what are vertex presentation

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

• Key Points |

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

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

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

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Vertex Position: What It Is, Why It's Important, and How to Get There

Jamie Grill / Getty Images

What Is the Vertex Position?

• Why It's Important

When the Vertex Position Usually Occurs

• How to Get Baby in This Position

Options if Baby Is Not in the Vertex Position

While you are pregnant, you may hear your healthcare provider frequently refer to the position or presentation of your baby, particularly as you get closer to your due date . What they are referring to is which part of your baby is presenting first—or which part is at the lower end of your womb or the pelvic inlet.

Consequently, when they tell you that your baby's head is down, that likely means they are in the vertex position (or another cephalic position). This type of presentation is the most common presentation in the third trimester. Here is what you need to know about the vertex position including how you might get your baby into that position before you go into labor .

The vertex position is a medical term that means the fetus has its head down in the maternal pelvis and the occipital (back) portion of the fetal skull is in the lowest position or presenting, explains Jill Purdie, MD, an OB/GYN and medical director at Northside Women’s Specialists , which is part of Pediatrix Medical Group.

When a baby is in the vertex position, their head is in the down position in the pelvis in preparation for a vaginal birth, adds Shaghayegh DeNoble, MD, FACOG , a board-certified gynecologist and a fellowship-trained minimally invasive gynecologic surgeon. "More specifically, the fetus’s chin is tucked to the chest so that the back of the head is presenting first."

Why the Vertex Position Is Important

When it comes to labor and delivery, the vertex position is the ideal position for a vaginal delivery, especially if the baby is in the occiput anterior position—where the back of the baby's head is toward the front of the pregnant person's pelvis, says Dr. DeNoble.

"[This] is the best position for vaginal birth because it is associated with fewer Cesarean sections , faster births, and less painful births," she says. "In this position, the fetus’s skull fits the birth canal best. In the occiput posterior position, the back of the fetus's head is toward the [pregnant person's] spine. This position is usually associated with longer labor and sometimes more painful birth."

Other fetal positions are sometimes less-than-ideal for labor and delivery. According to Dr. DeNoble, they can cause more prolonged labor, fetal distress, and interventions such as vacuum or forceps delivery and Cesarean delivery.

"Another important fact is that positions other than vertex present an increased risk of cord prolapse, which is when the umbilical cord falls into the vaginal canal ahead of the baby," she says. "For example, if the fetus is in the transverse position and the [pregnant person's] water breaks , there is an increased risk of the umbilical cord prolapsing through the cervix into the vaginal canal."

When it comes to your baby's positioning, obstetricians will look to see what part of the fetus is in position to present during vaginal birth. If your baby’s head is down during labor, they will look to see if the back of the head is facing your front or your back as well as whether the back of the head is presenting or rather face or brow, Dr. DeNoble explains.

"These determinations are important during labor, especially if there is consideration to the use of a vacuum or forceps," she says.

According to Dr. Purdie, healthcare providers will begin assessing the position of the baby as early as 32 to 34 weeks of pregnancy. About 75% to 80% of fetuses will be in the vertex presentation by 30 weeks and 96% to 97% by 37 weeks. Approximately 3% to 4% of fetuses will be in a non-cephalic position at term, she adds.

Typically, your provider will perform what is called Leopold maneuvers to determine the position of the baby. "Leopold maneuvers involve the doctor placing their hands on the gravid abdomen in several locations to find the fetal head and buttocks," Dr. Purdie explains.

If your baby is not in the vertex position, the next most common position would be breech, she says. This means that your baby's legs or buttocks are presenting first and the head is up toward the rib cage.

"The fetus may also be transverse," Dr. Purdie says. "The transverse position means the fetus is sideways within the uterus and no part is presenting in the maternal pelvis. In other words, the head is either on the left or right side of the uterus and the fetus goes straight across to the opposite side."

There is even a chance that your baby will be in an oblique position. This means they are at a diagonal within the uterus, Dr. Purdie says. "In this position, either the head or the buttocks can be down, but they are not in the maternal pelvis and instead off to the left or right side."

If your baby's head is not down, your provider will look to see if the buttocks are in the pelvis or one or two feet, Dr. DeNoble adds. "If the baby is laying horizontally, then the doctor needs to know if the back of the baby is facing downwards or upwards since at a Cesarean delivery it can be more difficult to deliver the baby when the back is down."

How to Get Baby Into the Vertex Position

One way you can help ensure that your baby gets into the vertex position is by staying active and walking, Dr. Purdie says. "Since the head is the heaviest part of the fetus, gravity may help move the head around to the lowest position."

If you already know that your baby is in a non-cephalic position and you are getting close to your delivery date, you also can try some techniques to encourage the baby to turn. For instance, Dr. Purdie suggests getting in the knee/chest position for 10 minutes per day. This has been shown to turn the baby around 60% to 70% of the time.

"In this technique, the mother gets on all fours, places her head down on her hands, and leaves her buttock higher than her head," she explains. "Again, we are trying to allow gravity to help us turn the fetus."

You also might consider visiting a chiropractor to try and help turn the fetus. "Most chiropractors will use the Webster technique to encourage the fetus into a cephalic presentation," Dr. Purdie adds.

There also are some home remedies, including using music, heat, ice, and incense to encourage the fetus to turn, she says. "These techniques do not have a lot of scientific data to support them, but they also are not harmful so can be tried without concern."

You also can try the pelvic tilt , where you lay on your back with your legs bent and your feet on the ground, suggests Dr. DeNoble. Then, you tilt your pelvis up into a bridge position and stay in this position for 10 minutes. She suggests doing this several times a day, ideally when your baby is most active.

"Another technique that has helped some women is to place headphones low down on the abdomen near the pubic bone to encourage the baby to turn toward the sound," Dr. DeNoble adds. "A cold bag of vegetables can be placed at the top of the uterus near the baby’s head and something warm over the lower part of the uterus to encourage the baby to turn toward the warmth. [And] acupuncture has also been used to help turn a baby into a vertex position."

If you are at term and your baby is not in the vertex position (or some type of cephalic presentation), you may want to discuss the option of an external cephalic version (ECV), suggests Dr. Purdie. This is a procedure done in the hospital where your healthcare provider will attempt to manually rotate your baby into the cephalic presentation.

"There are some risks associated with this and not every pregnant person is a candidate, so the details should be discussed with your physician," she says. "If despite interventions, the fetus remains in a non-cephalic position, most physicians will recommend a C-section for delivery."

Keep in mind that there are increased risks for your baby associated with a vaginal breech delivery. Current guidelines by the American College of Obstetricians and Gynecologists recommend a C-section in this situation, Dr. Purdie says.

"Once a pregnant person is in labor, it would be too late for the baby to get in cephalic presentation," she adds.

A Word From Verywell

If your baby is not yet in the vertex position, try not to worry too much. The majority of babies move into either the vertex position or another cephalic presentation before they are born. Until then, focus on staying active, getting plenty of rest, and taking care of yourself.

If you are concerned, talk to your provider about different options for getting your baby to move into the vertex position. They can let you know which tips and techniques might be right for your situation.

American College of Obstetrics and Gynecology. Obstetrics data definitions .

National Library of Medicine. Vaginal delivery .

Sayed Ahmed WA, Hamdy MA. Optimal management of umbilical cord prolapse .  Int J Womens Health . 2018;10:459-465. Published 2018 Aug 21. doi:10.2147/IJWH.S130879

Hjartardóttir H, Lund SH, Benediktsdóttir S, Geirsson RT, Eggebø TM. When does fetal head rotation occur in spontaneous labor at term: results of an ultrasound-based longitudinal study in nulliparous women .  Am J Obstet Gynecol . 2021;224(5):514.e1-514.e9. doi:10.1016/j.ajog.2020.10.054

Management of breech presentation: green-top guideline no. 20b .  BJOG: Int J Obstet Gy . 2017;124(7):e151-e177. doi:10.1111/1471-0528.14465

Kenfack B, Ateudjieu J, Ymele FF, Tebeu PM, Dohbit JS, Mbu RE. Does the advice to assume the knee-chest position at the 36th to 37th weeks of gestation reduce the incidence of breech presentation at delivery?   Clinics in Mother and Child Health . 2012;9:1-5. doi:10.4303/cmch/C120601

Cohain JS. Turning breech babies after 34 weeks: the if, how, & when of turning breech babies .  Midwifery Today Int Midwife . 2007;(83):18-65.

