lie presentation in pregnancy

• Getting Pregnant
• Registry Builder
• Baby Products
• Birth Clubs
• See all in Community
• Ovulation Calculator
• How To Get Pregnant
• How To Get Pregnant Fast
• Ovulation Discharge
• Implantation Bleeding
• Ovulation Symptoms
• Pregnancy Symptoms
• Am I Pregnant?
• Pregnancy Tests
• See all in Getting Pregnant
• Due Date Calculator
• Pregnancy Week by Week
• Pregnant Sex
• Weight Gain Tracker
• Signs of Labor
• Morning Sickness
• COVID Vaccine and Pregnancy
• Fetal Weight Chart
• Fetal Development
• Pregnancy Discharge
• Find Out Baby Gender
• Chinese Gender Predictor
• See all in Pregnancy
• Baby Name Generator
• Top Baby Names 2023
• Top Baby Names 2024
• How to Pick a Baby Name
• Most Popular Baby Names
• Baby Names by Letter
• Gender Neutral Names
• Unique Boy Names
• Unique Girl Names
• Top baby names by year
• See all in Baby Names
• Baby Development
• Baby Feeding Guide
• Newborn Sleep
• When Babies Roll Over
• First-Year Baby Costs Calculator
• Postpartum Health
• Baby Poop Chart
• See all in Baby
• Average Weight & Height
• Autism Signs
• Child Growth Chart
• Night Terrors
• Moving from Crib to Bed
• Toddler Feeding Guide
• Potty Training
• Bathing and Grooming
• See all in Toddler
• Height Predictor
• Potty Training: Boys
• Potty training: Girls
• How Much Sleep? (Ages 3+)
• Ready for Preschool?
• Thumb-Sucking
• Gross Motor Skills
• Napping (Ages 2 to 3)
• See all in Child
• Photos: Rashes & Skin Conditions
• Symptom Checker
• Vaccine Scheduler
• Reducing a Fever
• Acetaminophen Dosage Chart
• Constipation in Babies
• Ear Infection Symptoms
• Head Lice 101
• See all in Health
• Second Pregnancy
• Daycare Costs
• Family Finance
• Stay-At-Home Parents
• Breastfeeding Positions
• See all in Family
• Baby Sleep Training
• Preparing For Baby
• My Custom Checklist
• My Registries
• Take the Quiz
• Best Baby Products
• Best Breast Pump
• Best Convertible Car Seat
• Best Infant Car Seat
• Best Baby Bottle
• Best Baby Monitor
• Best Stroller
• Best Diapers
• Best Baby Carrier
• Best Diaper Bag
• Best Highchair
• See all in Baby Products
• Why Pregnant Belly Feels Tight
• Early Signs of Twins
• Teas During Pregnancy
• Baby Head Circumference Chart
• How Many Months Pregnant Am I
• What is a Rainbow Baby
• Braxton Hicks Contractions
• HCG Levels By Week
• When to Take a Pregnancy Test
• Am I Pregnant
• Why is Poop Green
• Can Pregnant Women Eat Shrimp
• Insemination
• UTI During Pregnancy
• Vitamin D Drops
• Best Baby Forumla
• Postpartum Depression
• Low Progesterone During Pregnancy
• Baby Shower
• Baby Shower Games

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

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

What to know if your baby is breech

9 of the most jaw-dropping breech birth photos

Cord prolapse during pregnancy

Augmentation of labor: Why it's used to speed up childbirth

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

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

Where to go next

• Mammary Glands
• Fallopian Tubes
• Supporting Ligaments
• Reproductive System
• Gametogenesis
• Placental Development
• Maternal Adaptations
• Menstrual Cycle
• Antenatal Care
• Small for Gestational Age
• Large for Gestational Age
• RBC Isoimmunisation
• Prematurity
• Prolonged Pregnancy
• Multiple Pregnancy
• Miscarriage
• Recurrent Miscarriage
• Ectopic Pregnancy
• Hyperemesis Gravidarum
• Gestational Trophoblastic Disease
• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
• Oligohydramnios
• Polyhydramnios
• Placenta Praevia
• Placental Abruption
• Pre-Eclampsia
• Gestational Diabetes
• Headaches in Pregnancy
• Haematological
• Obstetric Cholestasis
• Thyroid Disease in Pregnancy
• Epilepsy in Pregnancy
• Induction of Labour
• Operative Vaginal Delivery
• Prelabour Rupture of Membranes
• Caesarean Section
• Shoulder Dystocia
• Cord Prolapse
• Uterine Rupture
• Amniotic Fluid Embolism
• Primary PPH
• Secondary PPH
• Psychiatric Disease
• Postpartum Contraception
• Breastfeeding Problems
• Primary Dysmenorrhoea
• Amenorrhoea and Oligomenorrhoea
• Heavy Menstrual Bleeding
• Endometriosis
• Endometrial Cancer
• Adenomyosis
• Cervical Polyps
• Cervical Ectropion
• Cervical Intraepithelial Neoplasia + Cervical Screening
• Cervical Cancer
• Polycystic Ovary Syndrome (PCOS)
• Ovarian Cysts & Tumours
• Urinary Incontinence
• Genitourinary Prolapses
• Bartholin's Cyst
• Lichen Sclerosus
• Vulval Carcinoma
• Introduction to Infertility
• Female Factor Infertility
• Male Factor Infertility
• Female Genital Mutilation
• Barrier Contraception
• Combined Hormonal
• Progesterone Only Hormonal
• Intrauterine System & Device
• Emergency Contraception
• Pelvic Inflammatory Disease
• Genital Warts
• Genital Herpes
• Trichomonas Vaginalis
• Bacterial Vaginosis
• Vulvovaginal Candidiasis
• Obstetric History
• Gynaecological History
• Sexual History
• Obstetric Examination
• Speculum Examination
• Bimanual Examination
• Amniocentesis
• Chorionic Villus Sampling
• Hysterectomy
• Endometrial Ablation
• Tension-Free Vaginal Tape
• Contraceptive Implant
• Fitting an IUS or IUD

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

Found an error? Is our article missing some key information? Make the changes yourself here!

Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site.

We use cookies to improve your experience on our site and to show you relevant advertising. To find out more, read our privacy policy .

Privacy Overview

iCliniq Cope

For doctors and hospitals

Ask a Doctor Online Now

Abnormal Fetal Lie - An Overview

A baby's abnormal position (abnormal fetal lie) in the womb during the later stages of pregnancy may lead to severe consequences. Read this article to know more.

Dr. Ankita Balar

Medically reviewed by

Dr. Richa Agarwal

By subscribing, I agree to iCliniq's Terms & Privacy Policy.

What Is a Fetal Lie and Its Types?

The baby's position in the uterus is known as the fetal lie or presentation of the fetus. During pregnancy , the baby tends to move around in the uterus, a normal phenomenon. In the earlier stages of pregnancy, the baby is small enough to move around freely. But, when the baby gets larger, its movement becomes limited.

As the delivery day approaches, the baby starts to move into the position for birth. This position involves flipping over so that the baby's head is down and with the face towards the mother's back. The baby starts to move down in the uterus and prepares to go through the birth canal (cervix, vagina, and vulva) during childbirth.

1) Normal Fetal Lie- This position is ideal for labor and baby delivery. In this position, the baby is head-down with the chin tucked into its chest. The back of the head is positioned as it is ready to enter the pelvis. The baby is facing the mother's back. This position is called cephalic presentation, and most babies settle in this position at 32 weeks to 36 weeks of the pregnancy.

2) Abnormal Fetal Lie- Sometimes, the baby cannot get into the perfect cephalic presentation before birth. There are several positions that the baby can attain, and all these positions can render complications during childbirth. The different types of abnormal fetal lies are as follows-

Occiput or Cephalic Posterior Position- When the baby is positioned head down but facing the mother's abdomen. With the head in this position, the baby is looking up. This position is nicknamed sunny-side-up. This position can increase the chance of a long, painful delivery.

Frank Breech- In a frank breech, the baby's buttocks enter the birth canal, and the hips are flexed while the knees are extended. This position can cause an umbilical cord loop formation, and the baby can get injured during vaginal delivery .

Complete Breech- The baby is positioned with the buttocks in front, and both the hips and the knees are flexed. This position increases the risk of forming an umbilical cord loop and injuring the baby if delivered vaginally.

Transverse Lie- The baby lies crosswise in the uterus such that the shoulder enters the pelvis first. A cesarean (C-section) delivery is used for babies in this position.

Footling Breech- The baby's feet are pointed toward the birth canal, which increases the chances of the umbilical cord coming down into the mouth of the womb, thereby cutting off the blood supply to the baby.

Does Abnormal Fetal Lie Pose Any Risk?

An abnormal fetal position or breech makes the baby's delivery very complicated. The baby is safe inside the mother's womb, and vaginal delivery is considered a safe form of childbirth. However, when the baby is in an abnormal fetal position, vaginal delivery can get complicated.

The reason is that the baby's head is larger than the bottom and feet, so there is a risk of head entrapment in the uterus. In this situation, it becomes difficult for the doctor to deliver the baby. Some babies in the breech position are in a hurry to come out during labor, thus making it more difficult for the doctor and the mother.

Sometimes, the doctor may recommend a cesarean birth (c-section) instead of vaginal birth. Cesarean birth is a surgical procedure in which an incision is made in the mother's abdomen, and the baby is delivered in an operating room. The risk involved is much less for the baby during this procedure than vaginal birth if the baby has an abnormal fetal lie.

What Is the Ideal Time for a Baby to Attain the Birth Position?

The baby drops down in the uterus and moves into the birth position, usually in the third trimester. This happens between weeks 32 and week 36 of the pregnancy. The doctor can check the baby's position by touching the mother's abdomen during regular appointments or with the help of an ultrasound.

Can a Doctor Modify or Turn the Baby in Abnormal Fetal Lie?

There are several ways that a doctor can try and turn the baby before beginning labor. These methods may or may not work, as sometimes, the baby turns back into the abnormal fetal position again. The success rate is very low, but if the mother wishes to avoid cesarean delivery, they can try them. The following techniques can be tried to encourage the baby to turn on its own-

1) External Cephalic Version (ECV)- It is a non-invasive way to turn the baby and improve the chance of having a vaginal birth. In this method, on the delivery table, nurses or helpers apply pressure through the abdominal wall to the uterus while trying to rotate the baby's head forward or backward.

2) Exercises- The exercises may or may not work, but they might encourage the baby to turn, avoiding a c-section delivery. The exercise involves yoga-like poses. The following two specific movements are recommended-

Getting on the hands and knees and then gently rocking in back and forth directions.

While laying on the back with knees bent and feet flat on the floor, pushing the hips up in the air (bridge pose).

3) Sound Therapy- Music, temperature changes, talking, and light could interest the baby in the womb.

The mother can place headphones on the belly, towards the bottom, to see if this attracts the baby.

Applying cold objects to the top of the abdomen where the baby's head is present might encourage the baby to move away and downward.

A chiropractic technique (webster technique) can move the hips. This allows the uterus to relax. Relaxation can promote baby movement and help the baby to get into the best possible birth position.

What Factors Promote an Abnormal Fetal Lie?

Premature delivery and early labor.

Abnormal placental position.

Multiple pregnancies.

Anatomical defects in the uterus.

Uterine fibroids .

Conclusion:

Knowing about abnormal fetal lies before delivery can add to the mother's anxiety surrounding childbirth. However, it can help doctors form an ideal labor and delivery birth plan. Most pregnant women do not have a c-section as a part of their birth plan. But the main goal is to safely deliver the baby and protect the mother's health.

Frequently Asked Questions

What is the reason for an abnormal fetal lie, what are the types of fetal lies, what do you mean by a normal fetal lie, what is the optimal position for normal delivery, what are the factors responsible for fetal abnormalities during pregnancy, what does abnormal fetal ultrasound indicate, what are the clinical features of an abnormal fetus, does stress lead to an abnormal pregnancy, what is the prevalence of fetal abnormalities.

NIH- Abnormal fetal presentation or lie

https://pubmed.ncbi.nlm.nih.gov/1919834/

ACOG- If Your Baby Is Breech

https://www.acog.org/womens-health/faqs/if-your-baby-is-breech

Obstetrics and Gynecology

Rate this article

Related topics

What is the use of quadruple marker test?

Is it safe to conceive at 40 years of age?

