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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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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, 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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Malpresentation

8-minute read

If you feel your waters break and you have been told that your baby is not in a head-first position, seek medical help immediately .

• Malpresentation is when your baby is not facing head-first down the birth canal as birth approaches.
• The most common type of malpresentation is breech — when your baby’s bottom or feet are facing downwards.
• A procedure called external cephalic version can sometimes turn a breech baby into a head-first position at 36 weeks.
• Most babies with malpresentation are born by caesarean, but you may be able to have a vaginal birth if your baby is breech.
• There is a serious risk of cord prolapse if your waters break and your baby is not head-first.

What are presentation and malpresentation?

‘Presentation’ describes how your baby is facing down the birth canal. The ‘presenting part’ is the part of your baby’s body that is against the cervix .

The ideal presentation is head-first, with the crown (top) of the baby’s head against the cervix, with the chin tucked into the baby’s chest. This is called ‘vertex presentation’.

If your baby is in any other position, it’s called ‘malpresentation’. Malpresentation can mean your baby’s face, brow, buttocks, foot, back, shoulder, arms or legs or the umbilical cord are against the cervix.

It’s safest for your baby’s head to come out first. If any other body part goes down the birth canal first, the risks to you and your baby may be higher. Malpresentation increases the chance that you will have a more complex vaginal birth or a caesarean.

If my baby is not head-first, what position could they be in?

Malpresentation is caused by your baby’s position (‘lie’). There are different types of malpresentation.

Breech presentation

This is when your baby is lying with their bottom or feet facing down. Sometimes one foot may enter the birth canal first (called a ‘footling presentation’).

Breech presentation is the most common type of malpresentation.

Face presentation

This is when your baby is head-first but stretching their neck, with their face against the cervix.

Transverse lie

This is when your baby is lying sideways. Their back, shoulders, arms or legs may be the first to enter the birth canal.

Oblique lie

This is when your baby is lying diagonally. No particular part of their body is against the cervix.

Unstable lie

This is when your baby continually changes their position after 36 weeks of pregnancy.

Cord presentation

This is when the umbilical cord is against the cervix, between your baby and the birth canal. It can happen in any situation where your baby’s presenting part is not sitting snugly in your pelvis. It can become an emergency if it leads to cord prolapse (when the cord is born before your baby, potentially reducing placental blood flow to your baby).

What is malposition?

If your baby is lying head-first, the best position for labour is when their face is towards your back.

If your baby is facing the front of your body (posterior position) or facing your side (transverse position) this is called malposition. Transverse position is not the same as transverse lie. A transverse position means your labour may take a bit longer and you might feel more pain in your back. Often your baby will move into a better position before or during labour.

Why might my baby be in the wrong position?

Malpresentation may be caused by:

• a low-lying placenta
• too much or too little amniotic fluid
• many previous pregnancies, making the muscles of the uterus less stable
• carrying twins or more

Often no cause is found.

Is it likely that my baby will be in the wrong position?

Many babies are in a breech position during pregnancy. They usually turn head-first as pregnancy progresses, and more than 9 in 10 babies in Australia have a vertex presentation (ideal presentation, head-first) at birth.

You are more likely to have a malpresentation if:

• this is your first baby
• you are over 40 years old
• you've had a previous breech baby
• you go into labour prematurely

How is malpresentation diagnosed?

Malpresentation is normally diagnosed when your doctor or midwife examines you, from 36 weeks of pregnancy. If it’s not clear, it can be confirmed with an ultrasound.

Can my baby’s position be changed?

If you are 36 weeks pregnant , it may be possible to gently turn your baby into a head-first position. This is done by an obstetrician using a technique called external cephalic version (ECV).

Some people try different postures or acupuncture to correct malpresentation, but there isn’t reliable evidence that either of these work.

Will I need a caesarean if my baby has a malpresentation?

Most babies with a malpresentation close to birth are born by caesarean . You may be able to have a vaginal birth with a breech baby, but you will need to go to a hospital that can offer you and your baby specialised care.

If your baby is breech, an elective (planned) caesarean is safer for your baby than a vaginal birth in the short term. However, in the longer term their health will be similar, on average, regardless of how they were born.

A vaginal birth is safer for you than an elective caesarean. However, about 4 in 10 people planning a vaginal breech birth end up needing an emergency caesarean . If this happens to you, the risk of complications will be higher.

Your doctor can talk to you about your options. Whether it’s safe for you to try a vaginal birth will depend on many factors. These include how big your baby is, the position of your baby, the structure of your pelvis and whether you’ve had a caesarean in the past.

What are the risks if I have my baby when it’s not head-first?

If your waters break when your baby is not head-first, there is a risk of cord prolapse. This is an emergency.

Vaginal breech birth

Risks to your baby can include:

• Erb’s palsy
• fractures, dislocations or other injuries
• bleeding in your baby’s brain
• low Apgar scores
• their head getting stuck – this is an emergency

Risks to you include:

• blood loss or blood clots
• infection in the wound
• problems with the anaesthetic
• damage to other organs nearby, such as your bladder
• a higher chance of problems in future pregnancies
• a longer recovery time than after a vaginal birth

Risks to your baby include:

• trouble with breathing — this is temporary
• getting a small cut during the surgery

Will I have a malpresentation in my future pregnancies?

If you had a malpresentation in one pregnancy, you have a higher chance of it happening again, but it won’t necessarily happen in future pregnancies. If you’re worried, it may help to talk to your doctor or midwife so they can explain what happened.

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• v.43(496); 1967 Feb

Unstable lie in pregnancy and in labour.

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (741K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References .

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

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