American College of Obstetrics and Gynecology. If your baby is breech .

By Sherri Gordon Sherri Gordon, CLC is a published author, certified professional life coach, and bullying prevention expert. 

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What to Know About the Vertex Position

When you give birth, your baby usually comes out headfirst, also called the vertex position. In the weeks before you give birth, your baby will move to place their head above your vagina .

Your baby could also try to come out feet -first, bottom-first, or both feet- and bottom-first. This is the breech position and only happens in about 3% to 4% of births. Your baby could also be in transverse position if they’re sideways inside of you. If your baby is in breech position or transverse position, your doctor will talk to you about different options that you have to give birth.

Birth in Vertex Position

Before you give birth, your baby will change positions inside of you. But when labor begins, babies usually move into the vertex position.

They will move farther down to the opening of your vagina . The doctor or  midwife  will instruct you on pushing your baby until their head is almost ready to come out. You'll take long, deep breaths to oxygenate the baby. A slow birth of your baby’s head will also help stretch the skin and muscles around your vagina.

Other Positions Your Baby Can Be In

Breech position. If your baby is still in the breech position at 36 weeks of pregnancy , your doctor may offer you an external cephalic version (ECV), which is where a doctor puts pressure on your uterus to try to turn your baby to a headfirst position. It may be slightly uncomfortable or even painful, but it’s generally a safe way to help your baby reach the vertex position. ECV helps babies get to a headfirst position about 50% of the time.

You shouldn’t have an ECV if you have had recent bleeding from your vagina, if your baby’s heartbeat is abnormal, if your water is broken, or if you’re pregnant with more than one baby.

If ECV doesn’t work, you’ll either have a cesarean section (C-section), which is when a baby is delivered through a cut in the uterus and abdomen , or a vaginal breech birth.

It may not be safe to have a vaginal breech birth if your baby’s feet are under their bottom, your baby is bigger or smaller than average, your baby is in an odd position, you have a low placenta , or you have preeclampsia , which is when you have high blood pressure and damage to organs with pregnancy.

Transverse position. If your baby is laying sideways across your uterus close to the time of delivery, your doctor would offer an ECV or C-section. 

Your doctors may be able to turn your baby to a headfirst position, but if they can’t or you begin labor before they can turn your baby, you’ll most likely have a C-section.

Risks of Breech and Transverse Position

ECV problems. If your baby isn’t in vertex position and your doctor uses ECV to move them, some problems can happen. Your amniotic sac, or the part that holds liquid during pregnancy, can break early, your baby’s heart rate may change, your placenta may pull apart from your uterus, or you could go into labor too early.

Your baby may also move back into a breech position once your doctor moves them into vertex position. Your doctor can try to move them again, but this gets harder as the baby gets bigger.

Breech birth problems. If you give birth in the breech position, your baby’s body may not be able to stretch your cervix enough for their head to come out. Your baby’s shoulders or head could get stuck against your pelvis.

Breech births can also cause your umbilical cord to go into your vagina before your baby does. This is an emergency and requires an immediate C-section.

C-section problems. Since this is a major surgery, infections, bleeding, and organ damage can happen. C-sections can also cause you to have issues with later pregnancies, such as a tear in your uterus or issues with your placenta.

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Face and Brow Presentation

• Author: Teresa Marino, MD; Chief Editor: Carl V Smith, MD  more...
• Sections Face and Brow Presentation
• Mechanism of Labor
• Labor Management

At the onset of labor, assessment of the fetal presentation with respect to the maternal birth canal is critical to the route of delivery. At term, the vast majority of fetuses present in the vertex presentation, where the fetal head is flexed so that the chin is in contact with the fetal thorax. The fetal spine typically lies along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively.

In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an internal examination through the cervix. The occiput of a vertex is usually hard and has a smooth contour, while the face and brow tend to be more irregular and soft. Like the occiput, the mentum can present in any position relative to the maternal pelvis. For example, if the mentum presents in the left anterior quadrant of the maternal pelvis, it is designated as left mentum anterior (LMA).

In a brow presentation, the fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis. The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included. The frontal bones are the point of designation and can present (as with the occiput during a vertex delivery) in any position relative to the maternal pelvis. When the sagittal suture is transverse to the pelvic axis and the anterior fontanel is on the right maternal side, the fetus would be in the right frontotransverse position (RFT).

Face presentation occurs in 1 of every 600-800 live births, averaging about 0.2% of live births. Causative factors associated with a face presentation are similar to those leading to general malpresentation and those that prevent head flexion or favor extension. Possible etiology includes multiple gestations, grand multiparity, fetal malformations, prematurity, and cephalopelvic disproportion. At least one etiological factor may be identified in up to 90% of cases with face presentation.

Fetal anomalies such as hydrocephalus, anencephaly, and neck masses are common risk factors and may account for as many as 60% of cases of face presentation. For example, anencephaly is found in more than 30% of cases of face presentation. Fetal thyromegaly and neck masses also lead to extension of the fetal head.

A contracted pelvis or cephalopelvic disproportion, from either a small pelvis or a large fetus, occurs in 10-40% of cases. Multiparity or a large abdomen can cause decreased uterine tone, leading to natural extension of the fetal head.

Face presentation is diagnosed late in the first or second stage of labor by examination of a dilated cervix. On digital examination, the distinctive facial features of the nose, mouth, and chin, the malar bones, and particularly the orbital ridges can be palpated. This presentation can be confused with a breech presentation because the mouth may be confused with the anus and the malar bones or orbital ridges may be confused with the ischial tuberosities. The facial presentation has a triangular configuration of the mouth to the orbital ridges compared to the breech presentation of the anus and fetal genitalia. During Leopold maneuvers, diagnosis is very unlikely. Diagnosis can be confirmed by ultrasound evaluation, which reveals a hyperextended fetal neck. [ 1 , 2 ]

Brow presentation is the least common of all fetal presentations and the incidence varies from 1 in 500 deliveries to 1 in 1400 deliveries. 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 causes of a persistent brow presentation are generally similar to those causing a face presentation and include cephalopelvic disproportion or pelvic contracture, increasing parity and prematurity. These are implicated in more than 60% of cases of persistent brow presentation. Premature rupture of membranes may precede brow presentation in as many as 27% of cases.

Diagnosis of a brow presentation can occasionally be made with abdominal palpation by Leopold maneuvers. A prominent occipital prominence is encountered along the fetal back, and the fetal chin is also palpable; however, the diagnosis of a brow presentation is usually confirmed by examination of a dilated cervix. The orbital ridge, eyes, nose, forehead, and anterior fontanelle are palpated. The mouth and chin are not palpable, thus excluding face presentation. Fetal ultrasound evaluation again notes a hyperextended neck.

As with face presentation, diagnosis is often made late in labor with half of cases occurring in the second stage of labor. The most common position is the mentum anterior, which occurs about twice as often as either transverse or posterior positions. A higher cesarean delivery rate occurs with a mentum transverse or posterior [ 3 ] position than with a mentum anterior position.

The mechanism of labor consists of the cardinal movements of engagement, descent, flexion, internal rotation, and the accessory movements of extension and external rotation. Intuitively, the cardinal movements of labor for a face presentation are not completely identical to those of a vertex presentation.