Baby's Heartbeat - Development and Monitoring Heartbeat

Cesarean Section

Why is there spotting and brown discharge with clots in a six weeks pregnant woman?

Source Article Arrow Most popular articles

Ovulation and Safe Period: What is the Safe Period to Have Sex?

Dr. Sabita Laskar

Unwanted 72 - Uses, Dosage, Side Effects, Drug Warnings, and Precautions

Dr. Veena Madhan Kumar

Jelqing - Penis Enlargement Exercise

Dr. Ramchandra Lamba

Dolo 650 MG Tablet

Dr. Anshul Varshney

I-Pill - Uses, Dosage, Side Effects, Drug Warnings, and Precautions

Ask your health query to a doctor online

*guaranteed answer within 4 hours

Disclaimer: No content published on this website is intended to be a substitute for professional medical diagnosis, advice or treatment by a trained physician. Seek advice from your physician or other qualified healthcare providers with questions you may have regarding your symptoms and medical condition for a complete medical diagnosis. Do not delay or disregard seeking professional medical advice because of something you have read on this website. Read our Editorial Process to know how we create content for health articles and queries.

This website uses cookies to ensure you get the best experience on our website. iCliniq privacy policy

7.6 Transverse lie and shoulder presentation

A transverse lie constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible.

This is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and foetal distress.

7.6.1 Diagnosis

• The uterus is very wide: the transverse axis is virtually equivalent to the longitudinal axis; fundal height is less than 30 cm near term.
• On examination: head in one side, breech in the other (Figures 7.1a and 7.1b). Vaginal examination reveals a nearly empty true pelvis or a shoulder with—sometimes—an arm prolapsing from the vagina (Figure 7.1c).

Figures 7.1 - Transverse lie and shoulder presentation

7.6.2 Possible causes

• Grand multiparity (5 deliveries or more)
• Uterine malformation

Twin pregnancy

• Prematurity
• Placenta praevia
• Foeto-pelvic disproportion

7.6.3 Management

This diagnosis should be made before labour begins, at the last prenatal visit before the birth.

At the end of pregnancy

Singleton pregnancy.

• External version 4 to 6 weeks before delivery, in a CEmONC facility ( Section 7.7 ).
• If this fails, delivery should be carried out by caesarean section, either planned or at the beginning of labour (Chapter 6, Section 6.4.1 ).
• External version is contra-indicated.
• If the first twin is in a transverse lie (unusual): schedule a caesarean section.
• If the second twin is in a transverse lie: there is no indication for caesarean section, but plan delivery in a CEmONC facility so that it can be performed if necessary. Deliver the first twin and then, assess the foetal position and give a few minutes for the second twin to adopt a longitudinal lie. If the second twin stays in a transverse lie, and depending on the experience of the operator, perform external version ( Section 7.7 ) and/or internal version ( Section 7.8 ) on the second twin.

During labour, in a CEmONC facility

Foetus alive and membranes intact.

• Gentle external version, between two contractions, as early as possible, then proceed as with normal delivery.
• If this fails: caesarean section.

Foetus alive and membranes ruptured

• Multipara with relaxed uterus and mobile foetus, and an experienced operator: internal version and total breech extraction.
• Primipara, or tight uterus, or immobile foetus, or engaged arm, or scarred uterus or insufficiently-experienced operator: caesarean section.
• Incomplete dilation: caesarean section.

Caesarean section can be difficult due to uterine retraction. Vertical hysterotomy is preferable. To perform extraction, grasp a foot in the fundus (equivalent to a total breech extraction, but by caesarean section).

Foetus dead

Embryotomy for transverse lie (Chapter 9, Section 9.7.7 ).

During labour, in remote settings where surgery is not available

Try to refer the patient to a CEmONC facility. If not feasible:

• Attempt external version as early as possible.
• If this fails, wait for complete dilation.
• Perform an external version ( Section 7.7 ) combined with an internal version ( Section 7.8 ), possibly placing the woman in various positions (Trendelenburg or knee-chest).
• Put the woman into the knee-chest position.
• Between contractions, push the foetus back and try to engage his head.
• Vacuum extraction (Chapter 5, Section 5.6.1 ) and symphysiotomy (Chapter 5, Section 5.7 ) at the slightest difficulty.
• Incomplete dilation: Trendelenburg position and watchful waiting until complete dilation.

Try to refer the patient, even if referral takes some time. If not feasible, embryotomy for transverse lie (Chapter 9, Section 9.7.7 ).

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.

Distance Learning for Medical and Nursing Professionals

Fetal Lie or Baby Position in womb – Does it really matter?

Medically Reviewed by: Dr. Veena Shinde (M.D, D.G.O,  PG – Assisted Reproductive Technology (ART) from Warick, UK) Mumbai, India

• >> Post Created: March 22, 2022
• >> Last Updated: August 29, 2024

Fetal Lie or baby position in the womb - All you need to know - Content flow

It is an absolute wonder how a tiny life grows inside a womb – from the size of an apple seed to a small, but complete human baby.

Within the womb, this growing fetus moves around till it grows big enough to run out of space and is ready to enter this world.

The baby’s position , also referred to as the ‘ fetal lie ,’ in the last month of pregnancy decides the mother’s journey through labor and delivery.

If words like anterior position , posterior position , breech , or transverse baby position shows up in your test reports while describing your baby’s position, then this article will help you decode what it means.

This article will help you understand about all the various types of fetal lie or various different positions your baby could be in while growing in your womb.

Understanding fetal lie/fetal position

Fetal lie/fetal position or the baby’s position in the womb is of utmost importance generally towards the end of your pregnancy, i.e. generally in the last month of your pregnancy.

When the fetus is still growing, it moves around in the womb, but as it grows, it settles in one particular position – the most common position is the head-down position or also referred to as cephalic position and the vertex presentation. In this position the baby is facing the mother’s back with its head entering the pelvis.

The head-down position/cephalic position is the optimal position for delivery, where the baby’s head is right above the birth canal.

The birth canal comprises of the mother’s cervix (uterus’ outlet), vagina, and vulva. The birth canal can be seen as an elastic tunnel through which the baby passes to come into this world.

However, the fetus can settle in other not-so-desirable positions as well, which have their own set of challenges.

Fetal Lie/fetal position vs. fetal presentation

To describe the baby’s accurate position in the womb, medical professionals use both the terms – fetal position and fetal presentation.

Fetal lie/fetal position , also referred to as baby position in womb before labor, establishes where the baby’s face is – toward the mother’s back or her belly.

Fetal presentation actually tells you what part of the baby’s body will lead the way out of the birth canal. With this, one can determine the direction the baby’s head and feet are.

Together these terms tell a doctor the baby’s exact position in the womb and whether it is an optimal one or in one of those positions that may cause some hiccups in the delivery.

Types of fetal lie/fetal positions

An unborn baby instinctively just knows when it is time for it to come into this world and accordingly settles in the best position for delivery just before labor. This generally happens between 32 and 36 weeks of pregnancy.

However, some babies get comfortable in other not-very-favorable positions, which can cause some delay or difficulty in labor, calling for a caesarean delivery.

Occiput anterior position (OA position)

Your child is said to be in the occiput anterior position /occiput anterior fetal lie, when your baby is positioned head-down (near the cervix), feet up (near the ribs), facing the mother’s back with the head resting against the mother’s belly.

The occiput anterior position/occiput anterior fetal lie is not only the most common position but also the best position for a smooth delivery, as it helps the baby fit in and move through the birth canal in the easiest way.

The fetal presentation here is the baby’s head (crown to be precise).

Occiput posterior position (OP baby position)

Occiput posterior position /occiput posterior fetal lie is similar to the occiput anterior fetal lie, with the only difference being that instead of facing the mother’s back, the baby faces the mother’s belly, with its back against the mother’s back.

Hence, the occiput posterior position/occiput posterior fetal lie is also referred to as the back-to-back position.

The fetal presentation in the occiput posterior position is the head, but the baby comes out face-up; hence, this is also titled the sunny-side up position .

Labor is a little more painful if the baby is in the occiput posterior position, as the mother experiences pressure on her spine. In this fetal lie/fetal position, the baby is unable to tuck its chin down to fit into the birth canal as easily as OA baby position , and hence, labor can be longer here. Your doctor may analyze your situation and may recommend a C-section.

Breech position

In this position, the baby takes up the position that is exact opposite to that of OA baby position – it settles in the head-up, feet-down position. This is one of the uncommon baby positions – merely 3-4% of

Almost all breech fetal positions require a caesarean delivery.

There are different types of breech positions –

• Complete breech : Here, the baby’s bottom is above the birth canal (making it the fetal presentation if vaginal delivery was possible), knees bent, and feet close to the bottom.
• Frank breech baby position : Again, baby’s bottom is near the birth canal, but here baby lies in V-shape, with its legs straight up near the head.
• Footling breech : Baby has one or both legs near the birth canal, making its feet the fetal presentation here.
• Flexed breech : Here one or both of the baby’s knees are bent and the buttocks and feet are at the birth canal opening.

Oblique fetal position/oblique fetal lie/oblique lie

The oblique lie , as the name says, indicates that your baby is in a diagonal or slanted position in the womb just before labor. It is one of the rarest baby positions which is also risky at the same time.

In the oblique fetal lie, the baby’s head or any other body part is not aligned with the opening of the birth canal, which can result in umbilical cord compression, and hence, lead to an emergency.

Oblique lie is risky in case of a vaginal delivery, and it can cause injuries to the baby or even be life threatening.

Therefore, if the baby cannot be turned in a proper head-down position, your doctor may recommend a C-section.

Transverse baby position/transverse lie

In the transverse baby position , the baby lies horizontally or sideways in the mother’s womb. It can have either its shoulder, back, hands, or even feet near the birth canal when in a transverse baby position. This is an extremely rare fetal lie for a full-term baby.

The transverse baby position carries the risk of damaging the placenta during delivery or in an attempt to turn the baby into a more favorable position. Here as well, the risk of umbilical cord prolapse looms, which can turn into a medical emergency. Your

doctor will examine your condition before deciding on a C-section.

Continue reading below ↓

Read this next

Vertex Presentation: How does it affect your labor & delivery?

Everything you need to know about Placenta Position & Placenta Health – with FAQs

The Ultimate List of Baby Must Haves

What is the reason behind uncommon fetal positions.

Most mothers might feel they are responsible in some way for the baby not settling in the best position. That is never the case. However, some physical traits/issues, like an unusual shape of the uterus, fibroids, or the alignment of the hip, etc. might be some of the reasons that the baby takes up unusual positions.

But do not be disheartened, there are a few ways to try to fix the baby’s position.

How to tell what position the baby is in the womb?

So, how can a mother understand the baby’s position?

After you enter the 8 th month of pregnancy, i.e. around 32 weeks of your pregnancy, you can try belly mapping to know what baby position/fetal lie your little one is settling into.

It is recommended that you try this method right after you visit your doctor so that you have an idea where the baby’s head is placed.

All you need is non-toxic, washable paint or marker for doing this – i.e. mapping the position of your baby on your belly.

• Divide your belly area with the marker with 2 lines – one horizontal and one vertical intersecting in the middle, such that your belly is divided into 4 quadrants.
• Start by lying down and putting slight pressure with your hand on the pelvic region to feel your baby’s head. It will feel like a small bowling ball. Mark it.
• Use a fetoscope to detect your baby’s heartbeat and mark it on your belly as its heart, as shown in the image.
• Your baby’s bottom will be hard and round. You will get an idea of where exactly it can be once you know where the head is.
• Remember where you feel the baby’s movements. Its kicks and wiggles can give you an idea of where its legs and knees are. Mark it on your belly.

Mothers or their caretakers can then draw a baby on the belly to understand the exact position on their own. Of course, an ultrasound scan is the best way to know this.

Can I turn my baby in the womb?

Yes! If you are aware that your baby is not in the optimal occiput anterior position, then you can try certain simple methods to try to turn your baby before you get into labor.

• Whenever you sit, do so in such a way that your pelvis is tilted forward instead of backward.
• Sitting on exercise ball or birth ball.
• When seated, ensure that your hips are always higher than your knees.
• Do not sit continuously in one place, do move around at regular intervals.
• In a car, sit on a cushion to lift and tilt your bottom forward.
• A few times in a day go on your hands and knees (like what you do while scrubbing the floor) to encourage your baby to move to the OA fetal lie.
• Some also recommend using temperature changes as a guiding tool. A baby in the womb dislikes extreme cold temperatures and moves towards a warm one.

