 , 59 , 65 , 66 ].

In prior published analyses using this data set, members of this research team recommended that, due to increased risk of adverse outcomes in community birth, breech presentations were better managed in birth settings with immediate access to hospital staff and facilities [ 2 ]. However, despite US recommendations supporting care for planned vaginal breech birth for appropriately screened candidates in hospitals [ 17 , 22 ], access to vaginal breech birth and skilled breech providers in hospitals remains limited [ 25 , 26 ]. Findings from this study, along with the recent increase in US breech community births, reinforce consensus recommendations that US hospitals have a “clear and urgent responsibility” [ 25 ] to increase access to care for planned vaginal breech given the increased risk of adverse perinatal outcomes associated with breech community birth compared to cephalic presentations. Policies and medicolegal reforms that incorporate best available evidence and center the birthing person and their rights to autonomy are necessary to improve maternal and neonatal outcomes and support informed choice for breech pregnancy and birth.

Breech presentation in all birth settings is associated with increased risk of adverse outcomes compared to cephalic presentation, and further research is needed to explore maternal and neonatal outcomes in matched cohorts of breech births in different settings with skilled breech providers. There is a need for development and adoption of a consistent and well-defined breech nomenclature to minimize ambiguity between presentation types and facilitate evidence synthesis. Future studies should explore outcomes based on type of breech presentation using this standardized nomenclature and report outcomes according to a standardized core outcome set (e.g., Breech-COS, currently in development) [ 67 ]. Research on breech labor outcomes is needed to guide decision-making, given that comparisons of prelabor cesarean to planned vaginal birth are not generalizable to laboring persons facing either emergent cesarean or unplanned vaginal breech birth. Researchers should assess the proportion of breech presentations correlated with underlying conditions (i.e., fetal growth restriction, congenital anomalies, oligohydramnios, placenta previa, maternal gestational diabetes mellitus or hypertensive disorders, uterine malformation, or history of cesarean) [ 45 , 68 ] and investigate how these conditions affect morbidity and mortality, regardless of mode or site of birth. Finally, research is needed to explore the barriers and facilitators of breech birth care in the United States to guide recommendations to improve access to quality care [ 26 ].

In planned community births, all types of breech presentation pose substantial risk of adverse outcomes, including high rates of intrapartum and neonatal death. This research provides evidence about breech labor in community birth settings and adverse maternal and neonatal outcomes associated with breech birth to inform decision-making. There is a need for increased training and research on vaginal breech birth. Reforms are needed to ensure accessible, high-quality care for planned vaginal breech birth in US hospitals.

Supporting information

S1 appendix, acknowledgments.

The authors gratefully acknowledge the midwives who contributed data to the MANA Stats Project.

Funding Statement

Marit L. Bovbjerg and Melissa Cheyney received funding from the United States National Institute of Health (Grant R03HD096094) towards this research effort. The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability