cephalic presentation normal

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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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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

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

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

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

Getty Images

Why Is the Cephalic Position Best?

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

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

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

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

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

Cephalic Posterior

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

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

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

There are three different types of breech fetal positioning:

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

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

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

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

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

Likelihood of a Breech Baby

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

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

Transverse Lie

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

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

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

Determining Fetal Position

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

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

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

Turning a Fetus So They Are in Cephalic Position

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

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

External Cephalic Version (ECV)

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

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

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

Natural Methods For Turning a Fetus

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

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

A Word From Verywell

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

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

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

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

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

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

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

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

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

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

• Key Points |

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

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

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

Fetal position: Relation of the presenting part to an anatomic axis; for vertex 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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• Cephalic Presentation
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Management of Labour and Delivery – Questions

Rekha Wuntakal, Madhavi Kalidindi, Tony Hollingworth in Get Through , 2014

For each clinical scenario below, choose the single most appropriate stage of labour from the above list of options. Each option may be used once, more than once or not at all. A 30-year-old para 3 woman was admitted at term with regular uterine activity at 5 cm cervical dilatation and 4 hours later she delivered a female neonate with APGARs 9, 10, 10 at 1, 5 and 10 minutes. Syntometrine injection was given immediately after delivery and placenta with membranes was delivered completely 20 minutes after the delivery of the baby by continuous cord traction.A 23-year-old para 3 woman was admitted after spontaneous rupture of membranes at 39 weeks’ gestation. She is contracting 4 in 10 minutes and pushing involuntarily. On vaginal examination the cervix was fully dilated, vertex was 2 cm below the spines in direct occipito-anterior position with minimal caput and moulding.A 30-year-old nulliparous woman was admitted at term with uterine contractions once in every 5 minutes. On examination, the fetus is in cephalic presentation with two fifths palpable per abdomen. The cervix is central, soft, fully effaced and 2 cm dilated with intact membranes.

Biometric Measurements and Normal Growth Parameters in a Child

Nirmal Raj Gopinathan in Clinical Orthopedic Examination of a Child , 2021

In cephalic presentation, the intra-uterine fetal position is of universal flexion, which is carried by the child to the immediate post-partum period. The hips and knees are flexed. The lower legs are internally rotated. The feet are further internally rotated with respect to the lower legs. At times there is an external rotational contracture of the hip that tends to mask the true femoral rotational profile. The anatomy of the lower limbs changes significantly as the child grows. This is primarily in response to the development of motor abilities and the ability of the child to crawl, cruise, stand, walk, and finally run. These changes are seen right from the hip joints, the femoral neck, knees, and tibia to the feet.

DRCOG MCQs for Circuit A Questions

Una F. Coales in DRCOG: Practice MCQs and OSCEs: How to Pass First Time three Complete MCQ Practice Exams (180 MCQs) Three Complete OSCE Practice Papers (60 Questions) Detailed Answers and Tips , 2020

External cephalic version: Used to convert a breech presentation to cephalic presentation.Not contraindicated if there is a prior Caesarean section scar.Can cause premature labour.Contraindicated in hypertension.Can be performed after 33 weeks' gestation in a rhesus-negative mother.

Complex maternal congenital anomalies – a rare presentation and delivery through a supra-umbilical abdominal incision

Published in Journal of Obstetrics and Gynaecology , 2018

Samantha Bonner, Yara Mohammed

She had a spontaneous conception and booked at 9 weeks of gestation under consultant-led care. A scan confirmed the pregnancy was in the right uterus. She had no other significant medical history but did suffer from recurrent urinary tract infections and hence was on low-dose antibiotic prophylaxis. There was no sonographic evidence of hydronephrosis. Her body mass index (BMI) was 18 at the time of booking. Combined screening was low risk and she had a normal 20 week anomaly scan. She had serial growth scans which demonstrated a normal growth trajectory on a customised chart. The baby was consistently a cephalic presentation. She had multidisciplinary antenatal care, including specialist urologists, general surgeons, obstetricians and anaesthetists. An antenatal MRI scan had shown extensive adhesions over the lower segment of the uterus. She was extensively counselled regarding the mode of delivery and this was scheduled at 37 weeks of gestation to avoid the potential of spontaneous labour and an emergency Caesarean section.

Utilization of epidural volume extension technique for external cephalic version

Published in Baylor University Medical Center Proceedings , 2021

Hanna Hussey, James Damron, Mark F. Powell, Michelle Tubinis

Repeat ultrasound demonstrated breech presentation, normal amniotic fluid volume, and fetal head toward the maternal left abdomen. After 0.25 mg of intramuscular terbutaline injection, a forward roll was initiated by applying pressure from behind the fetal head toward the maternal left. Continuous progress was made and bedside ultrasound showed cephalic presentation. Immediately after successful ECV, the fetal heart rate was 70 beats/min but returned to baseline with conservative measures. Motor blockade regressed after approximately 1.5 hours. After 4 hours of fetal heart rate monitoring and tocometry, the patient was deemed stable for discharge. Follow-up discussion with the patient via phone call on postprocedure day 1 confirmed that she was not experiencing pain or concerning symptoms for neuraxial complications. She returned to the labor and delivery unit at 40 weeks’ gestation for elective induction of labor and had a successful vaginal delivery.

Antenatal scoring system in predicting the success of planned vaginal birth following one previous caesarean section

Aida Kalok, Shahril A. Zabil, Muhammad Abdul Jamil, Pei Shan Lim, Mohamad Nasir Shafiee, Nirmala Kampan, Shamsul Azhar Shah, Nor Azlin Mohamed Ismail

The inclusion criteria were pregnant women at 36 weeks of gestation or more with singleton foetus in cephalic presentation, who agreed for trial of vaginal delivery after one lower segment caesarean section. We excluded women with contraindication for vaginal birth, or who declined trial of vaginal delivery from this study. Previous antenatal history was noted and recorded during the 36-week assessment, including year and indication for previous caesarean section. Recurrent indications involved were cephalopelvic disproportion and obstructed labour. While non-recurrent indications were foetal distress and malpresentation. Past operative notes were checked for any operative complications such as extended uterine tear, organ injury and post-partum haemorrhage. Information regarding current pregnancy including pre-existing medical disorder was recorded. Estimated foetal weight based on ultrasound scan at 36 weeks of gestation was used in this study.

Related Knowledge Centers

• Breech Birth
• Occipital Bone
• Pelvic Cavity
• Presentation
• Shoulder Presentation

Current Research

• Clinical Trials (United States)
• Clinical Trials (Europe)
• Clinical Trials (Australia/New Zealand)
• Clinical Trials (India)

Knowledge is an evolving asset. Help us improve this page for a future release.

Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

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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• Prenatal Care

Fetal Cephalic Presentation During Pregnancy

What Is Cephalic Position?

Types of cephalic position, benefits of cephalic presentation, risks of cephalic position, what are some other positions and their associated risks, when does a foetus get into the cephalic position, how do you know if baby is in cephalic position, how to turn a breech baby into cephalic position, natural ways to turn a baby into cephalic position.

If your baby is moving around in the womb, it’s a good sign as it tells you that your baby is developing just fine. A baby starts moving around in the belly at around 14 weeks. And their first movements are usually called ‘ quickening’ or ‘fluttering’.

A baby can settle into many different positions throughout the pregnancy, and it’s alright. But it is only when you have reached your third and final trimester that the position of your baby in your womb will matter the most. The position that your baby takes at the end of the gestation period will most likely be how your baby will make its appearance in the world. Out of all the different positions that your baby can settle into, the cephalic position at 36 weeks is considered the best position. Read on to learn more about fetal cephalic presentation.

When it comes to cephalic presentation meaning, the following can be considered. A baby is in the cephalic position when he is in a head-down position. This is the best position for them to come out in. In case of a ‘cephalic presentation’, the chances of a smooth delivery are higher. This position is where your baby’s head has positioned itself close to the birth canal, and the feet and bottom are up. This is the best position for your baby to be in for safe and healthy delivery.

Your doctor will begin to keep an eye on the position of your baby at around 34 weeks to 36 weeks . The closer you get to your due date, the more important it is that your baby takes the cephalic position. If your baby is not in this position, your doctor will try gentle nudges to get your baby in the right position.