It is recommended to put a bag of frozen peas near the baby’s head and a warm bottle where you intend the head to be for the best position. The baby will move away from the cold towards the warmth.

• Music too is recommended; place the speakers on your belly where you want the baby’s head for the optimal position.
• Visiting a chiropractor who has an expertise in the Webster technique can also help in changing the fetal lie.
• Acupuncture is also said to help some times

These techniques do not necessarily work, as there is no scientific evidence to back them. But then, what’s the harm in trying? Do talk to you doctor in case you have doubts.

Your doctor too can use a few techniques to cajole your baby to turn to a more desirable fetal position/fetal lie for delivery. If a baby is turned to occiput anterior fetal lie, then a vaginal birth is possible.

Medically the procedure to try to turn the baby in the uterus is called External Cephalic Version (ECV) .

External (because the procedure is done externally)

Cephalic (head-down position)

Version (turning the baby)

Your doctor can attempt to turn the baby in the uterus, provided –

• The pregnancy is about 36 to 42 weeks
• Labor has not begun
• Labor has begun, but the water has not broken
• The baby has aplenty amniotic fluid to move in
• The baby is not touching the entrance of the birth canal
• The mother is carrying a single baby, not carrying twins or multiples
• The mother has had previous delivery/deliveries, which makes the stomach muscles less firm
• You are in a hospital; in case an emergency C-section is required while trying to turn the baby

Performing ECV:

To perform this, the doctor gently massages and puts firm pressure at specific places on the belly to encourage the baby to move into the OA cephalic position. This works about 65% of the time and it can help you avoid a breech baby C-section surgery .

During the procedure , the mother might be given an injection to relax her muscles or a numbing (epidural) medication to keep her comfortable. However, an epidural is not recommended in certain specific cases.

The mother and baby’s heart rate will be monitored to avoid any issues. The baby’s movements during the procedure will be monitored through an ultrasound to check if the technique is working.

The mother and baby’s health are taken into account before this procedure and the baby is closely monitored during the process to ensure it isn’t taking this negatively.

During the procedure if the mother’s contractions get stronger, water breaks or baby moves near or enters partly into the birth canal, the ECV is abandoned and an urgent C-section is done for a safe delivery.

How do I know I am ready for labor?

As the pregnancy comes to its full-term, a mother on her own will feel as though her baby has dropped lower in the abdomen. This is called Lightening .

While readying itself for delivery, the baby settles deeper in the mother’s pelvis, taking the pressure off from her diaphragm, making it easier to breathe. The baby dropping lower in the belly is among the first signs that the big day is close.

In a nutshell

Baby position/fetal lie should not be a concern until after 36 weeks of pregnancy. It is quite common that a baby might adjust its position by itself by the time the mother gets into labor or even if she is already in labor. Contractions can also help the baby turn. It is necessary that the mother stays relaxed and positive to aid this.

If the fetal lie is not in an ideal position for birth, then it is necessary that you go to the hospital for delivery in case an emergency C-section is required. It is important that skilled and experienced doctors handle a delivery with unusual baby positions.

Hope our article provides you with detailed understanding about a fetal lie and how it affects your pregnancy and labor.

Your baby’s position/fetal lie before labor may change the course of your labor and delivery experience, but at the end of it all, what matters is having a happy, healthy baby in your arms.

Happy Pregnancy!

Khushboo Kirale

You may also be interested in.

Sequential Screening – Why is it so important for you to get it done?

Placenta Previa or Low Lying Placenta: How much should you be concerned?

Looking for Diapers on Sale? Here’s where you can get great diaper deals on buying bulk diapers

Lateral Placenta: How does this placenta position impact pregnancy and delivery?

hCG levels twins vs. singleton – What’s the difference?

Anterior Placenta Position – How It Affects Pregnancy, Labor and Delivery

3 thoughts on “fetal lie or baby position in womb – does it really matter”.

so much excellent info on here, : D.

Enjoyed looking through this, very good stuff, regards.

Best Content I Have Found Every Time On This Site, Best Of Luck.

Comments are closed.

Subscribe to get our latest posts on parenting and we will make sure you don’t miss a thing!

Privacy Policy - Terms and Conditions

An expert resource for medical professionals Provided FREE as a service to women’s health

The Global Library of Women’s Medicine EXPERT – RELIABLE - FREE Over 20,000 resources for health professionals

The Alliance for Global Women’s Medicine A worldwide fellowship of health professionals working together to promote, advocate for and enhance the Welfare of Women everywhere

An Educational Platform for FIGO

The Global Library of Women’s Medicine Clinical guidance and resources

A vast range of expert online resources. A FREE and entirely CHARITABLE site to support women’s healthcare professionals

The Global Academy of Women’s Medicine Teaching, research and Diplomates Association

• Expert clinical guidance
• Safer motherhood
• Skills videos
• Clinical films
• Special textbooks
• Ambassadors
• Can you help us?
• Introduction
• Definitions
• Complications
• External Cephalic Version
• Management of Labor And Delivery
• Cesarean Delivery
• Perinatal Outcome
• Practice Recommendations
• Study Assessment – Optional
• Your Feedback

This chapter should be cited as follows: Okemo J, Gulavi E, et al , Glob. libr. women's med ., ISSN: 1756-2228; DOI 10.3843/GLOWM.414593

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Common obstetric conditions

Volume Editor: Professor Sikolia Wanyonyi , Aga Khan University Hospital, Nairobi, Kenya

Abnormal Lie/Presentation

First published: February 2021

Study Assessment Option

By completing 4 multiple-choice questions (randomly selected) after studying this chapter readers can qualify for Continuing Professional Development awards from FIGO plus a Study Completion Certificate from GLOWM See end of chapter for details

INTRODUCTION

The mechanism of labor and delivery, as well as the safety and efficacy, is determined by the specifics of the fetal and maternal pelvic relationship at the onset of labor. Normal labor occurs when regular and painful contractions cause progressive cervical dilatation and effacement, accompanied by descent and expulsion of the fetus. Abnormal labor involves any pattern deviating from that observed in the majority of women who have a spontaneous vaginal delivery and includes:

• Protraction disorders (slower than normal progress);
• Arrest disorders (complete cessation of progress).

Among the causes of abnormal labor is the disproportion between the presenting part of the fetus and the maternal pelvis, which rather than being a true disparity between fetal size and maternal pelvic dimensions, is usually due to a malposition or malpresentation of the fetus.

This chapter reviews how to define, diagnose, and manage the clinical impact of abnormalities of fetal lie and malpresentation with the most commonly occurring being the breech-presenting fetus.

DEFINITIONS

At the onset of labor, the position of the fetus in relation to the birth canal is critical to the route of delivery and, thus, should be determined early. Important relationships include fetal lie, presentation, attitude, and position .

Fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99% of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent when the fetal and maternal axes may cross at a 90 ° angle, and predisposing factors include multiparity, placenta previa, hydramnios, and uterine anomalies. Occasionally, the fetal and maternal axes may cross at a 45 ° angle, forming an oblique lie . 

Fetal presentation

The presenting part is the portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. Thus, in longitudinal lie, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations , respectively. The shoulder is the presenting part when the fetus lies with the long axis transversely.

Commonly the baby lies longitudinally with cephalic presentation. However, in some instances, a fetus may be in breech where the fetal buttocks are the presenting part. Breech fetuses are also referred to as malpresentations. Fetuses that are in a transverse lie may present the fetal back (or shoulders, as in the acromial presentation), small parts (arms and legs), or the umbilical cord (as in a funic presentation) to the pelvic inlet. When the fetal long axis is at an angle to the bony inlet, and no palpable fetal part generally is presenting, the fetus is likely in oblique lie. This lie usually is transitory and occurs during fetal conversion between other lies during labor.

The point of direction is the most dependent portion of the presenting part. In cephalic presentation in a well-flexed fetus, the occiput is the point of direction.

The fetal position refers to the location of the point of direction with reference to the four quadrants of the maternal outlet as viewed by the examiner. Thus, position may be right or left as well as anterior or posterior.

Unstable lie

Refers to the frequent changing of fetal lie and presentation in late pregnancy (usually refers to pregnancies >37 weeks).

Fetal position

Fetal position refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal. With each presentation there may be two positions – right or left. The fetal occiput, chin (mentum) and sacrum are the determining points in vertex, face, and breech presentations. Thus:

• left and right occipital presentations
• left and right mental presentations
• left and right sacral presentations.

Fetal attitude

The fetus instinctively forms an ovoid mass that corresponds to the shape of the uterine cavity towards the third trimester, a characteristic posture described as attitude or habitus. The fetus becomes folded upon itself to create a convex back, the head is flexed, and the chin is almost in contact with the chest. The thighs are flexed over the abdomen and the legs are bent at the knees. The arms are usually parallel to the sides or lie across the chest while the umbilical cord fills the space between the extremities. This posture is as a result of fetal growth and accommodation to the uterine cavity. It is possible that the fetal head can become progressively extended from the vertex to face presentation resulting in a change of fetal attitude from convex (flexed) to concave (extended) contour of the vertebral column.

The categories of frank, complete, and incomplete breech presentations differ in their varying relations between the lower extremities and buttocks (Figure 1). With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. With a complete breech, both hips are flexed, and one or both knees are also flexed. With an incomplete breech, one or both hips are extended. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. A footling breech is an incomplete breech with one or both feet below the breech.

Types of breech presentation. Reproduced from WHO 2006, 1 with permission.

The relative incidence of differing fetal and pelvic relations varies with diagnostic and clinical approaches to care.

About 1 in 25 fetuses are breech at the onset of labor and about 1 in 100 are transverse or oblique, also referred to as non-axial. 2

With increasing gestational age, the prevalence of breech presentation decreases. In early pregnancy the fetus is highly mobile within a relatively large volume of amniotic fluid, therefore it is a common finding. The incidence of breech presentation is 20–25% of fetuses at <28 weeks, but only 7–16% at 32 weeks, and only 3–4% at term. 2 , 3

Face and brow presentation are uncommon. Their prevalence compared with other types of malpresentations are shown below. 4

• Occiput posterior – 1/19 deliveries;
• Breech – 1/33 deliveries;
• Face – 1/600–1/800 deliveries;
• Brow – 1/500–1/4000 deliveries;
• Transverse lie – 1/833 deliveries;
• Compound – 1/1500 deliveries.

Transverse lie is often unstable and fetuses in this lie early in pregnancy later convert to a cephalic or breech presentation.

The fetus has a relatively larger head than body during most of the late second and early third trimester, it therefore tends to spend much of its time in breech presentation or in a non-axial lie as it rotates back and forth between cephalic and breech presentations. The relatively large volume of amniotic fluid present facilitates this dynamic presentation.

Abnormal fetal lie is frequently seen in multifetal gestation, especially with the second twin. In women of grand parity, in whom relaxation of the abdominal and uterine musculature tends to occur, a transverse lie may be encountered. Prematurity and macrosomia are also predisposing factors. Distortion of the uterine cavity shape, such as that seen with leiomyomas, prior uterine surgery, or developmental anomalies (Mullerian fusion defects), predisposes to both abnormalities in fetal lie and malpresentations. The location of the placenta also plays a contributing role with fundal and cornual implantation being seen more frequently in breech presentation. Placenta previa is a well-described affiliate for both transverse lie and breech presentation.

Fetuses with congenital anomalies also present with abnormalities in either presentation or lie. It is possibly as a cause (i.e. fitting the uterine cavity optimally) or effect (the fetus with a neuromuscular condition that prevents the normal turning mechanism). The finding of an abnormal lie or malpresentation requires a thorough search for fetal abnormalities. Such abnormalities could include chromosomal (autosomal trisomy) and structural abnormalities (hydrocephalus), as well as syndromes of multiple effects (fetal alcohol syndrome).

In most cases, breech presentation appears to be as a chance occurrence; however, up to 15% may be owing to fetal, maternal, or placental abnormalities. It is commonly thought that a fetus with normal anatomy, activity, amniotic fluid volume, and placental location adopts the cephalic presentation near term because this position is the best fit for the intrauterine space, but if any of these variables is abnormal, then breech presentation is more likely.

Factors associated with breech presentation are shown in Table 1.

Risk factors for breech presentation.

Spontaneous version may occur at any time before delivery, even after 40 weeks of gestation. A prospective longitudinal study using serial ultrasound examinations reported the likelihood of spontaneous version to cephalic presentation after 36 weeks was 25%. 5

In population-based registries, the frequency of breech presentation in a second pregnancy was approximately 2% if the first pregnancy was not a breech presentation and approximately 9% if the first pregnancy was a breech presentation. After two consecutive pregnancies with breech presentation at delivery, the risk of another breech presentation was approximately 25% and this rose to 40% after three consecutive breech deliveries. 6 , 7

In addition, parents who themselves were delivered at term from breech presentation were twice as likely to have their offspring in breech presentation as parents who were delivered in cephalic presentation. This suggests a possible heritable component to fetal presentation. 8

Leopold’s maneuvers

The Leopold’s maneuvers: palpation of fetus in left occiput anterior position. Reproduced from World Health Organization, 2006, 1   with permission.

Abdominal examination can be conducted systematically employing the four maneuvers described by Leopold in 1894. 9 , 10 In obese patients, in polyhydramnios patients or those with anterior placenta, these maneuvers are difficult to perform and interpret.

The first maneuver is to assess the uterine fundus. This allows the identification of fetal lie and determination of which fetal pole, cephalic or podalic – occupies the fundus. In breech presentation, there is a sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile.

The second maneuver is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is felt – the back. On the other, numerous small, irregular, mobile parts are felt – the fetal extremities. By noting whether the back is directed anteriorly, transversely, or posteriorly, fetal orientation can be determined.

The third maneuver aids confirmation of fetal presentation. The thumb and fingers of one hand grasp the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The differentiation between head and breech is made as in the first maneuver.

The fourth maneuver helps determine the degree of descent. The examiner faces the mother’s feet, and the fingertips of both hands are positioned on either side of the presenting part. They exert inward pressure and then slide caudad along the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder or the space created by the neck may be differentiated readily from the hard head.

According to Lyndon-Rochelle et al ., 11 experienced clinicians have accurately identified fetal malpresentation using Leopold maneuvers with a high sensitivity 88%, specificity 94%, positive-predictive value 74%, and negative-predictive value 97%.

Vaginal examination

Prelabor diagnosis of fetal presentation is difficult as the presenting part cannot be palpated through a closed cervix. Once labor begins and the cervix dilates, and palpation through vaginal examination is possible. Vertex presentations and their positions are recognized by palpation of the various fetal sutures and fontanels, while face and breech presentations are identified by palpation of facial features or the fetal sacrum and perineum, respectively.

Sonography and radiology

Sonography is the gold standard for identifying fetal presentation. This can be done during antenatal period or intrapartum. In obese women or in women with muscular abdominal walls this is especially important. Compared with digital examinations, sonography for fetal head position determination during second stage labor is more accurate. 12 , 13

COMPLICATIONS

Adverse outcomes in malpresented fetuses are multifactorial. They could be due to either underlying conditions associated with breech presentation (e.g., congenital anomalies, intrauterine growth restriction, preterm birth) or trauma during delivery.

Neonates who were breech in utero are more at risk for mild deformations (e.g., frontal bossing, prominent occiput, upward slant and low-set ears), torticollis, and developmental dysplasia of the hip.

Other obstetric complications include prolapse of the umbilical cord, intrauterine infection, maldevelopment as a result of oligohydramnios, asphyxia, and birth trauma and all are concerns.

Birth trauma especially to the head and cervical spine, is a significant risk to both term and preterm infants who present breech. In cephalic presenting fetuses, the labor process prepares the head for delivery by causing molding which helps the fetus to adapt to the birth canal. Conversely, the after-coming head of the breech fetus must descend and deliver rapidly and without significant change in shape. Therefore, small alterations in the dimensions or shape of the maternal bony pelvis or the attitude of the fetal head may have grave consequences. This process poses greater risk to the preterm infant because of the relative size of the fetal head and body. Trauma to the head is not eliminated by cesarean section; both intracranial and cervical spine trauma may result from entrapment in either the uterine or abdominal incisions.

In resource-limited countries where ultrasound imaging, urgent cesarean delivery, and neonatal intensive care are not readily available, the maternal and perinatal mortality/morbidity associated with transverse lie in labor can be high. Uterine rupture from prolonged labor in a transverse lie is a major reason for maternal/perinatal mortality and morbidity.

EXTERNAL CEPHALIC VERSION

External cephalic version (ECV) is the manual rotation of the fetus from a non-cephalic to a cephalic presentation by manipulation through the maternal abdomen (Figure 3).

External version of breech presentation . Reproduced from WHO 2003 , 14  with  permission .

This procedure is usually performed as an elective procedure in women who are not in labor at or near term to improve their chances of having a vaginal cephalic birth. ECV reduces the risk of non-cephalic presentation at birth by approximately 60% (relative risk [RR] 0.42, 95% CI 0.29–0.61) and reduces the risk of cesarean delivery by approximately 40% (RR 0.57, 95% CI 0.40–0.82). 7

In a 2008 systematic review of 84 studies including almost 13,000 version attempts at term, the pooled success rate was 58%. 15  

A subsequent large series of 2614 ECV attempts over 18 years reported a success rate of 49% and provided more details): 16

• The success rate was 40% in nulliparous women and 64% in parous women.
• After successful ECV, 97% of fetuses remained cephalic at birth, 86% of which were delivered vaginally.
• Spontaneous version to a cephalic presentation occurred after 4.3% of failed attempts, and 2.2% of successfully vertexed cases reverted to breech.

Factors associated with lower ECV success rates include nulliparity, anterior placenta, lateral or cornual placenta, decreased amniotic fluid volume, low birth weight, obesity, posteriorly located fetal spine, frank breech presentation, ruptured membranes.

The following factors should be considered while managing malpresentations: type of malpresentation, gestational age at diagnosis, availability of skilled personnel, institutional resources and protocols and patient factors and preferences.

Breech presentation

According to a term breech trial, 17 planned cesarean delivery carries a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to vaginal breech delivery. When planning a breech vaginal birth, appropriate patient selection and skilled personnel in breech delivery are key in achieving good neonatal outcomes. In appropriately selected patients and skilled personnel in vaginal breech deliveries, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned cesarean section. 18 , 19 The choice of the route of delivery should therefore be made considering the availability of skilled personnel in conducting breech vaginal delivery; providing competent newborn care; conducting rapid cesarean delivery should need arise and performing ECV if desired; availability of resources for continuous intrapartum fetal heart rate and labor monitoring; patient clinical features, preferences and values; and institutional policies, protocols and resources.

Four approaches to the management of breech presentation are shown in Figure 4: 8

Management of breech presentation. ECV, external cephalic version.

The options available are:

• Attempting external cephalic version (ECV) before labor with a trial of labor if successful and conducting cesarean delivery if unsuccessful.
• Footling or kneeling breech presentation;
• Fetal macrosomia;
• Fetal growth restriction;
• Hyperextended fetal neck in labor;
• Previous cesarean delivery;
• Unavailability of skilled personnel in breech delivery;
• Other contraindications to vaginal delivery like placenta previa, cord prolapse;
• Fetal anomaly that may interfere with vaginal delivery like hydrocephalus.
• Planned cesarean delivery without an attempt at ECV.
• Planned trial of vaginal breech delivery in patients with favorable clinical characteristics for vaginal delivery without an attempt at ECV.

All the four approaches should be discussed in detail with the patient, and in light of all the considerations highlighted above, a safe plan of care agreed upon by both the patient and the clinician in good time.

Transverse and oblique lie

If a diagnosis of transverse/oblique fetal lie is made before onset of labor and there are no contraindications to vaginal birth or ECV, ECV can be attempted at 37 weeks' gestation. If the malpresentation recurs, further attempts at ECV can be made at 38–39 weeks with induction of labor if successful.

ECV can also be attempted in early labor with intact fetal membranes and no contraindications to vaginal birth.

If ECV is declined or is unsuccessful, then planned cesarean section should be arranged after 39 weeks' gestation.

MANAGEMENT OF LABOR AND DELIVERY

Skills to conduct vaginal breech delivery are very important as there are women who may opt for planned vaginal breech birth and even among those who choose planned cesarean delivery, about 10% may go into labor and end up with a vaginal breech delivery. 17 Some implications of cesarean delivery such as need for repeat cesarean deliveries, placental attachment disorders and uterine rupture make vaginal birth more desirable to some individuals. In addition, vaginal birth has advantages such as affordability, quicker recovery, shorter hospital stay, less complications and is more favorable for resource poor settings.

In appropriately selected women, planned vaginal breech birth is not associated with any significant long-term neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1,000 breech births, and abnormal neurological development occurs in approximately 3/100. 18 Careful patient selection is very important for good outcomes and it is generally agreed that women who choose to undergo a trial of labor and vaginal breech delivery should be at low risk of complications from vaginal breech delivery. Some contraindications to vaginal breech delivery have been highlighted above.

Women with breech presentation near term, pre- or early-labor ultrasound should be performed to assess type of breech presentation, flexion of the fetal head and fetal growth. If a woman presents in labor and ultrasound is unavailable and has not recently been performed, cesarean section is recommended. Vaginal breech deliveries should only take place in a facility with ability and resources readily available for emergency cesarean delivery should the need arise.

Induction of labor may be considered in carefully selected low-risk women. Augmentation of labor is controversial as poor progress of labor may be a sign of cephalo-pelvic disproportion, however, it may be considered in the event of weak contractions. A cesarean delivery should be performed if there is poor progress of labor despite adequate contractions. Labor analgesia including epidural can be used as needed.

Vaginal breech delivery should be conducted in a facility that is able to carry out continuous electronic fetal heart rate monitoring sufficient personnel to monitor the progress of labor. From the term breech trial, 17 the commonest indications for cesarean section are poor progress of labor (50%) and fetal distress (29%). There is an increased risk of cord compression which causes variable decelerations. Since the fetal head is at the fundus where contractions begin, the incidence of early decelerations arising from head compression is also higher. Due to the irregular contour of the presenting part which presents a high risk of cord prolapse, immediate vaginal examination should be undertaken if membranes rupture to rule out cord prolapse. The frequency of cord prolapse is 1% with frank breech and more than 10% in footling breech. 8

Fetal blood sampling from the buttocks is not recommended. A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes. 18

During planned vaginal breech birth, a skilled clinician experienced in vaginal breech birth should supervise the first stage of labor and be present for the active second stage of labor and delivery. Staff required for rapid cesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labor.

The optimum maternal position in second stage has not been extensively studied. Episiotomy should be undertaken as needed and only after the fetal anus is visible at the vulva. Breech extraction of the fetus should be avoided. The baby should be allowed to deliver spontaneously with maternal effort only and without any manipulations at least until the level of the umbilicus. A loop of the cord is then pulled to avoid cord compression. After this point, suprapubic pressure can be applied to facilitate flexion of the fetal head and descent.

Delay of arm delivery can be managed by sweeping them across the face and downwards towards in front of the chest or by holding the fetus at the hips or bony pelvis and performing a 180° rotation to deliver the first arm and shoulder and then in the opposite direction so that the other arm and shoulder can be delivered i.e.,  Lovset’s maneuver (Figure 5).

Lovset’s maneuver. Reproduced from WHO 2006 , 1  with  permission . 

The fetal head can deliver spontaneously or by the following maneuvers:

• Turning the body to the floor with application of suprapubic pressure to flex the head and neck.

Mauriceau-smellie-veit maneuver . Reproduced from WHO 2003, 14 with permission.

• By use of Piper’s forceps.
• Burns-Marshall maneuver  where the baby’s legs and trunk are allowed to hang until the nape of the neck is visible at the mother’s perineum so that its weight exerts gentle downwards and backwards traction to promote flexion of the head. The fetal trunk is then swept in a wide arc over the maternal abdomen by grasping both the feet and maintaining gentle traction; the aftercoming head is slowly born in this process.

If the above methods fail to deliver the fetal head, symphysiotomy and zavanelli maneuver with cesarean section can be attempted. Duhrssen incisions where 1–3 full length incisions are made on an incompletely dilated cervix at the 6, 2 and 10 o’clock positions can be done especially in preterm.

Face presentation

The diagnosis of face presentation is made during vaginal examination where the presenting portion of the fetus is the fetal face between the orbital ridges and the chin. At diagnosis, 60% of all face presentations are mentum anterior, 26% are mentum posterior and 15% are mentum transverse. Since the submentobregmatic (face presentation) and suboccipitobregmatic (vertex presentation) have the same diameter of 9.5 cm, most face presentations can have a successful vaginal birth and not necessarily require cesarean section delivery. 6 The position of a fetus in face presentation helps in guiding the management plan. Over 75% of mentum anterior presentations will have a successful vaginal delivery, whereas it is impossible to have a vaginal birth in mentum posterior position unless it converts spontaneously to mentum anterior position. In mentum posterior position the neck is maximally extended and cannot extend further to deliver beneath the symphysis pubis (Figure 7).

Face presentation. Reproduced from WHO 2003, 14 with permission.

As in breech management, face presentation also requires continuous fetal heart rate monitoring, since abnormalities of fetal heart rate are more common. 5 , 6 In one study , 20 only 14% of pregnancies had normal tracings, 29% developed variable decelerations and 24% had late decelerations. Internal fetal heart rate monitoring with an electrode is not recommended, as it may cause facial and ophthalmic injuries if incorrectly placed. Labor augmentation and cesarean sections are performed as per standard obstetric indications. Vacuum and midforceps delivery should be avoided, but an outlet forceps delivery can be attempted. Attempts to manually convert the face to vertex or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality, and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment.

Brow presentation

The diagnosis of brow presentation is made during vaginal examination in second stage of labor where the presenting portion of the fetal head is between the orbital ridge and the anterior fontanel.

Brow presentation may be encountered early in labor, but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation. The majority of brow presentations diagnosed early in labor convert to a more favorable presentation and deliver vaginally. Once brow presentation is confirmed, continuous fetal heart rate monitoring is necessary and labor progress should be monitored closely in order to pick any signs of abnormal labor. Since the brow diameter is large (13.5 cm), persistent brow presentation usually results in prolonged or arrested labor requiring a cesarean delivery. Labor augmentation and instrumental deliveries are therefore not recommended.

CESAREAN DELIVERY

This is an option for women with breech presentation at term to choose cesarean section as their preferred mode of delivery, for those with unsuccessful ECV who do not want to attempt vaginal breech delivery, have contraindications for vaginal breech delivery or in the event that there is no available skilled personnel to safely conduct a vaginal breech delivery. Women should be given enough and accurate information about pros and cons for both planned cesarean section and planned vaginal delivery to help them make an informed decision.

Since the publication of the term breech trial, 17 , 19 there has been a dramatic global shift from selective to planned cesarean delivery for women with breech presentation at term. This study revealed that planned cesarean section carried a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to planned vaginal birth (RR 0.33, 95% CI 0.19–0.56). The cesarean delivery rate for breech presentation is now about 70% in European countries, 95% in the United States and within 2 months of the study’s publication, there was a 50–80% increase in rates of cesarean section for breech presentation in The Netherlands.

A planned cesarean delivery should be scheduled at term between 39–41 weeks' gestation to allow maximum time for spontaneous cephalic version and minimize the risk of neonatal respiratory problems. 8 Physical exam and ultrasound should be performed immediately prior to the surgery to confirm the fetal presentation. A detailed consent should be obtained prior to surgery and should include both short- and long-term complications of cesarean section and the alternatives of care that are available. The abdominal and uterine incisions should be sufficiently large to facilitate easy delivery. Thereafter, extraction of the fetus is similar to what is detailed above for vaginal delivery.

Cesarean section for face presentation is indicated for persistent mentum posterior position, mentum transverse and some mentum anterior positions where there is standard indication for cesarean section.

Persistent brow presentation usually necessitates cesarean delivery due to the large presenting diameter that causes arrest or protracted labor.

Transverse/oblique lie

Cesarean section is indicated for patients who present in active labor, in those who decline ECV, following an unsuccessful ECV or in those with contraindications to vaginal birth.

For dorsosuperior (back up) transverse lie, a low transverse incision is made on the uterus and an attempt to grasp the fetal feet with footling breech extraction is made. If this does not succeed, a vertical incision is made to convert the hysterotomy into an inverted T incision.

Dorsoinferior (back down) transverse lie is more difficult to deliver since the fetal feet are hard to grasp. An attempt at intraabdominal version to cephalic or breech presentation can be done if membranes are intact before the uterine incision is made. Another option is to make a vertical uterine incision; however, the disadvantage of this is the risk of uterine rupture in subsequent pregnancies.

PERINATAL OUTCOME

Availability of skilled neonatal care at delivery is important for good perinatal outcomes to facilitate resuscitation if needed for all fetal malpresentations. 8 All newborns born from fetal malpresentations require a thorough examination to check for possible injuries resulting from birth or as the cause of the malpresentation.

Neonates who were in face presentation often have facial edema and bruising/ecchymosis from vaginal examinations that usually resolve within 24–48 hours of life and low Apgar scores. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress and difficulties in resuscitative efforts.

PRACTICE RECOMMENDATIONS

• Diagnosis of unstable lie is made when a varying fetal lie is found on repeated clinical examination in the last month of pregnancy.
• Consider external version to correct lie if not longitudinal.
• Consider ultrasound to exclude mechanical cause.
• Inform woman of need for prompt admission to hospital if membranes rupture or when labor starts.
• If spontaneous rupture of membranes occurs, perform vaginal examination to exclude the presence of a cord or malpresentation.
• If the lie is not longitudinal in labor and cannot be corrected perform cesarean section.

CONFLICTS OF INTEREST

Author(s) statement awaited.

Publishers’ note: We are constantly trying to update and enhance chapters in this Series. So if you have any constructive comments about this chapter please provide them to us by selecting the "Your Feedback" link in the left-hand column.

Online Study Assessment Option All readers who are qualified doctors or allied medical professionals can now automatically receive 2 Continuing Professional Development credits from FIGO plus a Study Completion Certificate from GLOWM for successfully answering 4 multiple choice questions (randomly selected) based on the study of this chapter. Medical students can receive the Study Completion Certificate only.

(To find out more about FIGO’s Continuing Professional Development awards programme CLICK HERE )

I wish to proceed with Study Assessment for this chapter

We use cookies to ensure you get the best experience from our website. By using the website or clicking OK we will assume you are happy to receive all cookies from us.

• Oblique Lie

A baby is oblique when the baby’s head is in the mother’s hip. The baby’s body and head are diagonal, not vertical and not horizontal ( transverse lie ).

Oblique is considered   a malposition . I’ve heard from a number of women with oblique babies that these are helpful:

• Forward-leaning Inversion
• Side-lying (Pelvic Floor) Release
• Dip the Hip

All women (who are not at risk for stroke) may begin doing a daily Forward-leaning Inversion for 30 seconds from about 15-20 weeks gestation. However, if an oblique issue lasts beyond 30 weeks gestation, be more diligent. After 35 weeks gestation, the Forward-leaning Inversion may be done 5 times within 36 hours, but only for 30 seconds each time. These activities give room in the lower portion of the uterus for baby to drop into a head-down – and vertical! – position. If that isn’t enough, it’s worth seeing a   chiropractor or another provider   who is trained in a way of soft tissue body balancing, such as Webster or Dynamic Body Balancing TM . Other things that may help, and better to do these following the above body balancing techniques:

• When is Breech an Issue?
• Belly Mapping® Breech
• Flip a Breech
• When Baby Flips Head Down
• Breech & Bicornuate Uterus
• Breech for Providers
• What if My Breech Baby Doesn't Turn?
• Belly Mapping ®️ Method
• After Baby Turns
• Head Down is Not Enough
• Sideways/Transverse
• Asynclitism
• Left Occiput Transverse
• Right Occiput Anterior
• Right Occiput Posterior
• Right Occiput Transverse
• Face Presentation
• Left Occiput Anterior
• OP Truths & Myths
• Anterior Placenta
• Body Balancing
• Wearing a pregnancy belt may help give tone to the lower uterine segment and help baby to center over the pelvic opening.
• To help move baby over, stick a rolled washcloth on your right side under the belt.
• Sleep on the side that the baby’s head is on after you’ve done the exercises for one week.

How many do you do?

Forward-leaning Inversion : Do this every day for 30 seconds each time. After 36 weeks, do 2-3 a day for only 30 seconds each time.

Side-lying Release : Once a day while baby is oblique, and in early labor to help straighten baby vertically over your pelvis. It can be repeated in labor if necessary.

Dip the Hip with loose hip joints for 15 minutes a few times a day.   See directions .

In labor with an oblique lie?

If you find yourself with a baby in an oblique lie while you are in labor, you may have a chance to slip your baby head down. If you do, you can avoid a   cesarean . Do the  Side-lying Release   first, through 1-3 contractions on each side. You must do the release on the left and on the right! See the article for more. Then, when standing if possible, do the   lunge   3-6 times on each leg. See the article describing the   lunge . It works with the contractions.

Other useful information

You may find some helpful information on what to do in labor for the   asynclitic baby  (a tipped head during birth). If the reason for an oblique lie continuing after 30 weeks isn’t completely resolved by labor, there may be a higher chance of asynclitism. I don’t “know” that by data, but it makes sense.

Twins?   Oblique is not uncommon for a second twin. If the first is born vaginally, and you find the second twin remains oblique, simply lift that leg as in a lunge, whether standing or on your side through a contraction or two. The baby will slip head down during the contraction.  Repeating the   Side-lying   Release in labor may also help any oblique lie whether 1 or 2 or more babies. Begin SLR before 3 cm as a preventative measure.

A similar article, here on Spinning Babies ® , to serve your baby’s position is the one about the   Transverse Lie , and while the fetal position is not exactly the same, the solutions are often the same.

Featured Products

Shop spinning babies®.

For additional education to even further enhance your pregnancy and labor preparation, shop our extensive collection of digital downloads, videos, DVDs, workbooks, and more.

Connect with Us

Sign up for our newsletter:, more information:.

Have any questions or concerns? Email us at [email protected]

Daily Essentials

Activities for pregnancy comfort and easier birth.

• Not logged in
• Contributions

Fetal lie, Position and Attitude

• 1 General characteristics
• 2 Fetal Growth
• 3 Fetal Lie
• 4 Fetal Position
• 5 Fetal Attitude

General characteristics [ edit | edit source ]

The characteristics of a full term baby are:

• Average weight of 3500g
• Average length of 50cm
• Well developed external genitalia; testes in scrotum and labia majora covering labia minora
• Remnants of lanugo hair on back
• Nails extending beyond tips of fingers and toes

Length of pregnancy is from the 1st day of the last menstruation up until approximately 280days (i.e. 10 lunar months). Or in other terms, approximately 266 days after fertilization. During this time certain check-ups on the fetus are carried out so as to check for healthiness and identification of any problems that may exist.

Fetal Growth [ edit | edit source ]

Fetal Lie [ edit | edit source ]

Fetal lie is the relationship of the fetus to the long axis of the mother...

NORMAL lie- longitudinal lie- fetus' long axis is in line with the mother's uterus with its head down

ABNORMAL lie- is referred to a breech, where the buttocks are in positioned in uterus as to where the head should normally be

Fetal Position [ edit | edit source ]

• LOA - Left Occiput Anterior (most frequent)
• LOT - Left Occiput Transverse
• LOP - Left Occiput Posterior
• ROA - Right Occiput Anterior
• ROT - Right Occiput Transverse
• ROP - Right Occiput Posterior

(Where Occiput refers to Occipital Bone position)

Fetal Attitude [ edit | edit source ]

This describes the relationship of fetus' body parts to one another. Normal fetal attitude is when the head is tucked down to the chest with its arms and legs drawn in towards center of chest.

