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Abnormal Position and Presentation of the Fetus

By Julie S. Moldenhauer, MD, Associate Professor of Clinical Obstetrics and Gynecology in Surgery, The Garbose Family Special Delivery Unit; Attending Physician, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia; The University of Pennsylvania Perelman School of Medicine

Position refers to whether the fetus is facing rearward (toward the woman’s back—that is, face down when the woman lies on her back) or forward (face up).

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks or a shoulder leads the way.

The most common and safest combination consists of the following:

  • Head first (called a vertex or cephalic presentation)

  • Facing rearward

  • Face and body angled toward the right or left

  • Neck bent forward

  • Chin tucked in

  • Arms folded across the chest

If the fetus is in a different position or presentation, labor may be more difficult, and delivery through the vagina may not be possible.

Position and Presentation of the Fetus

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the position of a fetus is facing rearward (toward the woman’s back) with the face and body angled to one side and the neck flexed, and presentation is head first.

An abnormal position is facing forward, and abnormal presentations include face, brow, breech, and shoulder.

Abnormal Presentations

There are several abnormal presentations.

Occiput posterior presentation

In occiput posterior presentation (also called sunny-side up), the fetus is head first but is facing up (toward the mother's abdomen). It is the most common abnormal position or presentation.

When a fetus faces forward, the neck is often straightened rather than bent, and the head requires more space to pass through the birth canal. Delivery by a vacuum extractor or forceps or cesarean delivery may be necessary.

Breech presentation

The buttocks or sometimes the feet present first. Breech presentation occurs in 3 to 4% of full-term deliveries. When delivered vaginally, babies that present buttocks first are more likely to be injured than those that present head first. Such injuries may occur before, during, or after birth. The baby may even die. Complications are less likely when breech presentation is detected before labor or delivery.

Breech presentation is more likely to occur in the following circumstances:

Sometimes the doctor can turn the fetus to present head first by pressing on the woman’s abdomen before labor begins, usually after 36 weeks of pregnancy. However, if labor begins and the fetus is in breech presentation, problems may occur.

The passageway made by the buttocks in the birth canal may not be large enough for the head (which is wider) to pass through. In addition, when the head follows the buttocks, it cannot be molded to fit through the birth canal, as it normally is. Thus, the baby’s body may be delivered and the head may be caught inside the woman. When the baby’s head is caught, it puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among babies presenting buttocks first than among those presenting head first.

In a first delivery, these problems may occur more frequently because the woman’s tissues have not been stretched by previous deliveries. Because the baby could be injured or die, cesarean delivery is preferred when the fetus is in breech presentation unless the doctor is very experienced with and skilled at delivering in breech babies.

Other presentations

In face presentation, the neck arches back so that the face presents first.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. They often correct themselves. If they do not, forceps, vacuum extractor, or cesarean delivery may be used.

Occasionally, a fetus lying horizontally across the birth canal (called transverse lie) presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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