Though it is pretty straightforward, the cephalic position actually has two types, which are explained below:

1. Cephalic Occiput Anterior

Most babies settle in this position. Out of all the babies who settle in the cephalic position, 95% of them will settle this way. This is when a baby is in the head-down position but is facing the mother’s back. This is the preferred position as the baby is able to slide out more easily than in any other position.

2. Cephalic Occiput Posterior

In this position, the baby is in the head-down position but the baby’s face is turned towards the mother’s belly. This type of cephalic presentation is not the best position for delivery as the baby’s head could get stuck owing to its wide position. Almost 5% of the babies in cephalic presentation settle into this position. Babies who come out in this position are said to come out ‘sunny side up’.

Cephalic presentation, where the baby’s head is positioned down towards the birth canal, is the most common and optimal fetal presentation for childbirth. This positioning facilitates a smoother delivery process for both the mother and the baby. Here are several benefits associated with cephalic presentation:

1. Reduced risk of complications

Cephalic presentation decreases the likelihood of complications during labor and delivery , such as umbilical cord prolapse or shoulder dystocia, which can occur with other presentations.

2. Easier vaginal delivery

With the baby’s head positioned first, vaginal delivery is generally easier and less complicated compared to other presentations, resulting in a smoother labor process for the mother.

3. Lower risk of birth injuries

Cephalic presentation reduces the risk of birth injuries to the baby, such as head trauma or brachial plexus injuries, which may occur with other presentations, particularly breech or transverse positions.

4. Faster progression of labor

Babies in cephalic presentation often help to stimulate labor progression more effectively through their positioning, potentially shortening the duration of labor and reducing the need for medical interventions.

5. Better fetal oxygenation

Cephalic presentation typically allows for optimal positioning of the baby’s head, which facilitates adequate blood flow and oxygenation, contributing to the baby’s well-being during labor and delivery.

Factors such as the cephalic posterior position of the baby and a narrow maternal pelvis can increase the likelihood of complications during childbirth. Occasionally, infants in the cephalic presentation may exhibit a backward tilt of their heads, potentially leading to preterm delivery in rare instances.

In addition to cephalic presentation, there are several other fetal positions that can occur during pregnancy and childbirth, each with its own associated risks. These positions can impact the delivery process and may require different management strategies. Here are two common fetal positions and their associated risks:

1. Breech Presentation

• Babies in breech presentation, where the buttocks or feet are positioned to enter the birth canal first, are at higher risk of birth injuries such as hip dysplasia or brachial plexus injuries.
• Breech presentation can lead to complications during labor and delivery, including umbilical cord prolapse, entrapment of the head, or difficulty delivering the shoulders, necessitating interventions such as cesarean section.

2. Transverse Lie Presentation

• Transverse lie , where the baby is positioned sideways across the uterus, often leads to prolonged labor and increases the likelihood of cesarean section due to difficulties in the baby’s descent through the birth canal.
• The transverse position of the baby may result in compression of the umbilical cord during labor, leading to decreased oxygen supply and potential fetal distress. This situation requires careful monitoring and intervention to ensure the baby’s well-being.

When a foetus is moving into the cephalic position, it is known as ‘head engagement’. The baby stars getting into this position in the third trimester, between the 32nd and the 36th weeks, to be precise. When the head engagement begins, the foetus starts moving down into the pelvic canal. At this stage, very little of the baby is felt in the abdomen, but more is felt moving downward into the pelvic canal in preparation for birth.

You may think that in order to find out if your baby has a cephalic presentation, an ultrasound is your only option. This is not always the case. You can actually find out the position of your baby just by touching and feeling their movements.

By rubbing your hand on your belly, you might be able to feel their position. If your baby is in the cephalic position, you might feel their kicks in the upper stomach. Whereas, if the baby is in the breech position, you might feel their kicks in the lower stomach.

Even in the cephalic position, it may be possible to tell if your baby is in the anterior position or in the posterior position. When your baby is in the anterior position, they may be facing your back. You may be able to feel your baby move underneath your ribs. It is likely that your belly button will also pop out.

When your baby is in the posterior position, you will usually feel your baby start to kick you in your stomach. When your baby has its back pressed up against your back, your stomach may not look rounded out, but flat instead.

Mothers whose placentas have attached in the front, something known as anterior placenta , you may not be able to feel the movements of your baby as well as you might like to.

Breech babies can make things complicated. Both the mother and the baby will face some problems. A breech baby is positioned head-up and bottom down. In order to deliver the baby, the birth canal needs to open a lot wider than it has to in the cephalic position. Besides this, your baby can get an arm or leg entangled while coming out.

If your baby is in the breech position, there are some things that you can do to encourage the baby to get into the cephalic position. There are a few exercises that could help such as pelvic tilts , swimming , spending a bit of time upside down, and belly dancing are a few ways you can try yourself to get your baby into the head-down position .

If this is not working either, your doctor will try an ECV (External Cephalic Version) . Here, your doctor will be hands-on, applying some gentle, but firm pressure to your tummy. In order to reach a cephalic position, the baby will need to be rolled into a bottom’s up position. This technique is successful around 50% of the time. When this happens, you will be able to have a normal vaginal delivery.

Though it sounds simple enough to get the fetal presentation into cephalic, there are some risks involved with ECV. If your doctor notices your baby’s heart rate starts to become problematic, the doctor will stop the procedure right away.

Encouraging a baby to move into the cephalic position, where the head is down towards the birth canal, is often desirable for smoother labor and delivery. While medical interventions may be necessary in some cases, there are natural methods that pregnant individuals can try to help facilitate this positioning. Here are several techniques that may help turn a baby into the cephalic position:

1. Optimal Maternal Positioning

Maintaining positions such as kneeling, hands and knees, or pelvic tilts may encourage the baby to move into the cephalic position by utilizing gravity and reducing pressure on the pelvis.

2. Spinning Babies Techniques

Specific exercises and positions recommended by the Spinning Babies organization, such as Forward-Leaning Inversion or the Sidelying Release, aim to promote optimal fetal positioning and may help encourage the baby to turn cephalic.

3. Chiropractic Care or Acupuncture

Some individuals find that chiropractic adjustments or acupuncture sessions with qualified practitioners can help address pelvic misalignment or relax tight muscles, potentially creating more space for the baby to maneuver into the cephalic position.

4. Prenatal Yoga and Swimming

Engaging in gentle exercises like prenatal yoga or swimming may help promote relaxation, reduce stress on the uterine ligaments, and encourage the baby to move into the cephalic position naturally. These activities also support overall physical and mental well-being during pregnancy.

1. What factors influence whether my baby will be in cephalic presentation?

Several factors can influence your baby’s position during pregnancy, including the shape and size of your uterus, the strength of your abdominal muscles, the amount of amniotic fluid, and the position of the placenta . Additionally, your baby’s own movements and preferences play a role.

2. Is it necessary for my baby to be in cephalic presentation for a vaginal delivery?

While cephalic presentation is considered the optimal position for vaginal delivery, some babies born in non-cephalic presentations can still be safely delivered vaginally with the guidance of a skilled healthcare provider. However, certain non-cephalic presentations may increase the likelihood of needing a cesarean section.

3. What can I do to encourage my baby to stay in the cephalic presentation?

Maintaining good posture, avoiding positions that encourage the baby to settle into a breech or transverse lie, staying active with gentle exercises, and avoiding excessive reclining can all help encourage your baby to remain in the cephalic presentation. Additionally, discussing any concerns with your healthcare provider and following their recommendations can be beneficial.

This was all about fetus with cephalic presentation. Most babies get into the cephalic position on their own. This is the most ideal situation as there will be little to no complications during normal vaginal labour. There are different cephalic positions, but these should not cause a lot of issues. If your baby is in any position other than cephalic in pregnancy, you may need C-Section . Keep yourself updated on the smallest of progress during your pregnancy so that you are aware of everything that is going on. Go for regular check-ups as your doctor will be able to help you if a complication arises during acephalic presentation at 20, 28 and 30 weeks.