• This page was last edited on 14 March 2012, at 23:06.
• WikiLectures, project of the First Faculty of Medicine, Charles University , as the contribution to the MEFANET project. • ISSN 1804-9885 • Content is available under Creative Commons Attribution-ShareAlike 4.0 license, additional terms may apply. See Author Law , Terms of use and General Disclaimer for details. Created with the support of OP VVV project CZ.02.2.69/0.0/0.0/16_015/0002362.
• Privacy policy
• About WikiLectures
• Disclaimers
• Cookie statement

Lie, Presentation, Position, Attitude and Denominator

Aug 15, 2012

710 likes | 4.57k Views

Lie, Presentation, Position, Attitude and Denominator. Lie. The lie refers to the relationship of the longitudinal axis of the fetus to long axis of maternal spine. Lie – 1.Vertical or Longitudinal(99.5%) 2.Transverse 3.Oblique. Lie. Longitudinal :-

Share Presentation

• vertex presentation-8 position
• uterus birth
• breech presentation
• equal segments

Presentation Transcript

Lie The lie refers to the relationship of the longitudinal axis of the fetus to long axis of maternal spine. Lie – 1.Vertical or Longitudinal(99.5%) 2.Transverse 3.Oblique

Lie • Longitudinal:- • when long axis of the foetus corresponds to the long axis of the mother. E.g.:- in cephalic and breech presentation. • Transverse:- • When the long axis of the fetus is perpendicular( 900) to long axis of mother. e.g.:- in shoulder presentation • Oblique:- • When the long axis of fetus crosses the maternal long axis obliquely at an angle other than right angle.

Presentation- The part of the fetus which occupies the lower pole of the uterus/birth canal/ maternal pelvis is called presentation of the fetus. The presentation may be- 1.Cephalic presentation-96.5% 2.Breech presentation or podalic-3% 3.Shoulder presentation-0.5% 4.Compound presentation.

Presentation • 1. Cephalic presentation :- • when fetal head occupies the lower segment of uterus, it is called cephalic presentation. • Depending up on degree of flexion or extension, cephalic presentation may be:- • Vertex presentation • Brow presentation • Face presentation

Presentation A. Vertex:-It is the quadrangular area bounded anteriorly by the bregma (anterior fontanelle) and coronal sutures behind by the lambda (posterior fontanelle) and the lambdoid sutures and laterally by the line passing through the parietal eminences. B. Brow:-It is an area bounded on one side by the anterior fontanelle and the coronal sutures and on the other side by the root of the nose and supra-orbital ridges of the either side. C. Face:- It is an area bounded on one side by the root of the nose and the supra-orbital ridges and on the other by the (chin) junction of the floor of mouth with neck.

Presentation • 2. Breech presentation or podalic:- • when buttock of fetal occupies the lower segment of uterus, it is called breech presentation. • Types of breech:- • 1. Full/Complete Breech:- arms & legs flexed • 2. Incomplete Breech • 3. Frank Breech:- arms flexed but legs extended straight up over head • 4. Footling Breech:- one or both feet extended downward and may exit the birth canal first.

Presentation

Presentation 3. Shoulder presentation:- when shoulder of baby comes in the lower segment of uterus, it is called shoulder presentation.

Presentation 4. Compound presentation:- when 2 or more part of baby comes in to lower segment of uterus, it is called compound presentation.

Attitude The relation of the different parts (head and body) of the fetus to one another is called attitude of the fetus. The universal attitude is flexion. Flexed Deflexed Extended

Denominator • Denominator:- It is an arbitrary fixed bony point at the presenting part which come in relation with the various quadrants of the maternal pelvis. Occiput O Sacrum S Mentum M Frontal F Acromion AC

Denominator

Lie:- • Longitudinal • Presentation:- • Breech • Denominator:- • Sacrum

Lie:- • Longitudinal • Presentation:- • Vertex • Denominator:- • Occiput

Lie:- • Transverse • Presentation:- • Shoulder • Denominator:- • Acromion

Position Itis the relation of the denominator to the different quadrants of the maternal pelvis. The pelvis id divided in the equal segments of 450 i.e. it is divided into 8 parts. The positions are- DOA DOP LOA ROA LOT ROT LOP ROP

In Vertex Presentation-8 Position DOA-2% DOP-1% LOA-13%, LOP-3%, LOT-40% ROT-24%, ROA-10%, ROP-7% DOA LOA ROA ROT LOT ROP LOP DOP

In Vertex Presentation -8 Position

LOA Right occiputo anterior (ROA)

In Vertex Presentation-8 Position

In Face presentation- 6 position 1. Mento- anterior:- Right Left Direct 2. Mento- posterior:- Right Left Direct

Lt mento-ant Rt mento-ant Rt mento-post

In Breech presentation - 6 position 1. Sacro - anterior:- Right Left Direct 2. Sacro- posterior:- Right Left Direct

Engagement • Engagement means maximum transverse diameter of the presenting part passes through the pelvic brim. • For head bi-parietal diameter. • For breech bi-trochanteric diameter. • This is usually done by dividing the head into ”fifths” • if the head is still palpable abdominally, it is “2/5” or less engaged

• More by User

Rationalizing the denominator

Rationalizing the denominator. Rational numbers. Another word for ‘fraction’ is ratio. Any number that can be written as a fraction is a ratio nal number. Rational numbers. Some fractions convert to terminating decimals. If you need to make them longer, you add zeros.

581 views • 13 slides

3. Lie Derivatives And Lie Groups

3. Lie Derivatives And Lie Groups. 3.1 Introduction: How A Vector Field Maps A Manifold Into Itself 3.2 Lie Dragging A Function 3.3 Lie Dragging A Vector Field 3.4 Lie Derivatives 3.5 Lie Derivative Of A One-form 3.6 Submanifolds 3.7 Frobenius' Theorem (Vector Field Version)

1.71k views • 60 slides

Automated Celestial Systems for Attitude &amp; Position Determination

Automated Celestial Systems for Attitude &amp; Position Determination. Sixth DoD Astrometry Forum U.S. Naval Observatory, 5-6 Dec 2000. George Kaplan Astronomical Applications Department Astrometry Department U.S. Naval Observatory. Isn’t GPS Enough?.

450 views • 18 slides

Presentation of 2014 Position Paper

Presentation of 2014 Position Paper. MEAL PATTERN FLEXIBILITY. Retain the initial requirement that 50% of grains offered through school lunch and breakfast programs be whole grain rich.

394 views • 29 slides

Rationalizing the Denominator

Rationalizing the Denominator. Since we can’t leave radicals OR IMAGINARY NUMBERS IN THE DENOMINATOR, WE NEED TO RATIONALIZE IT. You should remember how to do this…. That’s right, multiply by the conjugate!. = =. Rationalizing the Denominator. c). a). b ). RationalizE the Denominator.

879 views • 6 slides

Rationalizing a Denominator

Rationalizing a Denominator. Rationalizing Irrational and Complex Denominators.

174 views • 2 slides

Rationalizing a Denominator. Page 252. Sometimes when we use shortcuts to help find the length of sides, we get answers that have a radical (square root) in the denominator Example: a= . Rationalizing a Denominator.

309 views • 3 slides

Rationalizing the Denominator. Binomial Denominators. Presented by Kathryn Maloney. Rationalizing the Denominator. (1) Multiply both the numerator and denominator by the conjugate of the denominator . (2) Simplify the result. Cool Math Term. Conjugate Surd.

1.02k views • 14 slides

Position and Attitude Determination using Digital Image Processing

Position and Attitude Determination using Digital Image Processing. A UROP sponsored research project. Sean VandenAvond. Mentors: Brian Taylor, Dr. Demoz Gebre-Egziabher. Overview. Motivation Introduction Feature Matching Position Determination Google Earth Navigation Simulation

500 views • 30 slides

Lie. Life. Lift. Light. Limb. Lime. Limp. Line. Link. Lint. Lip. List.

188 views • 1 slides

Lay and Lie

Lay and Lie. Which is which???? Do you think you know?. Lay and Lie. Both are VERBS- meaning they indicate an action of some sort. Both of words have completely different meanings just like the words hippopotamus and apple. They are NOT variants of the same word. The Difference.

285 views • 11 slides

Automatic network configuration: Position presentation

Automatic network configuration: Position presentation. Cristel Pelsser WODNAFO, Feb. 2010. Objectives of automatic network configuration. Reduce configuration errors Speed-up configuration changes Improve response time in case of unexpected events. What are we looking for?.

204 views • 6 slides

Common Denominator Division

Common Denominator Division. Created By: Mia Peric. Introduction.

169 views • 7 slides

The Denominator

The Denominator. By Erick,Thirein,Aaliyana, Lucas. Our ride starts off with a loop and the entrance looks Like a tornado with lots of wind. Our ride is powered by solar power. Our ride is a roller coaster. Our ride is an example of variable motion because it goes in different speedS.

252 views • 6 slides

Denominator for Procedure

Denominator for Procedure. OMB No. 0920-0666 Exp. Date: 05-31-2014. * required for saving.

111 views • 1 slides

Transverse Lie and Unstable Lie

Transverse Lie and Unstable Lie. Dr. ROZHAN YASSIN KHALIL FICOG,CABOG, HDOG, MBChB 2011. Introduction and definitions:. Presentation: The lowest pole of the fetus that presents to the lower uterine segment and the cervix.

5.16k views • 31 slides

Common Denominator

Common Denominator. A common multiple of the denominators of two or more fractions. An approximate symbol. Not equal. ≈. Area. The measure of the surface enclosed by a 2-dimensional geometric figure. Composite Number. A whole number greater than 1 that has more than two factors.

889 views • 32 slides

Attitude Stability and Attitude Change

Attitude Stability and Attitude Change. April 18, 2011. Objectives. By the end of this meeting, you should be able to: Describe the main theories of individual attitude change. Argue whether or not public opinion is sufficiently informed or thought-out to make important choices.

447 views • 18 slides

EIS 500: Position Presentation

EIS 500: Position Presentation. Hollie Butcher and Katie Mey Western Illinois University. Position. Institutions of higher education should provide gender-inclusive options for on-campus housing in order to provide the same benefits and opportunities to all students living on campus.

333 views • 11 slides

Attitude and Attitude Change

Attitude and Attitude Change. Attitude and Attitude Change. Background Definition -- learned predisposition to respond in a consistently favorable or unfavorable manner with respect to an object or a class of objects Attributes of attitudes Learned Targeted (toward an object) Stability.

694 views • 16 slides

Relative Attitude and Position Estimation Program Integrated Sensors, Inc. Utica, NY

Relative Attitude and Position Estimation Program Integrated Sensors, Inc. Utica, NY. Innovation A unique Kalman filter that enhances the ability to perform the proximity sensing phase of the Automated Rendezvous and Capture (AR&amp;C) mission. Accomplishments

137 views • 1 slides

Abnormalities of presentation position and lie

Abnormalities of presentation position and lie. Dr Ismaiel Abu Mahfouz. Outline. Malpresentation Breech Face presentation Brow presentation Shoulder / Compound / Cord Malposition Occipitoposterior Abnormal lies Unstable / transverse Oblique lies. Definitions.

522 views • 46 slides

Blake Lively Gets Dragged Again For Joking That Pregnancy Cravings Are A 'Lie' In An Old Interview

By Favour Adegoke on August 22, 2024 at 8:15 PM EDT Updated on August 23, 2024 at 7:34 AM EDT

Blake Lively is under fire again for a 2014 interview where she joked that pregnancy cravings aren't real. The actress made the comments to reporter AJ Calloway but clarified that she was only "teasing him."

However, fans have still criticized Lively after the video re-emerged online, calling her insensitive. The fresh backlash comes amid Lively's feud with Justin Baldoni , her co-star from "It Ends With Us."

Blake Lively has now been accused of bullying the actor and being "tone-deaf" during the publicity tour for their new movie.

Blake Lively Joked That Pregnancy Cravings Aren't Real

Lively is facing another controversy after saying that pregnancy cravings are a "lie" that pregnant women use to get their way.

The 2014 footage has caused many women on social media to accuse the actress of diminishing the side effects of carrying and birthing a child.

Lively had the controversial interview with reporter AJ Calloway for Extra while attending the Angel Ball.

At the time, she was pregnant with her first child, James, and Calloway said that his wife was "seven months right now," so he understood the experience Lively and her husband, Ryan Reynolds, were having.

As they spoke, Lively laughed and said that Calloway's wife was "taking advantage" of him through the pregnancy cravings.

When he said that he spent "every night" rubbing his wife's feet to help with the pain, the actress playfully called him a "sucker" and said he shouldn't fall for it because pregnancy cravings are a "lie."

Lively joked that it's not necessary to do everything a pregnant woman wants because "you can exploit it."

She said, "It's the perfect way to get what you want. You want chocolate ice cream at midnight? You have a craving!"

However, as their conversation ended, Lively clarified that she was only "teasing" with her remarks.

The Actress Is Facing Heavy Backlash For Her Remarks About Pregnancy Cravings

Despite her stating that it was a joke at the end of the interview, the resurfaced clip angered many social media users, especially on TikTok.