While descending into the pelvis, the natural contractile forces combined with the maternal pelvic architecture allow the fetal head to either flex or extend. In the vertex presentation, the vertex is flexed such that the chin rests on the fetal chest, allowing the suboccipitobregmatic diameter of approximately 9.5 cm to be the widest diameter through the maternal pelvis. This is the smallest of the diameters to negotiate the maternal pelvis. Following engagement in the face presentation, descent is made. The widest diameter of the fetal head negotiating the pelvis is the trachelobregmatic or submentobregmatic diameter, which is 10.2 cm (0.7 cm larger than the suboccipitobregmatic diameter). Because of this increased diameter, engagement does not occur until the face is at +2 station.

Fetuses with face presentation may initially begin labor in the brow position. Using x-ray pelvimetry in a series of 7 patients, Borrell and Ferstrom demonstrated that internal rotation occurs between the ischial spines and the ischial tuberosities, making the chin the presenting part, lower than in the vertex presentation. [ 4 , 5 ] Following internal rotation, the mentum is below the maternal symphysis, and delivery occurs by flexion of the fetal neck. As the face descends onto the perineum, the anterior fetal chin passes under the symphysis and flexion of the head occurs, making delivery possible with maternal expulsive forces.

The above mechanisms of labor in the term infant can occur only if the mentum is anterior and at term, only the mentum anterior face presentation is likely to deliver vaginally. If the mentum is posterior or transverse, the fetal neck is too short to span the length of the maternal sacrum and is already at the point of maximal extension. The head cannot deliver as it cannot extend any further through the symphysis and cesarean delivery is the safest route of delivery.

Fortunately, the mentum is anterior in over 60% of cases of face presentation, transverse in 10-12% of cases, and posterior only 20-25% of the time. Fetuses with the mentum transverse position usually rotate to the mentum anterior position, and 25-33% of fetuses with mentum posterior position rotate to a mentum anterior position. When the mentum is posterior, the neck, head and shoulders must enter the pelvis simultaneously, resulting in a diameter too large for the maternal pelvis to accommodate unless in the very preterm or small infant.

Three labor courses are possible when the fetal head engages in a brow presentation. The brow may convert to a vertex presentation, to a face presentation, or remain as a persistent brow presentation. More than 50% of brow presentations will convert to vertex or face presentation and labor courses are managed accordingly when spontaneous conversion occurs.

In the brow presentation, the occipitomental diameter, which is the largest diameter of the fetal head, is the presenting portion. Descent and internal rotation occur only with an adequate pelvis and if the face can fit under the pubic arch. While the head descends, it becomes wedged into the hollow of the sacrum. Downward pressure from uterine contractions and maternal expulsive forces may cause the mentum to extend anteriorly and low to present at the perineum as a mentum anterior face presentation.

If internal rotation does not occur, the occipitomental diameter, which measures 1.5 cm wider than the suboccipitobregmatic diameter and is thus the largest diameter of the fetal head, presents at the pelvic inlet. The head may engage but can descend only with significant molding. This molding and subsequent caput succedaneum over the forehead can become so extensive that identification of the brow by palpation is impossible late in labor. This may result in a missed diagnosis in a patient who presents later in active labor.

If the mentum is anterior and the forces of labor are directed toward the fetal occiput, flexing the head and pivoting the face under the pubic arch, there is conversion to a vertex occiput posterior position. If the occiput lies against the sacrum and the forces of labor are directed against the fetal mentum, the neck may extend further, leading to a face presentation.

The persistent brow presentation with subsequent delivery only occurs in cases of a large pelvis and/or a small infant. Women with gynecoid pelvis or multiparity may be given the option to labor; however, dysfunctional labor and cephalopelvic disproportion are more likely if this presentation persists.

Labor management of face and brow presentation requires close observation of labor progression because cephalopelvic disproportion, dysfunctional labor, and prolonged labor are much more common. As mentioned above, the trachelobregmatic or submentobregmatic diameters are larger than the suboccipitobregmatic diameter. Duration of labor with a face presentation is generally the same as duration of labor with a vertex presentation, although a prolonged labor may occur. As long as maternal or fetal compromise is not evident, labor with a face presentation may continue. [ 6 ] A persistent mentum posterior presentation is an indication for delivery by cesarean section.

Continuous electronic fetal heart rate monitoring is considered mandatory by many authors because of the increased incidence of abnormal fetal heart rate patterns and/or nonreassuring fetal heart rate patterns. [ 7 ] An internal fetal scalp electrode may be used, but very careful application of the electrode must be ensured. The mentum is the recommended site of application. Facial edema is common and can obscure the fetal facial anatomy and improper placement can lead to facial and ophthalmic injuries. Oxytocin can be used to augment labor using the same precautions as in a vertex presentation and the same criteria of assessment of uterine activity, adequacy of the pelvis, and reassuring fetal heart tracing.

Fetuses with face presentation can be delivered vaginally with overall success rates of 60-70%, while more than 20% of fetuses with face presentation require cesarean delivery. Cesarean delivery is performed for the usual obstetrical indications, including arrest of labor and nonreassuring fetal heart rate pattern.

Attempts to manually convert the face to vertex (Thom maneuver) 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. Given the availability and safety of cesarean delivery, internal rotation maneuvers are no longer justified unless cesarean section cannot be readily performed.

Internal podalic version and breech extraction are also no longer recommended in the modern management of the face presentation. [ 8 ]

Operative delivery with forceps must be approached with caution. Since engagement occurs when the face is at +2 position, forceps should only be applied to the face that has caused the perineum to bulge. Increased complications to both mother and fetus can occur [ 9 ] and operative delivery must be approached with caution or reserved when cesarean section is not readily available. Forceps may be used if the mentum is anterior. Although the landmarks are different, the application of any forceps is made as if the fetus were presenting directly in the occiput anterior position. The mouth substitutes for the posterior fontanelle, and the mentum substitutes for the occiput. Traction should be downward to maintain extension until the mentum passes under the symphysis, and then gradually elevated to allow the head to deliver by flexion. During delivery, hyperextension of the fetal head should be avoided.

As previously mentioned, the persistent brow presentation has a poor prognosis for vaginal delivery unless the fetus is small, premature, or the maternal pelvis is large. Expectant management is reasonable if labor is progressing well and the fetal well-being is assessed, as there can be spontaneous conversion to face or vertex presentation. The earlier in labor that brow presentation is diagnosed, the higher the likelihood of conversion. Minimal intervention during labor is recommended and some feel the use of oxytocin in the brow presentation is contraindicated.

The use of operative vaginal delivery or manual conversion of a brow to a more favorable presentation is contraindicated as the risks of perinatal morbidity and mortality are unacceptably high. Prolonged, dysfunctional, and arrest of labor are common, necessitating cesarean section delivery.

The incidence of perinatal morbidity and mortality and maternal morbidity has decreased due to the increased incidence of cesarean section delivery for malpresentation, including face and brow presentation.

Neonates delivered in the face presentation exhibit significant facial and skull edema, which usually resolves within 24-48 hours. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress. In addition, fetal anomalies or tumors, such as fetal goiters that may have contributed to fetal malpresentation, may make intubation difficult. Physicians with expertise in neonatal resuscitation should be present at delivery in the event that intubation is required. When a fetal anomaly has been previously diagnosed by ultrasonographic evaluation, the appropriate pediatric specialists should be consulted and informed at time of labor.

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Gardberg M, Leonova Y, Laakkonen E. Malpresentations--impact on mode of delivery. Acta Obstet Gynecol Scand . 2011 May. 90(5):540-2. [QxMD MEDLINE Link] .

Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand . 2004 Jun. 83(6):511-8. [QxMD MEDLINE Link] .

Verspyck E, Bisson V, Gromez A, Resch B, Diguet A, Marpeau L. Prophylactic attempt at manual rotation in brow presentation at full dilatation. Acta Obstet Gynecol Scand . 2012 Nov. 91(11):1342-5. [QxMD MEDLINE Link] .

Johnson JH, Figueroa R, Garry D. Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. Obstet Gynecol . 2004 Mar. 103(3):513-8. [QxMD MEDLINE Link] .

Benedetti TJ, Lowensohn RI, Truscott AM. Face presentation at term. Obstet Gynecol . 1980 Feb. 55(2):199-202. [QxMD MEDLINE Link] .

BROWNE AD, CARNEY D. OBSTETRICS IN GENERAL PRACTICE. MANAGEMENT OF MALPRESENTATIONS IN OBSTETRICS. Br Med J . 1964 May 16. 1(5393):1295-8. [QxMD MEDLINE Link] .

Campbell JM. Face presentation. Aust N Z J Obstet Gynaecol . 1965 Nov. 5(4):231-4. [QxMD MEDLINE Link] .

Contributor Information and Disclosures

Teresa Marino, MD Assistant Professor, Attending Physician, Division of Maternal-Fetal Medicine, Tufts Medical Center Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Council of University Chairs of Obstetrics and Gynecology , Nebraska Medical Association Disclosure: Nothing to disclose.

Chitra M Iyer, MD, Perinatologist, Obstetrix Medical Group, Fort Worth, Texas.

Chitra M Iyer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Maternal-Fetal Medicine .

Disclosure: Nothing to disclose.

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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

• Continuing Education Activity

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

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

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

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

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

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

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

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

• Anatomy and Physiology

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

Planes and Diameters of the Pelvis

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

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

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

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

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

Cardinal Movements of Normal Labor

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

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

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

• Indications

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

• Contraindications

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

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

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

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

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

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

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

• Technique or Treatment

Mechanism of Labor in Face Presentation

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

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

Mechanism of Labor in Brow Presentation

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

• Complications

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

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

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

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

• Clinical Significance

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

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

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

• Enhancing Healthcare Team Outcomes

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

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

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

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

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

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Vertex Presentation: What It Means for You & Your Baby

By Sitaram Bhartia Team | December 3, 2020 | Maternity | 2020-12-03 13 April 2023

During the course of your pregnancy, you may hear your gynecologist refer to the ‘position’ or ‘presentation’ of your baby. The ‘presentation’ of the baby is the part of the baby that lies at the lower end of the uterus (womb) or is at the entry of the pelvis. 

The ‘position’, in medical terms, indicates in which way the ‘presenting part’ of the baby lies in relation to the mother, i.e. whether it lies in the front, at the back or on the sides.  

“In layman terms, ‘presentation’ and ‘position’ are often used interchangeably,” says Dr. Anita Sabherwal Anand, Obstetrician-Gynecologist at Sitaram Bhartia Hospital in Delhi.

When a doctor says that your baby is in a head down position, it means that your baby is in vertex presentation .

What is vertex position in pregnancy? What is the difference between vertex and cephalic presentation?

In layman terms, the head down position is known as ‘cephalic presentation’ which means that the head of the baby lies towards the mouth of the uterus (cervix) and the buttocks and feet of the baby are located at the top of the uterus. Vertex is the medical term for “crown of head”. Vertex presentation indicates that the crown of the head or vertex of the baby is presenting towards the cervix.

Vertex presentation is the most common presentation observed in the third trimester.

The definition of vertex presentation , according to the American College of Obstetrics and Gynecologists is, “ A fetal presentation where the head is presenting first in the pelvic inlet.”

Is vertex presentation normal?

Yes, the vertex position of the baby is the most appropriate and favourable position to achieve normal delivery .

“About 95% of babies are in vertex presentation (head down) at 36 weeks, while 3-4% may lie in a ‘ breech position ,” says Dr. Anita.

Breech presentation is a non vertex presentation .

A baby is said to be in breech presentation when its feet and buttocks are at the bottom, on the cervix, and the head settles at the top of the uterus.

Should I be worried about a breech presentation?

“There is no need to worry because babies turn throughout pregnancy, “ explains Dr. Anita. 

In the early weeks of pregnancy, because the baby is small, it can lie in any position. As it grows heavier than 1 kg, it usually tumbles down and comes into the head down position. 

What may cause babies to be in the breech position?

There are a few situations that may increase the risk of having a breech baby even after 36 weeks of pregnancy. These are:

• Twins or multiple babies, wherein there is limited space for movement of the babies
• Low levels of amniotic fluid that prevents free movement of babies or very high volume of amniotic fluid that does not allow the baby to settle in a position
• Abnormalities in the uterus, either the presence of low lying placenta or large fibroids in the lower part of the uterus

Breech positions are higher in preterm birth where the baby is small and may not have had enough time to flip.

“Your gynecologist will place her hands on your abdomen and ascertain the baby’s position during your consultations in the third trimester.”

It was in one such consultation that Shilpa Newati found out that her baby was in breech presentation. She was consulting another hospital where her gynecologist advised a cesarean section. But Shilpa remained adamant and decided to get a second opinion. 

“When I came to Sitaram Bhartia Hospital, the gynecologist explained that babies can turn even until the last moment. Since my pregnancy was progressing well she saw no reason to rush into a cesarean section. “

“I was advised to wait and try a few simple techniques that may help the baby turn.”

Can a baby turn from being in breech presentation to vertex presentation ?

Yes. If your baby is in breech position, you could try turning your baby through these methods: 

• Daily walks (45-60 minutes) not only keep the mother fit but also help the baby tumble down into the head down position.
• Exercises like Cat and Camel or High Bridge may help turn the baby. “Be sure to learn these from a physiotherapist who can properly teach you what to do.”
• External Cephalic Version (ECV) is a maneuver to manually turn the baby to vertex presentation . It is usually done after 36 weeks by a gynecologist with the guidance of an ultrasound. ECV has a success rate of about 50% .

There are a few other methods that are not scientifically proven but may be safe to try.

• Torch: Placing a torch near your vagina may help the baby move in the direction of the light.
• Music: Playing music near the bottom of the belly may encourage the baby to move toward the sound of music.

In Shilpa’s case, the baby turned into vertex presentation at 37 weeks and she went on to have a vaginal delivery like she had hoped. 

Watch Shilpa share her story:

In very few instances, the baby may not turn into vertex presentation . In such a situation, a cesarean section may be safer for both mother and baby. 

Come in for a consultation  Please Chat with us on WhatsApp to schedule an appointment.

More Resources:

• Baby’s Head Engaged: Symptoms, Meaning & What You Can Do
• C Section Delivery: 9 Indications Where It May Be Avoidable
• How to Turn Baby’s Head Down Naturally [VIDEO]

This article has been written with and reviewed by Dr. Anita Sabherwal Anand , who has over 20 years of experience in Obstetrics and Gynecology. 

START TYPING AND PRESS ENTER TO SEARCH

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

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

• >> Post Created: February 11, 2022
• >> Last Updated: June 23, 2024

Vertex Position - Table of Contents

As you approach the due date for your baby’s delivery, the excitement and apprehensions are at their peak! What probably adds to the anxieties are the medical terms describing the baby, its ‘position’ and ‘presentation.’ Let’s strike that out from the list now!

In simple words, ‘ position ’ of the baby is always in reference to the mother ; on what side of the mother’s pelvis does the baby lean more (left or right) and if the baby is facing the mother’s spine or belly (anterior or posterior) – for eg.: Left Occiput Anterior , Right Occiput Anterior , Right Occiput Posterior and so on.

On the other hand, ‘ presentation’ is the body part of baby (head, shoulder, feet, and buttocks) that will enter the mother’s pelvic region first at the beginning of labor.

As ‘ presentation’ depends on the ‘ position’ of the baby, the terms cannot be used interchangeably, which is often mistakenly done. If you are told by your doctor that your baby is in a head-down position , which means its head will enter the pelvic region first , then it means the baby is in ‘vertex’ presentation or even sometimes loosely referred to as vertex position of baby though its conceptually incorrect however it means the same.

With this article, we aim to explain how exactly vertex presentation affects your labor and delivery.

Understanding Vertex Presentation

If your baby is in the head-down position by the third trimester, then you are one of the 95% mothers who have a vertex baby or a vertex delivery. When the baby enters the birth canal head first, then the top part of the head is called the ‘vertex.’

In exact medical terms, we give you the definition of vertex presentation by the American College of Obstetrics and Gynecologists (ACOG) – “a fetal presentation where the head is presenting first in the pelvic inlet.”

Besides vertex presentation (also sometimes referred to as vertex position of baby or vertex fetal position also), the other occasional presentations (non-vertex presentations) include –

• Breech – baby’s feet or buttocks are down and first to enter the mother’s pelvic region. Head is near the mother’s ribs
• Transverse – baby’s shoulder, arm or even the trunk are the first to enter the pelvis, as the baby is laying on the side and not in a vertical position 

It is common that babies turn to a particular position (hence, affecting the presentation) by 34 -36 weeks of pregnancy. Nevertheless, some babies have ‘unstable lies’ ; – wherein the baby keeps changing positions towards the end of the pregnancy and not remaining in any one position for long.

Should you be worried if the baby is in vertex presentation?

Absolutely not! The vertex presentation is not only the most common, but also the best for a smooth delivery. In fact, the chances of a vaginal delivery are better if you have a vertex fetal position.

By 36 weeks into pregnancy, about 95% of the babies position themselves to have the vertex presentation. However, if your baby hasn’t come into the vertex fetal position by this time, then you can talk to your doctor about the options.

You may be suggested a cephalic version procedure   also known as the version procedure /external cephalic version (ECV procedure) – which is used to turn the baby/ fetus from a malpresentation – like breech, oblique or transverse (which occur just about 3-4% times) to the cephalic position (head down).

This is how your doctor will try to turn your baby manually by pushing on your belly to get the baby into the vertex presentation. But it is necessary for you to know that this procedure does involve some risk and is successful only 60-70% of the time.

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Risks of vertex position of baby: can there be any complications for the baby in the vertex presentation.

As discussed above, the vertex fetal position/presentation is the best for labor and delivery, but there can be some complications as the baby makes its way through the birth canal. One such complication can arise if the baby is on the larger side. The baby can face difficulty while passing through the birth canal even if it is in the head-down position because of the size.

Babies who weigh over 9 to 10 pounds are called ‘ macrosomic’ or even referred to as fetal macrosomia , and they are at a higher risk of getting their shoulders stuck in the birth canal during delivery, despite being in the head-down position.

In such cases, to avoid birth trauma for the baby, the American College of Obstetricians and Gynecologists (ACOG) suggests that cesarean deliveries should be limited to estimated fetal weights of at least 11 pounds in women without diabetes and about 9 pounds in women with diabetes.

In case of fetal macrosomia, your doctor will monitor your pregnancy more often and work out a particular birth plan for you subject to your age (mothers age) and size of your baby.

How will I deliver a baby in the vertex fetal position?

Even unborn human babies can astonish you if you observe the way they make their way through the birth canal during delivery.

A vertex baby may be in the optimal position ( head-down first in pelvis) for labor and delivery, but it does its own twisting and turning while passing through the birth canal to fit through. In humans, unlike other mammals, the ratio of the baby’s head to the space in the birth canal is quite limited.

The baby has to flex and turn its head in different positions to fit through and ultimately arrive in this world. And it does so successfully! It is a wonder how they know how to do this so naturally.

And to answer the question ‘how will I deliver a baby in the vertex position?’ – Simply NATURALLY i.e. vaginal delivery. Don’t worry, follow your doctor’s instructions, do your breathing and PUSH.

FAQs to keep ready: How can my doctor help me prepare as I approach my due date?

As your due date nears, apart from bodily discomfort, you may experience nervousness about the big day. Your doctor can help by clearing your doubts and putting you at ease. You can ask them the following questions to understand the process better.

Q1) How will I know if my baby is in vertex fetal position?

A doctor can confidently tell you whether or not your baby is in the vertex presentation. Many medical professionals will be able to determine your baby’s position merely by using their hands; this is called ‘Leopold’s maneuvers.’

However, in case they aren’t very confident about the baby’s position even after this, then an ultrasound can confirm the exact position of the baby.

You can also understand this through belly mapping . You are sure to feel the kicks towards the top of your stomach and head (distinct hard circular feel) towards your pelvis. 

Q2)Is there any risk of my vertex baby turning and changing positions?

Yes, in case of some women, the baby who has a vertex presentation may turn at the last moment.

What may cause this? Women who have extra amniotic fluid (polyhydramnios) have increased chances of a vertex baby turning into a breech baby at the last minute.

Discuss this with your doctor to understand what are the chances this might happen to you and what all you can do to keep the baby in the vertex presentation for delivery.

Q3) Is there need to be worried if my baby has a breech presentation?

Not really! There are loads of exercises which you which can help you get your baby in the right position.

Then there are the ECV (external cephalic version) procedure which can help in changing the position of your baby into the desired vertex position. Speak with your doctor.

Having a baby in breech position just before labor will require you to have a C-section . Let your doctor guide you. But there is nothing to worry about.

Q4) What may cause babies to come into breech position?

A few circumstances may cause the baby to come into breech position even after 36 weeks into pregnancy.

• If you are carrying twins or multiple babies , in which case there is limited space for each baby to move around.
• Low levels of amniotic fluid which restricts the free movement of the baby or even high levels of amniotic fluid that does not permit the baby to remain in any one position.
• If there are abnormalities in the uterus or other conditions like low-lying placenta or large fibroids in the lower part of the uterus.

Chances of breech babies are higher in births that are pre-term as the baby does not get enough time to flip into a head-down position – cephalic position – vertex presentation (vertex position of baby/ vertex fetal position).

Q5) Can a baby turn from breech position to vertex presentation?

Yes, a baby can turn from a breech position to vertex position / vertex fetal position over time with exercises and sometimes through ECV.

If an ultrasound has confirmed you have a breech baby, then you can do the following to turn it to a vertex baby. Try the following –

• Do not underestimate the wonders of daily walks of about 45-60 mins when it comes to bringing your baby in vertex presentation from breech presentation.
• Talk to your doctor about certain exercises that can help turn your baby in the head-down position. Exercises like ‘ high bridge’ or ‘cat and camel’ can help here. We recommend you to learn and try this only in the presence of a professional.
• External Cephalic Version (ECV ) is a way to manually maneuver the baby to vertex presentation. It is done with the help of an ultrasound and generally after 36 weeks into pregnancy. However, it has the success rate of just 50%. Discuss the risks, if any, with your gynecologist before opting for this procedure.

There are a couple of other unscientific methods that may not be safe to try –

• Light : Placing a torch near your vagina may guide the baby toward the light, and hence, get it in the vertex presentation.
• Music : Playing music near your belly’s bottom may urge the baby to move itself in the head-down position.

Q6) What all can I do to ensure I have a healthy delivery?

A healthy delivery requires the mother to be active, eating well, and staying happy. For any apprehensions regarding labor and delivery, do not hesitate to talk to your doctor and clarify your doubts.

Your doctor can help you understand your baby’s position and presentation, and then based on that they can plan your delivery to ensure your baby’s birth will happen in the safest possible way.

Try and maintain a healthy lifestyle which will also help in overall of your child and placenta health .

Key Takeaway

Yes, vertex presentation or vertex position of baby and vertex delivery are very common, normal, safe, and the best for labor and delivery of the baby. There is probability of complications sometimes, but that is only subject to certain conditions that we discussed above.

However, understand that any other baby position is also safe. The only thing with other positions and presentations is that the chances of a cesarean delivery goes up. Nevertheless, know what matters at the end of it all is a happy and healthy baby in your arms!

Happy pregnancy!

Khushboo Kirale

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Breech Births

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

What are the different types of breech birth presentations?

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

What causes a breech presentation?

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

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

How is a breech presentation diagnosed?

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

Can a breech presentation mean something is wrong?

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

Can a breech presentation be changed?

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

Medical Techniques

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

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

ECV will not be tried if:

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

Complications of EVC include:

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

Vaginal delivery versus cesarean for breech birth?

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

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

What are the risks and complications of a vaginal delivery?

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

When is a cesarean delivery used with a breech presentation?

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

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

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

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Twin fetal presentation – also known as the position of your babies in the womb – dictates whether you'll have a vaginal or c-section birth. Toward the end of pregnancy, most twins will move in the head-down position (vertex), but there's a risk that the second twin will change position after the first twin is born. While there are options to change the second twin's position, this can increase the risk of c-section and other health issues. Learn about the six possible twin fetal presentations: vertex-vertex, vertex-breech, breech-breech, vertex-transverse, breech-transverse, and transverse-transverse – and how they'll impact your delivery and risks for complications.

What is fetal presentation and what does it mean for your twins?

As your due date approaches, you might be wondering how your twins are currently positioned in the womb, also known as the fetal presentation, and what that means for your delivery. Throughout your pregnancy, your twin babies will move in the uterus, but sometime during the third trimester – usually between 32 and 36 weeks – their fetal presentation changes as they prepare to go down the birth canal.

The good news is that at most twin births, both babies are head-down (vertex), which means you can have a vaginal delivery. In fact, nearly 40 percent of twins are delivered vaginally.

But if one baby has feet or bottom first (breech) or is sideways (transverse), your doctor might deliver the lower twin vaginally and then try to rotate the other twin so that they face head-down (also called external cephalic version or internal podalic version) and can be delivered vaginally. But if that doesn't work, there's still a chance that your doctor will be able to deliver the second twin feet first vaginally via breech extraction (delivering the breech baby feet or butt first through the vagina).

That said, a breech extraction depends on a variety of factors – including how experienced your doctor is in the procedure and how much the second twin weighs. Studies show that the higher rate of vaginal births among nonvertex second twins is associated with labor induction and more experienced doctors, suggesting that proper delivery planning may increase your chances of a vaginal birth .

That said, you shouldn't totally rule out a Cesarean delivery with twins . If the first twin is breech or neither of the twins are head-down, then you'll most likely have a Cesarean delivery.

Research also shows that twin babies who are born at less than 34 weeks and have moms with multiple children are associated with intrapartum presentation change (when the fetal presentation of the second twin changes from head-down to feet first after the delivery of the first twin) of the second twin. Women who have intrapartum presentation change are more likely to undergo a Cesarean delivery for their second twin.

Here's a breakdown of the different fetal presentations for twin births and how they will affect your delivery.

Head down, head down (vertex, vertex)

This fetal presentation is the most promising for a vaginal delivery because both twins are head-down. Twins can change positions, but if they're head-down at 28 weeks, they're likely to stay that way.

When delivering twins vaginally, there is a risk that the second twin will change position after the delivery of the first. Research shows that second twins change positions in 20 percent of planned vaginal deliveries. If this happens, your doctor may try to rotate the second twin so it faces head-down or consider a breech extraction. But if neither of these work or are an option, then a Cesarean delivery is likely.

In vertex-vertex pairs, the rate of Cesarean delivery for the second twin after a vaginal delivery of the first one is 16.9 percent.

Like all vaginal deliveries, there's also a chance you'll have an assisted birth, where forceps or a vacuum are needed to help deliver your twins.

Head down, bottom down (vertex, breech)

When the first twin's (the lower one) head is down, but the second twin isn't, your doctor may attempt a vaginal delivery by changing the baby's position or doing breech extraction, which isn't possible if the second twin weighs much more than the first twin.

The rates of emergency C-section deliveries for the second twin after a vaginal delivery of the first twin are higher in second twins who have a very low birth weight. Small babies may not tolerate labor as well.

Head down, sideways (vertex, transverse)

If one twin is lying sideways or diagonally (oblique), there's a chance the baby may shift position as your labor progresses, or your doctor may try to turn the baby head-down via external cephalic version or internal podalic version (changing position in the uterus), which means you may be able to deliver both vaginally.

Bottom down, bottom down (breech, breech)

When both twins are breech, a planned C-section is recommended because your doctor isn't able to turn the fetuses. Studies also show that there are fewer negative neonatal outcomes for planned C-sections than planned vaginal births in breech babies.

As with any C-section, the risks for a planned one with twins include infection, loss of blood, blood clots, injury to the bowel or bladder, a weak uterine wall, placenta abnormalities in future pregnancies and fetal injury.

Bottom down, sideways (breech, transverse)

When the twin lowest in your uterus is breech or transverse (which happens in 25 percent of cases), you'll need to have a c-section.

Sideways, sideways (transverse, transverse)

This fetal presentation is rare with less than 1 percent of cases. If both babies are lying horizontally, you'll almost definitely have a C-section.

Learn more:

• Twin fetal development month by month
• Your likelihood of having twins or more
• When and how to find out if you’re carrying twins or more

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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 .

Cleveland Clinic. Fetal Positions for Birth: https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth Opens a new window [Accessed July 2021]

Mayo Clinic. Fetal Presentation Before Birth: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615?s=7 Opens a new window [Accessed July 2021]

NHS. Giving Birth to Twins or More: https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

Science Direct. Breech Extraction: https://www.sciencedirect.com/topics/medicine-and-dentistry/breech-extraction Opens a new window [Accessed July 2021]

Obstetrics & Gynecology. Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

American Journal of Obstetrics and Gynecology. Fetal presentation and successful twin vaginal delivery: https://www.ajog.org/article/S0002-9378(04)00482-X/fulltext [Accessed July 2021]

The Journal of Maternal-Fetal & Neonatal Medicine. Changes in fetal presentation in twin pregnancies https://www.tandfonline.com/doi/abs/10.1080/14767050400028592 Opens a new window [Accessed July 2021]

Reviews in Obstetrics & Gynecology. An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252881/ Opens a new window [Accessed July 2021]

Nature. Neonatal mortality and morbidity in vertex–vertex second twins according to mode of delivery and birth weight: https://www.nature.com/articles/7211408 Opens a new window [Accessed July 2021]

Cochrane. Planned cesarean for a twin pregnancy: https://www.cochrane.org/CD006553/PREG_planned-caesarean-section-twin-pregnancy Opens a new window [Accessed July 2021]

Kids Health. What Is the Apgar Score?: https://www.kidshealth.org/Nemours/en/parents/apgar0.html Opens a new window [Accessed July 2021]

American Journal of Obstetrics & Gynecology. Neonatal mortality in second twin according to cause of death, gestational age, and mode of delivery https://pubmed.ncbi.nlm.nih.gov/15467540/ Opens a new window [Accessed July 2021]

Lancet. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group https://pubmed.ncbi.nlm.nih.gov/11052579/ Opens a new window [Accessed July 2021]

Cleveland Clinic. Cesarean Birth (C-Section): https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section Opens a new window [Accessed July 2021]

St. Jude Medical Staff. Delivery of Twin Gestation: http://www.sjmedstaff.org/documents/Delivery-of-twins.pdf Opens a new window [Accessed July 2021]

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Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

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

b. Presentation/Presenting Part.

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

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

(2) Percentages of presentations.

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

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

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

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

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

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

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

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

c. Attitude.

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

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

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

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

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

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

(2) Areas to look at for flexion.

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

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

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

(e) Arms-crossed over the thorax.

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

d. Station.

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

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

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

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

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

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

e. Engagement.

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

f. Position.

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

(1) The maternal pelvis is divided into quadrants.

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

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

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

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

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

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

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

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

(b) Breech or butt presentation.

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

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

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

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

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

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

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

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

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

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

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

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

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

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

A–Complete. B–Frank. C–Incomplete.

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

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

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

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

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

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

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

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

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

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

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vertex presentation

Medical Definition of vertex presentation

Dictionary entries near vertex presentation, cite this entry.