References/Resources:

1. Glezerman. M; Planned vaginal breech delivery: current status and the need to reconsider (Expert Review of Obstetrics & Gynecology); Taylor & Francis Online; https://www.tandfonline.com/doi/full/10.1586/eog.12.2 ; January 2014

2. Feeling your baby move during pregnancy; UT Southwestern Medical Center; https://utswmed.org/medblog/fetal-movements/

3. Fetal presentation before birth; Mayo Clinic; https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/fetal-positions/art-20546850

4. Fetal Positions; Cleveland Clinic; https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth

5. FAQs: If Your Baby Is Breech; American College of Obstetricians and Gynecologists; https://www.acog.org/womens-health/faqs/if-your-baby-is-breech

6. Roecker. C; Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios (Journal of Chiropractic Medicine); Science Direct; https://www.sciencedirect.com/science/article/abs/pii/S1556370713000588 ; June 2013

7. Presentation and position of baby through pregnancy and at birth; Pregnancy, Birth & Baby; https://www.pregnancybirthbaby.org.au/presentation-and-position-of-baby-through-pregnancy-and-at-birth

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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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Malpresentations.

• TRANSVERSE POSITIONS OF THE OCCIPUT
• POSTERIOR POSITIONS OF THE OCCIPUT
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The fetus enters the pelvis in a cephalic presentation approximately 95 to 96 percent of the time. In these cephalic presentations, the occiput may be in the persistent transverse or posterior positions. In about 3 to 4 percent of pregnancies, there is a breech-presenting fetus (see Chapter 25 ). In the remaining 1 percent, the fetus may be either in a transverse or oblique lie (see Chapter 26 ), or the head may be extended with the face or brow presenting.

Predisposing Factors

Maternal and uterine factors.

Contracted pelvis: This is the most common and important factor

Pendulous maternal abdomen: If the uterus and fetus are allowed to fall forward, there may be difficulty in engagement

Neoplasms: Uterine fibromyomas or ovarian cysts can block the entry to the pelvis

Uterine anomalies: In a bicornuate uterus, the nonpregnant horn may obstruct labor in the pregnant one

Abnormalities of placental size or location: Conditions such as placenta previa are associated with unfavorable positions of the fetus

High parity

Fetal Factors

Errors in fetal polarity, such as breech presentation and transverse lie

Abnormal internal rotation: The occiput rotates posteriorly or fails to rotate at all

Fetal attitude: Extension in place of normal flexion

Multiple pregnancy

Fetal anomalies, including hydrocephaly and anencephaly

Polyhydramnios: An excessive amount of amniotic fluid allows the fetus freedom of activity, and he or she may assume abnormal positions

Prematurity

Placenta and Membranes

Placenta previa

Cornual implantation

Premature rupture of membranes

Effects of Malpresentations

Effects on labor.

The less symmetrical adaptation of the presenting part to the cervix and to the pelvis plays a part in reducing the efficiency of labor.

The incidence of fetopelvic disproportion is higher

Inefficient uterine action is common. The contractions tend to be weak and irregular

Prolonged labor is seen frequently

Pathologic retraction rings can develop, and rupture of the lower uterine segment may be the end result

The cervix often dilates slowly and incompletely

The presenting part stays high

Premature rupture of the membranes occurs often

The need for operative delivery is increased

Effects on the Mother

Because greater uterine and intra-abdominal muscular effort is required and because labor is often prolonged, maternal exhaustion is common

There is more stretching of the perineum and soft parts, and there are more lacerations

Bleeding is more profuse, originating from:

Tears of the uterus, cervix, and vagina

Uterine atony from prolonged labor

There is a greater incidence of infection. This is caused by:

Early rupture of the membranes

Excessive blood loss

Tissue damage

Frequent rectal and vaginal examinations

Prolonged labor

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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 vertex 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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External cephalic version.

Meaghan M. Shanahan ; Daniel J. Martingano ; Caron J. Gray .

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Last Update: December 13, 2023 .

• Continuing Education Activity

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

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

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

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

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

• Anatomy and Physiology

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

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

• Indications

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

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

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

• Contraindications

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

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

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

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

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

The personnel typically required to perform an ECV include:

• Obstetrician
• Labor and delivery nurse.

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

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

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

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

• Technique or Treatment

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

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

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

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

• Complications

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

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

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

• Clinical Significance

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

• Enhancing Healthcare Team Outcomes

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

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

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

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

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

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

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