According to the Daily Mail , a video of the interview posted on the social media platform has now received over 8.6 million views and 630,000 likes, with thousands of comments criticizing Lively.

One person wrote, "I'm guessing she lives a pampered life whether pregnant or not, so her feet probably aren't sore."

Another comment read, "Some of us work on our feet 40+ hrs and don't have the luxury of rest throughout an entire pregnancy."

However, some fans were on Lively's side and pointed out that the "Green Lantern" actress clarified that she was teasing.

One such comment read, "People are reading her so wrong both HER AND RYAN are extremely sarcastic and joke around. Relax."

Another fan wrote, "She's being sarcastic people!! This hate campaign is gross."

Blake Lively Was Also Recently Slammed For Using A Transphobic Slur In An Old Video

A person on X recently uncovered a 2012 interview with Elle Magazine in which Lively made comments about dressing up her future kids, using a term that has since been widely recognized as outdated and offensive.

"Sometimes ill [sic] be quietly going about my day and then ill [sic] remember the time Blake lively said this to a journalist," the user captioned their post on X.

The fan then shared an image of her quote: "I hope to have a few girls one day. If not girls, they better be tr-nnies. Because I have some amazing shoes and bags and stories that need to be appreciated."

The Criticisms Come Amid Her Feud With Justin Baldoni

The social media criticism over the interview comes during Lively's bitter public feud with Justin Baldoni, her co-star from "It Ends With Us."

The drama between the two actors started when rumors spread that there was tension between them on set and escalated during post-production.

One of the accusations that Lively allegedly made against Baldoni includes that he fat-shamed her during an incident where he asked his trainer for advice on protecting his back during filming for a scene where he lifted her. She's also allegedly accused him of inappropriate conduct during their time on set.

The feud between Lively and Baldoni has gotten so bad that the "Gossip Girl" star is now being accused of bullying her co-star out of his first major film.

During her solo publicity tour, she has also been criticized for being tone-deaf about the film's domestic violence elements.

Blake Lively And Justin Baldoni Will Likely Never Work Together Again

Sources have told the Daily Mail that plans for the film's sequel, "It Starts With Us," are now in doubt because of the ongoing feud.

They explained that creating the second film would be difficult, with the lead stars, Lively and Baldoni, refusing to promote their work on the first film together.

"It's hard to imagine Justin wanting to work with Blake - or vice versa - after all this bad blood," the source said. "Whatever started this feud, there certainly has been no obvious rapprochement between the pair."

• ABOUT THE BLAST
• PRIVACY POLICY
• TERMS OF USE
• Link to Facebook
• Link to Instagram
• Link to Twitter
• Link to Youtube
• Opt-out of personalized ads

Tommy Fury victim of vile pregnancy lie after Molly-Mae Hague heartbreak

Love Island stars Molly-Mae Hague and Tommy Fury confirmed they'd split earlier this month

• 13:34, 28 Aug 2024
• Updated 14:43, 28 Aug 2024

An Instagram account claiming to belong to Milla Corfixen - the Danish woman Tommy Fury is said to have kissed before his and Molly-Mae Hague’s relationship ended - has posted a photo of an ultrasound.

It has since been revealed the Instagram account, which posted a pink love heart alongside the image, is a fake. Last week, Milla revealed her Instagram handle is "millacorfixennn", not "millacorfixen", the account which posted the image on Wednesday. 

It comes days after Milla claimed she did actually kiss Love Island star Tommy - who shares one-year-old daughter Bambi with Molly-Mae - at a club in Macedonian.

Fans of the Love Island couple, who share daughter Bambi, one, were shocked when Molly-Mae, 25, announced her fairytale romance was over before Tommy, also 25, confirmed the split in a separate statement. Multiple allegations of cheating emerged following this month's breakup – but Tommy continues to deny any infidelity.

Over the weekend, the Danish woman who was accused of kissing Tommy during his wild night out in Macedonia made a major U-turn after previously denying they'd locked lips. Milla enjoyed a night out with the boxer and initially described him as "a proper gentleman".

However, she later changed her story, writing on Instagram : "I've had to delete all my posts due to the hate and nasty comments. As stated in the news story I have gave, I didn't do anything with Tommy Fury . I didn't even no who he was we only shared a kiss, nothing else happened."

Earlier this week, Milla took to social media again to reveal that she has "cleared the air" with mum-of-one Molly-Mae. She wrote on her Instagram Story: "Thank you to everyone for all of the love and support shown to me in the past few days.

"I've spoken to Molly and everything is cleared up. Her management account blocked me but we have been in contact privately this morning." Milla went on to reveal that she's set up a GoFundMe page to raise money for the mental health charity Mind after her mental health suffered amid the backlash she faced.

Meanwhile, Molly-Mae has broken her social media silence following her split from Tommy. The influencer shared a photo of herself wearing a pair of white pyjamas while leaning over a balcony of a wooden hut.

Molly-Mae was seen looking out into a peaceful lake while enjoying a hot beverage. She captioned the post: "Thank you for being the best online friends I could’ve ever wished for."

The Love Island star's fans rushed to share their support as they commented: "You got this queen!!; MOLLY YOU ARE OUR QUEEN; We love you sweetie; So much love for you; Stay strong! You got this."

Follow Mirror Celebs on Snapchat , Instagram , Twitter , Facebook , YouTube and Threads .

MORE ON Tommy Fury Love Island

Stay up-to-date with all the news from the love island villa this summer with our regular newsletter.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.16(7); 2024 Jul
• PMC11335133

New-Onset Rheumatoid Arthritis in Pregnancy: A Case Report

1 Obstetrics and Gynecology, Mardan Medical Complex, Mardan, PAK

Muzamil Khan

2 Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington DC, USA

Satkarjeet Kaur Gill

3 Internal Medicine, Jagare Ridge Medical Clinic, Edmonton, CAN

Rizwanullah

4 Internal Medicine, Hayatabad Medical Complex, Peshawar, PAK

Karthiga Vasudevan

5 Preventive Medicine, Yerevan State Medical University, Yerevan, ARM

Kiya Gurmessa

6 Public Health, Johns Hopkins University, Baltimore, USA

Sophia Tahir

7 Internal Medicine, Windsor University School of Medicine, Cayon, KNA

Rheumatoid arthritis (RA) is extremely uncommon during pregnancy. The alterations in the immune system that occur to support the developing fetus make the onset of RA during this period unlikely. In this case report, we describe a 26-year-old pregnant woman who presented with bilateral symmetrical pain in her hands, wrists, and ankles at 24 weeks of gestation. After a thorough evaluation, she was diagnosed with active RA based on clinical symptoms and laboratory findings, including elevated inflammatory markers, positive RA factor, and anti-cyclic citrullinated peptide antibodies. Treatment was initiated with hydroxychloroquine (HCQ), prednisolone, and paracetamol, resulting in significant symptom improvement and no postpartum complications. The patient gave birth to a healthy baby via vaginal delivery, highlighting the management challenges and outcomes linked to RA during pregnancy.

Introduction

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disorder that impacts women three times more often than men, typically during their most productive and childbearing years [ 1 ]. The progression of RA frequently alters during pregnancy, with around 50% of pregnant women experiencing low disease activity. Between 20% and 40% of these women achieve remission by the third trimester; however, nearly 20% will experience a worsening or moderate-to-high disease activity, necessitating additional therapeutic intervention [ 2 ].

The remission of RA during pregnancy can be linked to the shift from Th1-mediated immunity to Th2. This shift suppresses Th1 cells while enhancing Th2 cells, which promotes humoral and antibody-based immunity. RA is a chronic inflammatory condition mainly driven by immunological dysfunction and T-cell infiltration. These T cells release cytokines, causing inflammation and arthritis due to cartilage destruction and systemic symptoms. The primary characteristic of RA is inflammatory synovitis, usually affecting the peripheral joints [ 3 ].

The postpartum period is a time when women are especially susceptible to RA flares and the initial onset of RA. There is a higher incidence of RA following the first pregnancy, particularly within the first nine months. Up to 90% of patients with RA may experience postpartum flares, typically within the first three months, and these flares are more common after the first pregnancy [ 4 ].

Due to the immunological changes that occur during pregnancy, autoimmune diseases are rare during this period. There are only a few documented cases of RA in pregnant women. In this report, we present the case of a 26-year-old woman who, at 24 weeks of gestation, experienced bilateral symmetrical pain in her hands, wrists, and ankle joints. She was subsequently diagnosed with active RA.

Case presentation

A 26-year-old primigravida, who was 24 weeks pregnant, visited the outpatient department of Hayatabad Medical Complex in Peshawar. She had been experiencing bilateral symmetrical pain in her hands, wrists, and ankles for the past three months. She reported no previous comorbidities and no family history of autoimmune diseases. Upon further questioning, she mentioned experiencing morning stiffness in the affected joints for about 30 minutes, which improved with physical activity.

During the rheumatological examination, she exhibited tenderness in eight proximal interphalangeal joints, as well as in her wrist and ankle joints. Her range of motion was restricted due to pain. The rest of her abdominal, respiratory, neurological, cardiovascular, and dermatological examinations were unremarkable. 

Our differential diagnosis included RA, systemic lupus erythematosus, carpal tunnel syndrome, and hypothyroidism. Hypothyroidism was ruled out as the patient exhibited no significant features of this condition, and her thyroid profile was normal. Carpal tunnel syndrome was also excluded due to negative results for Tinel's Sign and Phalen's Test, along with normal nerve conduction studies (NCS) and electromyography (EMG) studies. She presented no clinical features of SLE other than rheumatological signs, and her ANA and dsDNA tests were negative. Although RA is rare during pregnancy, some cases have been reported. Considering this possibility, we investigated her for RA, which was confirmed by the positivity of rheumatoid factor (RF) and anti-CCP antibodies.

Laboratory investigations revealed leukocytosis, elevated inflammatory markers, and significantly positive RA and anti-cyclic citrullinated peptide antibodies (anti-CCP). Other tests, including anti-neutrophilic antibodies (ANA), extractable nuclear antigen (ENA), and anti-double-stranded DNA (anti-dDNA), were negative (Table ​ (Table1). 1 ). Her Disease Activity Score 28 (DAS 28) was calculated at 4.3, indicating moderate severity.

WBC, white blood cell count; mcL, microliter; mg/dL, milligram per deciliter; IU/mL, international units per milliliter; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; RF, rheumatoid factor; anti-CCP, anti-cyclic citrullinated peptide 

Considering this a case of active RA, she was started on oral hydroxychloroquine (HCQ) 400 mg per day, oral prednisolone 10 mg per day, and analgesic paracetamol. After a one-month follow-up, her clinical condition had improved, along with a reduction in inflammatory markers (Figure ​ (Figure1). 1 ). At 38 weeks of gestation, she had a normal vaginal delivery, with a baby weighing 3.5 kg. No anomalies were detected during the pediatric assessment.

ESR, erythrocyte sedimentation rate; CRP, C-reactive protein

The precise mechanism through which RA tends to improve during pregnancy remains incompletely understood. However, it is thought that pregnancy creates a condition of immune tolerance because of the presence of the semi-allogeneic fetus. This tolerance encompasses several immunological mechanisms, such as thymus regression, decreased natural killer cell function, and a shift in immune reaction from Th1 cells toward Th2 dominance [ 5 ]. Additionally, molecules expressed by the syncytiotrophoblast, such as decay-accelerating factor and membrane cofactor protein, inhibit complement activation, protecting embryonic cells from complement-mediated damage [ 6 ]. From a cellular immunity standpoint, the activation of T cells at the maternal-fetal interface is suppressed by the local production of indoleamine 2,3-dioxygenase, an enzyme that breaks down tryptophan-an amino acid crucial for T-cell activation [ 7 ]. There have been a total of five documented cases of RA occurring during pregnancy [ 8 - 11 ].

Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered safe for use during pregnancy; however, they are not recommended during the final trimester due to the potential risk of premature closure of the ductus arteriosus. If symptoms arise or worsen during pregnancy, NSAIDs are the preferred treatment option. Glucocorticoids, such as prednisone, are commonly prescribed when NSAIDs are not advisable. The aim is to administer prednisone at the lowest effective dose, usually not exceeding 10 mg daily, to manage the condition. Nonfluorinated glucocorticoids like prednisolone, prednisone, and methylprednisolone pass through the placenta in small amounts and are metabolized into inactive forms before reaching the fetus. Hence, they are generally regarded as safe for use during pregnancy at low to moderate doses [ 12 ].