“Vertex presentation.” Merriam-Webster.com Medical Dictionary , Merriam-Webster, https://www.merriam-webster.com/medical/vertex%20presentation. Accessed 23 Jun. 2024.

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Abnormal Fetal Position and Presentation

Under normal circumstances, a baby is in the vertex (cephalic) position before delivery. In the vertex position, the baby’s head is at the lower part of the abdomen, and the baby is born head-first. However, some babies present differently before delivery. In these cases, abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma (1). Types of abnormal fetal positions and presentations include the following. We’ll cover each in more detail on this page.

What is the difference between fetal presentation and position?

In the womb, a fetus has both a presentation and a position . Presentation refers to the baby’s body that leads, or is expected to lead, out of the birth canal (9). For example, if a baby’s rear is set to come out of the birth canal first, the baby is said to be in “breech presentation.” Position refers to the direction the baby is facing in relation to the mother’s spine (9). A baby could be lying face-first against a mother’s spine, or face up towards the mother’s belly.

What way should a baby come out during birth?

Vertex presentation is the ‘normal’ way that a baby is positioned for birth and the lowest-risk presentation for vaginal birth (1). In vertex presentation, the baby is positioned head-first with their occiput (the part of the head close to the base of the skull) entering the birth canal first. In this position, the baby’s chin is tucked into their chest and they are facing the mother’s back (occipito-anterior position). Any position other than vertex position is abnormal and can make vaginal delivery much more difficult or sometimes impossible (2). If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury (1).

What happens if a baby isn’t in the standard vertex position during birth?

Before delivery, it is critical that the fetus is in the standard vertex presentation and within the normal range for weight and size. This helps ensure the safety of both baby and mother during labor. When the baby’s size or position is abnormal, physician intervention is usually warranted (1). This may mean simple manual procedures to help reposition the baby or, in many cases, a planned C-section delivery . The failure of healthcare professionals to identify and quickly resolve issues related to fetal size, weight, and presentation is medical malpractice . There are numerous complications related to abnormal weight, size, abnormal position, or abnormal presentation.

Compound presentation

In the safest presentation (vertex presentation), the baby is born head first, with the rest of the body following. In a compound presentation, however, there are multiple presenting parts. Most commonly, this means that the baby’s head and an arm come out first at the same time. Sometimes compound presentation can occur with twins where the head of the first twin presents with the extremity of the second twin (3).

Risk factors for compound presentation include (3):

• Prematurity
• Intrauterine growth restriction (IUGR)
• Multiple gestations ( twins , triplets, etc.)
• Polyhydramnios
• A large pelvis
• External cephalic version
• Rupture of membranes at high station

Compound presentations can be detected via ultrasound before the mother’s water breaks. During labor, compound presentation is identified as an irregular finding during a cervical examination (3).

If a mother has polyhydramnios, the risk of compound presentation is higher, as the flow of amniotic fluid when the membranes rupture can sweep extremities into the birth canal, or cause a cord prolapse , which is a medical emergency (3). If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency (3). Often, the safest way to deliver a baby with compound presentation is C-section, because complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy , intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE) (3).

Limb presentation

Limb presentation during childbirth means that the part of the baby’s body that emerges first is a limb – an arm or a leg. Babies with limb presentation cannot be delivered safely via vaginal delivery; they must be delivered quickly by emergency C-section (4). Limb presentation poses a large risk for dystocia (the baby getting stuck on the mother’s pelvis), which is a medical emergency.

Occipitoposterior (OP) position

Approximately 1 out of 19 babies present  in a posterior position rather than an anterior position. This  is called an occipitoposterior (OP) position or occiput posterior position (3)  In OP position, the baby is head-first with the back part of the head turned towards the mother’s back, rotated to the right  (right occipitoposterior position, or ROP), or to the left (left occipitoposterior position, or LOP) of the sacroiliac joint. Occipitoposterior position increases the baby’s risk of experiencing prolonged labor , prolapsed umbilical cord , and use of delivery instruments, such as forceps and vacuum extractors (5). These conditions can cause brain bleeds , a lack of oxygen to the brain, and birth asphyxia .

When OP position is present, if a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section (5).  A C-section can help prevent oxygen deprivation caused by prolonged labor, umbilical cord prolapse, or forceps and vacuum extractor use.

A nurse explains posterior position

Breech presentation

Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should turn to the cephalic position in time for labor. Breech presentation occurs when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because when vaginal delivery is attempted, a baby is at increased risk for prolapsed umbilical cord, traumatic head injury, spinal cord fracture, fatality, and other serious problems with labor (6).

There are 4 types of breech positions:

• Footling breech presentation : In footling position, one or both feet enter the birth canal first, with the buttocks at a higher position than the feet.
• Kneeling breech presentation : This is when the baby has one or both legs extended at the hips and flexed at the knees.
• Frank breech presentation : This is when the baby’s buttocks present first, the legs are flexed at the hip and extended at the knees, and the feet are near the ears.
• Complete breech presentation : In this position, the baby’s hips and knees are flexed so that the baby is sitting cross-legged, with the feet beside the buttocks.

When a baby is in breech position, physicians often try to maneuver the baby into a head-first position. This should only be attempted if fetal heart tracings are normal (the baby is not in distress ) (7). The only type of breech position that may allow for a vaginal delivery is frank breech , and the following conditions must be met:

• The baby’s heart rate is being closely monitored and the baby is not in distress.
• Cephalopelvic disproportion (CPD) is not present; x-rays and ultrasound show that the size of the mother’s pelvis will allow a safe vaginal birth.
• The hospital is equipped for and the physician is skilled in performing an emergency C-section .

If these conditions are not present, vaginal birth should not be attempted. Most experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth injuries (6). Mismanaged breech birth can result in the following conditions:

• Brain bleeds, intracranial hemorrhages
• Spinal cord fractures
• Hypoxic-ischemic encephalopathy (HIE)
• Cerebral palsy
• Intellectual disabilities
• Developmental delays

Face presentation

A face presentation occurs when the face is the presenting part of the baby. In this position, the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. This prevents head engagement and descent of the baby through the birth canal. In some cases of face presentation, the trauma of a vaginal delivery causes face deformation and fluid build-up (edema) in the face and upper airway, which often means the baby will need a breathing tube placed in the airway to maintain airway patency and assist breathing (1).

Image by healthhand.com

There are three types of face presentation:

• Mentum anterior (MA) : In this position, the chin is facing the front of the mother.
• Mentum posterior (MP) : The chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, the baby’s head, neck, and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
• Mentum transverse (MT) : The baby’s chin is facing the side of the birth canal in this position.

Trauma is very common during vaginal delivery of a baby in face presentation, so parents must be warned that their baby may be bruised and that a C-section is available to avoid this trauma.

Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position (1). Safe vaginal delivery of a term-sized infant in persistent MP position is impossible due to the presenting part of the baby compared to the size of the mother’s pelvis (1). Babies in MP position must be delivered by C-section. Babies in MT position must also be delivered by C-section. Some babies in the MP and MT positions will spontaneously convert to the MA position during the course of labor, which makes vaginal delivery a possibility. If the baby is in the MA position and vaginal delivery is able to proceed, engagement of the presenting part of the baby probably will not occur until the face is at a +2 station (1).

The management of face presentation requires close observation of the progress of labor due to the high incidence of CPD with face presentation. In face presentation, the diameter of the presenting part of the head is, on average, 0.7 cm greater than in the normal vertex position (1).

In any face presentation situation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section. In fact, when face presentation occurs, experts recommend liberal use of C-section (1).

Since there is an increased risk of trauma to the baby when the face presents, the physician should not try to rotate the baby internally. In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to extract the baby from the uterine cavity. Outlet forceps should only be used by experienced physicians; these forceps increase the risk of trauma and brain bleeds. In almost all clinical circumstances a cesarean delivery is the safest method of delivery.