Disease-modifying antirheumatic drugs (DMARDs) such as HCQ, sulfasalazine (SSZ), and azathioprine (AZA) can be continued for patients who do not respond adequately to NSAIDs or prednisone. For moderately active disease, HCQ and/or SSZ may be prescribed. Methotrexate (MTX) and leflunomide (LEF) should be avoided during pregnancy [ 13 ]. Biological treatments such as tumor necrosis factor (TNF) inhibitors may be maintained during pregnancy based on the particular medication and a careful assessment of the individual risks and benefits involved [ 14 ].

We initiated treatment for our patient with HCQ at a daily dose of 400 mg, oral prednisolone at 10 mg per day, and paracetamol for pain relief. After one month of monitoring, the patient experienced notable symptom improvement, with no complications or disease flare-ups postpartum. The baby was delivered vaginally without complications, weighed within normal limits, and showed no abnormalities.

While many women with RA often experience improvement during pregnancy, it is crucial not to overlook disease flares or mistake them for pregnancy-related symptoms. Patients presenting with both typical and atypical RA symptoms should undergo a thorough evaluation for various rheumatologic conditions to ensure accurate diagnosis and timely initiation of suitable treatment. The initial onset of RA during pregnancy could indicate a potentially more severe clinical trajectory. Further research focusing on this distinct patient population is essential to better understand the long-term prognosis of their condition.

Conclusions

This case report underscores the complexities of managing RA during pregnancy, where disease progression varies widely among individuals. Pregnancy-induced immunological changes often result in improved RA symptoms, influenced by shifts in immune responses and hormonal dynamics. However, some patients may experience disease flares or new-onset RA during pregnancy, necessitating vigilant monitoring and tailored therapeutic approaches. Our patient, diagnosed with active RA at 24 weeks of gestation, responded positively to treatment with HCQ, prednisolone, and paracetamol, achieving significant symptom relief and favorable postpartum outcomes. This highlights the critical role of early diagnosis and appropriate management in mitigating potential complications and ensuring the well-being of both mother and fetus. Further research is essential to better understand the underlying mechanisms of RA's behavior during pregnancy and optimize therapeutic strategies for pregnant women with RA.

Acknowledgments

All authors, representing various parts of the world, contributed per the International Committee of Medical Journal Editors (ICMJE) guidelines. We are a collective of researchers who regularly exchange ideas and collaborate on projects aligned with our specific areas of interest. Each author made significant contributions to the conception or design of the study or the acquisition, analysis, or interpretation of data. They were also involved in drafting the manuscript or critically revising it for essential intellectual content. Every author provided final approval of the version to be published and agreed to take responsibility for all aspects of the work, ensuring that any questions regarding the accuracy or integrity of any part of the work were properly addressed and resolved. We are committed to advancing the research component of our medical careers.

Disclosures

Human subjects: Consent was obtained or waived by all participants in this study.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Acquisition, analysis, or interpretation of data:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Drafting of the manuscript:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Critical review of the manuscript for important intellectual content:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Supervision:   . Rizwanullah, Aiysha Gul

trending now

Matt Lauer's daughter crashed into Hamptons fence and fled scene...

Elizabeth Chambers moves her kids for the 5th time in 5 years as...

Taylor Swift fans are convinced her cat made its debut on Travis...

Grier Henchy wore mom Brooke Shields' 1997 wedding dress to her...

Jax Taylor hit with Brittany Cartwright divorce papers while...

Shannon Beador spotted back behind the wheel – with a...

'RHOC' stars Alexis Bellino and John Janssen engaged after nine...

Peek inside Karlie Kloss and Josh Kushner’s $29.5M ‘Wave...

‘pampered’ blake lively slammed for claiming pregnant women ‘lie’ about symptoms in resurfaced interview.

Blake Lively has come under fire again amid her rumored feud with her “It Ends With Us” co-star Justin Baldoni .

During a 2014 interview with Extra reporter AJ Calloway, the “Gossip Girl” star joked that pregnant women “lie” about their symptoms and cravings. A clip from the red carpet moment has resurfaced on TikTok and fans are now calling out the “pampered” star.

Calloway opened the interview by calling attention to Lively’s baby bump and asking her, “How’s it going? My wife is seven months right now, so I know what it’s all like, the feet rubbing.”

@u_have_2_call_me_dragon Every pregnancy hits everyone differently. Ive had five kids.. and it was all different experiences while pregnant. You can have a completely different experience from someone else without saying shit like this… #blakelively #pregnantcravings #itendswithus #fypage ♬ original sound – Victoria

Lively — who was pregnant with her first child, James, 9, at the time — jokingly told the reporter it sounded like his wife was “taking advantage” of him.

After watching the video, thousands of TikTok users said Lively’s life of luxury probably helped relieve some of her pregnancy symptoms.

“I was on my feet working until I had my son. Yes they hurt, yes my husband rubbed them for me. I’m guessing she lives a pampered life whether pregnant or not so her feet probably aren’t sore,” one person wrote.

Want more celebrity and pop culture news?

Start your day with Page Six Daily.

Thanks for signing up!

Please provide a valid email address.

By clicking above you agree to the Terms of Use and Privacy Policy .

Want celebrity news as it breaks? Hooked on Housewives?

Another said, “She does not speak for this ex pregnant woman and my swollen feet. Also some of us work on our feet 40+ hrs and don’t have the luxury of rest throughout an entire pregnancy.”

Meanwhile, one person defended Lively, saying, “I feel like she has a level of sarcasm and dry humor people don’t get.”

“You can exploit [pregnancy], if you want. You can’t fall for that stuff,” Lively told Calloway while playfully swatting his arm.

The 36-year-old — who is also mom to daughters Inez, 7, and Betty, 4, as well as son Olin — insisted that “pregnant women just lie” to dupe their husbands without feeling guilty.

“It’s the perfect way to get what you want. You want chocolate ice cream at midnight? You have a ‘craving’!”

This new backlash comes shortly after Lively came under fire for a 2016 interview she did, in which reporter Kjersti Flaa said the “nightmare” chat made her contemplate quitting journalism altogether.

After Flaa congratulated Lively on her pregnancy, the “Age of Adelaide” star responded with an awkward comment about the reporter’s “little bump.”

Flaa, who has since admitted she’s struggled with infertility , described the interview as “the most uncomfortable … situation” she has ever experienced.

Lively is currently under intense criticism as rumors of an alleged feud with Baldoni continue to swirl.

Earlier this month it was reported that Baldoni made Lively feel “uncomfortable” on the set of their new movie.

Industry insiders have claimed the division between the two became more apparent during the post-production process as Lively reportedly hired the “Deadpool & Wolverine” editor to make a second cut of the film.

The director — who reportedly felt “stifled” by Lively on set — has since commented that he would likely give his directing job to Lively if a second film, based on Colleen Hoover’s 2022 follow-up “It Starts With Us,” comes to fruition.

Advertisement

JD Vance said Tim Walz lied about IVF. What to know about IVF and IUI.

JD Vance is accusing Tim Walz of lying about using in-vitro fertilization , or IVF , to have children − and the back-and-forth raises important points about the differences between IVF and intrauterine insemination , or IUI .

On X Tuesday, Vance, the Republican vice presidential candidate, wrote: "Today it came out that Tim Walz had lied about having a family via IVF. Who lies about something like that?" Vance also shared an interview clip of Walz in which he says that, if it were up to Vance, he "wouldn't have a family because of IVF and the things that we need to do reproductively."

Vance's post comes after a Glamour magazine article Monday, in which Walz's wife Gwen shared she conceived via IUI. Tim and Gwen Walz have two children: daughter Hope, 23, and son Gus, 17.

Today it came out that Tim Walz had lied about having a family via IVF. Who lies about something like that? https://t.co/gKwUwgxHCD — JD Vance (@JDVance) August 20, 2024

Gwen said in the article that recent legislation restricting IVF inspired her to speak out about how fertility procedures have impacted her. "After seeing the extreme attacks on reproductive health care across the country — particularly the efforts in Alabama that jeopardized access to fertility treatments — Tim and I agreed that it was time to formally speak out about our experience," she said.

What is the difference between IUI and IVF?

IUI and IVF are not the same. The biggest difference between them is that the former involves egg fertilization inside the body while the latter happens outside.

IVF begins with patients taking medication to stimulate ovary follicle growth, gynecologist Dr. Karen Tang previously told USA TODAY. Doctors then conduct a procedure to retrieve those eggs, during which they put the patient under anesthesia and use a long, thin needle that's inserted through the vagina.

Following this procedure, medical professionals fertilize the eggs with sperm. Then the "resulting embryos are grown and evaluated for appearance and quality," Tang added.

What is IVF? Explaining the procedure in Alabama's controversial Supreme Court ruling.

In some cases, the embryos are tested genetically, such as if one of the patients is a carrier for a serious medical condition or if they've experienced several miscarriages. The "highest quality embryos are then transferred into the uterus," Tang said.

IUI, on the other hand, may or may not require medication for follicle growth, Tang noted. Gwen Walz described to Glamour how a neighbor who was a nurse helped her administer "the shots I needed as part of the IUI process.” ("She would give me the shots to ensure we stayed on track.”)

Instead of IVF's process of retrieving eggs, fertilizing them outside of the body and re-inserting them back into the body, IUI involves inserting sperm directly through the cervix into the uterus, fertilizing the egg inside the body.

While Tang noted IVF has a higher average success rate than IUI, that doesn't mean there's a guarantee of getting pregnant the first time around with IVF.

Why is IVF controversial?

It's common in IVF procedures for unused or low quality embryos to be discarded, which is why the procedure is heavily criticized by some pro-life advocates. In February, the  Alabama Supreme Court ruled that embryos created during IVF are legally protected  like any other child. Alabama's constitution protects unborn children, which legally typically refers to a  fetus  in utero.

So why can't doctors create and transfer one embryo at a time to avoid having to store or discard embryos during IVF? Tang said it's all about giving patients their best chance at getting pregnant.

More: Lala Kent of 'Vanderpump Rules' is using IUI to get pregnant. What is that?

How long does IUI take to get pregnant?

The short answer: It depends. But the actual process of IUI has less steps than IVF.

IUI has a lower average success rate than IVF, so people may go through more cycles of IUI than IVF, Tang said. Cost can also be a deterrent in trying multiple rounds of IVF. The estimated average cost per IVF cycle is about $12,000, according to the American Society for Reproductive Medicine (ASMR). But Tang noted it can wind up a tab as much as $25,000 or more.

Contributing: Hannah Yasharoff

Advertisement

Full Transcript of Kamala Harris’s Democratic Convention Speech

The vice president’s remarks lasted roughly 35 minutes on the final night of the convention in Chicago.

• Share full article

By The New York Times

• Aug. 23, 2024

This is a transcript of Vice President Kamala Harris’s speech on Thursday night in which she formally accepted the Democratic Party’s nomination for the presidency.

OK, let’s get to business. Let’s get to business. All right.

So, let me start by thanking my most incredible husband, Doug. For being an incredible partner to me, an incredible father to Cole and Ella, and happy anniversary, Dougie. I love you so very much.

To our president, Joe Biden. When I think about the path that we have traveled together, Joe, I am filled with gratitude. Your record is extraordinary, as history will show, and your character is inspiring. And Doug and I love you and Jill, and are forever thankful to you both.

And to Coach Tim Walz. You are going to be an incredible vice president. And to the delegates and everyone who has put your faith in our campaign, your support is humbling.

So, America, the path that led me here in recent weeks was, no doubt, unexpected. But I’m no stranger to unlikely journeys. So, my mother, our mother, Shyamala Harris, had one of her own. And I miss her every day, and especially right now. And I know she’s looking down smiling. I know that.

So, my mother was 19 when she crossed the world alone, traveling from India to California with an unshakable dream to be the scientist who would cure breast cancer.

We are having trouble retrieving the article content.

Please enable JavaScript in your browser settings.

Thank you for your patience while we verify access. If you are in Reader mode please exit and  log into  your Times account, or  subscribe  for all of The Times.

Thank you for your patience while we verify access.

Already a subscriber?  Log in .

Want all of The Times?  Subscribe .