Listed below are complications that can occur if face presentation is mismanaged by the medical team:

• Prolonged labor
• Facial trauma
• Facial and upper airway edema (fluid build-up in the face, often caused by trauma)
• Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
• Respiratory distress or difficulty in ventilation (the baby being able to move air in and out of lungs) due to upper airway trauma and edema
• Spinal cord injury
• Abnormal fetal heart rate patterns
• 10-fold increase in fetal compromise
• Brain bleeds
• Intracranial hemorrhages
• Permanent brain damage

Brow presentation

Brow presentation is similar to face presentation, but the baby’s neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backward. As the term “brow presentation” suggests, the brow (forehead) is the part that is situated to go through the pelvis first. Vaginal delivery can be difficult or impossible with brow presentation, because the diameter of the presenting part of the head may be too big to safely fit through the pelvis.

Risk factors and conditions associated with brow presentation

Brow presentation has been linked to several risk factors and co-occurring conditions. These include:

• Multiparity (having previously given birth)
• Premature delivery
• Fetal anomalies such as anencephaly (an absence of major parts of the brain and skull) or anterior neck mass (a growth on the front of the neck)
• Previous c-section delivery
• Polyhydramnios (excessive amniotic fluid: infants swallow amniotic fluid while in utero, but this may be difficult if their neck is extended)

Diagnosis of brow presentation

Brow presentation can often be diagnosed through a vaginal examination during labor. If there are no conclusive signs from the physical examination alone, an ultrasound can also be used. Warning signs of brow presentation may include signs of fetal distress or lack of labor progression.

Management of brow presentation

Infants who assume a brow presentation early in labor may spontaneously move into a more optimal position during the delivery process. Additionally, safe delivery in brow presentation may be possible if the infant is unusually small and/or the mother’s pelvic opening is unusually large. For these reasons, physicians occasionally recommend vaginal delivery of infants in brow presentation.

Doctors attempting vaginal delivery of a baby in brow presentation must be very careful to watch for signs of fetal distress (such as an abnormal heart rate), and to monitor the progression of labor. Prolonged labor can cause extended periods of fetal oxygen deprivation, which can cause birth asphyxia and permanent injury. Signs of fetal distress can indicate that a baby is in danger of sustaining serious brain damage if action is not quickly taken to prevent this. If an infant in brow presentation begins to show signs of distress, or if labor progress stops or slows significantly, physicians should be ready to move on to a cesarean delivery.

Labor induction or augmentation with the drug Pitocin (synthetic oxytocin) is very dangerous in cases of brow presentation. Pitocin can lead to excessive uterine contractions, which can put pressure on the infant’s head and cut off their oxygen supply; this is especially risky when safe fetal descent is already compromised, such as in cases of brow presentation.

Complications of brow presentation

If brow presentation is diagnosed in a timely fashion and is appropriately managed, there are typically no serious negative effects on the mother or baby. However, if medical professionals fail to recognize brow presentation and intervene as necessary, there can be lasting consequences. Infants may suffer  oxygen deprivation  due to prolonged labor, or  traumatic injuries from a difficult delivery. Some of the most severe conditions resulting from mismanaged brow presentation births include:

• Hypoxic-ischemic encephalopathy
• Periventricular leukomalacia
• Seizure disorders
• Developmental disabilities

Shoulder presentation (transverse lie)

Shoulder presentation (transverse lie) is when the arm, shoulder or trunk of the baby enter the birth canal first. When a baby is in a transverse lie position during labor, C-section is almost always used as the delivery method (8).  Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa, or have a baby with intrauterine growth restriction (IUGR) are more likely to have a baby in the transverse lie position (8). Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position; thus, a C-section should ideally be performed before the membranes break (8). Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe birth asphyxia due to cord compression and trauma to the baby. This can cause hypoxic-ischemic encephalopathy (HIE), seizures, permanent brain damage, and cerebral palsy.

Legal help for birth injuries from abnormal position or presentation

The award-winning birth injury attorneys at ABC Law Centers: Birth Injury Lawyers have over 100 years of joint experience handling birth trauma cases related to abnormal position or presentation. If you believe your loved one’s birth injury resulted from an instance of medical malpractice, you may be entitled to compensation from a medical malpractice or personal injury case. During your free legal consultation, our birth injury attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you.

• Free Case Review
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• No Fee Unless We Win

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• Julien, S., and Galerneau, F. (2017). Face and brow presentations in labor. Retrieved from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor .
• World Health Organization, UNICEF, and United Nations Population Fund. Malpositions and malpresentations. Retrieved from http://hetv.org/resources/reproductive-health/impac/Symptoms/Malpositions__malpresetations_S69_S81.html .
• Barth, W. (2016). Compound fetal presentation. Retrieved from https://www.uptodate.com/contents/compound-fetal-presentation .
• Gabbe, S.G., … Grobman, W.A. (2017). Compound Presentation. Retrieved from https://expertconsult.inkling.com/read/gabbe-obstetrics-normal-problem-pregnancies-7e/chapter-17/compound-presentation .
• Argani, C.H. and Satin, A.J. (2018) Occiput posterior position. Retrieved from https://www.uptodate.com/contents/occiput-posterior-position .
• Hofmeyr, G.J. (2018). Overview of issues related to breech presentation. Retrieved from https://www.uptodate.com/contents/overview-of-issues-related-to-breech-presentation .
• Hofmeyr, G.J. (2017). Delivery of the fetus in breech presentation. Retrieved from https://www.uptodate.com/contents/delivery-of-the-fetus-in-breech-presentation .
• Strauss, R.A. (2017). Transverse fetal lie. Retrieved from https://www.uptodate.com/contents/transverse-fetal-lie .
• Moldenhauer, J.S. (2018). Abnormal Position and Presentation of the Fetus. Retrieved from https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/abnormal-position-and-presentation-of-the-fetus .

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Buy Rating on Vertex Pharmaceuticals’ VX-880 Backed by Breakthrough Efficacy in Type 1 Diabetes

Mohit Bansal , an analyst from Wells Fargo, maintained the Buy rating on Vertex Pharmaceuticals ( VRTX – Research Report ). The associated price target remains the same with $540.00.

Mohit Bansal has given his Buy rating due to a combination of factors surrounding Vertex Pharmaceuticals’ latest data on their VX-880 cell therapy program. The reported data from the ADA presentation underlines the therapy’s potential to be curative for Type 1 diabetes, a significant breakthrough in the medical community. Bansal finds the safety profile of VX-880 to be reassuring, highlighting that adverse events were consistent with expected outcomes of immunosuppression therapy and not directly attributed to VX-880 itself. Furthermore, the analyst draws attention to the successful engraftment and insulin production in all patients who received the full dose. In addition, Bansal’s optimism is bolstered by the efficacy results which show that all evaluable patients met the primary endpoint of the study, including the elimination of severe hypoglycemic events and achievement of A1c levels below 7%. Also notable is the fact that a significant number of patients have either reduced or completely eliminated the need for exogenous insulin. While Bansal notes that longer-term data on durability are needed to fully assess the treatment’s potential, he acknowledges a sizeable market opportunity for Vertex, estimating it at $1.2 billion worldwide. Despite the current limitation of the treatment to patients with severe conditions due to the necessity of immunosuppression, Bansal’s rating reflects the promising data and potential market impact of VX-880.

In another report released on June 17, Argus Research also maintained a Buy rating on the stock with a $550.00 price target.

VRTX’s price has also changed moderately for the past six months – from $400.630 to $468.710, which is a 16.99% increase.

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Vertex Pharmaceuticals (VRTX) Company Description:

Based in Massachusetts and incorporated in 1989, Vertex Pharmaceuticals, Inc. is a biopharmaceutical company, which is engaged in the development and commercializing therapies for the treatment of cystic fibrosis, infectious diseases including viral infections such as influenza and bacterial infections, autoimmune diseases such as rheumatoid arthritis, cancer, inflammatory bowel disease and neurological disorders including pain and multiple sclerosis.

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